GEORGE MICHAEL P.

LIM, RN, MN-NAS

Corporate Chief For Nursing

Director, TRAINING AND STAFF DEVELOPMENT

INTRAVENOUS INFUSION
this is an efficient and effective method of supplying fluids and medications directly into the intravascular department usually ordered by the physician the nurse is responsible for administering and maintaining the therapy, and for teaching the client and significant others how to continue the therapy at home

INDICATIONS/PURPOSES:
Establish or maintain a fluid or electrolyte balance Administer continuous or intermittent medication Administer bolus medication Administer fluid to keep vein open Administer blood or blood components Administer intravenous anesthetics Maintain or correct a patients nutritional state Administer diagnostic reagents Monitor hemodynamic functions

Drop factor 1. Macrodrop gtt; 15gtt/ml 2. Microdrop mgtt; 60 mgtt/ml

FLUID & ELECTROLYTES

Fluid compartments: 1. Cells 2. Blood vessels 3. Tissues space Types of Fluid: 1. Intracellular Fluid 2. Extracellular Fluid

2/3 or 70% of the body fluid 1/3 or 30% of the body fluid

1/4 intravascular 3/4 interstitial fluid

functions of water:
1. Transporting nutrients to cells and wastes from cells 2. Transporting hormones, enzymes, blood platelets, and 3. 4. 5. 6. 7.

red and white blood cells Facilitating cellular metabolism and proper cellular chemical functioning Acting as a solvent for electrolytes and nonelectrolytes Helping maintain normal body temperature Facilitating digestion and promoting elimination Acting as a tissue lubricant

(-) Effect of water loss: every 2% to 5% water loss --> 30% decrease in work performance.

Electrolytes
Active chemicals that carry positive (cations) and negative (anions) electrical charges Major cations:
Sodium Potassium Calcium Magnesium Hydrogen ions

Major anions:
Chloride

Bicarbonate
Phosphate Sulfate Proteinate ions

Electrolyte concentrations differ in the fluid compartments

Electrolytes (cont.)
Major cation in ECF
Sodium

Major cation in ICF

Potassium

Physiological functions in the body:

1. Promote neuromuscular irritability 2. Maintain body fluid osmolarity 3. Regulate acid-base balance 4. Distribute body fluids between the fluid compartments

Regulation of Fluid
Movement of fluid through capillary walls depends

on: Hydrostatic pressure Pressure exerted on the walls of blood vessels Osmotic pressure Pressure exerted by the protein in the plasma The direction of fluid movement depends on the differences of hydrostatic and osmotic pressure

Regulation of Fluid (cont.)

Osmosis

Diffusion Filtration Active transport

INTRAVENOUS SOLUTIONS
Isotonic Solutions:
Type:

- Normal Saline 0.9% NaCl

- D5W: acts as a hypotonic solution in the body - Ringers Solution - Lactated Ringers Solution Nursing Responsibilities:

- Expands the intravascular compartment.

- Monitor for fluid overload. - avoid D5W if at risk with increase ICP

Hypotonic Solution:
Type: - 0.33% NaCl

- 0.45% NaCl
- 2.5% Dextrose Nursing Responsibilities:

- these solutions shift fluid from the intravascular compartment into the cells
- contraindicated for clients with increased ICP because of shift into the brain cells - also contraindicated for clients who are at risk for 3rd-space fluid shifts

Hypertonic Solutions:
Types:
- D5 0.45%NaCl - D5NSS - D5LR Nursing Responsibilities: - expands the intravascular compartment - contraindicated for clients with kidney and heart problem - contraindicated for clients who are dehydrated because it draws fluid from the intravascular compartment - 3.0% NaCl - Sodium Bicarbonate 5%

Electrolyte Solutions:
contain varying amounts of cations and anions includes:

- 0.9% NaCl
- Ringers Solution: with Na, Cl, Ca, & K - Lactated Ringers Solution: same as above with lactate. Lactate is salt of lactic acid that is metabolized in the liver to form HCO3 saline solutions hydrating solutions are frequently used as initial

multiple electrolyte solutions approximate the ionic profile of plasma and are used to prevent dehydration or to restore or correct fluid and electrolyte imbalances

Nutrient Solutions: contain some form of carbohydrate (dextrose and glucose) and water

water is supplied for fluid requirements while carbohydrate is for calories and energy
useful in preventing dehydration and ketosis but do not provide sufficient calories for wound healing, weight gain or normal growth in children

Alkalinizing Solutions:
administered to counteract metabolic acidosis. example: Lactated Ringers Solution

Acidifying Solutions:
administered to counteract metabolic alkalosis. example: 0.45% NaCl and 0.9 % Nacl

Blood Volume Expander: used to increase the volume of blood following severe loss of blood or loss of plasma examples: dextran, serum albumin human

PERIPHERAL VENIPUNCTURE SITES

- site chosen varies with clients age, the length of time the infusion to run, the type of solution used. ARM: - cephalic vein - basilic vein HAND: - basilic vein - dorsal venous network - accessory cephalic vein - median cubital vein

- median antebrachial vein

- radial vein

- cephalic vein
FOOT:

- dorsal metacarpal veins

- dorsal plexus

- great saphenous vein

Venipuncture sites

The site chosen for venipuncture varies with: Age Length of time of infusion is to run The type of solution used Condition of the veins

Venipuncture sites
The metacarpal, basilic and cephalic veins are commonly used for intermittent and continuous infusions Although the basilic and median cubital veins in the anticubital space are convenient sites for the venipuncture, they are usually used for

blood draws, bolus injections of medications and insertion sites for a PICC

GUIDELINES FOR VEIN SELECTION

- use distal veins of the arm first - use the clients non-dominant arm whenever possible - use veins in the feet and legs only when arm veins are inaccessible, since they are more prone to thrombus formation and subsequent emboli - select a vein that: a. is easily palpated and feels soft and full

b. is naturally splinted by bone

c. is large enough to allow adequate circulation around the catheter

- avoid using the following veins:

a. those areas that are highly visible since they tend to roll away from the needle

b. those damaged by previous use, phlebitis, infiltration or sclerosis

c. those continually distended with blood or that have been knotted or tortous d. veins of surgically compromised or injured extremity because of possible impaired circulation and discomfort for the client

INTRAVENOUS EQUIPMENT
- infusion set tubing, specify if for adult, child or for blood transfusion - sterile parenteral solution - IV pole - antiseptic swab - clean gloves - tourniquet - IV catheter

- adhesive or non-allergenic tape

- antiseptic ointment such as Betadine - gauze squares or other appropriate dressings - arm splint if required - towel or pad

INFUSION SET & EQUIPMENT

VOLUMETRIC SET

HEPARIN LOCK

STARTING INTRAVENOUS INFUSION

1. Check the doctors order. Verify the type of solution, the amount to be administered and the rate of the infusion.
2. Take the initial assessment of the client. (Vital signs, skin turgor, bleeding tendencies, disease or injuries of the extremity, status of the veins) 3. Explain the procedure to the client. 4. Provide any scheduled care before establishing the infusion to minimize movement of the affected limb during the procedure. 5. Prepare the equipment. Check the clarity, expiration date and sterility of the IV solution as well as the tubing and the venipuncture set or IC catheter. 6. Do handwashing.

7. Open and prepare the infusion set aseptically. a. Remove the tubing from the container and straighten it out. b. Slide the tubing clap along the tubing until it is just below the drip chamber. c. Close the clamp/regulator.

d. Leave the ends of the tubing with plastic cap until the infusion is started.
8. Open the seal of the IV solution and disinfect the port with cotton balls with alcohol.

9. Spike the solution container aseptically.

a. Remove the plastic cap of the spike and insert it to the solution.
b. Follow agency protocols regarding insertion. It is recommended though, that twisting motion be not applied while inserting the tubing to the bottle.

10. Hang the solution container on the IV pole. Adjust the pole so that the container is suspended about 1 meter above the clients head.
11. Partially fill the drip chamber with solution. Squeeze the drip chamber gently until it is half full.

12. Prime the tubing.

a. Remove the protective and hold the tubing over a container. Maintain sterility of the end of the tubing and the cap.
b. Release the clamp and let the fluid run through the tubing until all the bubbles are removed. This is done to prevent air from entering the client. c. Re-clamp the tubing and replace the tubing cap while maintaining sterility. 13. Apply appropriate labels to the solution container. Include the clients name, solution, drugs incorporated, date, time infusion started and IVF regulation. 14. Apply a timing label on the solution container. 15. Wash hands again if necessary.

16. Select and prepare the venipuncture site. Starting at the distal end of the vein, select a site by palpating accessible veins.
17. Dilate the vein: a. Place the arm in a dependent position or lower than the clients heart. Gravity slows venous return and distends the vein. b. Apply tourniquet firmly to about 4-6 inches above the venipuncture site. It should be tight enough to obstruct venous flow but not so tight to occlude the arterial flow. c. Check by palpating the radial pulse.

18.Put on clean gloves, and clean the venipuncture site with the povidone-iodine or alcohol. Use circular motion going from the center towards the outside of the venipuncture site. Permit the solution to dry into skin before insertion.
19.Insert the IV catheter and initiate the infusion. 20.Tape the catheter. Commonly used is the U method but methods may vary according to manufacture. 21.Dress and label the venipucture site and tubing according to agency policy.

22. Ensure appropriate infusion flow. 23. Label the IV tubing. 24. Document relevant data including assessments.

REGULATING INTRAVENOUS FLOW RATES

nurse should first determine the drop factor of the infusion set used. It is printed on the packaging of the infusion set.

to calculate the flow rates, nurse must know the volume of the fluid to be infused and the specific time for the infusion
millimeters per hour: volume to be infused total time of the infusion drops per minute: total infusion X drop factor

# of hours to infuse X 60 minutes

electronic infusion devices (EID) devices that regulate the infusion depending on the presets selected

FACTORS INFLUENCING FLOW RATES

position for the forearm
position and patency of the tubing height of the infusion bottle possible infiltration or fluid leakage relationship of the size of the IV catheter to the size of the vein

MONITORING AN INTRAVENOUS INFUSION

observe the rate of flow every hour inspect the patency of the IV tubing and needle observe the tubing for pinches or kinds of obstruction to flow open the drip regulator and observe for a rapid flow (rapid flow would indicate patency) regulate the infusion after checking patency lower the IVF bottle below the insertion site to note blood backflow inspect the insertion site for fluid infiltration, dislodged needle, phlebitis or bleeding

teach the client ways to maintain the infusion system: - call for assistance if:

a.The solution is not dripping b.The venipuncture site is swollen c.There is a sudden change in the flow rate d.The solution container is nearly empty e.There is blood in the IV tubing - avoid sudden twisting or turning of the arm where
the insertion site is

- avoid stretching or placing tension on the tubing - document all relevant information

TROUBLESHOOTING IV PROBLEMS
PROBLEM
1. 2. IV off Schedule Incorrect Solution Flow stopped

ACTION
Figure rate to finish over remaining time ( if >3cc/hr, consult physician Slow rate to a minimum while initiating change to correct solution assess patient. Notify Physician To reestablish Flow: Look for obstruction of tubing and correct if present Open regulator completely, move to new position, and regulate again if flow begins Reposition arm Place bottle lower than needle to see if blood flows back, which would indicate tubing is patent Gently raise needle hub. If this starts to flow, support hub with cotton ball or gauze. Pinch off tubing close to arm above soft rubber section of tube then squeeze firmly Obtain sterile needle & syringe. Insert into injection port closest to needle. Pinch off tubing syringe and aspirate. Then open flow.

3.

PROBLEM
4.
5.

ACTION
Straighten tubing and check flow rate again
For a few small bubbles high in tubing: Turn off flow - Stretch tubing downward Flick tubing with fingers - Start flow rate & regulate For large amount of air high in tubing: Turn off flow Insert sterile open needle into injection port to close air Open flow slowly - Start flow & regulate For air low in tubing, below last port: Turn off flow - Obtain sterile needle & syringe Insert into last port closest to patient Pinch tubing distal to the port & close it off Aspirate air into syringe Start flow rapidly to flush out blood Regulate flow For flexible drip chamber: Pinch off tubing Squeeze fluid back into container Release tubing

Tubing Kinked
Bubbles in tubing

6.

Drip Chamber full of fluid

- Invert container - Hang up bottle

CHANGING AN IV SOLUTION
1. Verify the doctors order for the IV solution to follow.

2. Explain the procedure to the client and assess IV site for complications. Check the date of the IV insertion. Ideally, insertion site should be changed every 72 hours.
3. Wash hands before and after the procedure. 4. Prepare the necessary materials. Check the sterility of the IV solution.

5. Place the necessary labels on the IV solution.

6. Open and disinfect the rubber port of the IV solution to follow. 7. Close the clamp or kink the tubing just below the drip chamber, then remove the existing bottle, and then spike the solution to follow aseptically. 8. Open the clamp or un-kink the tubing and regulate the new solution as prescribe.

COMPLICATIONS OF IV THERAPY
COMPLICATION

MANIFESTATION

NURSING INTERVENTIONS

INFILTRATION

- blanching of the skin - edema - swelling - pain at site - cool to touch - decrease infusion - apply, tourniquet above the infusion site, if infusion continues to drip, it is infiltrated

- discontinue IV, reinsert in a new site - apply warm compress to increase fluid absorption - apply sterile dressing - elevate arm

PHLEBITIS

THROMBO PHLEBITIS

- redness - heat - swelling IV site - possible pain - red line along the course of vein - pain - swelling - redness, warmth around IV site or path of the vein - fever] - leukocytosis

- discontinue IV - reinsert new site - apply warm compress - d/c IV; reinsert IV on the other extremity - apply warm compress - elevate arm

HEMATOMA

- ecchymosis - STAT IV site swelling - leakage of blood at the IV site

- d/c IV, reinsert in opposite extremity - apply pressure with sterile dressing - apply ice bag for 24 hours then warm compress

CLOTTING

- decrease IV flow rate - backflow of blood into IV tubing

PYROGENIC REACTION

- d/c IV - dont irrigate or milk the tubing - dont increase the rate or hang it higher - dont aspirate the clot from the cannula - urokinase may be used - fever, chills - d/c IV STAT - gen. malaise - monitor V/S - N/V - notify the physician - head & back - retain IV equipment ache for culture study

AIR EMBOLISM

- dyspnea - cyanosis - hypotension - tachycardia - loss of consciousness

CIRCULATORY OVERLOAD

SOB; increase BP restlessness coughing frothy sputum crackles engorge neck veins

- d/c IV STAT - turn client to the left side with head down - ad. O2 - notify the physician - slow IVF rate - monitor V/S - notify the physician

DISCONTINUING IV INFUSIONS
Infusions are discontinued for one of the 3 reasons:

a. the clients oral fluid intake and hydration status are satisfactory, so that no further IV solutions are ordered b. there is a problem with the infusion that cannot be fixed
c. the medications administered intravenous route are no longer required by

STEPS IN DISCONTINUING IV INFUSION

1. Verify doctors order to discontinue Iv infusion or IV medications. 2. Assess and inform the patient of the order. 3. Prepare the necessary materials: a. IV tray

b. Sterile cotton balls with alcohol. pick-up forceps d. Antiseptic solution

e. Plaster f. Kidney basin

Supply with

c. Sterile-dressing depends on hospital policy

4. Wash hands before and after the procedure.

5. Close IV clamp of the tubing. 6. Wear clean gloves for protection.

7. Moisten adhesive tapes around the IV catheter with cotton balls soaked in alcohol.
8. Remove the plaster gently layer by layer while holding the needle firmly and apply counter traction to the skin. 9. Use pick-up forceps to get the cotton ball soaked in alcohol. Without applying pressure, withdraw the IV catheter by pulling it out along the line of the vein. Apply pressure after removal and then tape or place dressing as indicated. Applying pressure for 2-3 minutes.

10. Inspect IV catheter for completeness.

a. Check the IV catheter if it is intact.

b. Report broken catheter to the nurse in charge or the physician immediately.

c. If the broken piece can be palpated, apply a tourniquet above the insertion site.
11. Discard all waste materials including the IV cannula depending on hospital protocols. 12. Document the discontinuance, status of the insertion site, and integrity of IV catheter.

ALTERNATE VENOUS ACCESS DEVICES

1. Implantable Venous Access Devices
- used in the management of client with chronic illness who require long term IV therapy - this device provides repeated access to the central venous system while avoiding trauma and complications of multiple venipunctures

2. Central Venous Catheter

- a catheter inserted into a large vein located centrally into the body like in the vena cava or in the right atrium - tubing is radio-opaque so that it will show up on x-ray for continuation of its placement
Insertion sites include: a. subclavian: infraclavicular approach supraclavicular approach b. internal jugular vein c. peripheral vein

TYPES OF CENTRAL VENOUS ACCESS DEVICES

1. Peripheral Inserted Central Catheter (PICC)
- venipuncture is performed above or below the anticubital fossa into the basilic, cephalic, or axillary veins of the dominant arm - tip of the catheter is in the superior vena cava or brachiocephalic veins

- may stay in place for up to 6 months

Potential Complications:
- malposition - pneumothorax - dysrrhythmias - nerve/tendon damage

- resp. distress
- thrombophlebitis

- catheter embolism

Nursing Care:
- change dressing 2-3 times a week when wet or non-occlusive - flush with 2cc normal saline followed by 1 cc Heparin (11U/ml) into each lumen

2. Midline Catheter (MLC)

- increases in size 2 hours after insertion and becomes softer - venipuncture is 2-3 finger breaths above the antecubital fossa into thecephalic, basilic, or median cubital vein - tip of the cathete is between the antecubital fossa and the head of the clavicle - may stay in place of 1-8 weeks

Complications:
- thrombosis - phlebitis - bleeding - vascular perforation

- air embolism
Nursing Care:

- infection

- change dressing 2-3 times a week, and when wet or non-occlusive - flush line after each infusion or every 12 hours with 5-10 ml of normal saline followed by 1 ml Heparun (100/ml) - anchor catheter securely

3. Percutaneous Central Catheters

- inserted through the subclavian vein - triple lumen central catheter

a. distal lumen blood samples

b. middle lumen

- G. 16: use to infuse/draw

- G. 18: used for TPN infusions

c. Proximal Port- G. 18: used to infuse or draw blood and administer medications
- extreme right atrial catheters Hickman/Broviac & Groshong - subcutaneous port Huber needle used to access port through skin

Insertion:

- place supine in head-low position: dilates the vessels and prevents air embolism
- patient turns head away from site during procedure - while catheter is being inserted, patient performs Valsalva maneuver

- antibiotic ointment and transparent dressing applied using sterile technique

- verify position of tip of catheter by x-ray - each lumen is secured with Leur-lock cap, and labeled to indicate location (proximal, middle, distal)

Nursing Care:

- site or catheter changes every 4 weeks

- each lumen flushed initially then twice a day with diluted heparin to ensure patency

- flushed also after each infusion, specimen withdrawal or when disconnected

- never use force to flush catheter if resistance met, notify physician - dressing changes every 2-3 times a week and PRN place in low fowlers position

- nurse and patient should wear mask

- alcohol and iodine swabs are used to clean site - change IV tubing every 2-4 hours