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IV THERAPY PART I Catherine Luksic BSN,RN WHAT IS IV THERAPY ? Intravenous – into the vein Administration of substances (fluids) directly into the vein Parenteral route PN SCOPE OF PRACTICE: IV THERAPY State of Pennsylvania – requirements Satisfactory completion of Board approved IV therapy course LPN complies w/ policies/procedures of institution Review of policies/procedures q 12 mos. Functions of PN Perform venipuncture Administer IV fluids May NOT administer: Antineoplastic agents Blood products Titrated medications IV push medications **As of 7/2012 – LPN may administer & maintain TPN, lipids PN SCOPE OF PRACTICE: RULES AND REGULATIONS Refer to Handout LEGAL ISSUES Informed Consent Pt. has right to refuse treatment If pt. is incompetent or unable to give consent, legally authorized rep. may consent Coercion of rational adult patient to place an IV catheter constitutes assault & battery Nurse must comply w/ acceptable nursing standards established by facility, as well as state/federal guidelines Manual of IV Therapeutics, Phillips, 2010 Infusion equipment, administration of meds, monitoring of pt., documentation, etc. If an act of malpractice causes harm, legal action can be initiated INDICATIONS FOR IV THERAPY Fluid & Electrolytes Maintenance Replacement – fluid or electrolyte deficit Restoration - ongoing losses. (i.e. drains, NGT’s, severe diarrhea, vomiting, burns) Medications Nutrients antibiotics, potassium, insulin, heparin, etc. TPN, PPN Blood Products PRBC’s, FFP, Platelets ADVANTAGES OF IV THERAPY 1. Bioavailability is immediate Drug enters circulation immediately, permits access to site of action 2. Absorption into bloodstream is complete and reliable 3. Large doses can be delivered at a continuous rate 4. No “first pass” effect in the liver DISADVANTAGES OF IV THERAPY 1. Adverse reactions may occur – can be life threatening If medication administered too quickly Allergic reaction 2. Increased risk of complications Extravasation Vein irritation (phlebitis) Systemic infection Air embolism THE HEART BLOOD VESSELS Arteries - carry blood away from heart. Branch off into smaller arteries eventually into capillaries. OXYGENATED BLOOD Veins - blood from capillaries flow into veins, carry blood back to the heart UNOXYGENATED BLOOD BLOOD VESSEL WALLS Tunica intima - innermost layer. Continuous with the endocardium. Tunica media - middle layer. Smooth muscle and elastic tissue. Tunica adventicia (externa) - tough outer layer. BLOOD VESSEL WALLS BLOOD VESSEL WALLS ARTERIES VS. VEINS Middle layer (tunica media) much thicker in artery Arteries contract & relax Due to high pressure and thicker muscle layer Pressure much less within veins. Veins have one-way valves to direct blood flow toward the heart. Veins store blood (70% of blood volume). ARTERIES: Thick wall (tunica media) Lacks valves Pulsates Bright red blood High pressure VEINS: Thin wall valves present approx. every 3 in. No pulsation Dark red blood Lower pressure *pulsation may be seen in jugular vein VEINS VEINS Used for IV therapy Peripheral (arms/hands): Cephalic (upper and lower) Basilic Median (antecubital) Metacarpal *First choice for site selection *allows for increased mobility *less risk of phlebitis (Burton textbook recommends forearm veins – to avoid nerve/tendon damage in hands ???) PERIPHERAL VEINS – UPPER EXTREMITY FACTORS TO CONSIDER Adipose Edema tissue Color ? Adequate tissue perfusion ? Dehydration, volume overload, normovolemic Avoid these areas ? Lack of, can pt. feel “pain” Hydration Tissue elasticity Bruising, rashes, breaks in skin Sensation VEINS Refer to handout: Veins Practice identification of peripheral veins in classroom Learn to properly apply tourniquet to upper extremities VENOSCOPE: VEIN FINDER IV ACCESS Peripheral - Located in peripheral veins of upper (and sometimes lower) extremities Can be placed by nursing (qualified LPN’s & RN’s) Central - Located in large vessels near heart (ie, subclavian, internal jugular, femoral) Can only be placed by physician or specially trained practitioners PERIPHERAL IV Smaller vessels Slower blood flow Easy access Veins of hands, arms most commonly used Metacarpal, cephalic, basilic, accessory cephalic, median, upper cephalic Needs to be changed regularly Every 48-72 hours, according to policy 2011 Infusion Nursing Standards of Practice – rotate peripheral IV catheters based on clinical condition vs. set time frame CENTRAL IV ACCESS Higher risk of life-threatening complications Larger vessels More turbulent blood flow Care includes sterile dressing changes and flushes Used if peripheral access not possible, or for long-term use. Percutaneous, tunneled, or implanted. Includes PICC lines (peripherally inserted central catheter) CENTRAL IV LINES Usually located in subclavian vein, jugular vein Can also have access through cephalic, basilic, antecubital and axillary veins PICC lines PICC LINE CENTRAL IV LINE CENTRAL IV LINE IV SOLUTIONS Bottle vs. Bag Types of Solutions Tonicity Electrolyte Solutions SOLUTION CONTAINERS Bottle - Not commonly used Meds that cannot be in plastic Advantages: Very easy to visualize solution and to see calibrations Disadvantages: BREAKS. Easier to contaminate. Takes more storage space. Examples: Nitroglycerin, Albumin, Lipids Lipids are also stable in special plastic Requires tubing w/ vent IV BOTTLE SOLUTION CONTAINERS Plastic - Most common container Atmospheric pressure collapses bag , forces fluid out. Advantages: Easy to store. Not greatly affected by temp fluctuations. Disadvantages: Can be punctured. Some meds can adhere to plastic. **ALWAYS inspect bag/bottle before use TYPES OF SOLUTIONS Colloids - Pulls fluid into intravascular space, volume expanders Albumin – treat low BP/shock, provides protein Dextran – to prevent venous thrombosis during OR Hespan (hetastarch) Considered to be a blood product Similar to albumin Crystalloids - Used for hydration, most common ** Saline, Dextrose TYPES OF SOLUTIONS Blood and blood products Restore blood volume or components PRBC’s – acute blood loss, anemia Hg <8.0 FFP – replace coag factors, will reverse effect of coumadin (PT/INR elevated) Platelets – thrombocytopenia, control bleeding Whole blood – rarely used, restores blood volume LPN cannot admin. but can monitor pt. during infusion Beware of transfusion reaction TYPES OF SOLUTIONS: BLOOD PRODUCTS Physician order & consent required Type and crossmatch required (ABO type, Rh group) Only compatible with 0.9% NS ** Dextrose can cause hemolysis Frequent VS, monitor pt. continuously for first 15 min. 2 RN’s must check blood product before initiating infusion TYPES OF SOLUTIONS Transfusion Reactions 1. Hemolytic: DANGEROUS, RBC’s attacked by immune system – cells burst Bleeding (urine), chest pain, back pain, low BP, chills May be a delayed reaction, usually immediate 2. Febrile: 3. Allergic Itching, SOB, wheezing, possible rash 4. Anaphylaxis: DANGEROUS N/V, fever, chills, headache, chest pain Wheezing/stridor, SOB, low BP, cyanosis, anxiety 5. Circulatory Overload Low SP02, tachycardia, high BP, dyspnea ALWAYS STOP THE TRANSFUSION IMMEDIATELY IV NUTRITIONAL SUPPORT TPN – Total Parenteral Nutrition: IV infusion of amino acids, vitamins, electrolytes, and minerals Usually high dextrose concentration Used when GI system cannot be used for feeding LPN can administer ** High dextrose concentration (>10%) can damage veins, usually given via central vein Intralipids - intravenous infusion of fat (fatty acids) essential fatty acid is linoleic acid, needed for proper metabolism. IV lipids are “white” Lipids can be “piggybacked” with TPN IV NUTRITIONAL SUPPORT Increased dextrose level of TPN can lead to increased microbial growth TPN & LIPIDS FLUID COMPARTMENTS IN THE BODY Intracellular : fluid inside cells of the body High concentrations of potassium(K+), phosphate, and magnesium ions 2/3 of body water Extracellular: fluids outside cells Includes interstitial & intravascular compartments Contains high concentrations of sodium, chloride, and bicarbonate ions 1/3 of body water ELECTROLYTES Sodium (Na+) Major extracellular cation Normal 135-145 meq/L Calcium (Ca+) – extracellular cation Chloride (Cl-) Major extracellular anion Bicarbonate (HCO3) – extracellular Magnesium (Mg+) – intracellular cation Potassium (K+) Major intracellular cation Normal 3.5-5.0 Hyperkalemia = serious danger ! IV SOLUTIONS Osmosis: regulates fluid & electrolyte balance = movement of water through SPM from area of lower concentration (solutes) to higher concentration SPM’s = tunica intima, capillary walls, and cell membranes of RBC’s Rate of osmosis – depends on osmotic pressure within tissues/cells Draws water through SPM to more concentrated area IN or OUT of cell IV SOLUTIONS Tonicity = osmolarity or concentration of IV solution Amount of solute in a fluid (dextrose, sodium, etc.) ISOTONIC: concentration same as blood No osmosis No change in solute or water in blood, no shrink or swell Increases amount of ECF Caution w/ fluid volume overload (CHF, renal patients) Uses: replace fluid loss, dehydration, to administer IVPB 0.9% NS, LR, D5%W ISOTONIC SOLUTIONS IV SOLUTIONS HYPERTONIC: Higher concentration of solutes Osmosis pulls water out of cells Fluid shifts from intracellular > intravascular Increased fluid volume in vascular space CAUTION with CHF patients May raise BP May irritate the vein walls Cells shrink Can cause “cellular dehydration”, cellular death Uses: dehydration, electrolyte replacement (severe), expand blood volume D5LR, D5 0.9% NS, D5 0.45% NS, D10%, albumin, dextran HYPERTONIC SOLUTIONS IV SOLUTIONS HYPOTONIC: Lower concentration of solutes Osmosis pushes water into cell Fluid shifts from intravascular > interstitial > intracellular Cell is re-hydrated Cells swell, can possibly “burst” – hemolysis Uses: DKA Can cause intravascular fluid depletion – caution ! May cause hypotension Can increase ICP from quick fluid shift Cerebral edema 0.45% NS, 0.3% NS, 0.25% NS HYPOTONIC SOLUTIONS IV SOLUTIONS ISOTONIC HYPERTONIC HYPOTONIC No osmosis; no shift Osmosis pulls water out of cell; “raisin” Osmosis pushes water into cell; “grape” Uses: dehydration, fluid loss, commonly used for IVPB Uses: dehydration, electrolyte replacement (severe) Uses: DKA, cellular re-hydration, can replace daily NaCl requirement Caution: fluid volume overload (cardiac, renal) Cautions: fluid volume overload, hypertension, vein irritiation Caution: hemolysis of cells, intravascular volume depletion, hypotension, cerebral edema 0.9% NS, LR, D5%W D5 0.9% NS, D5 045% NS, D5 LR, D 10%, Albumin 0.45% NS, 0.3% NS, 0.25 % NS NORMAL SALINE 0.9% NS Isotonic – osmo same as blood NaCl = sodium chloride Non-caloric Standard “flush” solution Standard hydrating solution 0.45% NS (1/2) is hypotonic Lower osmo, less concentrated SALINE Saline - “NS” or “NaCl” .9% (is isotonic) .45% is ½ (is hypotonic) When mixed with D5 may become hypertonic - MUST WATCH FOR FLUID OVERLOAD More fluid in intravascular space DEXTROSE Contains dextrose and free water Available in a variety of concentrations, 5% most common. 5% (D5W) is isotonic. Usually in mixture with NS; D5W alone can cause severe hyponatremia, hypokalemia, and water intoxication. Dilutes body’s normal level of electrolytes NOT 1st choice for hydration Cannot be administered w/ blood hemolysis DEXTROSE Dextrose usually - “D” 5% Also 10%, 20% (usually TPN only – hypertonic) provides calories D5 = 170 cal/liter cannot D10 = 340 cal/liter be used with blood, certain meds Check compatibility can affect blood glucose monitor DM ELECTROLYTE SOLUTIONS Usually isotonic solutions that contain electrolytes in concentrations similar to plasma Lactated Ringer’s most common contains potassium, sodium, chloride, and calcium. Lactate added as buffer Ringers solution = no lactate added short-term use (48 hours) used for fluid loss (vomiting, diarrhea) Electrolyte replacement ELECTROLYTE SOLUTIONS Electrolyte solutions Ringer’s or Lactated Ringer’s (LR) provides electrolytes and hydration short-term monitor ELECTROLYTES no calories cannot use lactate if liver disease present – cannot metabolize ELECTROLYTE SOLUTIONS Plasmalyte Multiple combination Dextrose Sodium chloride Sodium acetate Sodium gluconate Potassium chloride Magnesium Chloride IV THERAPY: ABBREVIATIONS D5W 0.9% NS NS = 0.9% ½ NS = 0.45% (5% dextrose solution ¼ NS = 0.225% D5 w/ 0.9% normal saline) D5 0.45% NS (referred to as D5 ½ NS) D5 0.45% NS @ 50 cc/hr D5 ½ NS @ 50 ml/hr IV THERAPY: ABBREVIATIONS PICC POC TLC HL SL KCL (meq) CaGluc MgSO4 TYPES OF IV INFUSIONS Continuous rate – not interrupted, ordered Intermittent - access for infusions that are only given at specific times IV antibiotics IV push - meds that are given all at once. Not given by LPN’s with exception of saline flush. IV PUSH Meds NOT administered by LPN’s Must be given by RN Delivery is immediate Saline flush (non-med) – 3-10 mL given directly into IV to maintain patency. CAN IVP be given by LPN INTERMITTENT INFUSIONS Not continuous “Piggy-back” meds (IVPB) - intermittent infusions given through continuous primary IV line. ie; IV antibiotics, IV potassium Check compatability between “piggyback” and continuous IV solution Call Pharmacy re: drug-drug interactions Use on-line resources Use IV compatibility chart Incompatible drugs can cause a precipitate CONTINUOUS IV INFUSION Can be large volume (250 to 1000cc) of solution administered continuously correct or maintain fluid and electrolyte balance. Can be a medication being delivered on a continuous basis to maintain a constant serum level – ie; heparin, insulin Needs to be infused with IV pump to avoid error Continuous IV medications cannot be titrated (regulated) by LPN’s – must be done by RN