Parenteral Fluid

PARENTERAL FLUID THERAPY Maria Carmela L. Domocmat, RN, MSN Assistant Professor School of Nursing Northern Luzon Adventist College

Outline • Definition of IV therapy • Indication of IV therapy • Type of IV solution

• Nursing role in managing patient receiving IV therapy

DEFINITION OF IV THERAPY

Definition of IV therapy It is an effective and efficient method of supplying fluid directly into intravenous fluid compartment producing rapid effect with availability of injecting large volume of fluid more than other method of administration.

INDICATION OF IV THERAPY

PURPOSE • The choice of an IV solution depends on the purpose of

its administration. • Restore or maintain F & E • Administer meds

• Provide nutrition • Transfusion

• Route for blood samples

TYPE OF IV SOLUTION

Types of Solutions • Isotonic • Expand intravascular volume • 0.9% Saline • D5W • Lactated ringers

Types of Solutions • Hypertonic • Draw fluid from cells • D5 in 0.45 Saline • D5 in NS • D5 LR • 3% NaCl • D10W

• Hypotonic • Shift fluid into cells • 0.33% Saline • 0.45% Saline • 2.5 Dextrose

EQUIPMENT OF I.V. THERAPY

Equipment • Containers • Glass bottles • Plastic bags

• Administration Sets • IV set • Macro drips • Microdrips

• Y ports • Buretrols • In line filters • Timing strips • Electronic Infusion

Devices

IV Infusion Method I.V. Bolus (I.V. push)

IV Infusion Method Intermittent infusion

Continuousdrip infusion

Equipment of I.V. therapy Solution containers

administration sets

VENIPUNCTURE DEVICES • Equipment used to gain access to the vasculature

includes • Cannulas • needleless IV delivery systems

• peripherally inserted central catheter or midline catheter access

lines.

Venipuncture Devices: CANNULAS • Most common peripheral access devices • have an obturator inside a tube that is later removed.

“Catheter” and “cannula” : used interchangeably. • main types of cannula devices available are those referred to • winged infusion sets (butterfly) with a steel needle or as over-the-

needle catheter with wings • indwelling plastic cannulas inserted over a steel needle • indwelling plastic cannulas inserted through a steel needle.

• Scalp vein or butterfly needles • short steel needles with plastic wing handles • Easy to insert • but infiltration occurs easily • because they are small and nonpliable,

• use should be limited to obtaining blood specimens or

administering bolus injections or infusions lasting only a few hours • increase the risk for vein injury and infiltration.

• over-the-needle catheter • less likely to cause infiltration • available in long lengths • well suited for placement in central locations. • Parts: • Intracatheters: Plastic cannulas inserted through a hollow needle • Stylet

Venipuncture Devices: NEEDLELESS IV

DELIVERY SYSTEMS • an effort to decrease needlestick injuries and exposure to

HIV, hepatitis, and other bloodborne pathogens

Blunt cannula syringe

Venipuncture Devices: Peripherally Inserted Central

Catheter or Midline Catheter Access Lines • Patients who need moderate- to long-term parenteral

therapy • For patients with limited peripheral access • obese or emaciated patients, IV/injection drug users

• require IV antibiotics, blood, and parenteral nutrition.

• Requires median cephalic, basilic, and cephalic veins • pliable (not sclerosed or hardened) • not subject to repeated puncture. • If these veins are damaged • central venous access via the subclavian or internal jugular vein • surgical placement of an implanted port or a vascular access device

NURSING MANAGEMENT OF THE PATIENT RECEIVING IV THERAPY

Components of IV Orders • Type of Solution • Additives

• Rate and volume • Duration • Method

ASSESSMENT

Nursing assessment 1- assess the solution:

No leakage

Sterile

No small particles

Clear and not expired

2- Reading the label on the solution. 3- Determine the compatibility of all fluid and additives.

Nursing assessment 4- observe I.V sets

Cracks

Holes

Missing clamps

Expired date

• Also assess the patient for :

1- Any allergies and arm placement preference. 2- Any planned surgeries. 3- Patient’s activities of daily living. 4- Type and duration of I.V therapy, amount, and rate.

PREPARING TO ADMINISTER IV THERAPY • Before performing venipuncture • hand hygiene • applies gloves • informs patient about procedure • Select most appropriate insertion site and type of cannula

for a particular patient.

Factors influencing choices of insertion site • type of solution to be administered • expected duration of IV therapy

• patient’s general condition • availability of veins • skill of the person initiating the infusion

CHOOSING AN IV SITE • Many sites can be used for IV therapy, but ease of access

and potential hazards vary. • peripheral locations • ordinarily only sites used by nurses

• arm veins are most commonly used – coz safe and easy to enter

• arm veins • metacarpal, cephalic, basilic, and median veins • More distal sites should be used first, with more proximal

sites used subsequently.

CHOOSING AN IV SITE • Avoid the following • Leg veins because of high risk of thromboembolism. • veins distal to a previous IV infiltration or phlebitic area, sclerosed or thrombosed veins, • arm with arteriovenous shunt or fistula • arm affected by edema, infection, blood clot, or skin breakdown. • arm on side of mastectomy because of impaired lymphatic flow.

• Central veins • commonly used by physicians • subclavian and internal jugular veins. • Can gain access to (or cannulate) even when peripheral sites have collapsed • allow for administration of hyperosmolar solutions. • Hazards are much greater

• Consider mobility • Inspect both arms and hands and choose the site that does not interfere with mobility. • antecubital fossa is avoided : except as a last resort. • Take note from far to near • most distal site of the arm or hand is generally used first so that subsequent IV access sites can be moved progressively upward.

factors to consider when selecting a site for venipuncture: • Condition of the vein • Type of fluid or medication to be infused

• Duration of therapy • Patient’s age and size • Whether the patient is right- or left-handed

• Patient’s medical history and current health status • Skill of the person performing the venipuncture

• After applying a tourniquet, the nurse palpates and

inspects the vein. • The vein should feel firm, elastic, engorged, and round, not hard, flat, or bumpy. • Because arteries lie close to veins in the antecubital fossa, the vessel should be palpated for arterial pulsation (even with a tourniquet on), and cannulation of pulsating vessels should be avoided.

General guidelines for selecting a cannula include: • Length: 3⁄4 to 1.25 inches long • Diameter: narrow diameter of the cannula to occupy minimal space within the vein • Gauge: • 20 to 22 gauge for most IV fluids; a larger gauge for caustic or viscous

solutions • 14 to 18 gauge for blood administration and for trauma patients and those undergoing surgery • 22 to 24gauge for elderly

Note: Hand veins are easiest to cannulate. Cannula tips should not rest in a flexion area (eg, the antecubital fossa) as this could inhibit the IV flow.

PREPARING THE IV SITE • Before preparing the skin, ask patient allergy to latex or

iodine • Excessive hair at selected site may be removed by clipping • to increase the visibility of the veins and • to facilitate insertion of the cannula and adherence of dressings to

the IV insertion site.

Sites • Peripheral • arms • legs • Central • subclavian • internal jugular • uses

Figure 48.13b

Figure 48.13a

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Figure 48.14

Figure 48.14b

NURSING DIAGNOSIS

Nursing diagnosis: • Anxiety (mild, moderate, severe) related to threat

regarding therapy. • Fluid volume excess. • Fluid volume deficit. • Risk for infection. • Risk for sleep pattern disturbance. • Knowledge deficit related to I.V therapy.

PLANNING

Planning • Identify expected outcomes which focus on: • preventing complications from I.V therapy. • minimal discomfort to the patient. • restoration of normal fluid and electrolyte balance . • patient’s ability to verbalize complications.

IMPLEMENTATION

Implementation during initiation phase • Solution preparation • Label the I.V container. • Avoid the use of felt-tip pens or permanent markers on plastic bag. • Hang I.V bag or bottle

• Site preparation 1. Cleanse infusion site • The insertion site is scrubbed with a sterile pad soaked in 10%

povidone–iodine (Betadine) or chlorhexidine gluconate solution for 2 to 3 minutes • from the center of the area to the periphery • Allow the area to air day. • site should not be wiped with 70% alcohol • because the alcohol negates the effect of the disinfecting solution • Alcohol pledgets are used for 30 seconds instead, only if the patient is allergic to iodine

2. Excessive hair at selected site should be clipped with scissor .

• Maintain sterility of equipment • IV device, the fluid, the container, and tubing must be sterile • Because infection can be a major complication of IV therapy • perform hand hygiene

• put on gloves: nonsterile disposable gloves

PERFORMING VENIPUNCTURE • Venipuncture: the ability to gain access to the venous

system for administering fluids and medications

Source: Brunner and Suddhart, 2010)

Implementation during maintenance phase • inspect the tubing. • inspect the I.V set at routine intervals at least daily.

• Monitor vital signs . • recount the flow rate after 5 and 15 minutes after • •

• •

initiation Site care Dressings Tubing and bag changes Prevent complications

• Intermittent flushing of I.V lines • Peripheral intermittent are usually flushed with saline (2-3 ml 0.9% NS.) • Replacing equipments (I.V container, I.V set, I.V

dressing): •

• •

•

I.V container should be changed when it is empty. I.V set should be changed every 24 hours. The site should be inspected and palpated for tenderness every shift or daily/cannula should be changed every 72hours and if needs. I.V dressing should be changed daily and when needed

• Regulating flow rate

volume to be infused (ml/h)  gtt/ml(IV set)  gtt/min time in minutes (60 min/1h)

MONITORING THERAPY • Maintaining an existing IV infusion is a nursing

responsibility that demands knowledge of the solutions being administered and the principles of flow. • patients must be assessed carefully for both local and systemic complications.

Monitoring Therapy • Flow Rate • Influences • Height of container • Diameter of tubing/cannula • Length of tubing • Viscosity • Cannula position • Position of extremity

• Site care • dressings • site change • Tubing and bag changes • Prevent complications

FACTORS AFFECTING FLOW • Height of container

• Flow is directly proportional to the height of the liquid column. • Raising the height of the infusion container may improve sluggish

flow. • Diameter of tubing and cannula

• Flow is directly proportional to the diameter of the tubing. • The clamp on IV tubing regulates the flow by changing the tubing

diameter. • flow is faster through large-gauge rather than small- gauge cannulas.

FACTORS AFFECTING FLOW • Length of tubing • Flow is inversely proportional to the length of the tubing. • Adding extension tubing to an IV line will decrease the flow. • Viscosity • Flow is inversely proportional to the viscosity of a fluid. • viscous IV solutions (ex: blood) require a larger cannula than water or saline solutions • Cannula position

• Position of extremity

IV infusion pumps

EVALUATION

Evaluation • Produce therapeutic response to medication, fluid and

electrolyte balance. • Observe functioning and patency of I.V system. • Absence of complications.

DISCONTINUING AN INFUSION • The nurse never use scissors to remove the tape or • • • •

dressing. Apply pressure to the site for 2 to 3 minutes using a dry, sterile gauze pad. Inspect the catheter for intactness. The arm or hand may be flexed or extended several times.

DISCONTINUING AN INFUSION • The removal of an IV catheter is associated with two

possible dangers: • bleeding • catheter embolism

• To prevent excessive bleeding • dry, sterile pressure dressing should be held over the site as the catheter is removed. • Firm pressure is applied until hemostasis occurs.

• Catheter embolism • Preventive measures • Avoid using scissors near the catheter. • Avoid withdrawing the catheter through the insertion needle. • Follow the manufacturer’s guidelines carefully (eg, cover the needle

point with the bevel shield to prevent severance of the catheter). • Management • If the catheter clearly has been severed, the nurse can attempt to

occlude the vein above the site by applying a tourniquet to prevent the catheter from entering the central circulation (until surgical removal is possible). As always, however, it is better to prevent a potentially fatal problem than to deal with it after it has occurred

DOCUMENTATION

Recording and reporting: • Type of fluid, amount, flow rate, and any drug added. • Insertion site.

• Size and type of I.V catheter or needle. • The use of pump. • When infusion was begun and discontinuing.

• Expected time to change I.V bag or bottle, tubing,

cannula, and dressing.

• Any side effect. • Type and amount of flush solution.

• Intake and output every shift, daily weight. • Temperature every 4 hours. • Blood glucose monitoring every 6 hours, and rate of

infusion.

Documentation • Starting the IV • 10/3/08 – 0900 hours – #22 1-inch Gelco inserted on first attempt to R cephalic vein, NS infusing via pump at 125cc/hr. Pt tolerated procedure well. S. Wise, RNC • Discontinuing the IV • 10/3/08 – 2000 hours – IV R wrist removed without difficulty, cathlon intact. Pt tolerated well. S. Wise, RNC

COMPLICATIONS

Complications Local • Hematoma • Thrombosis • Thrombophlebitis • Phlebitis • Infiltration • Extravasation • Infection

Local Complication Infiltration

Extravasation

Infiltration and Extravasation • Infiltration : unintentional administration of a nonvesicant

solution or medication into surrounding tissue. • occur when IV cannula dislodges or perforates the wall of the vein.

Infiltration: S/S • edema around insertion site • leakage of IV fluid from insertion site

• discomfort and coolness in area of infiltration • significant decrease in the flow rate • When solution is particularly irritating, sloughing of tissue

may result.

• Closely monitoring the insertion site is necessary to detect

infiltration before it becomes severe. • How to check? • insertion area is larger than same site of the opposite extremity

• Backflow of blood into tubing proves that the catheter is properly

placed within the vein. True or false? • If the catheter tip has pierced the wall of the vessel, however, IV fluid

will seep into tissues as well as flow into the vein. • Although blood return occurs, infiltration has occurred as well.

• Closely monitoring the insertion site is necessary to detect

infiltration before it becomes severe. • How to check? • apply a tourniquet above (or proximal to) infusion site and

tighten it enough to restrict venous flow. • If the infusion continues to drip despite the venous obstruction,

infiltration is present.

Management • infusion should be stopped • IV discontinued

• a sterile dressing applied to the site after careful

inspection to determine the extent of infiltration. • infiltration of any amount of blood product, irritant, or vesicant is

considered the most severe.

• Start another IV infusion at new site or proximal to

infiltration if same extremity is used.

Management • warm compress to the site • if small volumes of noncaustic solutions have infiltrated over a long time • cold compress • ithe infiltration is recent • Elevate affected extremity to promote the absorption of

fluid • Use standardized infiltration scale to document the infiltration (Infusion Nursing Standards of Practice)

Standardized infiltration scale 0 = No symptoms 1 = Skin blanched, edema less than 1 inch in any direction, cool to touch, with or without pain 2 = Skin blanched, edema 1 to 6 inches in any direction, cool to touch, with or without pain 3 = Skin blanched, translucent, gross edema greater than 6 inches in any direction, cool to touch, mild to moderate pain, possible numbness 4 = Skin blanched, translucent, skin tight, leaking, skin discolored, bruised, swollen, gross edema greater than 6 inches in any direction, deep pitting tissue edema, circulatory impairment, moderate to severe pain, infiltration of any amount of blood products, irritant, or vesicant

Prevention • Inspect site every hour for • Redness • Pain • Edema • blood return • coolness at the site • IV fluid draining from the IV site. • Use appropriate size and type of cannula for vein

prevents this complication

Very Serious Complications Can Occur • Infiltration • Non vesicant solution • Extravasation • Vesicant solution

Extravasation • similar to infiltration with an inadvertent administration of

vesicant or irritant solution or medication into the surrounding tissue. • Medications such as dopamine

• calcium preparations • chemotherapeutic agents

• can cause pain, burning, and redness at the site • Blistering, inflammation, and necrosis of tissues can

occur.

Vesicant Medications/Solutions • Fluoroquinolones • Cipro, levaquin, floxin

• • • • • • • • •

Gentamicin Nafcillin Penicillin Vancomycin Calcium chloride Calcium gluconate Potassium chloride Sodium bicarbonate Cytotoxic agents

• • • • • • • • • •

Valium Dextrose Dobutrex Dopamine Fat emulsion TPN Dilantin Phenergan Diprovan Radiographic contrast agents

• The extent of tissue damage is determined by • concentration of medication • quantity that extravasated • location of the infusion site • tissue response • duration of process of extravasation

Management • Stop infusion • Notify physician promptly.

• Initiate agency’s protocol for extravasation • protocol may specify specific treatments, including • Antidotes specific to the medication that extravasated • IV line should remain in place or be removed before treatment. • infusion site be infiltrated with an antidote prescribed after assessment by the physician and application of warm or cold compresses, depending on the medication infusing. • extremity should not be used for further cannula

placement. • Thorough neurovascular assessments of the affected extremity must be performed frequently

Prevention • Review institution’s IV policy and procedures and

incompatibility charts and checking with the pharmacist before administering any IV medication, whether given peripherally or centrally • to determine incompatibilities and vesicant potential.

• Careful, frequent monitoring of the IV site

• avoid insertion of IV devices in areas of flexion

Prevention • secure the IV line • use smallest catheter possible that accommodates the

vein • when vesicant medication is administered by IV push, it should be given through a side port of an infusing IV solution to dilute the medication and decrease severity of tissue damage if extravasation occurs

Phlebitis • inflammation of a vein related to a chemical or mechanical

irritation, or both.

S/S • reddened, warm area around the insertion site or along

the path of the vein • pain or tenderness at the site or along the vein, and swelling. • incidence of phlebitis increases with • Length of time the IV line is in place • composition of the fluid or medication infused (especially its pH and

• •

• •

tonicity) size and site of the cannula inserted ineffective filtration improper anchoring of the line introduction of microorganisms at the time of insertion.

specific standards for assessing phlebitis • Intravenous Nursing Society

Thrombophlebitis • refers to presence of a clot plus inflammation in the vein.

Thrombophlebitis- S/S • Localized pain • redness, warmth, and swelling around the insertion site or • • • •

•

along the path of the vein immobility of the extremity because of discomfort swelling, sluggish flow rate Fever Malaise Leukocytosis

Management • D/C IV infusion • 1st: cold compress to decrease the flow of blood and • • • •

increase platelet aggregation followed by a warm compress Elevate extremity Restart line in the opposite extremity If (+) patient has signs and symptoms of thrombophlebitis, the IV line should not be flushed • (although flushing may be indicated in the absence of phlebitis to

ensure cannula patency and to prevent mixing incompatible medications and solutions).

Prevention • Avoid trauma to vein at time the IV is inserted, • Observe site every hour

• Check medication additives for compatibility

Local Complication- Hematoma • Hematoma •S&S • Interventions • Prevention

Hematoma • Hematoma results when blood leaks into tissues

surrounding the IV insertion site. • Leakage can result from • perforation of opposite vein wall during venipuncture

• Needle slipping out of vein • insufficient pressure applied to the site after removing the needle or

cannula.

s/s • Ecchymosis • immediate swelling at site

• leakage of blood at site.

Management • Remove needle or cannula and apply pressure with a

sterile dressing • Apply ice for 24 hours to • site to avoid extension of the hematoma

• then warm compress to increase absorption of blood; • assessing the site • Restart the line in the other extremity if indicated.

Prevention • carefully insert needle • use diligent care when a patient has a bleeding disorder,

takes anticoagulant medication, or has advanced liver disease

Clotting and Obstruction • Blood clots may form in the IV line as a result of • kinked IV tubing • very slow infusion rate • Empty IV bag • failure to flush the IV line after intermittent medication or solution administrations. • The signs are decreased flow rate and blood backflow

into the IV tubing.

Management • If blood clots in the IV line • DC infusion • Restart another site with a new cannula and administration set. • The tubing should not be irrigated or milked. Neither the infusion rate nor the solution container should be raised, and the clot should not be aspirated from the tubing

Prevention • Do not permit IV solution bag to run dry • Tape the tubing to prevent kinking and maintain patency

• Maintain adequate flow rate • Flushing line after intermittent medication or other solution

administration. • In some cases, a specially trained nurse or physician • may inject a thrombolytic agent into the catheter to clear an occlusion resulting from fibrin or clotted blood.

Local ComplicationSite Infection • Site infection •S&S • Interventions • Prevention

Local complicationTissue Sloughing • Tissue Sloughing •S&S • Interventions • Prevention

Systemic Complication • Circulatory or Fluid Overload • Septicemia/ Systemic Infection

• Pulmonary Edema • Catheter Embolism • Air Embolism

• Pulmonary Embolus

Fluid Overload • Overloading the circulatory system with excessive IV

fluids causes increased blood pressure and central venous pressure.

Fluid Overload – S/S • moist crackles on auscultation of the lungs • Edema

• weight gain • Dyspnea • respirations : shallow and increased rate.

Fluid Overload – causes • rapid infusion of an IV solution or hepatic, cardiac, or

renal disease. • risk for fluid overload and subsequent pulmonary edema is especially increased in elderly patients with cardiac • disease; this is referred to as circulatory overload.

Management • Decrease IV rate • Monitor VS frequently

• Assess breath sounds • Place patient in high Fowler’s position • Contact physician immediately.

Prevention • Use infusion pump for infusions • carefully monitoring all infusions. • Complications of circulatory overload • include heart failure and pulmonary edema.

Air Embolism • risk of air embolism is rare but ever-present. • most often associated with cannulation of central veins.

Air Embolism • dyspnea • Cyanosis

• hypotension • weak, rapid pulse • loss of consciousness

• chest, shoulder, and low back pain.

Management • Immediately clamp the cannula • Place patient on the left side in Trendelenburg position,

• Assess VS and breath sounds • Administer oxygen.

Prevention • Use a Luer-Lock adapter on all lines • filling all tubing completely with solution

• Use an air detection alarm on an IV pump.

Septicemia and Other Infection • Pyrogenic substances in either the infusion solution or the

IV administration set can induce a febrile reaction and septicemia.

S/s • abrupt temperature elevation shortly after the infusion is • • • • •

• • •

started Backache Headache increased pulse and respiratory rate Nausea and vomiting Diarrhea chills and shaking general malaise. In severe septicemia: • vascular collapse and septic shock

Causes of septicemia • contamination of the IV product or a break in aseptic

technique • especially in immunocompromised patients.

Management • Treatment is symptomatic • culturing of the IV cannula, tubing, or solution if suspect

• establishing a new IV site for medication or fluid

administration.

• Infection ranges in severity from local involvement of the

insertion site to systemic dissemination of organisms through the bloodstream, as in septicemia. • Measures to prevent infection are essential at the time the IV line is inserted and throughout the entire infusion.

Prevention • Careful hand hygiene before every contact with any part of the infusion system or patient • Examine the IV containers for cracks, leaks, or cloudiness, which may indicate a contaminated solution • Use strict aseptic technique

Prevention • Firmly anchor the IV cannula to prevent to-and-fro motion • Inspect the IV site daily and replace a soiled or wet dressing with a dry sterile dressing. (Antimicrobial agents that should be used for site care include 2% tincture of iodine, 10% povidone–iodine, alcohol, or chlorhexidine, used alone or in combination.

Prevention • Remove the IV cannula at the first sign of local inflammation, contamination, or complication • Replace the peripheral IV cannula every 48 to 72 hours, or as indicated • Replace the IV cannula inserted during emergency conditions (with questionable asepsis) as soon as possible

Prevention • Use a 0.2-micron air-eliminating and bacteria/particulate

retentive filter with non-lipid-containing solutions that require filtration. • The filter can be added to the proximal or distal end of the

administration set. • If added to the proximal end between the fluid container and the tubing spike, the filter ensures sterility and particulate removal from the infusate container and prevents inadvertent infusion of air. • If added to the distal end of the administration set, it filters air particles and contaminants introduced from add-on devices, secondary administration sets, or interruptions to the primary system

Disposable Infusion Set IV Filter

Prevention • Replace solution bag and administration set in

accordance with agency policy and procedure • Infuse or discard medication or solution within 24 hours of its addition to an administration set • Change primary and secondary continuous administration sets every 72 hours, or immediately if contamination is suspected • Change primary intermittent administration sets every 24 hours, or immediately if contamination is suspected

References • Brunner, L. S., Suddarth, D. S., & Smeltzer, S. C. O.

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•

(2008). Brunner & Suddarth's textbook of medicalsurgical nursing (11th ed.). Philadelphia: Lippincott Williams & Wilkins. http://webhome.broward.edu/~gbrickma/Slides/IV%20The rapy%209-12-08.ppt http://www.mc.vanderbilt.edu/root/sbworddocs/proceed_n ursing/Revised_web_IV_therapy.ppt http://uqu.edu.sa/files2/tiny_mce/plugins/filemanager/files/ 4300164/Type%20and%20indication%20of%20IV%20ther apy%202.ppt http://faculty.irsc.edu/FACULTY/SWise/IV%20therapy.PPT