intravenous parenteral therapy

8/4/2019 Intravenous Parenteral Therapy

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By the end of this lecture, students shall:

discuss the patient assessment required before

determining the need for IV cannulationidentify potential intravenous cannulation sites

determine cannula type and size

take precautions which must be undertaken wheninserting an intravenous cannula

know the theoretical and practical skills required to

perform intravenous cannulation


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participate in IV cannulation skills stations

demonstrating appropriate techniques and

environmental safety precautionsrecognize strategies to minimise IV cannulation

complications


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Intravenous infusion

(IV) is the installation of a

large amount of fluid

and/or electrolytes, or

nutrient substances into a

vein.

Venipuncture It is sterile technique that

permits insertion of aneedle or a catheter into avein .


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Two liters of water per day are generally sufficient

for adults

90-95% of patients in the hospital receive sometype of intravenous therapy.

It is based on a written doctors order


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Maintain & replace

body stores of water,

electrolytes, vitamins,

proteins, fat & calories

when patient or client

cannot maintain an

adequate intake bymouth

Provide nutrition while

resting the GI Tract


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Restore acid-base

balance

Restore volume ofblood components


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Provide avenue for the

administration of

medication

Administer diagnostic

reagents


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Diagnostic

Venous Blood Testing

Contrast Enhanced

Imaging

Therapeutic

Fluid Resuscitation

Medication Administration

Blood Product Transfusion

Parenteral Nutrition


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Administration of irritant

fluids or drugs through

peripheral access (i.e.highly concentrated, high

osmolarity solutions)


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Advantageused when patient

cannot take oral

medication

permits accurate dose

acts instantly

absorbed quickly by

the body

DisadvantageCarries risk like

bleeding, infiltration,

infection, and allergic

reactions

Limits patient activities

Costly costs more

than any other drug


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Physicians

Dentists

Nurses

Midwives

Pharmacists

Other licensed

health care

professionals


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The IV nurses are

registered nurses

committed to ensure the

safety of all patients

receiving IV therapy

An IV therapy nurse shallbe proficient and

competent in all clinical

aspects of the IV Therapy


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An IV therapy nurse shallperform procedures that

include but not limited to the ff:

Carry out MDs prescription forIV therapy

Perform peripheral

venipuncture (except insertion

of subclavian and cut-down

catheter)


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Prepare, initiate, monitor

and terminate IV therapy

Administer Blood and blood

components as prescribed

Determine solution and

medication incompatibilities

Change IV site, tubing and

dressings, according to IV

therapy standards


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Establish flow rates of solutions,

medications, blood and blood

components as prescribed by

the MDNursing management of

patients receiving IV therapy

and peripheral/central and

parenteral nutrition in various

set-ups (hospitals/home/others)


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Adherence to established

infection control practices

Observation and assessmentof all adverse reaction related

to IV therapy and initiation of

appropriate nursing

interventions


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Appropriate documentation

relevant to the preparation,

administration andtermination of all forms of

IV Therapy


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An IV therapy nurse

shall posses verbal

and writtencommunication

skills in translating

ideas and facts topatients, health

care members and

others


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An IV therapy nurse

have the responsibility

of educating patients

and significant others

on pertinent aspects of

IV therapy


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Continuing education

and staff development

are vital to professionaladvancement. In this

regard, the IV therapy

nurse actively participate

and share knowledge

with other disciplines.


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Legal therapeutic

prescription of a licensed

MD

Thorough knowledge of

the vascular system

Recognition of holistic

approach to patient care


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Individual profession

accountability

Networking and

linkages with external

environment

Collaboration with

members of health

team


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Assessment

Diagnosis

PlanningImplementation

Evaluation


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Sec. 27 (a) Art. V of R.A. 7164:

WHEREAS The Philippine

Nursing Act of 1991 providesthat intravenous injection is

within the scope of nursing and

that, in the administration of

intravenous injections, specialtraining shall be required

according to protocol

established.


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1. Obtain/Check

Doctors order


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Patients name

Type and amount of solution

Flow rate

Type, dose and frequency of

drugs

Others affecting the

procedures

MDs signature


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2. Select the

appropriate

equipment

3 Types of IV Systems

1. Luer Lock injection w/ J-loop2. IV fluid or medication on an

infusion pump

3. IV fluid Gravity Flow infusions

using the macro/microdrip or

Y type tubing


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This device maintainspatent venous access in

patients receiving IV

therapy regularly or

intermittently


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To transfuse accurate dosages

To deliver very large or small

amount of fluid accuratelyTo minimize risk for fluid

overload


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Emergency fluid

resuscitation

Short term medication

infusionBlood and blood products

Colloid administration


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Protective cap

Spike

Medication port

Drip chamber

Tubing

Nozzle/ thumbwheel/roller

clamp/ regulator


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Rubber medication port/ y-port

Luer connector/ connector


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Whats

wrongwith this

picture?


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Determine the following:

Purpose of infusion

Type of infusion

Size and condition of the patients vein

Duration of treatment

Condition of patient


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G26 - neonates

G24 - children/elderly/medical/post op surgical

patients

G22 - children/medical/post op surgical patients

G20 - adult/medical/ post op surgical patients

G18 - surgical patients/ BT

G16 - trauma patients

G14 - trauma patients


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Types of IVcannula


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Parts of IV

Cannula


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with smaller gauges (e.g.

14 ga) representing largerdiameters than larger

gauges (e.g. 20 ga).


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should always be

maintained to protect

the patient, the personperforming the

procedure, and other

individuals involved in

all aspects of care


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Consider Patients:

Medical history

Age

Body sizeWeight

Conditions of vein and skin

Type of fluid/medicationDuration of therapy

Skill at venipuncture


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Ease of access

Use of the non-

dominant extremity

Avoiding joint areas

Avoiding use of the

lower extremities


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Hand Veins Arm Veins


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Foot Veins Jugular Vein


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A vein thats suitable for

venipuncture should

feel round, firm, elastic,

and engorgednothard, bumpy, or flat.


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Successful cannulation

of a peripheral vein

requires proper site

selection, as well asknowledge of the gross

anatomy of a vein.


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Flexed areas

Extensive scars

HematomaInfiltration of

phlebitis site

FistulaSkin disease

Reminder:

If the patients chosen IVsite is hairy, dont

shave the area, instead,

clip/cut the hair.

The IV site and IV tubing

is good for 72 hours


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Dehydration/Hypovolemia

Chronic illness with venous scarring from frequent

IV accessIV drug use with venous scarring

Obesity

Significant edemaTortuous, fragile vessels due to advanced age

Thin vessel walls due to age, steroid use, certain

disease conditions


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3 Fluid Types:

Isotonic

Hypotonic

Hypertonic

REMINDER:

A bottle (1000ml or

500ml) of IVF is good

for 24 hours only. If notconsumed, discard and

hook a new IVF


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Crystalloid

Clear IV Fluid

Colloid

Murky

Dark Fluid


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Same osmolarity as

serum

Remain inside

intravascular

For hypotensive /

HypovolemiaRisk for overload

Examples:

PNSS - Plain Normal Saline

Solution or 0.9 % NaCl

Solution (green)

D5W (5% dextrose in

water) (red)

PLRS - Plain LactatedRingers Solution

(dark blue)


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Less osmolarity than

serum

Causes swelling of the

cells

For dehydration

For hyperglycemia

May cause increasedICP and cardiovascular

collapse

Examples:

Distilled water

0.18% NaCl0.45% NaCl (half

strength normal saline)

0.33% NaCl ( one third

strength normal saline)


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Higher osmolarity

than serum

Shrinking of cellsFor BP stabilization,

increase urine

output, reduce

edema

Examples:Blood products

Albumin

D5NSS (5% Dextrose in normalsaline solution)

D5 in 0.45% NaCl ( 5% Dextrose

in half strength normal saline)

D5LR (5% Dextrose in LactatedRinger's Solution)

D10W ( 10% Dextrose in water)

D50W50 (50% Dextrose in 50

ml of water)


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Hypertonicsolution

No fluid

movement

Fluid

movementinto veins

Fluid

movement

out of veins

Isotonic

solution

Hypotonic

solution


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STARTING

AN IV


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1. Apply tourniquet 5-6

inches above insertion

site

2. Never leave tourniqueton longer than one

minute

3. Then Remove tourniquet

and prepare equipment


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4. Open equipment and connect

flush to J-loop

5. Loosen caps of IV and J-loop

but leave in place for sterility.(They should just slide off when you pickup the device).

6. Cleanse skin with alcohol

solution in back & forth

motion X 30 seconds


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7. Allow to dry for 30 seconds

8. Put on Gloves!!!


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9. Immobilize vein

10. Position needle 10-15 degree

angle over site11. Insert cannula bevel up

12. Watch for blood backflow


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13. Advance cannula


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14. Advance cannula while holding stylet stationary

15. Release tourniquet!!

Stabilize the hub of the canula


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16.Withdraw stylet while putting pressure on veinabove injection site




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17. Insert tubing or prn adaptor

Apply pressure aboveinsertion site to slowbleeding

Stabilize the hub of the canulawhile inserting the tubing

Saline flush is already attached and tubingflushed and ready


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18. Flush with saline to clear tubing and insure IV has notinfiltrated.

19. Stabilize tubing with tape to prevent IV from pulling

out while applying the sterile dressing.

Leave the end of the hub of


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Leave the end of the hub ofthe canula outside thedressing so that tubing can bechanged without removing the

dressing.


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21. Date, time and initial site and tubing


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Local Complications:

Hematoma

ThrombosisPhlebitis

Infiltration/

Extravasation

Local infection

Allergic reactions

Systemic Complications:

Venous spasm

Speed shockSepticemia

Air embolism

Circulatory overloadCatheter embolism


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formations resulting

from the infiltration

of blood into the

tissues at the

venipuncture site

Causes:nicking the vein during

an unsuccessful

venipuncture attemptdiscontinuing the I.V.

cannula or needle

without pressure

applying a tourniquet

too tightly above a

previously attempted

venipuncture site


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discoloration of the skin,

site swelling and discomfort

inability to advance the

cannula all the way into the

vein during insertion,

resistance to positive

pressure during the lickflushing procedure


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Choose vein appropriately Location

Size

Soft, spongy, resilient

No pain or tenderness or rednesswith injection

Release torniquet as soon asinsertion is achieved

Remove IV

Check for bleeding


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Inflammation of the vein

wallprecursor to sepsis

What causes phlebitis?

IV left in too long

Cannula too large

Vein in poor conditionAcidic solution or high

osmolality

Infusion rate too fast


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Redness

Puffy area

Hard vein on

palpation

Increase bodytemperature


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Choose vein appropriately

Removed IV

Cold then Warm compress

Elevate site

Notify MD

Restart at large vein or use small

gauge cannula


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Leaking ofnonvesicant fluid

into tissues

surrounding the

vein

Cause : Cannuladislodgement or

perforation of wall

of vein


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Complications: Nerve compression


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coolness of skin around

site

taut skin

dependent edema

absence of blood

backflow

pinkish blood returninfusion rate slows but

the fluid continues to

infuse


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Inadvertent administration of vesicantdrug into surrounding tissues

Calcium

Magnesium

Phenergan

Potassium chloride

Antibiotics

Chemotherapy drugs

Vasopressors(Dopamine,epinephrine)

Dextrose > 10%

Lorazepam

Dilantin


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Mild

Extravasation


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Moderate

Extravasation


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complaints of pain or burning

swelling proximal to or distal

to the IV site

Puffiness limbskin tightness at the

venipuncture site

blanching and coolness of the

skin

slow or stopped infusion

damp or wet dressing


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Stop infusion immediately

Determine treatment prior to removal ofcatheter

Administer prescribed antidoteimmediately

Elevate extremity

Apply ice for 20 min q 4 hrs when indicated

Notify MDDont use same extremity for subsequentIV catheter placement if possible


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> 200,000 infections

per year

More than 60,000

patients die annuallyfrom bloodstream

infections caused by

intravenous therapy

Cost is so expensive


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Cellulitis:

An acute, spreading,

bacterial infection

below the surface of

the skin characterized

by redness

(erythema), warmth,swelling, and pain.

Sepsis:

clinical symptoms of

systemic illness, such

as fever, chills,

malaise, hypotension,

and mental status

changes.


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Poor insertion site

Squad starts

Unsterile startIV left too long

Hub contamination


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Cellulitis


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Check IV site every two hours

Removed IV & restart new site

Warm compress & elevate limbs

Check for pulse & numbness

Notify MD

May start Antibiotic as

prescribed


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If air is introduced into thevascular system, it may

accumulate and cause

complications such asblockage of the right side of

the vascular system (i.e.

venous) leading to outflow

obstruction of the right

ventricle and pulmonary

arteries.


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5 ml / kg of air is needed toproduce an "air lock" of the

right ventricle and

pulmonary artery, circulatorycollapse has been reported

with as little as 20cc of air.


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impaired gas exchangeHypotension

circulatory collapse


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all tubing should be flushed

prior to utilization.

all connections must be tightfluid bags should not be

allowed to completely empty

before replacement.

patient should be placed in a

left lateral recumbent


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intravenous parenteral therapy

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