IV TherapyIV Therapy

Peggy D. JohndrowPeggy D. Johndrow

IV AdministrationIV Administration

Administer into circulatory systemAdminister into circulatory system Large volume infusions: 250mL to 1000 mLLarge volume infusions: 250mL to 1000 mL Bolus injection: IV pushBolus injection: IV push Volume-controlled infusions: 50 mL to 250 Volume-controlled infusions: 50 mL to 250

mLmL PiggybackPiggyback TandemTandem Volume-control setVolume-control set Mini-infusor pumpMini-infusor pump

IV SolutionsIV Solutions Isotonic: concentration most like bloodIsotonic: concentration most like blood

Used to expand blood volumeUsed to expand blood volume Normal saline or 0.9% NaClNormal saline or 0.9% NaCl Lactated RingersLactated Ringers

Hypotonic: concentration less than Hypotonic: concentration less than bloodblood Used for dehydrationUsed for dehydration

0.45% NaCl0.45% NaCl 0.33% NaCl0.33% NaCl

Hypertonic : concentration greater Hypertonic : concentration greater than bloodthan blood Draws fluid into vascular compartment; not Draws fluid into vascular compartment; not

for clients with kidney or heart problemsfor clients with kidney or heart problems D5 NSD5 NS D5 1/2 NSD5 1/2 NS D5LRD5LR

Overview: IV InsertionOverview: IV Insertion Use needle with catheter sheathUse needle with catheter sheath

20-22 gauge typical for adult20-22 gauge typical for adult If blood transfusion anticipated , use 18 or If blood transfusion anticipated , use 18 or

20 gauge20 gauge Most Most IVIV solution sets deliver 10 drops solution sets deliver 10 drops

per mL, or 60 drops per per mL, or 60 drops per mL(microdrop)mL(microdrop)

IV solution should be clear; cloudy IV solution should be clear; cloudy solutions may indicate contaminationsolutions may indicate contamination

Safety shield type of catheter Safety shield type of catheter required by OSHA; also called over the required by OSHA; also called over the needle (ONC)needle (ONC)

IV sitesIV sites PeripheralPeripheral

Metacarpal: top of the handMetacarpal: top of the hand Basilic & Cephalic typically used on Basilic & Cephalic typically used on

forearmforearm Use most distal part firstUse most distal part first Consider type of solution to be Consider type of solution to be

infusedinfused CentralCentral

IVs inserted into subclavian or jugular IVs inserted into subclavian or jugular veinvein

GroshongGroshong Triple lumenTriple lumen Implanted portsImplanted ports

PICC linesPICC lines

Precautions for IV SitesPrecautions for IV Sites

AvoidAvoid Bony prominencesBony prominences Legs & feetLegs & feet Mastectomy armMastectomy arm Operative armOperative arm Injured armInjured arm

Documentation IV StartDocumentation IV Start

Number of attemptsNumber of attempts Type of fluid/saline lockType of fluid/saline lock Insertion siteInsertion site Type and size of catheter or needleType and size of catheter or needle Flow rateFlow rate Response to IVResponse to IV Record response to IV fluid, amount Record response to IV fluid, amount

infused integrity and patency of infused integrity and patency of system every 1-2 hourssystem every 1-2 hours

Procedure for Hanging IV FluidProcedure for Hanging IV Fluid

Remove IV bag from protective coverRemove IV bag from protective cover Check expiration date & assess for cloudiness Check expiration date & assess for cloudiness

or leaksor leaks Hang the IV bag on a poleHang the IV bag on a pole Remove IV tubing from its bag Remove IV tubing from its bag Close roller clampClose roller clamp Spike the bagSpike the bag Fill drip chamber ½ fullFill drip chamber ½ full Open the roller clamp & prime tubingOpen the roller clamp & prime tubing Close roller clamp & replace protective Close roller clamp & replace protective

capcap Label the tubing with date to be changedLabel the tubing with date to be changed Adjust roller clamp to appropriate drip Adjust roller clamp to appropriate drip

rate or place into IV pump and set raterate or place into IV pump and set rate

Procedure Hanging IVPBProcedure Hanging IVPB

1.1. Open tubing same as IVOpen tubing same as IV

2.2. Close roller clampClose roller clamp

3.3. Hang IVPB bag on poleHang IVPB bag on pole

4.4. Spike bag same as IVSpike bag same as IV

5.5. Prime tubingPrime tubing

6.6. Connect IVPB tubing to IV tubingConnect IVPB tubing to IV tubing

7.7. Place wire hanger on polePlace wire hanger on pole

8.8. Lower IV bag on to hangerLower IV bag on to hanger

9.9. Set correct drip rateSet correct drip rate

10.10. Label the tubing with date to be Label the tubing with date to be changedchanged

Preparation for IV Preparation for IV

Check physician orderCheck physician order Check fluid, electrolyte, and nutritional Check fluid, electrolyte, and nutritional

status for baseline information to make status for baseline information to make comparison of IV effectivenesscomparison of IV effectiveness

Know agency policiesKnow agency policies Assess client understanding of reasons Assess client understanding of reasons

for procedure for procedure Assess clothing appropriateness (need Assess clothing appropriateness (need

wide sleeves)wide sleeves) Assess veinsAssess veins

IV EquipmentIV Equipment

Obtain equipmentObtain equipment Safety catheter needleSafety catheter needle TourniquetTourniquet Povidone-iodine swabs or Povidone-iodine swabs or

chlorhexidine prepchlorhexidine prep Alcohol swabsAlcohol swabs GlovesGloves TowelTowel Transparent dressingTransparent dressing TapeTape IV tubing & solution bagIV tubing & solution bag IV pole and/or pumpIV pole and/or pump

CHAIN OF INFECTIONCHAIN OF INFECTION

Microorganism

CarrierPerson

Travel Method

A way outSkin puncture

SusceptiblePerson

Prevention of IV site infectionPrevention of IV site infection CDC guidelinesCDC guidelines

Wash HandsWash Hands Use sterile techniqueUse sterile technique Change IV solution q 24 hrsChange IV solution q 24 hrs Change IV site every 48 to 72 Change IV site every 48 to 72

hourshours Change IV tubing every 48 hoursChange IV tubing every 48 hours

Use gloves & sharps containersUse gloves & sharps containers Check agency policyCheck agency policy

Client EducationClient Education Teach Teach

S&S of infection or S&S of infection or problemsproblems

When to call for helpWhen to call for help How to prevent IV from How to prevent IV from

clotting or being pulled outclotting or being pulled out Arm positioningArm positioning Walking with IV poleWalking with IV pole

Starting IV Starting IV 1.1. Check client’s ID braceletCheck client’s ID bracelet

2.2. Wash handsWash hands

3.3. Use eye protectionUse eye protection

4.4. Organize equipment at bedside within Organize equipment at bedside within reachreach

5.5. Set bed height for ease of nurseSet bed height for ease of nurse

6.6. Put towel under armPut towel under arm

7.7. Place tourniquet around upper armPlace tourniquet around upper arm

8.8. Palpate dilated veinsPalpate dilated veins1.1. Hang arm down to dilate veinHang arm down to dilate vein

2.2. Select site low on arm firstSelect site low on arm first

3.3. Release tourniquetRelease tourniquet

Prepare Site & Insert IVPrepare Site & Insert IV Put on glovesPut on gloves Clean the site Clean the site

Alcohol, then betadine (let dry)Alcohol, then betadine (let dry) Re-apply the tourniquet 1-2 inches Re-apply the tourniquet 1-2 inches

above siteabove site Secure vein by placing thumb 2-3 in Secure vein by placing thumb 2-3 in

below site and gently stretching skinbelow site and gently stretching skin Stick vein (15 to 30 degree angle) with Stick vein (15 to 30 degree angle) with

bevel of needle upbevel of needle up Watch for flashback in chamberWatch for flashback in chamber

Insert CatheterInsert Catheter

Stabilize stylet and advance Stabilize stylet and advance cathetercatheter

Loosen stylet from catheterLoosen stylet from catheter Release tourniquetRelease tourniquet Hold thumb over vein above Hold thumb over vein above

catheter tipcatheter tip Remove stylet and attach IV Remove stylet and attach IV

tubing; put stylet in sharps tubing; put stylet in sharps containercontainer

Connect tubingConnect tubing

Start FluidStart Fluid Start IV fluid at slow rateStart IV fluid at slow rate Secure catheterSecure catheter

Transparent dressing over insertion Transparent dressing over insertion sitesite

Tape over hub of catheterTape over hub of catheter No tape near site of insertionNo tape near site of insertion

Label site with date, time & initialsLabel site with date, time & initials Label tubing with date to be changedLabel tubing with date to be changed ChartChart

Date, time, type & gauge of catheter, Date, time, type & gauge of catheter, dressing typedressing type

Fluid attached as IVFluid attached as IV Clients reaction to procedureClients reaction to procedure

IV Flow RateIV Flow Rate Nurse responsible for flow rate Nurse responsible for flow rate

maintenancemaintenance Can result in fluid overload leading to Can result in fluid overload leading to

cardiovascular, renal or neurological cardiovascular, renal or neurological impairmentimpairment

Controlled by roller clamp, Controlled by roller clamp, controller device or IV pump, & controller device or IV pump, & affected by client positionaffected by client position

Controller device & roller clamp Controller device & roller clamp work with gravity (must be 36 work with gravity (must be 36 inches above site)inches above site)

Controller Device & Roller Controller Device & Roller ClampClamp

Determine hourly rateDetermine hourly rate Determine drops/minute rateDetermine drops/minute rate Set rate by counting drips per Set rate by counting drips per

15 seconds & multiply by 4 to 15 seconds & multiply by 4 to get drops per minuteget drops per minute

Mark time in hours on IV bag Mark time in hours on IV bag tape help keep the rate tape help keep the rate accurateaccurate

Readjust rate as neededReadjust rate as needed

IV Pump/ControllerIV Pump/Controller IV pumpsIV pumps deliver IV fluids by exerting deliver IV fluids by exerting

positive pressure on fluid tubingpositive pressure on fluid tubing Most pumps alarm with an occlusion, but Most pumps alarm with an occlusion, but

many times they continue to infuse even many times they continue to infuse even when infiltratedwhen infiltrated

Insert tubing into pump’s flow control Insert tubing into pump’s flow control chamber or pathchamber or path

Set rate in mLs per hour on the pumpSet rate in mLs per hour on the pump Set the volume to be infused (VTBI)Set the volume to be infused (VTBI) Press the start buttonPress the start button Monitor a few minutes to be sure the Monitor a few minutes to be sure the

pump is functioningpump is functioning

Intermittent Therapy or Saline Intermittent Therapy or Saline LockLock

Must be flushed at regular intervals Must be flushed at regular intervals with saline or heparin to maintain with saline or heparin to maintain patency (usually q shift)patency (usually q shift)

Flushes prevent clotting of catheter Flushes prevent clotting of catheter & maintain patency of IV site& maintain patency of IV site For intermittent access (meds)For intermittent access (meds) For potential access (telemetry)For potential access (telemetry) For tests (stress test, etc)For tests (stress test, etc)

Use push-pull technique Use push-pull technique When client takes shower, cover IV When client takes shower, cover IV

site with plasticsite with plastic

Converting IV to Intermittent Converting IV to Intermittent TherapyTherapy

Check the orderCheck the order Obtain equipment & take to bedsideObtain equipment & take to bedside

Syringe with saline/heparinSyringe with saline/heparin INT device & extension tubingINT device & extension tubing

Check ID braceletCheck ID bracelet Instruct clientInstruct client Wash handsWash hands Don glovesDon gloves Prime INT devicePrime INT device Remove IV tubing & replace with INT device Remove IV tubing & replace with INT device Tape securelyTape securely Flush with saline (3 ccs)/heparin (as ordered)Flush with saline (3 ccs)/heparin (as ordered)

IV Site ComplicationsIV Site Complications

Assess IV site for: Assess IV site for: Infection: redness, warmth, swelling Infection: redness, warmth, swelling

& pain; possible fever, & site & pain; possible fever, & site dischargedischarge

Infiltration: redness, edema at the Infiltration: redness, edema at the site, burning pain, coldness, fluid will site, burning pain, coldness, fluid will not flow by gravitynot flow by gravity

Blood backflow does not always mean Blood backflow does not always mean IV not infiltratedIV not infiltrated

Other IV ComplicationsOther IV Complications Allergic reaction : rash, redness, Allergic reaction : rash, redness,

itching, anaphylaxisitching, anaphylaxis Circulatory overload: dyspnea, Circulatory overload: dyspnea,

cyanosis, JVD, edema, wt gain, cyanosis, JVD, edema, wt gain, ascitesascites

Air embolism: decreased blood Air embolism: decreased blood pressure, cyanosis, tachycardia, JVD, pressure, cyanosis, tachycardia, JVD, dyspneadyspnea

Macrodrops and Macrodrops and MicrodropsMicrodrops

IV Tubing LabelIV Tubing Label

IV Tubing LabelIV Tubing Label

Math problemsMath problems

Calculating Rate in Drops per Calculating Rate in Drops per MinuteMinute

FormulaFormula

Volume x drop factorVolume x drop factor = = gtts/mingtts/min

Time in minutes =60 x hoursTime in minutes =60 x hours

Calculating Rate in mL per Calculating Rate in mL per HourHour

Formula:Formula:

Volume Volume = mL/hr = mL/hr

Hours Hours

Infusion TimeInfusion Time

Formula:Formula:

Volume x drop factor (gtts/mL)Volume x drop factor (gtts/mL) = hours to = hours to infuseinfuse

Flow rate (gtts/min) x 60Flow rate (gtts/min) x 60

Calculation of MedicationCalculation of Medication

Use ratio and proportionUse ratio and proportion

Medication amount availableMedication amount available = = Amount to Amount to givegive

Amount of mLAmount of mL X mLX mL

Intermittent TherapyIntermittent Therapy

Special adapter: flush with NS every Special adapter: flush with NS every shift; use push-pull technique to flush shift; use push-pull technique to flush (push fluid in & continue to push in as (push fluid in & continue to push in as pull syringe out of adapter), if needle-pull syringe out of adapter), if needle-less system clamp tubing while still less system clamp tubing while still pushing fluid; usually use 2-3 cc of NS to pushing fluid; usually use 2-3 cc of NS to flushflush

SAS : saline, additive (medication), SAS : saline, additive (medication), salinesaline

Pediatric clients: often use heparin Pediatric clients: often use heparin solution to lock; SASHsolution to lock; SASH

IV Intake IV Intake

ExampleExample: John's primary IV is running at 34 : John's primary IV is running at 34 mL/hr while NPO. When the nurse runs the mL/hr while NPO. When the nurse runs the Vancomycin (250 mg IV q 8 hr) in over 90 Vancomycin (250 mg IV q 8 hr) in over 90 minutes [volume is 100 ml], the primary IV is minutes [volume is 100 ml], the primary IV is stopped. The ampicillin (395 mg IV q 6 hr) is stopped. The ampicillin (395 mg IV q 6 hr) is given concurrently in 10 ml of fluid over 30 given concurrently in 10 ml of fluid over 30 minutes. He received 2 boluses of minutes. He received 2 boluses of aminophylline (20 ml each over 20 minutes). aminophylline (20 ml each over 20 minutes). The IV fluids were stopped while the The IV fluids were stopped while the aminophylline infused. Since microtubing aminophylline infused. Since microtubing was used for the medications, total flush is was used for the medications, total flush is negligible (approximately 3 ml). What is negligible (approximately 3 ml). What is John’s total IV intake for 24 hours?John’s total IV intake for 24 hours?

Calculate using the critical Calculate using the critical

informationinformation: : Vancomycin runs 1.5 hrs x 3 doses = 4.5 hrs IV Vancomycin runs 1.5 hrs x 3 doses = 4.5 hrs IV

is stoppedis stopped Primary IV flds 24 (hr) minus 4.5 = 19.5 hrs.Primary IV flds 24 (hr) minus 4.5 = 19.5 hrs. Primary fld stopped as aminophylline is Primary fld stopped as aminophylline is

infusing:infusing: 20 min x 220 min x 2 = 40 minutes= 40 minutes Primary fld 19 hr 30 min. - 40 minutes = 18 hr Primary fld 19 hr 30 min. - 40 minutes = 18 hr

50min (18.83 hrs) x 34 mL50min (18.83 hrs) x 34 mL = 640.22 mL= 640.22 mL

CalculationCalculation Vancomycin: 100 cc x 3Vancomycin: 100 cc x 3 = 300 mL= 300 mL AmpicillinAmpicillin 20 cc x 220 cc x 2 = 40 mL= 40 mL Aminophylline 20 cc x 2 Aminophylline 20 cc x 2 = 40 mL= 40 mL Normal saline flush (approx.)Normal saline flush (approx.) = 3 mL= 3 mL 640.22 + 300 + 40 + 40 + 3640.22 + 300 + 40 + 40 + 3 =1023.22 =1023.22

mL/24hrsmL/24hrs John's daily IV intake, based on all John's daily IV intake, based on all

therapeutic modalities, is 1023.5 mLtherapeutic modalities, is 1023.5 mL

Calculate Total Intake and OutputCalculate Total Intake and Output ExampleExample:: Crystal has an IV infusing Crystal has an IV infusing

at KVO (10 mL/hr). She receives an at KVO (10 mL/hr). She receives an antibiotic in 22.5 mL q 8° antibiotic in 22.5 mL q 8° concurrently. One mL flush is given concurrently. One mL flush is given after each antibiotic. She is given 30 after each antibiotic. She is given 30 mL of formula q 3°. She had diaper mL of formula q 3°. She had diaper weights of 17 mL, 33 mL, 55 mL, 45 weights of 17 mL, 33 mL, 55 mL, 45 mL, 52 mL, 50 mL, 15 mL, and 36 mL. mL, 52 mL, 50 mL, 15 mL, and 36 mL.

Calculate her I & O for the past 24 Calculate her I & O for the past 24 hours. hours.

Intake:Intake: IV @ 10 mL/hr x 24 hrIV @ 10 mL/hr x 24 hr = 240 mL= 240 mL Med of 22.5 mL x 3 (q8°)Med of 22.5 mL x 3 (q8°) = 67.5 mL= 67.5 mL Flush of 1 mL x 3Flush of 1 mL x 3 = 3 mL= 3 mL Formula of 30 mLFormula of 30 mL x 8 (q 3°)x 8 (q 3°) = 240 = 240

mLmL 240 mL + 67.5 mL + 3 mL + 240 mL = 240 mL + 67.5 mL + 3 mL + 240 mL =

550.5 mL550.5 mL Crystal's intake is 550.5 mL for the past Crystal's intake is 550.5 mL for the past

24 hours24 hours

Weigh DiaperWeigh Diaper Gm and mLGm and mL Weight of diapers, measurement is "Weight of diapers, measurement is "gramsgrams““ VolumeVolume of urine output is "mL“ of urine output is "mL“ A 'gram' and a 'mL' are equivalent when A 'gram' and a 'mL' are equivalent when

measuring water. measuring water. In clinical setting, use grams and mLs as In clinical setting, use grams and mLs as

equivalent when measuring urine by diaper equivalent when measuring urine by diaper weightsweights

Best noninvasive method currently have and Best noninvasive method currently have and is close enough for clinical decision makingis close enough for clinical decision making

Process is to weigh diaper on a gram scale Process is to weigh diaper on a gram scale and record output in 'mL (must account for and record output in 'mL (must account for weight of dry diaper the same size used)weight of dry diaper the same size used)

Output:Output:

17 + 33 + 55 + 45 + 52 + 50 + 15 + 36 = 17 + 33 + 55 + 45 + 52 + 50 + 15 + 36 = 303 mL303 mL

Crystal's output is 303 mL for the past 24 Crystal's output is 303 mL for the past 24 hours.hours.