12th Lecture (NCM106 IVT) Care of Clients in Cellular Aberrations, ABC, Emergency and Disaster Nursing

Care of Clients in Cellular Aberrations, Acute Biologic Crisis (ABC), Emergency and Disaster Nursing (NCM106)  Intravenous Therapy

Intravenous Therapy Goals of Intravenous Therapy: Therapy :  Restores FLUID and ELECTROLYTE Balance o FVD – DHN   Electrolyte Imbalance - ↓ Na, K, Cl o  Maintains HYDRATION and FLUID replacement  Supplements CALORIES and NUTRIENTS – Nutrient solution  Correct electrolyte IMBALANCE  Restores ACID-BASE BALANCE  AVENUE to administer medications  Rapid response and absorption (fastest action) o  Administration of BLOOD PRODUCTS whole blood and its components

Basic Nursing Competencies 1. 2. 3. 4. 5.

Hand washing – To prevent transfer of microorganisms Assess vital signs Principle of aseptic technique Medication calculation Medication administration

Laws, Rules and Regulations -

Administration of IV Drug 1. Direct Injection – IV Push 2. Intermittent Infusion Volumetric Chamber •  Piggyback”, Soluset “ Piggyback”, • Dobutamine, Nicardipine • 3. Continuous Infusion Infusion Pump •

LOOKY HERE ☺

Topics Discussed Here Are: 1. Intravenous Therapy (Introduction) a. Competencies b. Ethico-moral Issues c. Nursing Roles and Responsibilities 2. Implementation of  Intravenous Therapy 3. Types of Intravenous Therapy Solutions 4. Complications of IV Therapy 5. Blood Transfusion 6. Drugs Commonly Used in IVT

Basis of Nursing Scope and Practice Independent – Individual professional accountability, accountability, professional competency Dependent – Legal of a  licensed Physician Invasive – Collaborative – M  HCT, network, linkages, blood bank  

Board of Nursing Resolution Number 8, Series of 1994 Section 27, Article V of the Republic Act 7164 “The Philippine Act of 1991” o Intravenous injection is within the scope of nursing, and that in the administration of intravenous injection, special training shall be required according to protocol established

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HEALTH TEACHING o

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Teaching ways to maintain the infusion system 1) Avoid sudden movement of the arm with the IV catheter 2) Avoid placing tension on tubing 3) Try to keep tubing from dangling below the needle level 4) Avoid regulating the flow rate 5) Notify the nurse: If IV solution is nearly empty 6) Notify the nurse: Pain, swelling, blood on the IV site

10 Rights in Drug Administration (RIGHT)      

Patient Dosage Route Refuse Interaction Education

 Note: OD, BID, QID – Px is AWAKE q Drugs – Px is NOT AWAKE (RTC)

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Drug-Drug Interaction, Drug-to-Food Interaction Documentation Time and Frequency (30 Minutes AC/PC) Drug Medication (Analgesic 1 st Before antibiotic)

Preparation of the Intravenous Therapy (Basic IV Setup) 

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Drip Chamber 1) Measures the speed of a manual IV set-up 2) Counts the number of drops we see per minute 3) Determines the IV infusion / flow rate Roller Clamp Controls the flow rate at which the intravenous fluid infuses Infusion Rate Synonym: IV Flow Rate, IV Infusion Rate The specific rate at which an intravenous fluid infuses • Slide Clamp Completely stops the IV from flowing without having to adjust the roller clamp Injection Port

Quick Notes: Introduce   Rapport  Explain procedure  Explain purpose

INSERTING AN IV THERAPY  IMPLEMENTATION  1. 2. 3.

4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14.

Verify Doctor’s orders and countercheck    AOR: Legal Responsibility Observe 10 Rights   AOR: Safe Quality Care Explain Procedure to Patient and Purpose to alleviate anxiety,   AOR: Communication Assess patient’s vein. Choose site   AOR: Safe Quality Care Hand Hygiene (  for clearness of bottle, order) Prepare materials ( Assemble all at bedside)   IV Bottle, infusion set, IV cannula, cotton ball with alcohol, tegaderm, tourniquet (used once), gloves, arm board/splint, IV stand) Check IV Bottle and solution Label the bottle (Before the procedure, with the IV card) Open IV Administration Set Aseptically Close the roller clamp Spike the infusate container aseptically Fill drip chamber Expel air bubbles put back cover getting ready for insertion Choose IV Site (Principles in Choosing) 1) Distal veins of arms first 2) Non-dominant hand

Assess for ALLERGIES/ 

28. Calibrate the IV Bottle and Regulate infusion rate 29. Label the IV Tape   AOR: Ethico-moral 30. Observe patient for untoward effect 31. Document ( AOR: Records) and endorse accordingly ( AOR: Collaboration ) 32. Discard sharp and waste appropriately   AOR: Management of Resources

CHANGING AN IV       

IV container is not allowed to hand over 24 hours (Unsterile) Check for cracks, leaks and cloudiness Check for discoloration, turbidity and particulates Check for expiration date Change the complete IV administration set Routine IV Site rotation o If from 48 – 72 hours, may cause complication, so ROTATE!

PURPOSE • • • •

Maintain flow rate Maintain Sterility of IV system Prevent Complication Maintain Patency

ASSESSMENT 1. 2.

IV Site Allergies

 MONITORING IV THERAPY  PURPOSE  

Maintains prescribed flow rate Prevents complications

ASSESSMENT 1. 2. 3. 4. 5.

IV Site Patency of IV System Infusion Rate Type of IV Fluid Patient’s Response

Intravenous Drip Rate A. ml/hr 

B. gtt/min 

The total number or milliliters ordered, divided by number of hours to run

ml Ordered  ____________  ml =  ___  hr hours to Run The number of milliliters per hour multiplied by tubing drip factor divided by number of minutes

ml/hr x drop factor =  ___  gtt  _______________ 

 DISCONTINUING IV THERAPY  PURPOSE  To discontinue IV Infusion  Completion of therapy  IV site needs to be changed ASSESSMENT 1. IV Site

IMPLEMENTATION 1. Verify Doctor’s orders and countercheck  2. Observe 10 Rights 3. Assess patient 4. Explain procedure to patient 5. Prepare equipment and place on tray

Types of Intravenous Therapy Solutions   

Isotonic Hypotonic Hypertonic

ISOTONIC SOLUTION Total osmolality is the same as blood/body fluid  Total electrolyte content is equal to 310 mEq/L 

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Purpose: To replace extracellular volume, and t o EXPAND vascular membrane Examples: o D5W / D5W = Provides free water, replaces ICFV, expander  CI: To ↑ ICP = May cause CEREBRAL EDEMA o 0.9 Sodium Chloride / NSS Plain NSS / NSS  Provides basic Na and Chloride (i.e. H onatremia 0.9% Na Cl  0.9% NSS  ***ONLY SOLUTION COMPATIBLE WITH BLOOD TRANSFUSION ***CAN CAUSE FLUID VOLUME EXCESS: Cause Na attracts WATER :o o Lactated Ringers (LR) Also known as Plain LR  Provides important electrolytes like Na, Cl, Ca, K, and Lactate  Indication: Burns, trauma, casualties, requires fluid resuscitation, Dehydration  (Ex. Dengue) Nursing Management: o Assess for Signs and Symptoms of HYPERVO LEMIA (↑PR ↑RR; Bounding and Crackles)  Remain in vascular compartment, expands vascular volume o

HYPOTONIC SOLUTION Total osmolality is less than the blood / body fluid  Total electrolyte content is lesser than 250 mEq/L  Total osmotic pressure is less than the extracellular fluid  Purpose:

Complications of Intravenous Therapy

Localized 1. 2. 3. 4. 5. 6.

Systemic

Infiltration Extravasation Thrombosis Phlebitis Thrombophlebitis Bleeding / Hematoma

1. 2. 3. 4. 5. 6.

Fluid volume excess Circulatory overload Embolism Pulmonary Embolism Air Embolism Catheter Embolism

LOCALIZED INFILTRATION  

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Definition: Intravenous fluid enters the surrounding space around the venipuncture site Clinical Manifestation: Swelling, Pallor, Coolness, Blanching, Pain and Edema, Slow IV Rate Nursing Management: 1. Stop infusion and discontinue IV 2. Elevate / raise the affected arm with pillow 3. Provide warm and moist compress for 20 minutes 4. Notify the physician immediately 5. Restart new IV as prescribed /  indicated

PHLEBITIS

EXTRAVASATION 

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Definition: Leakage of VESICANT IV solution or MEDICATION into the extravascular tissue Clinical Manifestations: Swelling, Pallor, Coolness, Blanching, Pain and Edema, Slow IV Rate, TISSUE SLOUGHING Nursing Management: 1. Stop infusion and discontinue IV 2. Elevate / raise the affected arm with pillow 3. Provide warm and moist compress for 20 minutes 4. Notify the physician immediately 5. Restart new IV as prescribed /  indicated 6. Administer antidote 7. Aspirate residual drug if possible 8. Administer IV push slowly, dilute drug, provide soluset as needed

THROMBOSIS  

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Definition: The presence of blood clot inside the vein Factors: Multiple/Traumatic venipuncture attempts, FVD, USE OF LARGE CATHETERS Clinical Manifestations: Pain, Erythema, Tender/ Engorged Vein, Swollen Extremity, Difficulty Moving the NECK/JAW, STOP INFUSION Nursing Management: 1. Stop infusion immediately 2. Apply cold then warm compress 3. Elevate extremities 4. Good venipuncture technique 5. Small gauge catheter 6. Secure catheter adequately – Use splint 7. Warfarin (Coumadin) and thrombolytic agent as prescribed 8. Adequate hydration

THROMBOPHLEBITIS  

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Definition: The presence of blood clot and vein inflammation Factors: Multiple/Traumatic venipuncture attempts, FVD, USE OF LARGE CATHETERS, MECHANICAL, CHEMICAL and BACTERIAL ETIOLOGY Clinical Manifestations: Pain, edema, erythema, vein becomes TENDER AND INCREASE in SKIN TEMPERATURE, TENDER/ENGORGED VEIN, SWOLLEN EXTREMITY, difficulty moving NECK/JAW, STOP INFUSION Nursing Management: 1. Stop infusion immediately 2. Apply cold then warm compress 3. Elevate extremities 4. Good venipuncture technique 5. Small gauge catheter 6. Secure catheter adequately – Use splint 7. Warfarin (Coumadin) and thrombolytic agent as prescribed 8. Adequate hydration

BLEEDING/HEMATOMA  

Definition: Blood leakage into the surrounding tissues of the IV insertion site Factors: Quick Notes: PSP-DB Perforation of vein during venipuncture   Perforation Needle slips out of the vein  Slipping  Pressure  Lack/excessive pressure to IV site after removal of catheter   Disconnection Disconnected/inpatient catheter needle   Bleeding

4. 5. 6.

Monitor vital signs frequently Assess the breath sounds Contact physician immediately

CATHETER EMBOLISM   

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Definition: Piece of catheter breaks off and floats freely in the blood vessel Factors: Needle is reinserted / inadvertently pulled back in the catheter Clinical Manifestations: Hypotension, Tachycardia, Thready PR, Cyanosis, Loss of  LOC Nursing Management: 1. Remove the catheter 2. Apply tourniquet high on limb 3. Inspect catheter for rough uneven surfaces 4. Expect for X-ray and surgery 5. Never reinsert the needle into the catheter

4. 5.

output. Notify imbalances Raise patient upright position Administer diuretics and oxygen therapy as prescribed

AIR EMBOLISM  

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Definition: Air enters the central venous system Factors: Air is inserted in the catheter during: Catheter Insertion  Quick Notes: I-CPR  Insertion IV Push   Push  Change Tubing Change   Removal Catheter Removal  Clinical Manifestations: Chest pain, DOB, Hypoxia, Nausea, Dizziness, Anxiety, Tachycardia, Hypotension, Loud Churning over the Heart (Auscultation) Nursing Management: 1. Clamp catheter immediately 2. Position patient to left lateral Trendelenburg 3. Notify doctor 4. Oxygen therapy 5. Expect for ECG and ABG 6. Perform valsalva maneuver

Blood Transfusion   

Synonym: Blood Replacement, Replacement Therapy Definition: Intravenous Administration of whole blood products or Blood components Functions: Functions of BT: 1. To increase circulating blood volume  ↑ Blood volume 2. To increase number of erythrocytes and maintain hemoglobin levels

3.

Clotting Factor Indication: Clotting factor deficiency  Purpose:  Provides the different factors involved in clotting pathway  Provides CRYOPRECIPITATE  Associated with clotting factors 

 Blood Transfusion Nursing Considerations  Nursing Management 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

Proper blood typing and blood matching Ensures signing of informed consent Careful assessment before, during and after transfusion Obtaining baseline vital signs Checking right patient, right blood product and compatibility Checking of the patency of IV catheter Ensures large gauge of catheter (gauge 18 – 19) Proper labeling of blood products Explains the procedure to the patient and their family Determine cultural background Requires another nurse to double-check the blood product and patient identification Use of appropriate Intravenous fluid solution (Plain Normal Saline Solution) Remain with the patient throughout the duration of the blood transfusion Assessment for the risk of allergic transfusion reaction Proper regulation of blood transfusion Assesses and instructs patient to report any untoward side effects once transfusion begins Promptly records and documents all findings and management done

Drugs Most Commonly Used in Intravenous Therapy     

Epinephrine Atropine Sodium Bicarbonate Morphine Dobutamine

 DRUG Epinephrine

DRUG CLASSIFICATION Bronchodilator

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Atropine

Anti-arrhythmia

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Sodium Bicarbonate

Acidifier/Alkalinizer

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Morphine

Opioid Analgesic

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Dobutamine **Put in intermittent solution

AdrenergicSympathomimetics

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INDICATION Bronchospasm Asthma Attack  Cardiac Arrest Anaphylaxis Bradycardia Bradyarrythmia Preoperative to ↓ Secretions Metabolic Acidosis Antacid Cardiac Arrest Moderate Pain Severe Pain Postoperative Meds

MECHANISM OF ACTION Relaxes the bronchial smooth muscles

Heart failure Cardiac Surgery Depressed cardiac contractility

Stimulates heart receptor to ↑ myocardial contractility, volume and cardiac output

Shock  Hemodynamic Imbalance Hypotension Acute Pulmonary Edema Hypertension

Stimulates dopaminergic reception in the SNS

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Inhibits Na and Cl reabsorption at loop of Henle and kidney tubules Activates plasminogen and converts it to plasmin for FIBRINOLYSIS

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Anticholinergic that blocks VAGAL effects that enhances heart conduction and ↑ PR/HR Restores body’s buffering capacity and neutralizes excess acid Bind with opiate receptor to alter perception and emotional response to pain

NURSING MANAGEMENT  Monitor BP, HR, ECG  Compatible with isotonic Intravenous Fluids  Give into a large vein  Give IV for 1 minutes  Avoid slow IV push 

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Monitor lab results regularly

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Dilute 4-5 ml sterile water Administer IV slowly for 4-5 minutes Note discomfort in IV site Compatible with isotonic/hypotonic IVF Dilute concentration Dilute with isotonic IVF Use infusion pump

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Dopamine

AdrenergicSympathomimetics

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Furosemide

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Diuretic

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Streptokinase ( Hematolytic)

Thrombolytic Enzyme

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Nitroglycerin

Antianginal

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Thrombosis P. Embolism Acute MI Cannula Occlusion Anginal Attacks A. Pectoris HTN, Heart Failure Surgery

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Nitrate reduces cardiac oxygen demand by decreasing preload and afterload

DRUGS COMMONLY USED IN INTRAVENOUS THERAPY

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Infused with isotonic solution Give 1-2 minutes Reconstitute / Dilute Drug Check for heparin Use filter solution 0.8 micron. Dilute the drug Use infusion pump as necessary