Date post: | 26-Oct-2014 |
Category: |
Documents |
Upload: | renee-hoover-coleman |
View: | 111 times |
Download: | 4 times |
6/25/2012
1
IV Therapy
Legal Issues
• Accountability
– The act of being professionally responsible and answerable for one’s actions, inactions, decisions, and judgments
• SC Nurse Practice Act
• Standards of Care
– Minimal acceptable level of care
• Employer’s Policy and Procedures
What is RN Accountable for?
• What IV therapy is ordered and its indication
• Desired outcome of the IV therapy
• Possible adverse or side effects that may occur
• Prepare the patient mentally & physically
• Administer, maintain, and monitor the therapy
• D/C the therapy when ordered
• Document and report
6/25/2012
2
Advantages of IV Therapy
• IV therapy provides:
– Access route for meds, fluids, anesthetics in an emergency situation
– Access route for unconscious or NPO patient
– Alternative choice for irritating or poorly absorbed meds by other routes
– Faster absorption
Disadvantages of IV Therapy
• Patient discomfort
• Fluid overload
• Allergic reaction
• Local or systemic infection
• Venous thrombosis or emboli
• Transmission of Hep B, Hep C, HIV
What is Ordered (cont)
• IVF are prepared in bags or bottles ranging in size from 50-1000mL
• Label contains the complete name of the fluid and fine print identifies the exact amount of each component
• Orders and charts contain abbreviations and numbers/symbols
6/25/2012
3
What is Ordered (cont) Common Abbreviations
• Abbreviation:
– D
– W
– S
– NS
– LR or RL
• Full Meaning:
– Dextrose
– Water
– Saline
– Normal saline
– Lactated ringers or ringer’s lactate
Isotonic Solutions
• Same amount of particles as body fluids
• Expand circulating volume but no shifts into or out of vessels/cells
• 0.9% NaCl = NS
• D5W
• LR
• D5 ¼ NS
• D2.5 NS
Hypotonic vs. Hypertonic
Hypotonic
• Less particles than intracellular
• Moves water into cells
• May deplete circulating volume
• D 2.5 W
• ½ NS
Hypertonic
• More particles than intracellular
• Moves water out of cells into circulating volume
• D10W
• 3%NS
• D 5 NS and D5 ½ NS
• D10NS
• Mannitol
6/25/2012
4
Equipment
• IV solution in container
• IV tubing
• Venous access device
• Start kit
• Electronic infusion device
• Labels
Equipment (cont)
• Solution containers
– Glass
• Require venting
– Plastic
• Do not require venting
– Label
– Extensions/ports on bottom
• One for IV tubing spike
• One for adding meds
6/25/2012
5
Equipment (cont)
• Tubing
– Primary
– Secondary
– Blood
– Lipids
– Extensions
– Parts
• See diagram
6/25/2012
6
Equipment (cont)
• Catheter
– Most frequently used
– Rigid needle on inside, flexible catheter on outside
– Hub is color coded to indicate gauge & length
– 14-24 gauge; ¼ - 12 inches
6/25/2012
7
Equipment (cont)
– Straight steel needles
• 14-27 gauge; ¼ - 3 inches long
• Rarely used today
– Winged Needles
• Used primarily for peds
Equipment (cont)
• Start Kit
– Tourniquet
– Antiseptic skin preparation
– Gauze
– Tape
– Dressing
6/25/2012
8
Equipment (cont)
• Electronic Infusion Device
– Rate in mL/h
– Volume to be Delivered
– Primary
– Secondary
– Total infused
– Infusion time
Equipment (cont)
• Labels
– IV solution
– Tubing
– Site
6/25/2012
9
Common Complications
• Hematoma
– Infiltration of blood into tissue
• Infiltration
– Catheter dislodges out of the vein and IVF infuse into surrounding tissue
• Thrombus
• Clot within or around the catheter
• Phlebitis
– Inflammation of the vein
Common Complications (cont)
• Thrombophlebitis
– Thrombus along with inflammation
• Fluid Overload
– Infusion of too much fluid for the body to handle
• Infection
• Air Emboli
• Speed Shock
6/25/2012
10
Hematoma
• Infiltration of blood into tissue
• At Risk:
– Bruise easily -anticoagulant therapy
– Long term steroid use
• S/S:
– Discoloration -Swelling/Discomfort
– Inability to advance catheter
– Resistance when attempt to flush
Hematoma (cont)
• Prevention:
– Be gentle when starting IV
– Use smallest needle
– Apply tourniquet just before sticking
• Treatment:
– Apply pressure when d/c catheter
– Elevate
– ice
6/25/2012
11
Infiltration
• Catheter dislodges and solution infuses into surrounding tissue
• S/S:
– Coolness -tautness of skin
– Dependent edema
– Slowed infusion rate -no back flow
• Prevention:
– Assess
Infiltration Treatment
• Stop infusion
• Remove IV catheter
• Apply pressure to stop bleeding
• Apply cold or your agency policy or HCP orders
6/25/2012
12
Thrombosis
• Clot within or around the catheter
• S/S:
– Slowed or stopped infusion
– Inability to flush catheter
• Prevention:
– Use pump or controller
– Avoid lower extremities or site near flexion joints
Thrombosis (cont)
• Treatment:
– NEVER flush and force clot to move
– d/c IV site and restart at new location
– Assess for circulatory impairment
– Notify MD
6/25/2012
13
Phlebitis
• Inflammation of the vein
• S/S:
– Redness -warm to touch
– Local swelling -palpable cord
– Sluggish infusion rate
• Prevention:
– Good hand washing
– Use smallest size catheter
– Change site q 72 hours; solution q 24 hours
Phlebitis Treatment
• Prevention is the best intervention
– Asepsis
– Good hand washing
– Use smallest length and gauge cannula
• If occurs:
– Stop IV infusion and d/c catheter
– Warm compresses per policy
– Culture drainage if present
– Notify HCP who may order antibiotics
6/25/2012
14
Thrombophlebitis
• Thrombus and inflammation
• S/S:
– Decreasing arterial pulses
– Mottling/cyanosis of extremity
• Prevention:
– Dilute irritating meds/solutions
– Use FA not hand veins
– Assess
Thrombophlebitis (cont)
• Treatment:
– d/c
– Comfort measures
Fluid Overload
• Signs & Symptoms
– Jugular vein distension
– Confusion
– Respiratory difficulties
– Increased respiratory rate
– Shortness of breath
– Crackles in lungs
6/25/2012
15
Fluid Overload (cont)
• Prevention is the best intervention
– Place IVF on electronic device and monitor flow rate closely
– Monitor I&O, breath sounds, respiratory rates
• If overload does occur:
– Decrease or stop IVF infusion
– Notify HCP for further orders
Infection:
• S/S:
– Redness and swelling
– Drainage
– Increased WBC’s
– Elevated temp
• Prevention:
– Assess
– Change site q 72 hours, solution q 24 hours
6/25/2012
16
Infection (cont)
• Treatment:
– d/c catheter
– Notify MD
Less Common Complications:
• Air Emboli
– Check all bags, syringes, tubing for air in them
– Do not push air through lines
• Speed Shock
– Use IV electronic infusion device
– Follow instructions carefully for IVP
Selection of a Vein
• Site selected should: – Provide the most appropriate access to the vessel
– Accommodate the prescribed therapy
– Minimize associated risks of complications
• The Nurse should consider: – Pt age & health status
– Purpose & duration of IV therapy
– Condition of the site
– Possible s/e of the IV therapy
6/25/2012
17
Steps to Venipuncture
• Check the Order
– Date & time of order
– Name of IVF and/or medication to be added
– Dosage of medication
– Volume to be infused (VTBI)
– Rate of infusion
– Duration of infusion
– Signature of provider
Selection of Veins (cont)
• Don’t use veins of lower extremities
• Don’t use veins that are irritated or sclerosed
• Don’t use areas of flexion unless joint is immobilized
• Don’t use veins in the antecubital fosssa
6/25/2012
18
Selection of Veins (cont)
• Don’t use veins on the side in an extremity
–Mastectomy
–CVA impairment
–Partially amputated
–Third degree burn
–Arm with an arteriovenous shunt or fistula
Difficulty Locating a Vein
– Stroke or gently tap extremity
– Open & closing the fist
– Apply warm washcloth or other heat on extremity
– Lower the extremity below level of the heart
Steps to Venipuncture
• Select the Appropriate Needle
– 18-20g hypertonic or isotonic solutions with additives
– 18-20g blood administration; trauma; surgery; labor
– 22g fragile veins in elderly
– 22-24g pediatric patients
6/25/2012
19
Steps to Venipuncture
• Apply Gloves
• Apply tourniquet
• Prepare the Site
– Povidine-iodine
– Alcohol
– ChloraPrep
– Tincture of Iodine
Steps to Venipuncture
• Enter the Vein
– Pull skin taunt
– Enter the skin at 15-45 degree angle
– After bevel enters vein and flashback is seen, lower the angle of the catheter and advance into the vein
– Release the tourniquet
– Remove the stylet
– Connect the catheter hub to the administration set
Steps to Venipuncture
• Stabilize catheter and apply dressing
• U, H, or Chevron methods
• Label the Site
– Date, time, size of jelco, nurse’s initials on dressing
– Date, time, nurse’s initials on tubing
– Date, time, nurse’s initials, any additives on IV bag
• Disposal of Equipment
• Regulate Flow Rate
6/25/2012
20
Steps to Venipuncture
• Document
– Date and time of insertion
– Location of IV catheter (vein used)
– Device used
• Brand name, style, gauge, length
– Name and Rate of IVF infusing
– Method of infusion
• Gravity, electronic infusion device
– Pt response
– Signature
Maintenance of IV Therapy
• Visually inspect and palpate the IV insertion site at least daily. Note any redness, edema, or drainage. Document per infiltration and /or phlebitis scale
• Keep site dressing clean, dry, and intact
• Replace dressing with each devise change or more often if wet or soiled
Maintenance of IV Therapy (cont)
• Replace peripheral catheters at least every 72-96 hours
• Replace administration set at least every 72-96 hours
• Replace IV bag every 24 hours or sooner per order
• Replace lipid containing solutions and infusion sets every 24 hours
6/25/2012
21
Maintenance of IV Therapy (cont)
• If IVF are discontinued but access device remains in place, then IV site must still be assesses as previously stated
• Jelco should be flushed with NS or heparin lock solution(10-100 units/mL) per facility policy
– For example: Every 8-12 hours or every shift
Discontinuing IV Fluids/Therapy
• Don gloves
• Obtain 2*2 inch gauze pad
• Loosen tape and apply gauze over insertion site
• Remove cannula and dressing as one unit
• Apply direct pressure to the site
• Apply band aid if needed
• Document cannula removed intact and condition of site
Special Considerations: Peds
• Selection of Vein
– Age and size of child
– Mobility and level of activity
– Cognitive ability
• Peripheral Veins
– Scalp
– Hand/forearm
– Dorsum of foot
6/25/2012
22
Special Considerations: Peds
• Equipment
– Container with no more than 500mL of IVF; 250mL if child less than 12 months
– Use volume control chamber
– Fill volume control with no more than 2 hours worth of IVF
– May use syringe pump
Special Considerations: Geriatrics
• Skin and Vein Changes
– Loss of subcutaneous fat and thinning make skin and veins fragile
– Use tourniquet loosely and for short period of time
– Select smallest access device
– Be careful with tape
• Cardiovascular Changes
– Increased risk fluid overload