PRINCIPLES AND
PRACTICE OF
INTRAVENOUS THERAPY
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
TABLE OF CONTENTS
Advantages of Intravenous Therapy .........................................................................................3
The Five Rights of Medication Administration ........................................................................4
Aseptic Technique ........................................................................................................................5
Reducing Risks of Infection ........................................................................................................7
Anaphylactic Shock ......................................................................................................................8
Emergency Care for Anaphylaxis ............................................................................................10
Antidotes for Reactions to Medications ..................................................................................11
Emergency Equipment ..............................................................................................................12
Complications of IV Therapy ....................................................................................................13
Symptoms of Fluid Deficit and Fluid Excess ..........................................................................17
Fluid Assessment ........................................................................................................................17
Preventing Complications of IV Therapy ...............................................................................18
Fluids ............................................................................................................................................19
Method for Estimating Osmolarity ..........................................................................................21
Selecting Equipment ..................................................................................................................25
Rates of Administration .............................................................................................................27
Calculating Flow Rates ..............................................................................................................28
Needle Sizes ................................................................................................................................29
Intramuscular Injections ............................................................................................................30
Pre Treatment Assessment ........................................................................................................31
The Physician’s Order ................................................................................................................33
Patient Teaching .........................................................................................................................34
Selecting A Site ............................................................................................................................35
Applying The Tourniquet .........................................................................................................40
Methods of Venous Distension .................................................................................................41
Caring For Patient Comfort .......................................................................................................42
Preparing the Solution ...............................................................................................................43
Steps in Preparing For Venipuncture ......................................................................................45
Documentation ............................................................................................................................46
Some Indications For Basic Vitamin Therapy ........................................................................48
Osmolarity Chart For A Sample Chelation Treatment .........................................................49
Protocol Ideas ..............................................................................................................................51
Vitamins .......................................................................................................................................52
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
First-pass effect: Whenever the route of administration is such that there is an organ of
elimination between the administration site and the systemic circulation, there is the
potential for a first-pass effect. This is sometimes referred to as presystemic elimination.
The consequence of the first-pass effect is that the fraction of drug reaching the systemic
circulation is substantially reduced. After oral administration, all of the drug must pass
through the liver before reaching the systemic circulation. This results in exposure to
drug metabolizing enzymes prior to the drug reaching the systemic circulation. An
example is nitroglycerin, which is totally inactivated by the liver. Its first pass effect is
100% complete.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
ASEPTIC TECHNIQUE
• Sterile or aseptic technique excludes pathogens. By definition it is the absence of
infectious microorganisms on living tissue. Complete destruction of all living
organisms is sterilization. Aseptic technique is imperative. Bacterial and fungal
contamination of solutions must be avoided.
• Wash hands thoroughly with soap and water before opening and preparation of
parenteral fluids. Wash hands for 1 - 2 minutes and dry with a paper towel. Do not
handle anything other than IV supplies during the procedure or wash and dry hands
again prior to handling the equipment.
• Only a sterile object can touch another sterile object. Unsterile touching sterile means
contamination has occurred. Always hold sterile objects above the level of the waist.
This will help ensure keeping the object in sight and prevent accidental
contamination.
• IV admixtures should be prepared in an isolated clean area. Medications should be
prepared in an area that permits complete concentration because distraction
increases the risk of human error.
• To keep the equipment sterile do not touch any part of the equipment that will come
in contact with IV medication or the blood stream.
• Avoid coughing, sneezing, breathing, laughing, talking or reaching over sterile
equipment.
• Never walk away from or turn your back on opened sterile equipment.
• Consider an object contaminated if you have any doubt of its sterility.
• Store medications according to the manufacturers instructions.
• Be aware if the medication is a single or multidose dose vial. Discard any leftover
medication from a single dose vial.
• If performing home therapy do not allow pets around the equipment.
• Introduction of extraneous particles must be avoided. Particles introduced into the
vein travel to the right atrium of the heart, through the tricuspid valve and into the
right ventricle. From there they are pumped into the pulmonary artery and on
through branches of arteries that decrease in size until the particles are trapped in
the massive capillary bed in the lungs where the capillaries measure 12 microns in
diameter. Five microns, the size of an erythrocyte suspended in fluid has been
suggested as the largest allowable size for a particle in the pulmonary capillary bed.
Particles larger than 5 microns are recognized as potentially dangerous because they
are likely to become lodged. Particles as large as 300 microns can pass through an 18-
gauge cannula. If occlusion of a small arteriole inhibits oxygenation or normal
metabolic activities, cellular damage or tissue death may occur. A particle that is not
biologically inert may incite an inflammatory reaction, a neoplastic response, or an
antigenic, sensitizing response.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
Needles may cut out fragments of rubber stoppers and accidentally inject them into
the solution. Entry into a port with a small gauge needle may help prevent
compromise of the port’s integrity; however smaller needles may encourage
particles that are difficult to see on inspection. Smaller particles may be of a size
capable of passing through the winged infusion set. A solution that on inspection
contains fragments of rubber must be discarded.
• Proper illumination permits visualization of particulate matter.
• Check solutions and additives for expiration dates. Outdated medications may have
a loss of stability or potency.
• Clean tops of multidose vials with povidone iodine, then wipe with alcohol.
• Medications should be administered through injection ports after disinfecting them.
• Wear clean disposable gloves for any patient procedure involving puncture of skin.
Wear gloves when touching blood or bodily fluids and for handling items or
surfaces contaminated with blood or bodily fluids. Wash hands or other skin
surfaces immediately and thoroughly if contaminated with blood or bodily fluids.
Change gloves after each patient contact. Consider all clients as potentially infected.
Look after yourself.
• To prevent needle stick injuries never recap used needles or bend or remove from
disposable syringes.
• A sharps container should be available for disposal of needles and syringes.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
PROTECTING YOURSELF
• Treat every patient as potentially infected with HIV or HBV.
• Always use disposable needles.
• To prevent needle stick injuries never bend or break needles, recap them,
separate them from the syringe or manipulate them in any way.
• Wear gloves whenever you work with IV infusions.
• Wash hands before and after use of IV equipment. Wash hands immediately
if they come in contact with blood or other bodily fluids.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
ANAPHYLACTIC SHOCK
The most common causes of anaphylactic shock are drugs and bee stings. At least 1% of
the general population are at risk of developing anaphylactic shock due to bee stings.
Anaphylactic shock is considered a grave medical emergency. Severity of the reaction is
inversely related to time elapsed between exposure and onset of symptoms. In other
words, the shorter the time before symptoms appear, the greater the risk of a fatal
reaction. Onset may occur within minutes or seconds.
Skin
• Itching and burning of the skin with flushing of face, neck and chest
• Cyanosis around lips
• Swelling of eyes, face and tongue
• Paleness
• Swelling of peripheral blood vessels
Respiratory Tract
• Painful tightness in chest
• Difficulty breathing, respiration rate of less than 10 or more than 20
• Wheezing, crowing breathing
• Swelling of mouth, tongue or throat leading to airway obstruction
• Anxiety
Gastrointestinal
• Nausea
• Vomiting
• Abdominal cramps
• Diarrhea
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
NASOPHARYNGEAL AIRWAY
INSERTION PROCEDURE
• Select the proper size. The diameter should be slightly smaller than the nostril. The
length should be a bit longer than the distance from the tip of the nose to the ear
lobe. If the airway is too short it will not go past the tongue to keep the airway open.
If it is too long it will enter the esophagus and fill the patient’s stomach with air.
• Lubricate the airway with a sterile water soluble lubricant, preferably one that
contains a topical anesthetic (xylocaine gel) for patient comfort. If no lubricant is
available use water. Do not use Vaseline or other petroleum based lubricant, they
will damage the nasopharyngeal mucosa and cause breakdown of the plastic.
• Push the tip of the nose up and gently insert the tube through the larger nostril.
Forcing the tube into place has the potential to damage the tissues or to kink the
tubing. If resistance is met, withdraw the tube and try the other nostril.
• If the patient is responsive have him exhale through his nose with his mouth closed.
You will feel air flow through the tube if it is correctly placed.
• Administer 100% oxygen at a high flow rate.
• Commence CPR if indicated. Stay current with CPR techniques. A review course
should be taken once a year.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
EMERGENCY EQUIPMENT
TO HAVE ON HAND
• Oxygen
• Bag and mask
• Benadryl
• Epinephrine
• Nasophyngeal airways
• Oropharygeal airways
• Xylocaine gel
• Normal saline bags
• Large gauge catheters
• Juice and crackers
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
COMPLICATIONS OF IV THERAPY
INFILTRATION
Infiltration is infusion or seepage of IV solution or medication into the extravascular
tissue. Infiltration occurs when the venipuncture needle penetrates both walls of the
vein or becomes fully or partially dislodged from the vein. This allows IV fluid to flow
into the surrounding tissues until swelling blocks the needle opening. Infiltration may
also occur if the needle has not been positioned correctly in the vein when initially
inserted. The seriousness of infiltration is related to the type of fluid, the concentration
and the amount of fluid infiltrated. Tissue necrosis and sloughing may occur if the
infusing fluid is caustic to the tissue. Vitamin C and DMPS are highly irritating fluids.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
THROMBOPHLEBITIS
Phlebitis is the inflammation of a vein and thrombosis is the formation of a clot in the
blood vessel. The vein may be injured during the venipuncture or by movement of the
needle during therapy. Irritation of a vein may occur as a result of irritating or
incompatible IV additives, use of a vein that is too small for the IV flow rate or use of a
needle size too large for the vein size. A sluggish flow rate may cause a clot formation.
CATHETER EMBOLISM
A catheter embolism is a free floating or dislodged fragment of a catheter in the
circulatory system. This usually occurs with flexible catheters rather than with needles,
but may occur with coring of rubber stoppers from multi-dose vials. If using an over the
needle catheter possible causes of embolism are withdrawing the catheter before the
needle or attempting to rethread a catheter with a needle.
HEMATOMA
Hematoma is the seepage of blood into the extravascular tissue. A hematoma may occur
when clients with coagulation defects are undergoing IV therapy, when anticoagulant
therapy is being administered to a patient, or when sufficient pressure is not applied to
the site post therapy.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
SYSTEMIC INFECTION
A systemic infection is an infection of the blood stream and like local infection is caused
by poor aseptic technique.
AIR EMBOLISM
An air embolus is the entry of a bubble into the client’s circulatory system. An air
embolism can occur if the IV container becomes empty, if air enters the IV tubing or is
not initially purged from the tubing or if the IV connections become loose allowing air to
enter.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
SPEED SHOCK
Speed shock is a rapid change in the venous system usually resulting in hypertension.
Administering infusions or boluses too quickly can cause speed shock.
ALLERGIC REACTION
An allergic response may be a local or generalized response to tape, cleansing agent,
medication, solution or intravenous device.
CIRCULATORY OVERLOAD
Circulatory overload is an excess of fluid disrupting the fluid homeostasis caused by
infusion of fluid at a rate greater than the patient’s system is able to accommodate.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
SYMPTOMS OF SYMPTOMS OF
FLUID DEFICIT FLUID EXCESS
• weight loss • weight gain
• lowered body temperature • elevated blood pressure
• increased or decreased pulse • bounding pulse not easily
obliterated
• decreased blood pressure,
• jugular distention
• includes postural hypotension
• increased respiratory rate
• sunken eyes, decreased tearing
• moist crackles or rhonchi
• decreased salivation
• edema of dependent parts, check
• dry cracked lips
sacrum
• furrows in tongue
• puny eyelids, periorbital edema
• cold limbs
• slow emptying of hand veins when
• decreased urine output arm raised
• increased serum osmolarity • reduced serum osmolarity
FLUID ASSESSMENT
An assessment of the client’s current and past use of medications is important. The
ingredients in many drugs especially over the counter drugs are often overlooked as
sources of sodium, postassium, calcium, magnesium and other electrolytes. There are
many prescription drugs that could cause fluid and electrolyte problems. Examples
include diuretics prescription and herbal, corticosteroids and electrolyte supplements.
The client should be questioned about any primary disease that could cause fluid and
electrolyte imbalances such as renal disease, diabetes mellitus, ulcerative colitis and
respiratory disease. Extremes of climate and activity may alter the body’s fluid
requirement. Clients who live alone may not satisfy their body’s need for balanced fluid
and electrolytes because they may not adequately prepare meals or drink enough fluids.
Client’s diets should be assessed to discover if he has been on a special diet such as
vegetarian - low protein, weight loss diet especially with weight loss supplements, or
fad diets. There is no unique physical examination to assess fluid and electrolyte
balance, but some common abnormal assessment findings give clues to imbalances.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
PREVENTING COMPLICATIONS
FROM IV THERAPY
• Use aseptic technique.
• Inspect all fluids and equipment before use.
• Use preservative free vitamins within 24 hours.
• Do not irrigate plugged needles or catheters.
• Remove non-functioning sets and needles.
• Avoid using veins of lower extremities.
• Never apply positive pressure when infusing fluids.
• Be alert to signs of circulatory overload.
• Avoid speed shock.
Phlebitis
• Do not use veins over an area of joint flexion.
• Anchor cannulas well to prevent motion and reduce risk of introducing
microorganisms into puncture wound.
• Adequately dilute medications.
• Use a needle or cannula smaller than the vein.
• Remove needle or cannula for erythema (redness of the skin caused by congestion of
the capillaries, occurring with skin injury, inflammation or infection), induration
(abnormal hardness), tenderness by palpation of venous cord or nonfunctioning
needle.
Infiltration
• Check questionable extremity against normal extremity.
• Apply a tourniquet tightly enough to restrict venous flow proximal to the injection
site. If the infusion continues regardless of the venous obstruction, extravasation is
evident.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
FLUIDS
Body fluids exist in two compartments separated by capillary walls and cell membranes.
Two thirds of bodily fluids exist inside the cells and is called intracellular fluid and one
third exists outside the cells and is called extracellular fluid. For fluid balance the
distribution between the two compartments must remain relatively constant.
Osmosis is the movement of water molecules through a selectively permeable
membrane from an area of higher water concentration to an area of lower water
concentration.
Osmotic pressure is the pressure required to prevent movement of pure water into a
solution containing solutes when the solutions arc separated by a selectively permeable
membrane. The greater the solute concentration of the solution the greater its osmotic
pressure.
The osmolality of blood plasma is 290 milliosmoles per litre. Intravenous fluids
considered in the isotonic range have an osmolality of 280-310 mOsm/L. Intravenous
fluids with an osmolality significantly higher than 290 (+50) are considered hypertonic,
while fluids with a significantly lower osmolality (- 50) arc considered hypotonic.
Tonicity of fluid infused into the circulation has a direct effect on the physical well being
of the patient. Hypertonic fluids increase the osmotic pressure of the blood plasma,
drawing fluid from the cells. Excessive infusion of hypertonic fluids can cause cellular
dehydration. Hypotonic fluids lower the osmotic pressure causing fluid to invade the
cells which can cause water intoxication. Isotonic fluids can cause excess extraccllular
fluid volume which can result in circulatory overload.
ISOTONIC SOLUTIONS
If the normal shape of a red blood cell is to be maintained, the cell must be placed in an
isotonic solution. This is a solution in which the total concentrations of water molecules
and solute molecules are the same on both sides of the selectively permeable membrane.
The concentration of solute and water in the extraccllular fluid must be the same as the
concentration inside the intracellular fluid. Under normal circumstances a 0.85% NaCl
solution is isotonic for red blood cells. In this condition, water molecules enter and exit
the cell at the same rate, allowing the cell to maintain its normal shape.
An isotonic solution possess the same osmolarity as serum and other body fluids.
Because the solution does not alter osmolarity it stays where you put it, inside the blood
vessel The solution expands this compartment without pulling fluid from any other
compartment.
Isotonic solutions
• expand the intravascular department.
• monitor patient for signs of fluid overload especially if he has hypertension or
congestive heart failure. See fluid overload chart.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
Red blood cells may be greatly impaired or destroyed if placed in solutions that
deviate significantly from the isotonic state. Patient safety and comfort is best
achieved by utilizing a solution which falls within the isotonic range.
HYPOTONIC SOLUTIONS
When red blood cells are placed in a solution that has a lower concentration of solutes
and a higher concentration of water the solution is called hypotonic. In this condition
water molecules enter the cells faster than they leave causing the red blood cells to swell
and eventually burst. The rupture of red blood cells in this manner is called hemolysis.
Sterile water is a strongly hypotonic solution.
Administer hypotonic solutions carefully. These solutions can cause a shift of fluid from
blood vessels into cells, with the potential to cause cardiovascular collapse from
intravascular fluid depletion and increased ICP from fluid shift into brain cells. Do not
give hypotonic solutions to patients at risk of third space fluid shifts, patients suffering
from burns, trauma, arthritis, low serum protein levels, malnutrition or liver disease.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
DESCRIPTION mOsm/ml
SOLUTIONS
5 % Dextrose 0.25
Lactated Ringers 0.28
0.45 % Sodium Chloride 0.16
0.9% Sodium Chloride 0.31
Sterile Water 0.00
3 % Amino Acid 0.41
15 % Amino Acid 0.45
5.5 % Amino Acid 0.58
8.5 % Amino Acid 0.89
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
HYPERTONIC SOLUTIONS
A hypertonic solution has a higher concentration of solutes and a lower concentration of
water than red blood cells. An example of a hypertonic solutions a 10% NaCI solution.
In such a solution water molecules move out of the cells faster than they can enter,
canning the cells to shrink. This situation is called crenation.
SOLUTION OSMOLARITY
Isotonic
Lactated Ringer’s 275 mOsm/L
0.9% sodium chloride (normal saline) 308 mOsm/L
D5 W 260 mOsm/L
Hypotonic
0.45% saline 154 mOsm/L
0.33% saline 103 mOsm/L
dextrose 2.5% in water 126 mOsm/L
sterile water 0 mOsm/L
Hypertonic
dextrose 5% in 0.45% saline 406 mOsm/L
dextrose 55 in normal saline 560 mOsm/L
dextrose 5% in Lactated Ringer’s 575 mOsm/L
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
Credits to: Managing I.V. Therapy, Nursing Photo Book, 1981, Editorial Director Jean Robinson,
Publisher Eugene W. Jackson.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
SELECTING EQUIPMENT
FLUID CONTAINERS
Two basic types of fluid containers exist. They are glass and plastic. Plastic bags are the
most widely used container but glass must be used for medications that are absorbed by
plastic such as insulin and diazepam. Glass bottles are evacuated and quickly pull in
injected additives. They must be vented to allow outflow of fluid. A vented
administration set provides sufficient air intake to enable the fluid to flow. In a closed
system only filtered air is allowed into the container. In an open system unfiltered air
enters the bottle through a plastic tube in the container. Venting can be achieved
through inserting a 22 gauge needle into the rubber stopper of the bottle. Risks involved
using a glass container include coring of the rubber stopper and particulate matter
entering the fluid, air embolism and airborne contamination. Plastic containers are the
most popular. They are easily transported with minimal risk of damage and arc easily
disposed o£ Because plastic does not require air venting and they collapse as air flows
out, risk for air embolism and contamination is greatly reduced. Plastic bags are
susceptible to accidental puncture, creating a port of entry for microorganisms.
Punctures may not be readily detected and all bags should be inspected visually and
squeezed to determine patency.
Check the container for size and correct fluid. Make note of the expiry date. Fluids
should never appear cloudy, turbid or separated. Discard out dated fluids, any kind of
damaged container and any fluids that are not clear.
ADMINISTRATION SETS
Selection of an administration set depends on the type and rate of infusion and the type
of solution container. Types of administration sets include basic, add a line and volume
control. For our purposes here only the basic administration set will be discussed.
Administration sets come with two types of drip systems, microdrip and macrodrip. A
macrodrip set delivers large quantities at rapid rates (10 -20 gtt/ml). Increased viscosity
causes the size of the drop to increase. A set that delivers 15 gtt/ml will deliver 10 gtt/ml
when blood is administered. A microdrip system delivers a smaller amount with each
drop e.g. (60 gtt/ml). Microdrip systems are usually used for pediatrics or adults
requiring closely regulated amounts of fluids.
A basic administration set consists of a spike at one end, a drop orifice at the other end, a
drip chamber, one or more injection ports, a roller clamp and a needle adapter. Sets
range in length from 70ʺ to 110ʺ long. The roller clamp is used to adjust the flow rate
which invariably changes after the rate is regulated.
VENIPUNCTURE DEVICES
Selecting a device depends on the length of time the device will stay in place, the type of
solution used and the type of vein available.
Over-the needle catheters are available in 14 - 26 gauge sizes from 1 to 2 inches in length.
They consist of a plastic outer catheter and an inner needle that extends beyond the
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
catheter. The needle pulls out after insertion leaving the catheter in place. The
advantages of using this device are: it allows the patient greater freedom of movement
and infiltration occurs less frequently. Disadvantages are: these devices are more
difficult to insert. If an unsuccessful attempt is made to insert the catheter, a new
catheter should be used for a repeat attempt in order to avoid shearing of plastic from
the catheter and potential plastic embolus. Cost of over-the-needle catheters is
approximately $1.80.
Winged infusion sets, commonly called butterflies, are the easiest intravascular device to
insert. They arc available in sizes 16-27 gauge and are about 3/4 inch long. Using a small
gauge ensures a slow infusion rate that cannot be speeded up by the patient Tubing
varies in length up to 12 inches. Use of a 12 inch tubing may reduce the need for an
administration extension set. Butterflies arc used for short term therapy and are ideal for
single IV push injections. Disadvantages of butterflies are the risk of infiltration is
greater than with a catheter and adequate veins must be available. Cost of butterflies is
about $0.75 each.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
RATES OF ADMINISTRATION
Cardiac and renal status of the patient play a vital role in determining the rate of
administration of intravenous fluids. Rapid infusion of fluids may cause an expanded
blood volume, overtaxing an impaired heart and renal damage causes fluid retention.
Because there is frequently some degree . of cardiac and renal damage in the elderly,
fluids are administered slowly to prevent increased venous pressure, pulmonary edema
and congestive heart failure.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
1. After calculating the required drip rate hold your watch next to the drip chamber to
allow simultaneous observation of the time and drops.
2. Release the clamp to the approximate flow rate desired and count the drops for 1
minute to account for drip rate irregularities. Continue to adjust the clamp and count
drops until the rate is accurate.
3. If the flow rate slows significantly avoid increasing the rate to catch up. Adjust the
rate to the infusion to the desired rate.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
NEEDLE SIZES
14 - 20 gauge are large bore needles used for blood, drawing up viscous medications. 18
gauge needles are most convenient for drawing up vitamin C and are preferred for
blood draws and major autohemotherapy (ozone). Smaller gauge needles may cause
hemolysis when blood cells are drawn through a too small opening
22 - 25 gauge most suitable sizes for IM injections. 22 gauge is the size most frequently
used in hospitals for IM injections. 25 gauge is more comfortable for the patient. 23
guage winged infusion sets are the most popular for in office infusions. 25 gauge may be
used to help regulate a slow flow rate for chelation treatments.
30 gauge is the smallest commercially available needle and is used for subcutaneous
injection. Some physicians believe it to be the kindest needle to use for IM injection for
children. This is debatable because more pressure must be applied to force fluid through
the small opening, causing a sharp jet of fluid to be introduced into the muscle.
NEEDLE LENGTH
A 1 inch long needle is generally adequate for IM injections. In obese patients a 1.5 inch
needle is required to ensure injection into the muscle rather than the fatty tissue. Muscle
tissue has more capillaries to take up medications than does fatty tissue. For
subcutaneous injection 0.5 inch is preferred and for intravenous injection 1 inch ensures
a solid position in the vein.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
INTRAMUSCULAR INJECTIONS
• Gather equipment together, ampoule, alcohol swab, needle and syringe.
• Wash hands thoroughly.
• Draw medication into syringe.
• Choose injection site:
upper outer quadrant of left or right buttock.
mid third of thigh.
upper arm four fingers from top of shoulder.
• Wipe injection area with alcohol swab and allow to dry.
• Remove needle cap by pulling it straight off
• Hold syringe in your dominant hand, between thumb and first finger (hold like a
pencil), and quickly dart the needle in at a 90 degree angle. NOTE: A one inch needle
goes all the way in except a small tip at the end of the needle where it joins the hub,
which is left exposed. In case of needle breakage the needle can be pulled out.
• As soon as the needle is in place, use your nondominant hand to hold the lower end
of the syringe (end closest to the patient). Use your dominant hand to operate the
plunger.
• To determine whether the needle is in a blood vessel aspirate slowly by pulling back
on the plunger. If blood is present in the syringe remove the needle, hold pressure
on the site until bleeding stops and choose a new site for injection.
• If no blood is aspirated inject the solution slowly.
• Remove the needle and gently massage the injection site with a dry swab.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
• Hematologic. Anemia, easy bruising or bleeding, past transfusions and any possible
reactions.
• Endocrine. Thyroid problems, heat or cold intolerance, excessive sweating, diabetes,
excessive thirst or hunger, polyuria.
• Psychiatric. Nervousness, tension, mood including depression and memory
• Transcultural and age considerations. African Americans have a smaller skin fold
thickness in their arms than Caucasians do and their arm veins may be closer to the
surface. In older patients small veins become more fragile and friable, but larger
veins become sclerotic.
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
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PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
PATIENT TEACHING
Many patients have feelings ranging from slightly apprehensive to totally terrified about
any therapy involving needles or blood. To help reassure your patient, before you begin
therapy, teach your patient what to expect during and after therapy. Thorough patient
teaching can reduce patient anxiety, making therapy easier to initiate for you and easier
for the patient to tolerate. Before commencing therapy tell your patient the following:
1. Describe the procedure including a description of what intravenous means. Tell your
patient intravenous means a needle or catheter will be placed in his vein. Explain
that fluid containing nutrients or medications will flow from the bag or bottle
through the tubing then through the needle and into his vein.
2. Give him a time frame for how long it will take for the fluid to infuse. Tell him how
much and what type of fluid he will receive and what type of nutrients and
medications he will receive. Explain to him what this therapy will do for him and
why he needs to have it.
3. Tell him the fee for this service and how often you expect him to repeat it.
4. Mention that he may feel transient pain during the insertion of the needle, but this
pain will pass once the catheter or needle is in place.
5. Tell him the IV fluid may feel cold at first. Explain that the fluid is at room
temperature which is cooler than body temperature. Reassure him by telling him if
he feels discomfort from the coolness a heat source will be placed around his arm.
6. Tell him to report any discomfort experienced after the needle is in place and the
fluid is flowing. Tell him how frequently you or an assistant will be checking on him.
Tell him how to call for assistance should he need to.
7. Explain any restrictions such as any restrictions on movement, remaining seated,
keeping his arm still etc. Can he eat, drink, or read books? Suggest he void before the
therapy is initiated.
8. Teach the patient how to care for the line. Tell him not to kink, put pressure on, or
pull on the tubing, or remove the container from the pole. Tell him he should call
staff if the flow rate speeds up or slows down suddenly.
9. Explain that removing the line is a simple procedure. Tell him to apply pressure to
the needle site for a minimum of three minutes, until bleeding stops and you will
check the site before he is released. Reassure him that once the IV is discontinued he
will have normal use of the involved limb.
10. Ask him if he has any unanswered questions or concerns.
34
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
SELECTING A SITE
• Assess both upper extremities.
• Accessibility must be considered, but the most prominent vein is not always the best
choice. A vein may be prominent because it is sclerosed. The vein of choice should
feel firm, round, elastic and engorged. Some veins appear suitable at first but, feel
hard, knotty and small on palpation. To palpate a vein place one or two fingers over
the vein and apply light pressure. Release pressure to assess elasticity and refilling.
Some veins feel and look suitable but are not easily cannulated because their lumens
are irregular or narrowed by scarring, causing difficulty advancing the cannula. A
patient who has been recently hospitalized should be expected to have fewer
suitable veins.
• Select a vein in the non-dominant arm preferably.
• Never choose a vein over an edematous site.
• If the infusion is acidic or caustic choose a vein away from joints, covered by plenty
of subcutaneous tissue.
• Ensure the vein can accommodate the cannula.
• To acquire a highly developed sense of touch palpate before every cannulation.
• Visualize the vein in your mind’s eye.
• For most adults veins in the hands will be your first choice. If problems arise with
infiltration, proximal sites remain available. Veins in the lower arm are also a good
choice, leaving the patient’s hands free.
• Consider your skill at venipuncture.
35
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
SITES TO AVOID
• veins over a previous IV infiltration site.
• veins below a phlebitic area.
• sclerosed or thromboses veins.
• areas of skin inflammation, disease, bruising or scarring.
• an arm affected by radical mastectomy, edema, blood clot or infection.
• arteries are rarely damaged during venipuncture because they are located deeper
than veins. In the anticubital fossa veins and arteries lie close together increasing the
risk of damage to an artery.
• Before performing any venipuncture palpate for arterial pulsation (this occurs even
after a tourniquet is applied unless the tourniquet is applied to tightly) to locate
nearby arteries.
36
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
37
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
Metacarpal Veins
• Formed by union of digital veins (dorsal venous area)
• Ideal position for IV use - primary choice IVs
• Venipuncture should be started at the most distal point on the extremity
• Proper support is needed after IV infusion is initiated to prevent movement of IV
catheter
• Veins are thin with inadequate tissue and muscle support in the elderly
Cephalic Vein
• Flows upward along the radial border of the forearm producing branches to both
surfaces of the forearm
• Because of their size and location, they provide an excellent site for IV infusion
• Readily accommodates large gauge IV catheters
• Is available for venipuncture in the upper arm region
Basilic Vein
• Originates in the ulnar portion of the dorsal venous network
• Ascends along the ulnar portion of the forearm. It curves toward the anterior surface
of the arm just below the elbow. It meets with the median cubital vein below the
elbow
• Is available for venipuncture above the antecubital fossa in the upper arm region
• Often overlooked because of its inconspicuous position
38
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
39
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
40
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
41
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
42
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
43
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
44
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
45
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
DOCUMENTATION
1. Size and type of device used.
2. Date and time of start and finish of infusion. Also label time on bag.
3. Type of solution.
4. Type of additives.
5. Patient assessment BP, pulse etc.
6. Site accessed.
7. Complications, patient response, interventions.
8. Condition of the site at discharge from office.
46
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
Name:
47
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
Millisosmole Total
Product Volume in mls
per ml Milliosmoles
Magnesium
200 mg/ml 4.0 2.95 11.80
chloride
Expected Total
Total volume
osmolarity milliosmoles
270 mls
299.07 80.75
48
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
Magnesium
200 mg/ml 10.0 2.95 29.50
chloride
Divide the total number of milliosmoles by the total volume then multiply by 1,000 for
an estimate of the osmolarity of the mixture in milliosmoles per litre.
174.67/562.0 X 1,000 = 310.8
HERPES
Vitamin C and zinc both stimulate the immune system and stimulate tissue
repair. B vitamins support nervous tissue. Infusions containing zinc may irritate
the small veins. Assess patient for pain several times during infusion. A variety
of homeopathics may be used singly or in combination as a bolus push into the
injection port. A few examples include: herpes nosodes, echinecea, mezereum,
ranunculus, rhus tox, sempervivum tectorum.
49
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
Millisomoles Extended
Additive Dose Volume
per ml Millisosmoles
Magnesium
200 mg 5.00 2.95 14.75
chloride
Zinc trace
l mg 10.00 0.11 1.10
metal
Expected
osmolarity
300.0
50
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
PROTOCOLS
Liver and gall bladder
• licorice
• vitamin C
• zinc
• B vitamins
• Heel Hepar Comp
• Pasco Cholo Injectopas
Impotence
• vitamin combination
• zinc
• Sanum Ginkgokehl
• Sanum Mucokehl
• Heel Testis Comp
• Pasco Calycast
Angina
• Magnesium
• Heel Cor Comp
• Pasco Cor Comp Forte
Hypertension
• B5
• Magnesium
• Heel Cor Comp
• Heel Rauwolfia
Asthma
• Magnesium
• Vitamin C
• Heel Spascupreel
• Pasco Asthma I and II Injectopas
Herpes virus
• vitamin C
• licorice
• zinc
• Heel Mezereum, Ranunculus, Herpes simplex nosode, zoster nosode,
Sempervivum Tectorum, Echinecea Comp
• Pasco J Injectopas for neuritis and neuralgia
• Procaine / Lidocaine infiltrated s.c.
51
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
VITAMINS
As a result of the growing interest of the public in alternative medicine and in becoming
more responsible for their own well being many people arc taking large doses of
vitamins daily, often without medical supervision. Thousands of people have made a
return to good health with a combination of diet and supplements and what’s more
vitamin and mineral supplements arc often more effective than drugs and surgery. Even
though nutrients arc safer than conventional drugs we must still be careful with their
use. Because nutritional therapy and research is still in its infancy many questions
remain unanswered.
DEFICIENCY SYMPTOMS
• Chronic peripheral neuritis.
• Beriberi which may or may not be associated with heart failure and edema. In dry
beriberi the patient complains of weakness, stiffness and is unable to walk more than
a short distance. As the disease progresses, the ankle jerk reflex is lost and muscular
weakness spreads upwards. The affected muscles become tender and numb. There is
pronounced foot drop and wrist drop. In the final stages the patient becomes bed
ridden and even slight pressure from bedclothes causes considerable pain. In wet
beriberi the heart is affected with dilatation of the arterioles, rapid blood flow and
increased pulse rate and pressure and increased jugular pressure leading to right
sided heart failure and edema. There is high concentration of circulating pyruvate
and lactate and a fall in the concentration of ATP in the heart.
52
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
PRECAUTIONS
• There is no evidence of any toxic effect of high intakes of thiamin although high
parenteral doses have been reported to cause respiratory depression in animals and
anaphylactic shock in human beings.
• Thiamin is not commonly administered IV, IM is preferred.
• Rarely administered alone, more often as part of a multiple B vitamin.
• Intradermal test recommended for suspected sensitivity.
• Protect from freezing and from light.
USUAL DOSE
Up to 100 mg daily. May be given by direct IV (100 mg or fraction thereof over 5
minutes) or added to most IV solutions or IM.
53
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
DEFICIENCY SYMPTOMS
• Impairment of lipid metabolism. There is an increase accumulation of triglycerides
in the liver with an increase in liver weight in proportion to body weight, which
leads to an impairment of growth.
• Cracks and sores at the comers of the mouth.
• Inflammation of tongue and lips.
• Eyes over sensitive to light and easily tired.
• Itching and scaling of skin around nose, mouth, scrotum, forehead, cars and scalp.
• Trembling.
• Dizziness.
• Insomnia.
• Slow learning.
• Itching, burning and reddening of eyes and damage to cornea of the eye.
54
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
PRECAUTIONS
• Mixing with baking soda destroys riboflavin.
• Assess for allergy.
• Because of its low solubility and limited absorption from the GI tract, riboflavin has
no significant or measurable toxicity by mouth. Nigh parenteral doses (300 - 400
mg/kg body weight) there may be crystallisation of riboflavin in the kidneys because
of its low solubility. Use caution with large doses in patients with chronic kidney
failure.
USUAL DOSE
RDA 1.2 - 1.8 mg/day. Usually B complex injectables supply 2 mg/ml.
55
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
DEFICIENCY SYMPTOMS
• Pellagra
• Muscle weakness
• General fatigue
• Loss of Appetite
• Headaches
• Swollen, red tongue
• Skin lesions, including rashes, dry scaly skin, wrinkles, course skin texture, dermatitis
• Diarrhea
• Irritability
• Dizziness
• Behavioral symptoms - apathy, anxiety, depression, hyperirritability, mania,
memory deficits, delirium, emotional liability.
56
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
PRECAUTIONS
• Modest doses causes a marked vasodilation with flushing, burning and itching of the
skin.
• Large single doses may cause sufficient vasodilation to lead to hypotension
• Side effects wear off considerably after several days taking niacin.
• At intake in excess of 1 gram niacin/day there is evidence of toxicity. Changes occur
in liver function tests, carbohydrate tolerance (increases blood sugar) and uric acid
metabolism, all are reversible on withdrawal of niacin.
• Sustained release preparations are associated with more severe liver damage and
clinical liver failure than simple preparations.
• Contraindicated in active acute peptic ulcer.
• Potentiates some antihypertensive drugs.
• Begin therapy with small doses and increase gradually.
USUAL DOSE
• - 100 mg 2 or more times in 24 hours may be given. RDA 6.6 mg/day.
• The body manufactures niacin from tryptophan. Assuming that 60 mg of tryptophan
is equivalent to 1 mg of dietary niacin, this suggests that an average diet provides
8.75 mg niacin equivalents/1000 kcal from tryptophan alone - significantly more than
the RDA.
• In injectable B complex niacin appears in the form of niacinamide at a concentration
of 100 mg/ml.
• Undiluted niacin given intravenously should be given at a rate not to exceed 2 mg or
fraction thereof over 1 minute.
57
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
BENEFITS
• Promotes normal growth and development.
• Fundamental component of CoA.
• Aids in release of energy from foods.
• Involved in the transport of fatty acids to and from cells and accelerates fatty acid
breakdown in the mitochondria.
• Pantethine reduces serum triglyceride and cholesterol levels and increases HDL
levels. Beneficial to angina patients.
• Improves symptoms of osteoarthritis.
• Stimulates healing.
• Supports adrenal glands and alleviates stress.
• Treats constipation.
• Relieves allergies.
• Treats fatigue.
• Enhances cholinergic function, reduces loss of memory and cognitive impairment in
some patients.
• Postoperatively for prevention of ileus.
• Growth factor for lactobacillus bulgaricus.
DEFICIENCY SYMPTOMS
Lack of one B vitamin usually means lack of other nutrients. Pantothenic acid is usually
given with other B vitamins if there are symptoms of any B deficiency including the
following:
• Skin problems
• Sleep disturbance
• Arthritis
• Adrenal atrophy
• Allergies
58
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
• Mental fatigue
• Muscle spasms
• Shortness of breath
USUAL DOSE
Pantothenate is usually administered as the calcium salt and is employed in combination
with other B vitamins. It may be given orally, IM or IV in doses of 5 to 100 mg.
59
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
DEFICIENCY SYMPTOMS
• In women B6 deficiency may be caused by an over supply of estrogen. One of the
consequences is depression, a symptom frequently seen in women on the pill or
suffering from PMS symptoms. B6 deficiency can result in inadequate production of
serotonin, which can lead to depression.
• B6 deficiency is one of the factors promoting atherosclerosis.
• Depressed immunity, reduction in number and activity of lymphocytes, shrinkage of
thymus gland and decreased thymic hormone activity.
60
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
PRECAUTIONS
• B6 may cause insomnia if taken late in the day.
• Deteriorates in excessive heat.
• May inhibit lactation.
• Excessive doses may elevate SGOT.
• Excessive doses may cause nerve damage.
• Large doses in utero may cause pyridoxine-dependency syndrome in the newborn.
• Inhibits phenobarbital and phenytoin.
• Contraindicated in known sensitivity to pyridoxine.
• In rare cases doses over 200 mg daily may be toxic.
USUAL DOSE
10 - 100 MG/24 hours. May be given by direct IV administration undiluted or added to
most IV solutions and given as an infusion If given undiluted administer 50 mg or
fraction thereof over one minute.
61
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
VITAMIN B12
Vitamin B12 is supplied in two injectable forms; hydroxocobalamin and cyanocobalamin
Hydroxocobalamin is the preferred form to use because its effects are longer lasting and
it does not contain the cyanide component of cyanocobalamin. For patients requiring
ongoing regular treatment of B 12, cyanide accumulation can become a problem over
time.
BENEFITS
• stress
• depression
• digestive disturbances
• treats some kinds of nerve damage
• treats diabetic and peripheral neuropathy
• treats restless legs, pernicious anemia, some allergies, menstrual disorders, skin
problems, fatigue, mental symptoms
• prevents B12 deficiency in vegan vegetarians and persons with absorption difficulties
• improves memory and teaming ability
• increases energy
Deficiency Symptoms
• Alzheimer’s disease symptoms
• psychosis
• shortness of breath
• pernicious anemia
• fatigue
• weak and tingling arms and legs
• skin problems
USUAL DOSE
Given intramuscularly, allopathic practitioners will usually give no more than 1000 mcg
per month The rationale being that B 12 is stored in the liver allowing for a potential
overdose. Vitamin B12 is a water soluble vitamin. In a search of literature there were no
reported cases of vitamin B12 overdose. There is a very low incidence of B12 toxicity
even with large amounts up to 1000 mcg daily. To produce a noticeable improvement of
symptoms for the patient, a dose of 2000 mcg IV and 3000 mcg IM is required.
62
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
DEFICIENCY SYMPTOMS
• Scurvy – muscle weakness, swollen and bleeding gums, loss of teeth, tiredness,
depression, irritability, bleeding under skin.
• Shortness of breath.
• Digestive difficulties.
• Easy bruising.
• Swollen painful joints.
• Nosebleeds.
• Anemia: weakness, tiredness, paleness.
• Frequent infections.
• Slow wound healing.
• Behavioral symptoms – lassitude, hypochondriasis, depression, hysteria.
63
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
PRECAUTIONS
• Bowel flush is diagnosis for vitamin C saturation.
• Antagonizes anticoagulants.
• There is much controversy and debate over whether large doses of vitamin C cause
renal calculi.
• Use caution in cardiac and renal patients. Sodium content may contribute to fluid
retention and congestive heart failure.
• Use caution in renal calculi/colic patients.
• Side effects, temporary dizziness and faintness occur with too rapid injection.
• Test for allergy in sensitive patients.
USUAL DOSE
Up to 6 grams over 24 hours, may be administered in diluted IV infusions. Given
undiluted 100 mg or fraction thereof over 1 minute.
64
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
DEFICIENCY SYMPTOMS
• Irritability.
• Weakness.
• Lack of energy.
• Sleep difficulties.
• Forgetfulness and confusion.
• Megaloblastic anemia.
• Indicated in alcoholism, sprue, celiac disease, pregnancy, GI anomalies, fish
tapeworm infestation.
PRECAUTIONS
• Oral or IM administration is adequate in most cases. Do not administer IV to
children.
• Obscures the peripheral blood picture and prevents the diagnosis of pernicious
anemia.
• Folic acid is inhibited by depressed hematopoiesis, alcoholism and deficiencies of
vitamins B6, B12, C, and E. Side effects arc almost non-existent. Some slight flushing
or feeling of warmth may occur and anaphylaxis may occur.
USUAL DOSE
1 mg daily and 5 mg infrequently. May be given IM or IV in solution or undiluted.
65
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
DEFICIENCY SYMPTOMS
• Osteoporosis.
• Osteomalacia, frequent fractures.
• Muscle contractions and cramps.
• Convulsive seizures.
• Low backache.
PRECAUTIONS
• Necrosis and sloughing can occur with IM or SC injections or extravasation Confirm
patency of vein and observe needle site for signs of infiltration.
66
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
DEFICIENCY SYMPTOMS
• Confusion and delirium.
• Irritability.
• Nervousness.
• Headaches.
• Hypertension.
• Skin problems.
• Hardening of soft tissues.
67
PRINCIPLES AND PRACTICE OF INTRAVENOUS THERAPY
PRECAUTIONS
• Contraindicated in cases of renal insufficiency. Over time excessive doses can be
toxic.
• May cause bradycardia and hypotension if given in too large doses or too quickly
intravenously.
• Overdose symptoms include drowsiness, heart block and respiratory depression.
• Treatment for overdose is 5 to 10 mEq of calcium gluconate (10 -20 ml of calcium
gluconate).
USUAL DOSE
Given orally magnesium may be given to bowel tolerance at a rate of 500 mg hourly. For
severe hypomagnesemia 5 Gm (40 mEq). May be given undiluted or in solution. Check
BP pre and post IV.
68