Intravenous Therapy

Intravenous Therapy

A. Purpose and uses

1. Used to sustain clients who are unable to take  substances orally
2. Replaces water, electrolytes, and nutrients more rapidly than oral administration
3. Provides immediate access to the vascular system for the rapid delivery of specific solutions without the time required for gastrointestinal tract
absorption

4. Provides a vascular route for the administrationof medication or blood components

B. Types of solutions 

1. Isotonic solutions

a. Have the same osmolality as body fluids
b. Increase extracellular fluid volume
c. Do not enter the cells because no osmotic force exists to shift the fluids

2. Hypotonic solutions

a. Are more dilute solutions and have a lower osmolality than body fluids
b. Cause the movement of water into cells by osmosis
c. Should be administered slowly to prevent cellular edema

3. Hypertonic solutions

a. Are more concentrated solutions and have ahigher osmolality than body fluids
b. Cause movement of water from cells into the extracellular fluid by osmosis

4. Colloids
a. Also called plasma expanders
b. Pull fluid from the interstitial compartment into the vascular compartment
c. Used to increase the vascular volume rapidly, such as in hemorrhage or severe hypovolemia

II. Intravenous Devices

A. IV cannulas

1. Butterfly sets

a. The set is a wing-tip needle with a metal cannula, plastic or rubber wings, and a plastic catheter or hub.
b. The needle is 0.5 to 1.5 inches in length, with needle gauge sizes from 16 to 26.
c. Infiltration ismore common with these devices.
d. The butterfly infusion set is used commonly in children and older clients, whose veins are likely to be small or fragile.

2. Plastic cannulas

a. Plastic cannulas may be an over-the-needle device or an in-needle catheter and are used primarily for short-term therapy.
b. Theover-the-needledeviceispreferred for rapid infusion and ismore comfortable for the client.
c. The in-needle catheter can cause catheter embolism if the tip of the cannula breaks

B. IV gauges

1. The gauge refers to the diameter of the lumen ofthe needle or cannula.
2. The smaller the gauge number, the larger thediameter of the lumen; the larger the gauge number, the smaller the 144 diameter of the lumen.

3. The size of the gauge used depends on the solution to be administered and the diameter of the available vein.
4. Large-diameter lumens (smaller gauge numbers) allow a higher fluid rate than smaller diameter lumens and allow the administration of higher concentrations of solutions.
5. For rapid emergency fluid administration, blood products, or anesthetics, preoperative and postoperative clients, large-diameter lumen needles or cannulas are used, such as an 18- or 19-gauge lumen or cannula.
6. For peripheral fat emulsion (lipids) infusions, a 20- or 21-gauge lumen or cannula is used.
7. For standard IV fluid and clear liquid IV medications, a 22- or 24-gauge lumen or cannula is used.
8. If the client has very small veins, a 24- to 25-gauge lumen or cannula is used.

C. IV containers
1. Container may be glass or plastic.
2. Squeeze the plastic bag to ensure intactness and assess the glass bottle for anycracks before hanging.
3. Reconstitute any medications per agency protocol and pharmacy instruction.

D. IV tubing 

1. IVtubing contains a spike end for the bag or bottle, drip chamber, roller clamp, Y site, and adapter end for attachment to the cannula or
needle that is inserted into the client’s vein.

2. Shorter, secondary tubing is used for piggyback solutions, connecting them to the injection sites nearest to the drip chamber 
3. Special tubing is used for medication that absorbs into plastic (check specific medication administration guidelines when administering IV medications).4. Vented and nonvented tubing are available.

a. A vent allows air to enter the IV container as the fluid leaves.
b. A vented adapter can be used to add a vent to a nonvented IV tubing system.

c. Use nonvented tubing for flexible containers.

d. Use vented tubing for glass or rigid plastic containers to allow air to enter and displace the fluid as it leaves; fluid will not flow from a rigid IV container unless it is vented.

E. Drip chambers 

1. Macrodrip chamber

a. The chamber is used if the solution is thick oris to be infused rapidly.
b. The drop factor varies from 10 to 20 drops (gtt)/mL, depending on the manufacturer.
c. Read the tubing package to determine how many drops per milliliter are delivered (drop factor)

2. Microdrip chamber

a. Normally, the chamber has a short vertical metal piece (stylet) where the drop forms.
b. The chamber delivers about 60 gtt/mL.
c. Read the tubing package to determine the drop factor (gtt/mL).
d. Microdrip chambers are used if fluid will be infused at a slow rate (less than 50 mL/hour) or if the solution contains potent medicationthat needs to be titrated, such as in a critical care setting or in pediatric clients.

F. Filters

1. Filters provide protection by preventing particles from entering the client’s veins.
2. They are used in IV lines to trap small particles such as undissolved substances, or medications that have precipitated in solution.
3. Check the agencypolicyregardingthe use of filters.
4. A 0.22-μm filter is used for most solutions; a 1.2- μm filter isused for solutionscontaininglipidsor albumin; and a special filter is used for blood
components.
5. Change filters every 24 to 72 hours (depending on agency policy) to prevent bacterial growth.
G. Needleless infusion devices

1. Needleless infusion devices include recessed needles, plastic cannulas, and 1-way valves; these systems decrease the exposure to contaminated needles.
2. Do not administer parenteral nutrition or blood products through a 1-way valve.

H. Intermittent infusion devices

1. Intermittent infusion devices are used when intravascular accessibility is desired for intermittent administration ofmedications by IVpush or IV piggyback.

2. Patency is maintained by periodic flushing with normal saline solution (sodium chloride and normal saline are interchangeable names).
3. Depending on agency policy, when administering medication, flush with 1 to 2 mL of normal saline to confirm placement of the IV cannula;
administer the prescribed medication and then flush the cannula again with 1 to 2 mLof normal saline to maintain patency.

I. Electronic IV infusion devices

1. IV infusion pumps control the amount of fluid infusing and should be used with central venous lines, arterial lines, solutions containing medication, and parenteral nutrition infusions. Most agencies use IV pumps for the infusion of any IV solution.
2. A syringe pump is used when a small volume of medication is administered; the syringe that contains the medication and solution fits into a
pump and is set to deliver the medication at a controlled rate.
3. Patient-controlled analgesia (PCA)

a. A device that allows the client to selfadminister IV medication, such as an analgesic; the client can administer doses at set intervals and the pump can be set to lock out doses that are not within the preset time frame to prevent overdose.
b. The PCA regimen may include a basal rate of infusion alongwith the demand dosing, basalrate infusion alone, or demand dosing alone.
c. A bolus dose can be given prior to any of the settings and should be set based on the HCP’s prescription.
d. PCAs are always kept locked and setup requires the witness of another registered nurse (RN).

III. Latex Allergy
A. Assess the client for an allergy to latex.
B. IV supplies, including IV catheters, IV tubing, IV ports (particularly IV rubber injection ports), rubber stoppers on multidose vials, and adhesive tape, may contain latex.
C. Latex-safe IVsupplies need to be used for clientswith a latex allergy; most agencies carry these now, but this still needs to be checked.

IV. Selection of a Peripheral IV Site

A. Veins in the hand, forearm, and antecubital fossa are  suitable sites 
B. Veins in the lower extremities (legs and feet) are not suitable for an adult client because ofthe risk of thrombus formation and the possible poolingofmedication in areas of decreased venous return 
C. Veins in the scalp and feet may be suitable sites for infants.

D. Assess the veins of both arms closely before selecting a site.

E. Start the IV infusion distally to provide the option of proceeding up the extremity if the vein is ruptured or infiltration occurs; if infiltration occurs from the antecubital vein, the lower veins in the same arm usually should not be used for further puncture sites.
F. Determine the client’s dominant side, and select the opposite side for a venipuncture site.
G. Bending the elbow on the arm with an IV may easily obstruct the flow of solution, causing infiltration that could lead to thrombophlebitis.
H. Avoid checking the blood pressure on the arm receiving the IV infusion if possible.
I. Do not place restraints over the venipuncture site.
J. Use an armboard as needed when the venipuncture site is located in an area of flexion

V. Initiation and Administration of IV Solutions

A. ChecktheIVsolution against theHCP’sprescription for the type, amount, percentage of solution, and rate of flow; follow the 6 rights formedication administration.
B. Assess the health status and medical disorders of the client and identify client conditions that contraindicate
use of a particular IV solution or IV equipment, such as an allergy to cleansing solution, adhesive materials, or latex. Check compatibility of IV solutions as appropriate.
C. Check client’s identification and explain the procedure to the client; assess client’s previous experience with IV therapy and preference for insertion site.
D. Wash hands thoroughly before inserting an IV line and before working with an IV line; wear gloves.
E. Use sterile technique when inserting an IV line and when changing the dressing over the IV site.
F. Change the venipuncture site every 72 to 96 hours in accordance with Centers for Disease Control and Prevention (CDC) recommendations and agency policy.
G. Change the IV dressing when the dressing is wet or
contaminated, or as specified by the agency policy.
H. Change the IV tubing every 96 hours in accordance with CDC recommendations and agency policy or with change of venipuncture site.

I. Do not let an IV bag or bottle of solution hang for more than 24 hours to diminish the potential for bacterial contamination and possibly sepsis.
J. Do not allow the IV tubing to touch the floor to prevent potential bacterial contamination.

VI. Precautions for IV Lines

A. On insertion, an IV line can cause initial pain and discomfort for the client.
B. An IV puncture provides a route of entry for microorganisms into the body.
C. Medications administered by the IV route enter the
blood immediately, and any adverse reactions or allergic responses can occur immediately.
D. Fluid (circulatory) overload or electrolyte imbalances can occur from excessive or too rapid infusion of IV fluids.
E. Incompatibilities between certain solutions andmedications can occur

VII. Complications 

A. Air embolism

1. Description: A bolus of air enters the vein through an inadequately primed IV line, from a loose connection, during tubing change, or during removal of the IV.
2. Prevention and interventions

a. Prime tubing with fluid before use, and monitor for any air bubbles in the tubing.
b. Secure all connections.
c. Replace the IV fluid before the bag or bottle is empty.
d. Monitor for signs of air embolism; if suspected, clamp the tubing, turn the client on the left side with the head of the bed lowered (Trendelenburg position) to trap the air in the right atrium, and notify the HCP.

B. Catheter embolism

1. Description: An obstruction that results from breakage of the catheter tip during IV line insertion or removal
2. Prevention and interventions

a. Remove the catheter carefully.
b. Inspect the catheter when removed.
c. If the catheter tip has broken off, place a tourniquet as proximally as possible to the IV site on the affected limb, notify the HCP immediately, prepare to obtain a radiograph, and prepare the client for surgery to remove the catheter piece(s), if necessary.

C. Circulatory overload

1. Description: Also known as fluid overload; results from the administration of fluids too rapidly, especially in a client at risk for fluid overload
2. Prevention and interventions

.a. Identify clients at risk for circulatory overload.
b. Calculate and monitor the drip (flow) rate frequently.
c. Use an electronic IV infusion device and frequently check the drip rate or setting (at least every hour for an adult).
d. Add a time tape (label) to the IV bag or bottle next to the volume markings. Mark on the tape the expected hourly decrease in volume based on the mL/hour calculatione.

e. Monitor for signs of circulatory overload. If circulatory overload occurs, decrease the flow rate to a minimum, at a keep-vein-open rate; elevate the head of the bed; keep the client warm; assess lung sounds; assess for edema; and notify the HCP.

D. Electrolyte overload

1. Description: An electrolyte imbalance is caused by too rapid or excessive infusion or by use of an inappropriate IV solution.
2. Prevention and interventions

a. Assess laboratory value reports.
b. Verify the correct solution.
c. Calculate and monitor the flow rate.
d. Use an electronic IV infusion device and frequently check the drip rate or setting (at least every hour for an adult).
e. Add a time tape (label) to the IV bag or bottle
.
f. Place a red medication sticker on the bag or bottle if a medication has been added to the IV solution .
g. Monitor for signs of an electrolyte imbalance, and notify the HCP if they occur.