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UNIT 1 PHARMACOLOGIC PRINCIPLES

Chapter 4 Intravenous Therapy

chapter 4INTRAVENOUS THERAPY

RN PHARMACOLOGY FOR NURSING 59

Overview

Intravenous therapy involves administering fluids via an intravenous catheter for thepurpose of providing medications, supplementing fluid intake, or giving fluid replacement,electrolytes, or nutrients.

Large-volume IV infusions are administered on a continuous basis.

An IV medication infusion may be mixed in a large volume of fluid and given as acontinuous IV infusion or mixed in a small amount of solution and given intermittently.It can also be administered as an IV bolus: The medication is given in a small amount ofsolution, concentrated or diluted, and injected over a short time (1 to 2 min).

Indications and Risk Factors

Advantages and Disadvantages of IV Therapy

ADVANTAGES DISADVANTAGES

Fast absorption and onset of action

Less discomfort after initial insertion

Maintains constant therapeutic bloodlevels

Less irritation to subcutaneous and muscletissue

Circulatory fluid overload is possible if theinfusion is large and/or too rapid.

Immediate absorption leaves no time tocorrect errors.

IV administration can cause irritation to thelining of the vein.

Failure to maintain surgical asepsis canlead to local infection and septicemia.

Description of Procedure

The provider prescribes the type of IV fluid, volume to be infused, and either the rate atwhich the IV fluid should be infused or the total amount of time it should take for thefluid to be infused. The nurse regulates the IV infusion to insure the appropriate amount isadministered. This can be done with an IV pump or manually.

Large-volume IV infusions are administered on a continuous basis such as 0.9% sodiumchloride IV to infuse at 100 mL/hr or 0.9% sodium chloride 1,000 mL to be given IV over 3 hr.

A fluid bolus is a large amount of IV fluid given in a short period of time, usually less than

an hour. It is given to rapidly replace fluid loss that could be caused by dehydration, shock,hemorrhage, burns, or trauma.

A large-gauge angiocatheter (18 gauge or larger) is needed to maintain the rapid ratenecessary to give a fluid bolus to an adult.

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60 RN PHARMACOLOGY FOR NURSING

IV medication infusions may be administered in the following ways:

The medication may be mixed in a large volume of fluid (500 to 1,000 mL) and givenas continuous IV infusion. Potassium chloride may be administered this way.

The medication can be found in premixed solution bags or can be added to the IV bagby the pharmacist or the nurse.

Volume-controlled infusions

Some medications, such as antibiotics, are given intermittently in a small amountof solution (25 to 250 mL) through a continuous IV system, or with saline orheparin lock systems.

The medications infuse for short periods of time and are given on a scheduledbasis.

These infusions can be administered by a piggyback IV bag or bottle or tandemsetup, volume-control administration set, or mini-infusion pump.

IV bolus dose administration

The medications are typically in small amounts of solution, concentrated ordiluted, that can be injected over a short time (1 to 2 min) in emergent and

nonemergent situations. Some medications, such as pain medications, are given directly into the

peripheral IV or access port to achieve an immediate medication level in thebloodstream.

Make sure medications are prepared according to recommended concentrationand administered according to the safe recommended rate.

Use extreme caution and observe for signs and symptoms of complications

(redness, burning, or increasing pain). Types of IV Access

Intravenous access can be via a peripheral or central vein (central venous accessdevice).

Central venous access devices can be peripherally inserted or directly inserted into thejugular or subclavian vein.

Guidelines for Safe IV Medication Administration

Certain medications, such as potassium chloride, can cause serious adverse reactions andshould be infused on an IV pump for accurate dosage control and never given by IV bolus.

Add medication to a new IV fluid container, not to an IV container that is already hanging.

Never administer IV medication through tubing that is infusing blood, blood products, orparenteral nutritional solutions.

Verify compatibility of medications before infusing a medication through tubing that isinfusing another medication.

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Needlestick Prevention

Be familiar with IV insertion equipment.

Avoid using needles when needleless systems are available. Use protective safety devices when available.

Dispose of needles immediately in designated puncture-resistant receptacles.

Do not break, bend, or recap needles.

Special Considerations

Older adult clients, clients taking anticoagulants, or clients with fragile veins:

Avoid tourniquets.

Use a blood pressure cuff instead.

Do not slap the extremity to visualize veins.

Edema in extremities:

Apply digital pressure over the selected vein to displace edema.

Apply pressure with an alcohol pad. Cannulation must be quick.

Obese clients may require the use of anatomical landmarks to find veins.

Preventing IV Infections

Use standard precautions.

Change IV sites according to facility/agency policy (usually 72 hr).

Remove catheters as soon as they are no longer clinically indicated.

Change catheter if any break in surgical aseptic technique is suspected, such asemergency insertions.

Use sterile needle/catheter for each insertion attempt.

Avoid writing on IV bags with pens or markers, because ink could contaminate thesolution.

Change tubing immediately if contamination is known or suspected.

Fluids should not hang more than 24 hr unless it is a closed system (pressure bags forhemodynamic monitoring).

Wipe all ports with alcohol or an antiseptic swab before connecting IV lines orinserting a syringe to prevent the introduction of micro-organisms into the system.

Never disconnect tubing for convenience or to position the client.

Do not allow ports to remain exposed to air.

Perform hand hygiene before and after handling the IV system.

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Preprocedure

Equipment

Correct size catheter: 16 gauge for trauma clients, rapid fluid volume

18 gauge for surgical clients, rapid blood administration

22 to 24 gauge all other clients (adults)

Correct tubing

Infusion pump, if indicated

Clean gloves

Scissors or electric shaver for hair removal

Nursing Actions

Check the providers order (e.g., solution, rate).

Assess the client for allergies to products used in initiating and maintaining IV therapy(latex, tape, iodine).

Follow the Six Rights of medication administration (including compatibilities of all IVsolutions).

Perform hand hygiene.

Examine the solution to be infused for clarity, leaks, and expiration date.

Prime tubing as indicated.

Don clean gloves before insertion. Assess extremities and veins. If hair removal is needed, clip it with scissors or shave it

with an electric shaver.

Client Education

Identify the client and explain the procedure.

Place the client in a comfortable position.

Intraprocedure

Nursing Actions

Use a clean tourniquet or blood pressure cuff (especially for older adults), 4 to 6 inchesabove the selected site to compress only venous blood flow.

Select vein by choosing:

Distal veins first on the nondominant hand

A site that is not painful or bruised and will not interfere with activity

A vein that is resilient with a soft, bouncy feeling

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Additional methods to enhance venous access include:

Gravity, fist clenching, friction with alcohol, and heat

Percussion with gentle tapping

Avoid:

Varicosed veins that are permanently dilated and tortuous

Veins in the inner wrist with bifurcations, in flexion areas, near valves(appearing as bumps), in lower extremities, and in the antecubital fossa(except for emergency access)

Veins that are sclerosed or hard

Veins in an extremity with impaired sensitivity (scar tissue, paralysis),lymph nodes removed, recent infiltration, or arteriovenous fistula/graft

Untie the tourniquet or deflate the BP cuff.

Cleanse the area at the site using friction in a circular motion from the middle andoutward with alcohol, iodine preparation, or chlorhexidine. Allow to air dry for 1 to 2min.

Remove cover from catheter, grasp plastic hub, and examine device for smooth edges.

Retie the tourniquet, or reinflate the BP cuff.

Anchor the vein below the site of insertion.

Pull skin taut and hold it.

Warn the client of a sharp, quick stick.

Insert the catheter into the skin with bevel up at an angle of 10 to 30 using steady,

smooth motion. Advance the catheter through the skin and into the vein, maintaining a 10 to 30

angle. Flashback of blood will confirm placement in vein.

Lower the hub of the catheter close to the skin to prepare for threading into the vein,approximately in.

Loosen the needle from the catheter and pull back slightly on the needle so that it nolonger extends past the tip of the catheter.

Use the thumb and index finger to advance the catheter into the vein until the hubrests against the insertion site.

Stabilize the IV catheter with one hand and release the tourniquet with the other.

Apply pressure approximately 1 in (3 cm) above the insertion site with the middlefinger and stabilize the catheter with the index finger.

Remove the needle and activate the safety device.

Maintain pressure above the IV site and connect the appropriate equipment to thehub of the IV catheter.

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Apply dressing per facility protocol. The dressing is usually left in place until thecatheter is removed, unless it becomes damp, loose, or soiled.

Avoid encircling the entire extremity with tape, and taping under the sterile dressing.

If continuous IV infusion is prescribed, regulate IV infusion rate according to theproviders order.

Dispose of used equipment properly.

Document in chart:

Date and time of insertion

Insertion site and appearance

Catheter size

Type of dressing

IV fluid and rate (if applicable)

Number, locations, and conditions of site-attempted cannulations

Client response

Sample documentation: 1/1/2010, 1635, #22-gauge IV catheter inserted into leftwrist cephalic vein (1 attempt) with sterile occlusive dressing applied. IV D5LR

infusing at 100 mL/hr per infusion pump without redness or edema at the site.Tolerated without complications. J. Doe, RN

Postprocedure

Nursing Actions

Maintaining patency of IV access Do not stop a continuous infusion or allow blood to back up into the catheter for

any length of time. Clots can form at the tip of the needle or catheter and can belodged against the vein wall, blocking the flow of fluid.

Instruct the client not to manipulate flow rate device, change settings on IVpump, or lie on the tubing.

Make sure the IV insertion site dressing is not too tight.

Flush intermittent IV catheters with appropriate solution after every medicationadministration or every 8 to 12 hr when not in use.

Monitor site and infusion rate at least every hour.

Discontinuing IV therapy

Check order/prepare equipment.

Perform hand hygiene.

Don clean gloves.

Remove tape and dressing, stabilizing IV.

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Clamp IV tubing.

Apply sterile gauze pad over the site without putting pressure on the vein. Do notuse alcohol.

Using the other hand, withdraw the catheter by pulling straight back from the site.

Elevate and apply pressure for 2 min.

Assess the site.

Apply tape over gauze.

Use pressure dressing, if needed.

Assess the catheter for intactness.

Document.

Complications

Complications require notification of the provider and complete documentation. All IVsshould be restarted with new tubing and catheters.

COMPLICATIONS FINDINGS TREATMENT PREVENTION

Infiltration Pallor, local swellingat the site, decreasedskin temperaturearound the site, dampdressing, slowedinfusion

Stop the infusion andremove the catheter.

Elevate the extremity.

Encourage activerange of motion.

Apply warmcompresses three to

four times/day. Restart the infusionproximal to thesite or in anotherextremity.

Carefully select siteand catheter.

Secure the catheter.

Phlebitis/thrombophlebitis

Edema; throbbing,burning, or pain at thesite; increased skin

temperature; erythema;a red line up the armwith a palpable bandat the vein site; slowedinfusion

Promptly discontinuethe infusion andremove the catheter.

Elevate the extremity. Apply warm

compresses three tofour times/day.

Restart the infusionproximal to thesite or in anotherextremity.

Culture the site andcatheter if drainage ispresent.

Rotate sites at leastevery 72 hr.

Avoid the lower

extremities. Use hand hygiene.

Use surgical aseptictechnique.

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COMPLICATIONS FINDINGS TREATMENT PREVENTION

Hematoma Ecchymosis at site Do not apply alcohol.

Apply pressure after

IV catheter removal. Use warm compress

and elevation afterbleeding stops.

Minimize tourniquettime.

Remove thetourniquet beforestarting IV infusion.

Maintain pressureafter IV catheterremoval.

Cellulitis Pain; warmth; edema;induration; redstreaking; fever, chills,and malaise

Promptly discontinuethe infusion andremove catheter.

Elevate the extremity.

Apply warmcompresses three tofour times/day.

Culture the site andcannula if drainage is

present. Administer:

Antibiotics

Analgesics

Antipyretics

Rotate sites at leastevery 72 hr.

Avoid the lowerextremities.

Use hand hygiene.

Use surgical aseptictechnique.

Fluid overload Distended neck veins,increased bloodpressure, tachycardia,shortness of breath,crackles in the lungs,edema

Stop infusion.

Raise the head of the

bed. Assess vital signs.

Adjust rate asprescribed.

Administer diuretics ifprescribed.

Use an infusionpump.

Monitor I&O.

Catheter embolus Missing catheter tipwhen discontinued;

severe pain at thesite with migration,or no symptoms if nomigration

Place the tourniquethigh on the extremity

to limit venous flow. Prepare for removal

under x-ray or viasurgery.

Save the catheterafter removal todetermine the cause.

Do not reinsertthe stylet into the

catheter.

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CHAPTER 4: INTRAVENOUS THERAPY

Application Exercises

1. When assessing the IV site for phlebitis, the nurse should look for which of the following findings?(Select all that apply.)

Red line on affected extremity

An increased rate of infusion

Palpable, hard mass or band above insertion site

Cool, pale skin

Pain at site

2. Which of the following techniques will minimize the risk of catheter embolism?

A. Use hand hygiene before and after IV insertion.

B. Rotate the IV sites at least every 72 hr.

C. Administer anticoagulants.

D. Once in the vein, never put the stylet back through the catheter.

3. The nurse checks for patency of an IV saline lock by

A. assessing the site for redness.

B. flushing the IV saline lock with 0.9% normal saline.

C. asking the client if the site is painful.

D. checking the date of insertion.

4. A nurse is caring for a client receiving dextrose 5% in water IV at 100 mL/hr. Which of the followingmay indicate fluid overload? (Select all that apply)

Decreased blood pressure

Bradycardia

Shortness of breath

Crackles heard in lungs

Distended neck veins.

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CHAPTER 4: INTRAVENOUS THERAPY

Application Exercises Answer Key

1. When assessing the IV site for phlebitis, the nurse should look for which of the following findings?(Select all that apply.)

X Red line on affected extremity

An increased rate of infusion

X Palpable, hard mass or band above insertion site

Cool, pale skin

X Pain at site

A red line over the vein of the affected extremity; a palpable, hardened band above theinsertion site; and pain at the site are signs and symptoms of phlebitis. The rate of theinfusion slows down with phlebitis. The skin is warm and red.

NCLEXConnection: Pharmacological and Parenteral Therapies, Parenteral/IntravenousTherapy

2. Which of the following techniques will minimize the risk of catheter embolism?

A. Use hand hygiene before and after IV insertion.

B. Rotate the IV sites at least every 72 hr.

C. Administer anticoagulants.

D. Once in the vein, never put the stylet back through the catheter.

Reinsertion of the stylet can damage the catheter, causing a small portion to break off and

enter the venous system. Hand hygiene will prevent infection. Rotating IV sites will preventphlebitis and thrombosis. A catheter embolism is not related to blood clotting.

NCLEX Connection: Pharmacological and Parenteral Therapies, Parenteral/IntravenousTherapy

3. The nurse checks for patency of an IV saline lock by

A. assessing the site for redness.

B. flushing the IV saline lock with 0.9% normal saline.

C. asking the client if the site is painful.

D. checking the date of insertion.

Free flow of solution through the IV indicates patency. Absence of redness and reportsof pain are not positive indicators of IV patency. How long an IV has been in will notdetermine if it is still patent.

NCLEX

Connection: Pharmacological and Parenteral Therapies, Parenteral/IntravenousTherapy

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4. A nurse is caring for a client receiving dextrose 5% in water IV at 100 mL/hr. Which of the followingmay indicate fluid overload? (Select all that apply)

Decreased blood pressure

Bradycardia X Shortness of breath

X Crackles heard in lungs

X Distended neck veins.

Findings of fluid overload include increased blood pressure, tachycardia, shortness of breath,crackles heard in the lungs, and distended neck veins.

NCLEX

Connection: Pharmacological and Parenteral Therapies, Parenteral/IntravenousTherapy

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