11

RN Skills LaboratoryRN Skills LaboratoryIntravenous TherapyIntravenous Therapy

West Coast UniversityWest Coast University

Week 7Week 7

ObjectivesObjectives

IV therapy overviewIV therapy overview Type of fluidsType of fluids IV drop factors & calculationsIV drop factors & calculations IVPBsIVPBs IVPsIVPs Central LinesCentral Lines Blood and Blood ProductsBlood and Blood Products TPNTPN

IV TherapyIV Therapy

IV therapy – peripheralIV therapy – peripheral Admission criteria in hospitalAdmission criteria in hospital Surgical, transfusion patientsSurgical, transfusion patients Hydration, restoring fluids/electrolyte imbalanceHydration, restoring fluids/electrolyte imbalance Administration of drugsAdministration of drugs

Side affectsSide affects Bleeding, infiltration, infection, hearing loss, bone Bleeding, infiltration, infection, hearing loss, bone

marrow suppression, kidney and heart damagemarrow suppression, kidney and heart damage Is not long-term therapy and more expensive than Is not long-term therapy and more expensive than

other routesother routes

Fluid ManagementFluid Management

Thin people 50-70% waterThin people 50-70% water Obese people 50% waterObese people 50% water Elder 46-52% waterElder 46-52% water Two main compartmentsTwo main compartments

Intracellular (64%)Intracellular (64%) Extracellular (36%)Extracellular (36%)

¾ interstitial¾ interstitial ¼ plasma¼ plasma

Fluid ManagementFluid Management

Physiological homeostasisPhysiological homeostasis Fluid movement done by osmotic pressure Fluid movement done by osmotic pressure

(holding on)(holding on) Hydrostatic pressure (letting go)Hydrostatic pressure (letting go)

Plasma uses osmotic pressure (why?)Plasma uses osmotic pressure (why?)

Kidneys are the primary regulator of fluidsKidneys are the primary regulator of fluids Usually produces 1-2L/24hUsually produces 1-2L/24h Must produce a minimum of 500-600mL/24hMust produce a minimum of 500-600mL/24h

Fluid ManagementFluid Management Homeostatic MechanismsHomeostatic Mechanisms

Thirst to CNSThirst to CNS Illness, LOC, age changes thirst mechanismIllness, LOC, age changes thirst mechanism

Antidiuretic hormone (ADH) – hypothalamusAntidiuretic hormone (ADH) – hypothalamus Extracellular volume is concentratedExtracellular volume is concentrated Fluid retention by hemorrhage, cardiac output, trauma, pain, Fluid retention by hemorrhage, cardiac output, trauma, pain,

fear, surgery, dehydrationfear, surgery, dehydration

Aldosterone – adrenal cortexAldosterone – adrenal cortex Reabsorbs Na & HReabsorbs Na & H22O = changes electrolytesO = changes electrolytes Na exchanges for K or HNa exchanges for K or H Kidneys and the angiotensin systemKidneys and the angiotensin system

Renin – angiotensin I – angiotensin IIRenin – angiotensin I – angiotensin II

Fluid Management - TonicityFluid Management - Tonicity

HypertonicHypertonic

Increased Increased solutes in solutes in relationship to relationship to plasmaplasma

D5.9%NSD5.9%NS

D5LRD5LR

D5.45%NSD5.45%NS

HypotonicHypotonic

Decreased Decreased solutes in solutes in relationship to relationship to plasmaplasma

.25%NS.25%NS

.45%NS.45%NS

2.5%Dextrose2.5%Dextrose

IsotonicIsotonic

Same tonicity as Same tonicity as plasmaplasma

.9%NS.9%NS

D5WD5W

LRLR

VenipunctureVenipuncture

Site selectionSite selection Gauge needleGauge needle SuppliesSupplies ProcedureProcedure Charting – location and identify vein Charting – location and identify vein

usedused

SuppliesSupplies The pumpThe pump The drip factor (varies by The drip factor (varies by

manufacturer)manufacturer) MicrodropMicrodrop

60gtt/mL60gtt/mL MacrodropMacrodrop

20gtt/mL20gtt/mL 15gtt/mL15gtt/mL 10gtt/mL10gtt/mL

The volume control setThe volume control set The filterThe filter

FormulasFormulas

FlowFlow raterate

Drops per minuteDrops per minute

Total Solution

# of hours to run

= mL/hr

mL/hr x gtt factor

60 mins

= gtts/min

Secondary InfusionsSecondary Infusions

Piggybacks - IVPBPiggybacks - IVPB Used for mediationsUsed for mediations

Check medicationCheck medication Check capabilityCheck capability

Stop primary, flush, infuse, flush and restart Stop primary, flush, infuse, flush and restart primaryprimary

Bactrim – don’t mix (usually D5W)Bactrim – don’t mix (usually D5W) Dilantin – only in NSDilantin – only in NS

Intravenous Line InjectionIntravenous Line Injection

Pushes - IVPsPushes - IVPs Dilute whenever possibleDilute whenever possible KNOW YOUR DRUGKNOW YOUR DRUG

Digitalis – usually monitoredDigitalis – usually monitored Benzodiazepines (do not mix or dilute)Benzodiazepines (do not mix or dilute)

Clamp, flush, push, flush, unclampClamp, flush, push, flush, unclamp Flush, push, flushFlush, push, flush

SASHSASH

Central Venous Access TypesCentral Venous Access Types

Peripherally PlacedPeripherally Placed PICC PICC

Tunneled Tunneled Groshong (same as PICC only tunneled)Groshong (same as PICC only tunneled) Triple LumensTriple Lumens Hickmans, BoviacsHickmans, Boviacs PortsPorts

Insertion SitesInsertion Sites

NeckNeck JugularJugular

Chest Chest SubclavianSubclavian

ArmArm BacilicBacilic CephalicCephalic AnticubitalAnticubital

SAFETYSAFETY

NO SCISSORS ONCE INSERTEDNO SCISSORS ONCE INSERTED PREVENT INFECTIONPREVENT INFECTION

Site CareSite Care

First 7 days (or if discharge)First 7 days (or if discharge) Use 2x2 gauzeUse 2x2 gauze NO betadine ointmentNO betadine ointment Then q72h or if soiledThen q72h or if soiled Check policyCheck policy

Tubing & Cap changesTubing & Cap changes

Both q72h with fluidsBoth q72h with fluids Blood change bothBlood change both

After 2-3 unitsAfter 2-3 units

TPN (PPN) change bothTPN (PPN) change both q24hq24h

Change caps q blood drawsChange caps q blood draws NO LABEL – change bothNO LABEL – change both

Blood drawingBlood drawing

Access line with prefilled 10cc NSAccess line with prefilled 10cc NS FlushFlush Draw back 10cc blood in same syringe Draw back 10cc blood in same syringe

(discard)(discard) New syringes – draw up sampleNew syringes – draw up sample Change capChange cap Flush with 10cc NS (heparin??)Flush with 10cc NS (heparin??)

CVC Side EffectsCVC Side Effects

Phlebitis Phlebitis mechanical vs bacterialmechanical vs bacterial

InfectionInfection PheumothoraxPheumothorax Superior vena cava syndromeSuperior vena cava syndrome

Flushing Flushing Know the following for allKnow the following for all

Manufactures Manufactures Guidelines Policy/ProtocolGuidelines Policy/Protocol

Peripheral LinesPeripheral Lines 3cc NS3cc NS

Central Lines Central Lines PICC: 10cc NS (No Heparin)PICC: 10cc NS (No Heparin) Central Line: 10cc NS & Heparin 100u/cc (3cc) Central Line: 10cc NS & Heparin 100u/cc (3cc) Tunneled: Same as Central Line (Groshong see PICC)Tunneled: Same as Central Line (Groshong see PICC)

Ports (Should have primary line)Ports (Should have primary line) NeedlesNeedles

-Huber (non-coring)-Huber (non-coring) -Change every Friday-Change every Friday -Flush when needle remove and not reinserted -use Heparin 100u/cc (5cc) -Flush when needle remove and not reinserted -use Heparin 100u/cc (5cc)

Blood AdministrationBlood Administration

Have saline infusing with Y-set upHave saline infusing with Y-set up Use 170 micron filterUse 170 micron filter Double check Double check

At lab/blood bankAt lab/blood bank At bed sideAt bed side

MonitoringMonitoring Prior, 5min after start, 15min after start then q30m Prior, 5min after start, 15min after start then q30m

until completeduntil completed

Should infuse over 1-2 hoursShould infuse over 1-2 hours

The Blood System The Blood System

ABO blood group systemABO blood group system Universal DonorUniversal Donor

O lacks A & B antigenO lacks A & B antigen Universal RecipientsUniversal Recipients

AB lacks anti-A & anti-B antibodiesAB lacks anti-A & anti-B antibodies

Blood ProductsBlood Products

Whole blood Whole blood Packed red cells Packed red cells Granulocyte concentrates Granulocyte concentrates Platelet concentrates Platelet concentrates Fresh frozen plasma Fresh frozen plasma Cryoprecipitate Cryoprecipitate Clotting factors - Factor VIII / IX Clotting factors - Factor VIII / IX

Complications of TransfusionsComplications of Transfusions

Complications of blood transfusionComplications of blood transfusion Haemolytic reactions (immediate or delayed) Haemolytic reactions (immediate or delayed) Bacterial infections from contamination Bacterial infections from contamination Allergic reactions to white cells or platelets Allergic reactions to white cells or platelets Pyogenic reactions Pyogenic reactions Circulatory overload Circulatory overload Air embolism Air embolism Thrombophlebitis Thrombophlebitis

Clotting abnormalities Clotting abnormalities

AnaphylaxisAnaphylaxis

ReactionReaction Usually occurs soon after start of transfusion Usually occurs soon after start of transfusion Presents with circulatory collapse and Presents with circulatory collapse and

bronchospasm bronchospasm

ManagementManagement Discontinue transfusion and remove giving set Discontinue transfusion and remove giving set Maintain airway and give oxygen Maintain airway and give oxygen

Autologous transfusionAutologous transfusion

Is the use of the patients own blood Is the use of the patients own blood Particularly useful in elective surgery Particularly useful in elective surgery Accounts for 5% of transfusions in USA Accounts for 5% of transfusions in USA Reduces the need for allogeneic blood Reduces the need for allogeneic blood

transfusion transfusion Reduces risk of postoperative Reduces risk of postoperative

complications (e.g. infection, tumor complications (e.g. infection, tumor recurrence) recurrence)

Total Parenteral NutritionTotal Parenteral Nutrition

Pharmacist may do formulationPharmacist may do formulation If dextrose >10% - need CVCIf dextrose >10% - need CVC Monitor blood glucose Monitor blood glucose Monitor electrolytesMonitor electrolytes Weigh qdWeigh qd Use filtersUse filters

1.2micron with lipids1.2micron with lipids .2micron without lipids.2micron without lipids

Know who to “ramp up and down”Know who to “ramp up and down”

TPN precautionsTPN precautions

Check compatibility of medicationsCheck compatibility of medications Don’t play “catch-up”Don’t play “catch-up” No bloodNo blood