Download LPN-C - Faculty Sites

Unit Six
Intravenous Interventions
Objective One
Explain the legal
implications of
intravenous therapy
The Five Rights of Medication
Administration
Right patient
Right medication
Right dose
Right route
Right time
3
The Three Checks of Medication
Administration
1.
2.
3.
Read the label of the medication as it is
removed from the shelf, unit dose cart,
refrigerator, or dispensing system
Read the label of the medication when
comparing it with the MAR
Read the medication label again before
administering the medication to the
patient
4
 LOOK at the label for verification of the
medication name, dosage, route, and
expiration date
 CHECK the medication itself, NOT just the
pharmacy label
 Be overly cautious with regards to dose, proper
dilution, and administration rate
 Watch decimal points
 Be aware of the unit
 Is the medication dispensed in mcg or mg?
 What is ordered in comparison?
5
Risk Management for
Infusion Therapy
 Know venous anatomy and physiology
 Know appropriate vein selection
 Use infusion equip. appropriately
 Clarify unclear orders
 Refuse to follow orders that you know are not within
the scope of safe nursing practice
 Know the infusion indications, side effects, and
special considerations for IV medications
 Administer medications and/or infusions at the
proper rate and within the ordered intervals
6
Risk Management (cont’d)
 Assess the patient and monitor the IV site for
complications
 Use proper IV care and maintenance
 Notify physician promptly of IV complications
 Know and give appropriate treatments for
complications
 Provide proper patient education
 Document all aspects of IV therapy, including patient
education
 Follow your institution’s policy/procedures
 Abide by Nebraska’s Nurse Practice Act and standards
of IV practice
7
Objective Two
Apply the concepts of standard
precautions in infusion therapy
Updated CDC Guidelines for Preventing
Infusion Device-Related Infections
 Prepping the skin
 Use 2% chlorhexidine, which is more effective in lowering
catheter-related bloodstream infection rates than 10%
povidone-iodine and 70% isopropyl alcohol
 Chlorhexidine persists on the skin longer, which is important
because it kills organisms that could repopulate the insertion
site from deeper skin layers
 Use “back and forth” scrubbing motion rather than outwardly
radiating concentric circles
 Allow solution to dry
 It has not been determined if chlorhexidine should be used on
infants less than 2 months of age
9
 Peripheral IV site recommended for only 72 to 96 hours to
prevent phlebitis
 Maintain peripheral IV in place in pediatric patients as long
as needed
 Ensure site is free from complications
 If catheter was placed in an emergency situation, replace
within 48 hours
 Follow hand antisepsis protocols (i.e. handwashing and
alcohol-based hand rubs)
 Use clean gloves to insert a peripheral catheter; do not
touch access site after skin prep has been applied
 Observe hand hygiene before and after palpating catheter
insertion sites; before and after inserting an IV; and before
and after replacing, accessing, repairing, or dressing an IV
site
10
Occupational HIV Exposure
 Preventing exposures to blood and body fluids is the primary
means of preventing occupationally acquired human
immunodeficiency virus (HIV) infection
 Universal precautions
 Handwashing
 Proper use of safety equipment
 Follow institutional policy/procedures
 Recommendations for post-exposure prophylaxis (PEP)
include urgent medical treatment to ensure timely initiation
 Prompt reporting of exposure
 4-week regimen of two antiretroviral medications to prevent
seroconversion of HIV infection in health care workers
 Counseling
11
Objective Three
Discuss the risks,
complications, and adverse
reactions of intravenous
therapy
Extravasation
Phlebitis
Hematoma
Infiltration
*Infiltration refers to the inadvertent administration of
nonvesicant solution into the surrounding tissue
 Causes of infiltration include dislodgement of the cannula
from the vein, puncture of the vein wall during venipuncture,
friction of the catheter against the vein wall, use of a high
pressure infusion device, and irritating infusate that weakens
the veins
 Signs and symptoms of infiltration—




Skin is taut and/or cool to the touch
Dependent edema
Absence of blood backflow or pinkish blood return
Slowing of the infusion rate
 Complications of infiltration may include ulceration (after
days/weeks) and compartment syndrome
17
*Infiltration (cont’d):
 Prevention of infiltration involves comparing extremities,
assessing if infusion stops running when pressure applied 3
inches above catheter site
 Treatment of infiltration—



Infuse antidote through the IV if applicable, then remove the IV
Apply warm compresses for antineoplastic agents, and cool
compresses for most other medications
Elevate the extremity if this promotes comfort for the patient
*Extravasation is the inadvertent administration of vesicant
medication or solution into the surrounding tissue
 Requires an incident report
 Determine treatment BEFORE removing IV
 Do not apply excessive pressure to the site
18
*Thrombosis occurs when blood flow through the vein is
obstructed by a local thrombus
 S/S include earache/jaw pain, edema/redness at insertion
site, tachycardia/tachypnea, malaise, unilateral arm/neck
pain, absence of pulse distal to the obstruction, digital
coldness/cyanosis/necrosis
 Treatment of thrombosis involves discontinuing and
restarting IV at a different site (never flush with force to
remove an occlusion)
*Phlebitis = inflammation of the vein
 S/S include localized redness/swelling, warmth/tenderness,
palpable “cord” along the vein, sluggish infusion rate,
increased temperature
 Prevention includes using smallest cannula appropriate,
19
stabilizing the catheter, and correct venipuncture technique
*Septicemia = a febrile disease caused by microorganisms in
the circulatory system; septicemia is a major complication
that occurs from cannula or infusate contamination
 S/S include fever, flushing, profuse diaphoresis, altered
mental status, nausea/vomiting, abdominal pain,
tachycardia, hypotension
 Treatment includes culturing IV catheter per order/agency
protocol, administering oxygen if needed, antimicrobial
therapy, IV fluids
 Prevention of septicemia includes good handwashing,
appropriate infusion site dressing, rotation of IV sites
*Pulmonary embolism is associated with IV-related thrombus
 S/S = shortness of breath, cyanosis, chest pain, tachypnea
 Prevent by avoiding venipuncture in lower extremities and not
applying pressure to regain IV patency
20
*Pulmonary embolism (cont’d)–
 Treated by positioning patient in left-sided trendelenburg,
administer oxygen, and transfer to ICU
*Air embolism is most frequent in central lines, and results
from small amounts of air in the circulatory system
 Causes include incorrect IV insertion, excessive catheter
manipulation, and loose connections in the IV tubing


Accumulation of small bubbles can block pulmonary capillaries
Blockage may be fatal due to sudden vascular collapse
 Symptoms include cyanosis, hypotension, ↑ venous pressure,
and rapid loss of consciousness
 Treatment includes immediately placing client in left-sided
trendelenburg so that air becomes trapped in the right atrium
and is prevented from entering the pulmonary artery;
administer oxygen; notify the physician ASAP
21
Objective Four
Identify central and peripherally
placed vascular access devices
utilized for various patient
needs
Central Lines
PICC Line
POWER PICC
Huber needles for port access
Objective Five
Identify the pharmacological
principles and administration
of intravenous medications
Vein Selection
 Do not use veins in ambulatory lower extremities
 Never access an arteriovenous fistula, graft, or shunt
 Do not use veins in an extremity that is impaired as a
result of a CVA
 Do not use veins on the side of the body with radical
mastectomy with lymph node dissection/stripping
 Bypass veins in an extremity that has undergone
reconstructive or orthopedic surgery
 Do not use veins in an area with a recent infiltration
 Do not use veins at or near 3rd degree burns
 Avoid veins in an extremity that is partially amputated
 Do not use veins that are irritated or sclerosed from
previous use
29
Tourniquet Application
 Applying a tourniquet assists in venous distention
 Apply tightly enough that venous blood flow is suppressed,
but not so tight that it obstructs arterial flow

Should be able to palpate pulse distal to the tourniquet
 Do not leave a tourniquet in place longer than four to six
minutes

Tourniquet paralysis from injury to a nerve can occur if the
tourniquet is applied too tightly or left for too long a period
 Contraindicated in some patients
http://www.youtube.com/watch?v=wul7KsoRdnQ
30
Cannula Selection
*Winged needles, referred to as butterflies, have one or two
“wings” that are held upright during insertion to facilitate
movement into the vein; once the needle is in the vein, the
wings are taped to the skin to secure the device
*Peripheral venous access catheters are the most commonly
used IV device
 Two-part flexible cannula in tandem with a rigid needle or
stylet, which is used to puncture and insert the catheter into
the vein
 Connects with a clear chamber that allows for visualization of
blood return, indicates successful venipuncture, and
facilitates removal of the needle
 Catheter is radiopaque so that it can be easily detected by
radiology in case of embolus
35
IV Administration Sets
 The IV administration set determines the rate at which fluid
can be delivered to the patient (i.e. the drop factor)
 Extra large (macrobore) tubings are used in emergency
surgical and trauma situations for rapid infusion of large
volumes of blood or fluid
 Extra small (microbore) tubings are used for the delivery of
small amounts of precisely controlled fluid or medication for
special volume restriction (neonatal care, epidural infusions)
 Primary administration sets carry fluid directly to the patient
through one tube
 Secondary administration sets (also referred to as piggyback
sets) are used to deliver continuous or intermittent doses of
fluid or medication
http://www.youtube.com/watch?v=tfQbbCx6xFU&feature=related 38
Objective Six
Demonstrate peripheral
venipuncture and
discontinuation of IV push
(*Lab Practice)
Objective Seven
Demonstrate calculation of
IV drip rates and IV dosages
 The IV flow rate is the speed at which the IV fluid
infuses into the body
 Often measured in drops per minute (abbreviated “gtt/min”)
 Factors affecting the flow rate include:
 The amount of fluid to be infused
 The time over which it is to be infused
 The size of the tubing
 The number of drops required to deliver 1 ml of fluid
varies with the type of IV administration set (tubing)
used; the size of the tubing is called the drop factor
 There are 2 types of IV administration sets:
 Macrodrip = 10, 15, or 20 gtt/ml
 Microdrip = 60 gtt/ml
 In calculating the flow rate, ratio/proportion cannot
be used because there are more than two
components to calculate
 The dosage calculation formula cannot be used
because a dosage is not being calculated
 When calculating the flow rate, all rates should be
rounded to the nearest whole number
 IV Flow Rate Formula:
volume of infusion (in mL) x drop factor = Flow rate
time of infusion (in minutes)
(in gtt/min)
*Note that time must be converted to minutes, and
that the drop factor is in gtt/mL
IV Calculation Examples
Administer D5 ½ NS at 30 mL/h. The drop factor is a
microdrip.
30mL x 60gtt/mL = 30gtt/min
60min
An IV medication in 60 mL of 0.9% NS is to be
administered in 45 minutes. The drop factor is a
microdrip.
60mL x 60gtt/mL = 80gtt/min
45min
Examples (cont’d)
Administer 3,000 mL D5 ½ NS in 24 hours. The drop
factor is 10 gtt/mL.
3000mL x 10gtt/mL = 21gtt/min
1440min
Administer Lactated Ringer’s at 125 ml/h. The drop
factor is 15 gtt/mL.
125mL x 15gtt/mL = 31gtt/min
60min
Examples (cont’d)
1,000 mL of Lactated Ringer’s solution is to infuse in
16 hours. The drop factor is 15 gtt/mL.
1000mL x 15gtt/mL = 16gtt/min
960min
Infuse 2,000 mL D5W in 12 hours. The drop factor is
15 gtt/mL.
2000mL x 15gtt/mL = 42gtt/min
720min
Electronic Flow Rate
 When using an electronic infusion device (IV pump),
the flow rate is calculated in milliliters per hour (mL/h)
 To find mL/h, you must divide the total milliliters by
the total hours
 You would then round your final answer to the nearest
whole
 Examples - 1000 mL in 8 hours = 1000/8 = 125mL/h
 500 mL in 24 hours = 500/24 = 21mL/h
 If an order is given without total milliliters, this
becomes a dose calculation; you would use ratioproportion, dimensional analysis, or the Formula
Recalculating the Flow Rate
 Sometimes the IV infusion rate changes due to a change in
the patient’s position
 If you notice that the flow rate needs to be adjusted, assess
the client and determine the percentage of change needed
to correct the infusion
 Please note that you can adjust the infusion flow rate by no
more than 25% without consulting the physician or
practitioner
 In order to determine the percentage of increase or
decrease of the flow rate:
 Determine the actual change in the flow rate
 Divide by the original flow rate
 Multiply by 100
Examples of IV Recalculation
Original infusion order : 1000mL D5W IV to infuse
over the next 10 hours.
Infusion start time: 1300 hours. Drop factor = 10.
Hourly rate = 100mL/h. Flow rate = 17gtt/min.
At 1430 hours, the infusate level is at 900mL. 150mL
should have already infused, leaving 850mL
remaining to infuse over the next 8 ½ hours.
The IV would be recalculated as follows:
900mL = 106mL/h – 100mL/h = 6mL/h
8.5h
6mL/h = 0.06 x 100 = 6% increase
100mL/h
Recalculation Examples (cont’d)
Original infusion order : 1000mL D5W IV to infuse over the
next 8 hours.
Infusion start time: 0900 hours. Drop factor = 15. Hourly
rate = 125mL/h. Flow rate = 31gtt/min.
At 1200 hours, the infusate level is at 850mL. 375mL
should have already infused, leaving 625mL remaining to
infuse over the next 5 hours.
The IV would be recalculated as follows:
850mL = 170mL/h – 125mL/h = 45mL/h
5h
45mL/h = 0.36 x 100 = 36% increase
125mL/h
Titrating Medications
 Titrating means to adjust the medication until it brings
about the desired effect
 Always start with the low end of “safe” and increase
dosage from there
 Follow institutional protocol for titrating medications
 Titrated medications are calculated in the same way as
non-titrated drugs
 An example of a titration order would be:
 A client weighing 50 kg is to receive a Dobutrex solution of
250 mg in 500 mL D5W ordered to titrate between 2.5–5
mcg/kg/min
Titration Calculation Examples
In the previous order, the initial dose would be set at the
low end of safe. Therefore, the client will receive
2.5mcg/kg/min of the ordered medication, and will receive
no more than 5mcg/kg/min.
The client’s weight is 50kg.
50 x 2.5 = 125mcg/min
safe range of drug
50 x 5 = 250mcg/min
Per IV pump, the client would receive the minimum dosage
of 7500mcg/h, or 7.5mg/h:
250mg = 500mL = 250 X mg/mL = 7.5mg(500mL)
7.5mg
X mL
X = 3750mg/mL = 15mL (initial dose is 15mL/h)
250mg
Objective Eight
Demonstrate safe
administration of medications
and IV piggyback medications
(*Lab Practice)