INTRAVENOUS PARENTERAL THERAPY Definition Intravenous (IV) therapy is the insertion of needle or catheter / cannula into a vein, based on the physician’s written prescription. The needle or catheter/cannula is attached to sterile tubing and a fluid container to provide medication and fluids. Philosophy Historical background of IV Therapy The record history of i.v. therapy began in 1492 when a blood transfusion from two Romans to the dying Pope Innocent was attempted. All three died. In 1628, Sir William Harvey’s discovery of the blood circulatory system formed the basis for more scientific experimentation. In 1658 Sir Christopher Wren predicted the p ossibility of introducing medication directly into the bloodstream, although it was Dr. Robert Boyle who used a quill and bladder to inject opium into a dog 1659, 165 9, with J D Major succeeding with the first injection into human in 1665. A 15 year old Parisian boy successfully received a transfusion of lamb’s blood in 1667. However, subsequent animal to human transfusions proved fatal and eventually, in 1687, the practice was made illegal. In 1834, James Bludell proved that only human blood was suitable for transfusion, and later the century Pastuer and Lister stressed the necessity for sepsis during infusion procedures. In 1900 Karl Landsteiner led the way in identifying and classifying different blood groups, and in 1914 it was recognized that sodium citrate prevented clotting which opened the gate for the extensive use of blood transfusions. Intravenous therapy was being used widely during World War II, and by the mid-1950s was being used mainly for the purposes of o f major surgery and rehydration only. Few medications were given via i.v. route, with antibiotics more commonly being given intramuscularly. Through the 1960s and 1970s, intermittent medications, filters, electronic infusion control devices and smaller plastic cannulae became available. Use of multiple electrolyte solutions and medications increased along with blood component therapy, and numerous i.v. drugs and antibiotics were being added to i.v. regimens. The use of i.v. therapy has expanded dramatically over the last 35 years. This expansion continues to accelerate and can be attributed to the following factors: •
The understanding of hazards and complication
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Improvement in i.v. equipment
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Increased knowledge of physiological requirements
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Increased knowledge of pharmacological and therapeutic implications
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Increased availability of nutrients and drugs in i.v. solutions
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Changes in the traditional roles of doctors and nurses, allowing nurses to develop skills that were traditionally the remit of the medical profession (e.g. insertion of central venous access devices).
Here in the Philippines, the Nursing Standards on Intravenous Practice was established in 1993 as a guide for those who who are and will be practicing practicing intravenous therapy. During the first first months after the promulgation of the professional regulations Commission (PRC), Board of Nursing (BON) Resolution No. 08 series, February 4, 1994, the maiden issues (First Edition) of the Intravenous Standards on Intravenous Therapy was printed and circulated. It was first used in Cagayan de Oro City where the Training for Trainers was conducted last June 9-11, 1994, after the ANSAP Board Members and Advisers had und ergone the Training for trainers at Philippine Heart Center on October 1993. Subsequently, another revision was required to incorporate the PRC-BON’s protocol of May 17, 1995. Because of the new concept and evolving technology, more revisions were deemed necessary. Revisions were made by a special committee of the Association of Nursing Service Administrators of the Philippines, Inc. (ANSAP) in collaboration with the PRC-BON, to ensure a safe and quality nursing practice in Intravenous therapy in 2002. The new Nursing Law RA 9173 has stated that the administration of parenteral injection is in the scope of n ursing practice. ANSAP believes that the certification of IV Therapist will be continued for several reasons, paramount of which is safe nursing practice.
•
Improvement in i.v. equipment
•
Increased knowledge of physiological requirements
•
Increased knowledge of pharmacological and therapeutic implications
•
Increased availability of nutrients and drugs in i.v. solutions
•
Changes in the traditional roles of doctors and nurses, allowing nurses to develop skills that were traditionally the remit of the medical profession (e.g. insertion of central venous access devices).
Here in the Philippines, the Nursing Standards on Intravenous Practice was established in 1993 as a guide for those who who are and will be practicing practicing intravenous therapy. During the first first months after the promulgation of the professional regulations Commission (PRC), Board of Nursing (BON) Resolution No. 08 series, February 4, 1994, the maiden issues (First Edition) of the Intravenous Standards on Intravenous Therapy was printed and circulated. It was first used in Cagayan de Oro City where the Training for Trainers was conducted last June 9-11, 1994, after the ANSAP Board Members and Advisers had und ergone the Training for trainers at Philippine Heart Center on October 1993. Subsequently, another revision was required to incorporate the PRC-BON’s protocol of May 17, 1995. Because of the new concept and evolving technology, more revisions were deemed necessary. Revisions were made by a special committee of the Association of Nursing Service Administrators of the Philippines, Inc. (ANSAP) in collaboration with the PRC-BON, to ensure a safe and quality nursing practice in Intravenous therapy in 2002. The new Nursing Law RA 9173 has stated that the administration of parenteral injection is in the scope of n ursing practice. ANSAP believes that the certification of IV Therapist will be continued for several reasons, paramount of which is safe nursing practice.
Standard and competencies of IV therapy Standard Operating Policies and Procedure are established to ensure safe IV therapy practice, to protect the patients by maximizing benefits and minimizing risks associated with IV therapy and to protect the practice of registered professional IV therapy nurses. The IV therapy policies and procedures are written and continuously updated and reviewed as necessary. nece ssary. 1. Key poin points ts prior prior to to initi initiati ation on of IV IV therap therapy y a. Physician’ Physician’ss prescribed prescribed treatmen treatment. t. The initiati initiation on of intravenous intravenous therapy therapy is is upon the written prescription of a licensed physician which is checked for the following:
Patient’s Name
Type and amount of solution
The flow rate
The type, dose and frequency of medication to be incorporated/pushed.
Others affecting the procedure (x-rays, treatment to the extremities, etc)
b. b. Pati Patient ent Asse Assess ssme ment nt Factors to consider for IV therapy
Clinical status of patient
Patient’s diagnosis
Patient’s age
Dominant arm ( non)
Condition of vein/ skin
Cannula size
Type of solution
Duration of therapy
c. IV set and equipment preparation
Check for expiration date Check for clarity; any presence of holes on plastic cover (packaging); plastic container (bag) for presence of sediments or insects.
Check label against the physician’s written prescription
Label for any medication that are added: date, time, dose of medication and amount; compatibility of drug with the solution.
Functionality of infusion pump, patient controlled analgesia (PCA)
d. Medications Nurses administering IV therapy should have knowledge on all medications administered including dosages, drug interaction and possible clinical effects on the vascular system. 10 GOLDEN RULES FOR ADMINISTERING DRUGS SAFELY 1. Administer the right drug. 2. Administer the right drug to the right patient. 3. Administer the right dose. 4. Administer the right drug by the right route. 5. Administer the right drug at the time. 6. Document each drug you administer. 7. Teach your patient about the drug he is receiving. 8. Take a complete patient drug history. 9. Find out if patient has drug allergies. 10. Be aware of potential drug – drug or drug-food interactions. Nursing 88 Vol. 18, August 1988 Cathleen McGovern, RN
Quality assuance Coordinator Edge Water Hospital Chicago, Illinois, USA
2. Competency a. Hand washing b. Assessing of vital signs c. Standard precautions d. Principles of aseptic technique e. Medication calculation f. Medication administration ANATOMY AND PHYSIOLOGY
Superficial veins of the upper limbs are usually selected for peripheral cannulation. Cannulation of the lower limbs is associated with an increased risk of venous thromboembolism. The wall of a vein is composed of three layers (Figure 1): •
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The tunica adventitia (the outer layer): a fibrous layer of connective tissue, collagen and nerve fibers which surrounds and supports the vessel. The tunica media (the middle layer): a muscular layer containing elastic tissue and smooth muscle fibers. The tunica intima (the inner layer): a thin layer of endothelium, which facilitates blood flow and prevents adherence of blood cells to the vessel wall. Trauma to the endothelium encourages platelet adherence and thrombus formation.
Figure 1. blood vessel structure.
Skin is composed of two main layers: Epidermis (skin surface): approximately 1mm thick containing sensory nerve endings. • Dermis (beneath the epidermis): thicker than the epidermis, composed of collagenous and • elastic connective tissue and containing fat, blood and lymph vessels, nerves, hair follicles, sweat glands and sebaceous glands. Ageing alters the structure and appearance of the skin. The dermal layers become thinner and there is less subcutaneous tissue to support the blood vessels. The veins of older people are often easier to see because of the reduction in subcutaneous tissue, particularly on the dorsum of the hand. The vessels are also more mobile, more fragile and often tortuous and thrombosed. The dorsum of the hand should be avoided in older people. Vein selection
Digital veins of the fingers are small and rarely used. The metacarpal veins and the dorsal venous arch are easily visualized and palpated. The radial end of the dorsal venous arch continues to form the cephalic vein while the ulnar end of the dorsal venous arch forms the basilic vein; all of these are suitable for cannulation (Figure 2).
Figure 2. The cephalic and basilic veins continue into the forearm. The basilic vein is often overlooked because it is inconspicuous, not easy to stabilize and can be difficult to access due to its location. However, the cephalic vein is large, easily stabilized and accessible (Figure 3).
Figure 3. The median cubital vein runs diagonally across the antecubital fossa connecting the basilic and the cephalic veins. There is great variation in the pattern of veins in this area. The median cubital vein is absent in 20 percent of the population (Moore and Dalley 1999). The veins of the antecubital fossa are usually easily visualized, palpated and accessed because of their superficial nature and size. However, their position over the flexor surface of the elbow makes these veins prone to mechanical phlebitis, and the cannula prone to failure from kinking or dislodgement. History taking and assessment should alert nursing staff to specific patient issues that should be considered when identifying a site for cannulation. A cannula should not be placed in areas of localized edema, dermatitis, cellulitis, arteriovenous fistulae, wounds, skin grafts, fractures, stroke, planned limb surgery and previous cannulation. Discussion with the patient is important. The patient may prefer the non-dominant limb to be selected for cannulation to remote independence and comfort. Both upper limbs should be inspected to identify possible veins for cannulation. Potential veins can then be palpated to assess their condition. An ideal vein is ‘soft and bouncy’ when palpated. Veins that are tender, thrombosed or hard should be avoided. Veins contain valves, crescent shaped folds of endothelium, which assist blood flow back to the heart. Valves are most plentiful in the veins of the limbs and occur more frequently at junctions where veins converge. Careful observation may reveal valves (small bulges) within the peripheral veins, which should be confirmed by palpation. Valves may prevent blood withdrawal and cannula advancement and, therefore, should be avoided. Palpation also allows the practitioner to differentiate between arteries and veins. Arteries are pulsatile and should be carefully avoided. New cannulae should be sited proximal to any previous sites to prevent drug or fluid infusion through damaged veins.
Cannulation procedure Position the patient comfortably. It may be helpful to support his or her arm on a pillow. • Wash hands and apply non-sterile gloves (Centers for Disease Control and Prevention • (CDC) 2002). Apply a tourniquet to the upper limb to improve venous filling. This should not obstruct arterial blood flow and the radial pulse should still be palpable. Ask the patient to open and close the fist to promote venous filling. • Clean the skin with a chlorhexidine-based solution and allow to dry. • Do not re-palpate the skin. Open the cannula carefully and ensure the stylet within the cannula is positioned with the bevel uppermost. Hold the patient’s arm or hand and use your thumb to pull the skin taut below the intended puncture site. This will stabilize and anch or the vein before cannulation. Hold the cannula in line with the vein at a 10-30˚ angle to the skin and insert the cannula through the skin. As the cannula enters the vein blood will be seen in the flashback chamber. Lower the cannula slightly to ensure it enters the lumen of the vein and does not puncture the posterior wall of the vessel. Withdraw the stylet slightly and blood should be seen to enter the cannula: this confirms the position in the vein. The stylet must not be re-inserted as this can damage the cannula, resulting in catheter embolus. Slowly advance the cannula into the vein, ensuring the vein remains anchored throughout • the procedure. Release the tourniquet. • Dispose of the stylet in the sharps’ container at the bedside. • Flush the cannula to check patency and to ensure easy administration without pain, resistance or localized swelling. Secure the cannula with a moisture-permeable transparent dressing (Royal College of Nursing (RCN) 2003. The dressing should allow viewing of the entry site while firmly stabilizing the cannula to prevent mechanical phlebitis or cannula dislodgement. Record the cannulation procedure in the patient’s notes, including device, gauge, location, nurse’s signature and number of insertion attempts. •
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FLUID AND ELECTROLYTE THERAPY
Types of therapy 1. Maintenance therapy Provides water, electrolytes, glucose, vitamins, and in some instances protein to meet daily requirements. 2. Restoration of deficits In addition to maintenance therapy, fluid and electrolytes are added to replace previous losses. 3. Replacement therapy Infusions to replace current losses in fluid and electrolytes.
Types of intravenous fluids 1. Isotonic solutions a. Fluids that approximate the osmolarity (280-300 mOsm/L) of normal blood p lasma. Sodium Chloride (0.9%) - Normal Saline • Indications: Extracellular fluid replacement when Cl- loss is equal to or greater the Na • loss. Treatment of matebolic alkalosis. • Na depletion • Initiating and terminating blood transfusions. • Possible side effects: Hypernatremia • Acidosis • Hypokalemia • Circulatory overload. • b. Five percent dextrose in water (D5W). Provides calories for energy, sparring body protein and preventing ketosis resulting from fat breakdown. Indications: Dehydration • Hypernatremia • Drug administration • Possible side effects: Hypokalemia • Osmotic diuresis – dehydration Transient hyperinsulinism • Water intoxication. • c. Five percent dextrose in normal saline (D5NS). Prevents ketone formation and loss of potassium and intracellular water. Indications: Hypovolemic shock – temporary measure. • Burns • Acute adrenocortical insufiency. • Possible side effects: Hypernatremia • Acidosis • Hypokalemia • Circulatory overload • d. Isotonic multiple-electrolyte fluids. Used for replacement therapy; ionic composition approximates blood plasma. Types: a. Plasmanate b. Polysol c. Lactated Ringers •
Indications: Vomiting • Diarrhea • Excessive diuresis • Burns • Possible side effects: Circulatory overload. • Lactated Ringers is contraindicated in severe metabolic acidosis and/or alkalosis • and liver disease. Hypernatremia • Acidosis • Hypokalemia • 2. Hypertonic solutions Fluids with an osmolarity much higher than 310 mOsm (+ 50 mOsm); increase osmotic pressure of blood plasma, thereby drawing fluid from cells. a. Ten percent dextrose in normal saline Administered in large vein to dilute and prevent venous trauma. Indications: Nutrition • Replenish Na and Cl. • Possible side effects: Hypernatremia (excess Na) • Acidosis (excess Cl) • Circulatory overload. • b. Sodium Chloride solutions, 3% and 5% Indications: Slow administration essential to prevent overload (100 mL/hr) • Water intoxication • Severe sodium depletion • 3. Hypotonic solutions Fluids whose osmolarity is significantly less than that of blood plasma (-50 mOsm); these fluids lower plasma osmotic pressure, causing fluid to enter cells. a. 0.45% sodium chloride Used for replacement when requirement for Na use is questionable. b. 2.5% dextrose in 0.45% saline, also 5% in 0.2 % NaCl Common rehydrating solution. Indications: Fluid replacement when some Na replacement is also necessary. • Encourage diuresis in clients who are dehydrated. • Evaluate kidney status before instituting electrolyte infusions. • Possible side effects: Hypernatremia • Circulatory overload •
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Used with caution in clients who are edematous, appropriate electrolytes should be given to avoid hypokalemia.
Table of Commonly Used IV Solutions Name of Solution 0.45% Sodium Chloride
Type of Solution
Hypotonic
Ingredients in 1-Liter 77 mEq Sodium
pH 5.6
77 mEq Chloride
Isotonic
154 mEq Sodium
pH 5.7
154 mEq Chloride
Hypertonic
513 mEq Sodium 513 mEq Chloride
Uses
Complications
hypotonic hydration; replace If too much is mixed with blood cells sodium and chloride; during transfusions, the cells will pull water hyperosmolar diabetes into them and rupture
Shorthand Notation: ½NS 0.9% Sodium Chloride Shorthand Notation:
isotonic hydration; replace None known sodium and chloride; alkalosis; blood transfusions (will not hemolyze blood cells)
NS 3% Sodium Chloride
pH 5.0 5% Sodium Chloride
Hypertonic
855 mEq Sodium 855 mEq Chloride
symptomatic hyponatremia rapid or continuous infusion can result in due toexcessive sweating, hypernatremia or vomiting, renal impairment, hyperchloremia and excessive water intake
pH 5.8 5% Dextrose in Isotonic Water pH 5.0 Shorthand Notation:
5 grams dextrose
isotonic hydration; provides some calories
(170 calories/liter) water intoxication and dilution of body’s electrolytes with long, continuous infusions
D5W 10% Dextrose in Water Shorthand Notation: D10W
Hypertonic
10 grams dextrose
may be infused peripherally;
pH 4.3
(340 calories/liter)
hypertonic hydration; provides some calories
5% Dextrose in Hypertonic 1/4 Strength (or 0.25%) Saline pH 4.4
5 grams Dextrose
Shorthand Notation:
34 mEq Chloride
34 mEq Sodium
fluid replacement; replacement of sodium, chloride and some calories vein irritation because of acidic pH, causes agglomeration (clustering) if used with blood transfusions; hyperglycemia with rapid infusion leading to osmotic diuresis
D5¼N 5% Dextrose in Hypertonic 0.45 Sodium pH 4.4 Chloride
5 grams Dextrose
Shorthand Notation:
77 mEq Chloride
77 mEq Sodium
hypertonic fluid replacement; replace sodium, chloride, and some calories
D5½NS 5% Dextrose in Hypertonic Normal Saline pH 4.4 Shorthand Notation:
5 grams Dextrose 154 mEq Sodium 154 mEq Chloride
hypertonic fluid replacement; replace sodium, chloride and some calories
Isotonic
147 mEq Sodium
pH 5.8
4 mEq Potassium
electrolyte replacement; hydration; often used to replace extracellular fluid losses
D5NS Ringer’s Injection, U.S.P.
4 mEq Calcium 155 mEq Chloride Lactated Ringer’s
Isotonic pH 6.6
Shorthand Notation: LR
130 mEq Sodium
rapid administration leads to excessive introduction of electrolytes and leads to fluid overload and congestive conditions; provides no calories and is not an adequate maintenance solution if abnormal fluid losses are present
isotonic hydration; replace electrolytes and extra4 mEq Potassium cellular fluid losses; mild to moderate acidosis (the lactate 3 mEq Calcium is metabolized into not enough electrolytes for maintenance; bicarbonate which patients with hepatic disease have trouble 109 mEq Chloride counteracts the acidosis) metabolizing the lactate; do not use if lactic acidosis is present 28 mEq Sodium Lactate (provides 9 calories/liter)
5% Dextrose in Hypertonic Lactated pH 4.9 Ringer’s Injection
Shorthand Notation: D5LR
5 grams Dextrose
hypertonic hydration; provides some calories; (170 calories/liter) replace electrolytes and extra130 mEq Sodium cellular fluid losses; mild to moderate acidosis (the lactate 4 mEq Potassium is metabolized into bicarbonate which 3 mEq Calcium counteracts the acidosis), the dextrose minimizes glycogen 109 mEq Chloride depletion 28 mEq Sodium Lactate (provides 9 calories/liter)
VENIPUNCTURE TECHNIQUE
Methods of vein entry There are different methods of vein entry for nee dles or over needle catheters; indirect, direct, direct, and bevel position either up or down. Use of over the needle cannula requires a different threading technique than a wing tip or scalp vein needle. With the wing tip usually use the bevel down position. The Bevel The bevel up method usually causes fewer traumas to the vein and is less painful for the patient; however, sometimes the bevel down position is better. If the needle and vein are approximately the same diameter, this position is likely to perforate the opposite wall of the vein on insertion causing a hematoma. This problem is less likely to occur in the bevel down position. Entering a vein successfully doesn’t guarantee that the vein won’t collapse and block the bevel when removing the tourniquet. In that case, manipulating the needle slight within the vein may relieve the blockage. A greater risk of perforating the opposite wall of the vein when the needle’s bevel is facing up. It is a good idea when entering a small vein with a large bore needle to use the bevel down position. Remember, a needle that is properly placed in the vein can be palpated. If not, probably it has gone through the vein. Remove the needle promptly and reinsert. Indirect method The first movement, penetrate the skin at a 54 degree angle to side of the vein about ½” below the point of the venipuncture, then decrease the needle angle until the is almost parallel to the skin surface.
The second movement , penetrate the vessel wall and advance the needle cautiously while lifting the vein with slight upward pressure. Watch for the back flow to confirm proper placement of the needle/catheter. If using the catheter, over the needle, advance the catheter while removing the needle. Never reinsert the needle into the catheter which may cause shearing off of the tip of the catheter leading to catheter embolus. Since the needle protrudes further than the catheter, need to be sure that the catheter itself is in the vein, not just the needle. Direct method In the direct method the needle is at 30 degree angle over the vein and is inserted in the direction of the blood flow. The vein is penetrated in one movement by approaching the vessel from the top or side. This method of venipuncture requires considerable more skill then the indirect method, but it is less painful for the patient when done correctly. When trying to penetrate the skin, be sure to hold the skin taught. This will cause fewer trauma and less pain. Before insertion, measure the cannula against the vein to be sure the cannula will clear joints and nodules to ease threading. Some veins have a tendency to roll or move away. Pull down on them slight and hold tension for easier penetration. Do not spend too much time probing. Gently feel for the tip of the cannula in relation to the vein to give some idea if it is below, to the right, or left of the vein. If cannot stabilize the vein or if it disappears, remove the cannula and attempt venipuncture in another vein. Methods of stabilizing the venipuncture site Chevron method Using a strip of tape ¼” to ½” wide apply sticky side up in a “V” formation. Apply a piece of 1” tape across the two wings of the chevron. The loop the tubing and secure it with another piece of 1” tape. This method can be used with both plastic cannula/ catheter and wingtip needle. U method Using a strip of tape ¼” to ½” wide place with a sticky side up under the hub folding each tape tail over each corresponding wing in the U formation. Use this method with wingtip needle. H method Place one strip of 1” tape over each wing. Then place another piece of 1” tape horizontally over the first two forming the letter H. This method is suitable for securing the wingtip needle.
INTRAVENOUS THERAPY COMPLICATIONS 1. LOCAL COMPLICATIONS
a. Infiltration b.
Extravasation
c. Thrombosis d. Thrombophlebitis e. Phlebitis 2. SYSTEMIC COMPLICATIONS
a. Embolism b. Pulmonary embolism c. Air embolism d. Catheter embolism e. Hematoma f. Systemic infection g. Speedshock h. Circulatory overload i.
Allergic reaction
INFILTRATION
Results when the infusion cannula becomes dislodged from the vein and fluids are infused into the surrounding tissues. Cause Device dislodged from vein or perforated vein Signs & Symptoms •
Increasing edema at the site of the infusion
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Discomfort, burning, pain at site
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Feeling of tightness at site
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Decreased skin temperature around site
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Blanching at site
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Absent backflow of blood
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Slower flow rate
Nursing intervention Remove the device Apply warm soaks to aid absorption Elevate the limb Notify the doctor if severe Assess circulation Restart the infusion Document the patient's condition and your interventions Prevention Check the I.V site frequently Don't obscure area above site with tape Teach the patient to report discomfort, pain, swelling
EXTRAVASATION
It occurs when fluids seep out from the lumen of a vessel into the surrounding tissue. Causes Damage to the posterior wall of the vein Occlusion of the vein proximal to the injection site Signs & Symptoms Swelling Discomfort Burning Tightness Coolness in the adjacent skin Slow flow rate Nursing Interventions
Immediately stop the infusion and remove the dev ice Elevate the affected limb Apply cold compress to decrease edema and pain Apply moist heat to facilitate the absorption of fluid at grossly infiltrated sites DRUGS ASSOCIATED WITH EXTRAVASATION NECROSIS
Generic Name
Brand Name
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Calcium chloride
Various
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Calcium gluconate
Various
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Dacarbazine
DTIC
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Dactinomycin
Cosmogen
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Daunorubicin
Cerubidine
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Dopamine
Various
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Doxorubicin
Adriamycin
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Idarubicin
Idamycin
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Mechlorethamine
Mustargen
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Mitomycin C
Mutamycin
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Plicamycin
Mithracin
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Streptozocin
Zanosar
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Teniposide
Vumon
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Vancomycin
Various
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Vinblastine
Velban
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Vincristine
Oncovin
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Vinorelbine
Navelbine
THROMBOSIS
Occurs when blood flow through a vein is obstructed by a local thrombus. Catheterrelated thrombosis arises as a result of injury to the endothelial cells of the venous wall. Cause
Injury to endothelial cells of vein wall, allowing platelets to adhere and thrombus form Signs & Symptoms Painful, reddened, & swollen vein Sluggish or stopped I.V flow Nursing Interventions Remove the device; restart the infusion in the opposite limb if possible Apply warm soaks Watch for I.V therapy – related infection Prevention Use proper venipuncture techniques to reduce injury to the vein THROMBOPHLEBITIS
Occurs when thrombosis is accompanied by inflammation. Infusions allowed to continue after thrombophlebitis develops will slow and eventually stop, indicating progression to an obstructive thrombophlebitis. All thrombotic complications have the associated danger of embolism, especially in cases where the thrombus is not well attached to the wall of the vein.
Signs & Symptoms Local tenderness Swelling Induration A red line detectable above the IV site. Recommendations to Reduce the Risk of Thrombotic Complications 1. 2. 3. 4. 5.
Use veins in the upper extremities Avoid placing catheters over joint flexions Select veins with adequate blood volume for solution characteristics Anchor cannulas securely Avoid multiple venipunctures
PHLEBITIS inflammation of a vein that may be caused by infection, the mere presence of a foreign body (the IV catheter) or the fluids or medication being given.
Causes: Injury during Venipuncture Prolonged use of the same IV site irritating./incompatible IV additives Use of vein that is too small for the flow rate Use of needle size too large for the vein size Signs & Symptoms Pain Vein that is sore, hard, cord like and warm to touch Red line above the site Signs of infection Phlebitis Rating 0 = No symptoms 1 = Erythema at site with or without pain 2 = pain at site, erythema and/or edema; no streak, no palpable cord 3 = pain at site, erythema and/or edema; streak present; palpable cord 4 = pain at site, erythema and/or edema; streak present; palpable cord > 1 inch; purulentdrainage Common Medication that can cause Phlebitis Phenytoin Diazepam Erythromycin Tetracycline Vancomycin Amphothericin B 40 mEq/L or more doses of KCL Nursing Interventions Upon assessment of phlebitis, removal the needle Avoid multiple insertion Application of warm compress Continuously monitor the patient- vital signs
PULMONARY EMBOLISM
It associated with venous access devices is usually the result of a thrombus that has become detached from the wall of the vein. It is carried by the venous circulation to the right side of the heart and then into the pulmonary artery. Circulatory and cardiac abnormalities are caused by full or partial obstruction of the pulmonary artery, with possible progression to pulmonary hypertension and right-sided heart failure. AIR EMBOLISM
Occurs most frequently with the use of central venou s access devices. Occur with the insertion of an IV catheter, during manipulation of the catheter or catheter site when the device is removed, or when IV lines associated with the catheter are disconnected. CATHETER EMBOLISM
This can occur during the insertion of a catheter if appropriate placement techniques are not strictly adhered to. The tip of the needle used during the placement of the catheter can shear off the tip of the catheter. The catheter tip then becomes a free-floating embolus. This can occur with both over-the-needle and through-the-needle ca theters. If this happens, cardiac catheterization may be required to remove the embolus. Signs & Symptoms Sudden vascular collapse with the hallmark symptoms of cyanosis, hypotension, increased venous pressures, and rapid loss of consciousness. Respiratory distress Unequal breath sounds Weak pulse Causes Empty solution container Solution container empties; next container pushes air down line Tubing disconnected from venous access device or I.V bag Nursing Interventions Discontinue the infusion Place the patient in Trendelenburg position on his left side to allow air to enter the right atrium and disperse through the pulmonary artery. Administer oxygen Notify the doctor Document the patient's condition and your interventions.
HEMATOMA
Blod accumulation resulting from the infiltration of blood into the tissues at the venipuncture site Causes:: Coagulation defects Inappropriate use of tourniquet Unsuccessful insertion attempts Little pressure upon removal of cannula Discoloration of the tissue at the IV site Nursing Interventions Frequent assessment of the site Upon insertion, slowly advance the needle to prevent puncturing both vein walls Discontinue therapy if with edema Apply pressure for at least 5 minutes upon removal
SYSTEMIC INFECTION
If bacteria do not remain in one area but spread through the bloodstream, the infection is called septicemia and can be rapid and life-threatening. An infected central IV poses a higher risk of septicemia, as it can deliver bacteria directly into the central circulation. Caused by: Staphylococcuaureus, Klebsiella, Serratia, Pseudomonas Aeruginosa Signs & symptoms Fever, chills, & malaise for no apparent reason Contaminated I.V site, usually with no visible signs of infection at site Causes Failure to maintain aseptic technique during insertion or site care Severe phlebitis, which can set up ideal conditions for organisms growth Poor taping Prolonged indwelling time of device Immunocompromised patient
Nursing Interventions Notify the doctor. Administer medications as prescribed Culture the site and the device Monitor the patient's vital signs Prevention Use scrupulous aseptic technique Secure all connections Change I.V solutions, tubing and venous access device at recommended times Use I.V filters Management and Prevention Tips •
Assess catheter site daily
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Accurately document visual inspection and palpation data.
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Refer to physician for any suspected infection.
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Use maximal sterile-barrier precautions during insertion (sterile technique)
Practice good hand hygiene before and after palpating, inserting, replacing, or dressing any intravascular device. •
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If any part of the system is disconnected, don’t rejoin it
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Remove at first sign of infection
Replace site, tubings and bags per policy example: change set= 72 hours, TPN and single use of antibiotics=24 hrs •
SPEEDSHOCK
Rapid introduction of a foreign substance, usually a medication, into the circulation. Signs & Symptoms •
Flushed face
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Headache
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Tight feeling in the chest
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Irregular pulse
In extreme cases: •
Loss of consciousness
Nursing Interventions
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STOP the infusion
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Careful monitoring of IV flow rate and patient response. Maintain prescribed
rate. •
Know the actions and side effects of the drug being administered
Nursing Interventions Use of IV pumps when indicated Begin infusion of 5% dextrose at a KVO rate in emergency cases Evaluate circulatory and neurologic status Notify the physician CIRCULATORY OVERLOAD
An excess of fluid disrupting homeostasis caused by infusion at a rate greater than the patient’s system is able to accommodate Signs & Symptoms •
Shortness of breath
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Elevated blood pressure
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Bounding pulse
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Jugular vein distention
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Increased Respiratory rate
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Edema
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Crackles or rhonchi upon auscultation
Causes Roller clamp loosened to allow run – on infusion Flow rate too rapid Miscalculation of fluid requirements Nursing Interventions Raise the head of the bed Slow the infusion rate Administer oxygen as needed
Notify the doctor Administer medications as ordered ALLERGIC REACTION
Maybe a Local or generalized response to tape, cleansing agent, medication, solution or intravenous device Signs & Symptoms SYSTEMIC •
Runny nose
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Tearing
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Bronchospasm
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Wheezing
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Generalized rash
LOCAL •
Wheal
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Redness
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Itching at the site
Nursing Interventions If reaction occurs, stop the infusion immediately and infuse normal saline solution. •
•
•
Maintain a patent airway. Notify the doctor.
Administer antihistaminic steroid, anti – inflammatory, & antipyretic drugs, as ordered. •
Give 0.2 to 0.5ml of aqueous epinephrine subcutaneously. Repeat at 3-minute intervals and as needed, as ordered •
FLUID OVERLOAD
This occurs when fluids are given at a higher rate or in a larger volume than the system can absorb or excrete. Possible consequences include hypertension, heart failure, and pulmonary edema.
INFECTION CONTROL
Infection at the venipuncture site is usually causd by a break in aseptic technique during the procedure. The following measures reduce patient’s risk: •
Wash hands before starting an IV or before handling any of the IV equipment.
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Use a approved antiseptic ( as per hospital’s protocol) to clean the patient’s skin.
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Cut/ clip the hairs of the venipuncture site if necessary. Do not share.
Documentation of IV therapy Proper documentation provides: •
An accurate description of care that can serve as legal protection.
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A mechanism for recording and r etrieving information.
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A record for health insurers and retrieving information documenting the insertion of a venipuncture devise or the beginning of therapy
a.
The following information of acre that can serve as legal protection: •
•
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Size, type, and length of cannula/needle Name of person who inserted the IV catheter Date and time of insertion
b. Label the IV solution specifying:
c.
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Type of IV fluid
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Medication additives and flow rate
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Use of any electronic infusion devise
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Duration of therapy and nurse’s signature
In additional documentation following information is documented in the patient’s chart: •
Location of and condition of insertion site
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Complications, patient’s response and nursing interventions
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Patient teaching and evidence of patient understanding (for example ability to explain instruction or perform a return demonstration).
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Signature of nurse
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Other observations
IV THERAPY PROCEDURE
A. Setting up B. Inserting IV utilizing the dummy arm C. Changing an IV solution
D. Discontinuing an IV infusion Steps A. Setting up 1. Verify written prescription and make IV label 2. Observe ten (10) Rs when preparing and administering IVF. 3. Explain procedure to reassure patient and/or significant others, secure consent if necessary. 4. Assess patient’s vein; choose appropriate site location, size/ condition.
5. Do hand hygiene before and after the procedure. 6. Prepare necessary materials for procedure (IV tray with IV solution, administration set, IV cannula, forceps soaked in antiseptic solution, alcohol swabs or cotton balls soaked in alcohol with cover (this should be exclusively used for IV), plaster, tourniquet, glove, splint, ad IV hook, sterile 2x2 gauze or transparent dressing. 7. Check the sterility and integrity of the IV solution, IV set and other devices. 8. Place IV label on IVF bottle duly signed by RN who prepared it (patient’s name, room no.,
solution, drug incorporation, bottle sequence and duration, time and date). 9. Open the seal of the IV infusion aseptically and disinfect rubber port with cotton ball with alcohol. 10. Open IV administration set aseptically and close the roller clamp and spike the infusate
container aseptically. 11. Fill drip chamber to at least half and prime it with IV fluid aseptically. 12. Expel air bubbles if any and put back the cover to the distal end of the IV set (get ready for
IV insertion). B. Inserting IV utilizing the dummy arm 1. Verify the written prescription for IV therapy; check prepared IVF and other things needed.
2. Explain procedure to assure the patient and significant others and observed the 10 R’s. 3. Do hand hygiene before and after the procedure. 4. Choose site for IV 5. Apply tourniquet 5 to 122 cm (2-6 inches) above injection site depending on condition of patient. 6. Check for radial pulse below tourniquet.
7. Prepare site with effective topical antiseptic according to hospital policy or cotton balls with alcohol in circular motion and allow 30 seconds to dry. ( no touch technique) Note: CDC Universal precaution: always wear gloves when doing any venipuncture. 8. Using the appropriate IV cannula, pierce skin with needle positioned on a 15-30 degree angle. 9. Upon flashback visualization decrease the angle, advance the catheter and stylet (1/4 inch)
into the vein, check if tip of catheter can be rotated freely inside the vein... 10. Position the IV catheter parallel to the skin. Hold stylet stationary and slowly advance the
catheter until the hub is 1 mm to the puncture site. 11. Slip sterile gauze under the hub. Release the tourniquet; remove the stylet while applying
digital pressure over the catheter with one finger about 1-2 inches from the tip of the inserted catheter. 12. Connect the infusion tubing of the prepared IVF aseptically to the IV catheter. 13. Open the clamp, regulate the flow rate, reassure patient. 14. Anchor needle firmly in place with the use of: a.
Transparent tape/ dressing directly on the puncture site.
b. Tape ( using any appropriate anchoring style) c.
Band-aid
15. Tape a small loop of IV tubing for additional anchoring ; apply splint ( if needed) 16. Calibrate the IVF bottle and regulate flow of infusion according to prescribed duration.
17. Label on IV tape near the IV site to indicate date of insertion, type and gauze of IV catheter and countersign. 18. Label with plaster on the IV tubing to indicate the date when to change the IV tubing. 19. Observe patient and report any untoward effect. 20. Document in the patient’s chart and endorse to incoming shift. 21. Discard sharps and waste according to Health Care Waste Management (DOH/ DENR).
C. Changing an IV solution 1. Verify doctor’s prescription in doctor’s order sheet; countercheck IV label, IV card, infusate
sequence, type, amount, additives (if any), and duration of infusion. 2. Observe ten (10) Rs.
3. Explain procedure to reassure the patient and significant other and assess IV site for redness, swelling, pain and etc. 4. Change IV tubing and cannula if 48-72 hrs. Has lapsed after IV infusion. 5. Wash hands before and after the procedure. 6. Prepare necessary materials; place on IV tray. 7. Check sterility and integrity of IV solution. 8. Place IV label on the IV bottle.
9. Calibrate new IV bottle according to duration of infusion as per prescription. 10. Open and disinfect rubber port of IV solution to follow. 11. Close the roller clamp and spike the container aseptically. 12. Regulate the flow based on the prescribed infusion rate of infusion. Expel air bubbles (if any). 13. Reiterate assurance to patient and significant others. 14. Discard all waste materials according to health care waste management. 15. Document and endorse accordingly. D. Discontinuing an IV infusion 1. Verify written doctor’s order to discontinue IV including IV medicines. 2. Observe ten (10) Rs. 3. Assess and inform the patient of the discontinuation of IV infusion and of any medicine. 4. Prepare the necessary materials; IV tray or injection tray with sterile cotton balls with alcohol, plaster, pick-up forceps in antiseptic solution, kidney basin band aid. 5. Wash hands before and after procedure. 6. Close the roller clamp of the IV administration set.
7. Moisten adhesive tapes around the IV catheter with cotton ball with alcohol; remove plaster gently. 8. Use pick-up forceps to get cotton balls with alcohol and without applying pressure, remove
needle or IV catheter then immediately apply pressure over the venipuncture site. 9. Inspect IV catheter for completeness.
