Intravenous Parenteral Therapy Lecture

8/6/2019 Intravenous Parenteral Therapy Lecture

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INTRAVENOUS PARENTERAL THERAPY

Definition

Intravenous (IV) therapy is the insertion of needle or catheter / cannula into a vein, based

on the physicians written prescription. The needle or catheter/cannula is attached to steriletubing and a fluid container to provide medication and fluids.

Philosophy

Historical background of IV Therapy

The record history of i.v. therapy began in 1492 when a blood transfusion from two

Romans to the dying Pope Innocent was attempted. All three died.

In 1628, Sir William Harveys discovery of the blood circulatory system formed the basis

for more scientific experimentation. In 1658 Sir Christopher Wren predicted the possibility of

introducing medication directly into the bloodstream, although it was Dr. Robert Boyle who used

a quill and bladder to inject opium into a dog 1659, with J D Major succeeding with the first

injection into human in 1665.

A 15 year old Parisian boy successfully received a transfusion of lambs blood in 1667.

However, subsequent animal to human transfusions proved fatal and eventually, in 1687, the

practice was made illegal.

In 1834, James Bludell proved that only human blood was suitable for transfusion, and

later the century Pastuer and Lister stressed the necessity for sepsis during infusion procedures.

In 1900 Karl Landsteiner led the way in identifying and classifying different blood

groups, and in 1914 it was recognized that sodium citrate prevented clotting which opened the

gate for the extensive use of blood transfusions.

Intravenous therapy was being used widely during World War II, and by the mid-1950s

was being used mainly for the purposes of major surgery and rehydration only. Few medications

were given via i.v. route, with antibiotics more commonly being given intramuscularly.

Through the 1960s and 1970s, intermittent medications, filters, electronic infusion

control devices and smaller plastic cannulae became available. Use of multiple electrolyte

solutions and medications increased along with blood component therapy, and numerous i.v.

drugs and antibiotics were being added to i.v. regimens.

The use of i.v. therapy has expanded dramatically over the last 35 years. This expansion

continues to accelerate and can be attributed to the following factors:

The understanding of hazards and complication


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Improvement in i.v. equipment

Increased knowledge of physiological requirements

Increased knowledge of pharmacological and therapeutic implications

Increased availability of nutrients and drugs in i.v. solutions

Changes in the traditional roles of doctors and nurses, allowing nurses to develop

skills that were traditionally the remit of the medical profession (e.g. insertion of

central venous access devices).

Here in the Philippines, the Nursing Standards on Intravenous Practice was established

in 1993 as a guide for those who are and will be practicing intravenous therapy. During the first

months after the promulgation of the professional regulations Commission (PRC), Board of

Nursing (BON) Resolution No. 08 series, February 4, 1994, the maiden issues (First Edition) of

the Intravenous Standards on Intravenous Therapy was printed and circulated. It was first used in

Cagayan de Oro City where the Training for Trainers was conducted last June 9-11, 1994, after

the ANSAP Board Members and Advisers had undergone the Training for trainers at Philippine

Heart Center on October 1993.

Subsequently, another revision was required to incorporate the PRC-BONs protocol of

May 17, 1995. Because of the new concept and evolving technology, more revisions were

deemed necessary. Revisions were made by a special committee of the Association of Nursing

Service Administrators of the Philippines, Inc. (ANSAP) in collaboration with the PRC-BON, to

ensure a safe and quality nursing practice in Intravenous therapy in 2002. The new Nursing Law

RA 9173 has stated that the administration of parenteral injection is in the scope of nursing

practice. ANSAP believes that the certification of IV Therapist will be continued for several

reasons, paramount of which is safe nursing practice.


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Standard and competencies of IV therapy

Standard Operating Policies and Procedure are established to ensure safe IV therapy

practice, to protect the patients by maximizing benefits and minimizing risks associated with IV

therapy and to protect the practice of registered professional IV therapy nurses. The IV therapy

policies and procedures are written and continuously updated and reviewed as necessary.

1. Key points prior to initiation of IV therapy

a. Physicians prescribed treatment. The initiation of intravenous therapy is upon the

written prescription of a licensed physician which is checked for the following:

Patients Name

Type and amount of solution

The flow rate

The type, dose and frequency of medication to be incorporated/pushed.

Others affecting the procedure (x-rays, treatment to the extremities, etc)

b. Patient Assessment

Factors to consider for IV therapy

Clinical status of patient

Patients diagnosis

Patients age

Dominant arm ( non)

Condition of vein/ skin

Cannula size


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Type of solution

Duration of therapy

c. IV set and equipment preparation

Check for expiration date

Check for clarity; any presence of holes on plastic cover (packaging);

plastic container (bag) for presence of sediments or insects.

Check label against the physicians written prescription

Label for any medication that are added: date, time, dose of medication

and amount; compatibility of drug with the solution.

Functionality of infusion pump, patient controlled analgesia (PCA)

d. Medications

Nurses administering IV therapy should have knowledge on all

medications administered including dosages, drug interaction and possible

clinical effects on the vascular system.

10 GOLDEN RULES FOR ADMINISTERING DRUGS SAFELY

1. Administer the right drug.

2. Administer the right drug to the right patient.

3. Administer the right dose.

4. Administer the right drug by the right route.

5. Administer the right drug at the time.

6. Document each drug you administer.

7. Teach your patient about the drug he is receiving.

8. Take a complete patient drug history.

9. Find out if patient has drug allergies.

10. Be aware of potential drug drug or drug-food interactions.

Nursing 88 Vol. 18, August 1988

Cathleen McGovern, RN


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Quality assuance Coordinator

Edge Water Hospital

Chicago, Illinois, USA

2. Competency

a. Hand washing

b. Assessing of vital signs

c. Standard precautions

d. Principles of aseptic technique

e. Medication calculation

f. Medication administration

ANATOMY AND PHYSIOLOGY

Superficial veins of the upper limbs are usually selected for peripheral cannulation.

Cannulation of the lower limbs is associated with an increased risk of venous thromboembolism.

The wall of a vein is composed of three layers (Figure 1):

The tunica adventitia (the outer layer): a fibrous layer of connective tissue, collagen and

nerve fibers which surrounds and supports the vessel.

The tunica media (the middle layer): a muscular layer containing elastic tissue and

smooth muscle fibers.

The tunica intima (the inner layer): a thin layer of endothelium, which facilitates blood

flow and prevents adherence of blood cells to the vessel wall. Trauma to the endothelium

encourages platelet adherence and thrombus formation.


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Figure 1. blood vessel structure.

Skin is composed of two main layers:

Epidermis (skin surface): approximately 1mm thick containing sensory nerve endings.

Dermis (beneath the epidermis): thicker than the epidermis, composed of collagenous and

elastic connective tissue and containing fat, blood and lymph vessels, nerves, hairfollicles, sweat glands and sebaceous glands.

Ageing alters the structure and appearance of the skin. The dermal layers become thinner andthere is less subcutaneous tissue to support the blood vessels. The veins of older people are often

easier to see because of the reduction in subcutaneous tissue, particularly on the dorsum of the

hand. The vessels are also more mobile, more fragile and often tortuous and thrombosed. Thedorsum of the hand should be avoided in older people.

Vein selection

Digital veins of the fingers are small and rarely used. The metacarpal veins and the dorsal venousarch are easily visualized and palpated. The radial end of the dorsal venous arch continues to

form the cephalic vein while the ulnar end of the dorsal venous arch forms the basilic vein; all ofthese are suitable for cannulation (Figure 2).


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Figure 2.

The cephalic and basilic veins continue into the forearm. The basilic vein is often

overlooked because it is inconspicuous, not easy to stabilize and can be difficult to access due to

its location. However, the cephalic vein is large, easily stabilized and accessible (Figure 3).


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Figure 3.

The median cubital vein runs diagonally across the antecubital fossa connecting the

basilic and the cephalic veins. There is great variation in the pattern of veins in this area. Themedian cubital vein is absent in 20 percent of the population (Moore and Dalley 1999). The

veins of the antecubital fossa are usually easily visualized, palpated and accessed because of

their superficial nature and size. However, their position over the flexor surface of the elbowmakes these veins prone to mechanical phlebitis, and the cannula prone to failure from kinking

or dislodgement.History taking and assessment should alert nursing staff to specific patient issues that

should be considered when identifying a site for cannulation. A cannula should not be placed in

areas of localized edema, dermatitis, cellulitis, arteriovenous fistulae, wounds, skin grafts,

fractures, stroke, planned limb surgery and previous cannulation. Discussion with the patient is

important. The patient may prefer the non-dominant limb to be selected for cannulation toremote independence and comfort. Both upper limbs should be inspected to identify possible

veins for cannulation. Potential veins can then be palpated to assess their condition. An ideal

vein is soft and bouncy when palpated. Veins that are tender, thrombosed or hard should beavoided. Veins contain valves, crescent shaped folds of endothelium, which assist blood flow

back to the heart. Valves are most plentiful in the veins of the limbs and occur more frequently at

junctions where veins converge. Careful observation may reveal valves (small bulges) within theperipheral veins, which should be confirmed by palpation. Valves may prevent blood withdrawal

and cannula advancement and, therefore, should be avoided. Palpation also allows the

practitioner to differentiate between arteries and veins. Arteries are pulsatile and should becarefully avoided. New cannulae should be sited proximal to any previous sites to prevent drug

or fluid infusion through damaged veins.


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Cannulation procedure

Position the patient comfortably. It may be helpful to support his or her arm on a pillow.

Wash hands and apply non-sterile gloves (Centers for Disease Control and Prevention(CDC) 2002).

Apply a tourniquet to the upper limb to improve venous filling. This should not obstruct

arterial blood flow and the radial pulse should still be palpable. Ask the patient to open and close the fist to promote venous filling.

Clean the skin with a chlorhexidine-based solution and allow to dry.

Do not re-palpate the skin.

Open the cannula carefully and ensure the stylet within the cannula is positioned with thebevel uppermost.

Hold the patients arm or hand and use your thumb to pull the skin taut below the

intended puncture site. This will stabilize and anchor the vein before cannulation.

Hold the cannula in line with the vein at a 10-30 angle to the skin and insert the cannulathrough the skin.

As the cannula enters the vein blood will be seen in the flashback chamber. Lower the

cannula slightly to ensure it enters the lumen of the vein and does not puncture theposterior wall of the vessel.

Withdraw the stylet slightly and blood should be seen to enter the cannula: this confirms

the position in the vein. The stylet must not be re-inserted as this can damage the cannula,

resulting in catheter embolus.

Slowly advance the cannula into the vein, ensuring the vein remains anchored throughout

the procedure.

Release the tourniquet.

Dispose of the stylet in the sharps container at the bedside.

Flush the cannula to check patency and to ensure easy administration without pain,resistance or localized swelling.

Secure the cannula with a moisture-permeable transparent dressing (Royal College ofNursing (RCN) 2003. The dressing should allow viewing of the entry site while firmly

stabilizing the cannula to prevent mechanical phlebitis or cannula dislodgement.

Record the cannulation procedure in the patients notes, including device, gauge,

location, nurses signature and number of insertion attempts.

FLUID AND ELECTROLYTE THERAPY

Types of therapy

1. Maintenance therapy

Provides water, electrolytes, glucose, vitamins, and in some instances protein to

meet daily requirements.

2. Restoration of deficits

In addition to maintenance therapy, fluid and electrolytes are added to replaceprevious losses.

3. Replacement therapy

Infusions to replace current losses in fluid and electrolytes.


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Types of intravenous fluids

1. Isotonic solutionsa. Fluids that approximate the osmolarity (280-300 mOsm/L) of normal blood plasma.

Sodium Chloride (0.9%) - Normal Saline

Indications: Extracellular fluid replacement when Cl- loss is equal to or greater the Na

loss.

Treatment of matebolic alkalosis.

Na depletion

Initiating and terminating blood transfusions.

Possible side effects:

Hypernatremia

Acidosis

Hypokalemia

Circulatory overload.

b. Five percent dextrose in water (D5W).

Provides calories for energy, sparring body protein and preventing ketosis resultingfrom fat breakdown.

Indications:

Dehydration

Hypernatremia

Drug administration


Hypokalemia

Osmotic diuresis dehydration

Transient hyperinsulinism Water intoxication.

c. Five percent dextrose in normal saline (D5NS).

Prevents ketone formation and loss of potassium and intracellular water.Indications:

Hypovolemic shock temporary measure.

Burns

Acute adrenocortical insufiency.


Hypernatremia

Acidosis

Hypokalemia Circulatory overload

d. Isotonic multiple-electrolyte fluids.

Used for replacement therapy; ionic composition approximates blood plasma.

Types:a. Plasmanate

b. Polysol

c. Lactated Ringers


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Indications:

Vomiting

Diarrhea

Excessive diuresis

Burns

Possible side effects: Circulatory overload.

Lactated Ringers is contraindicated in severe metabolic acidosis and/or alkalosis

and liver disease.

Hypernatremia

Acidosis

Hypokalemia2. Hypertonic solutions

Fluids with an osmolarity much higher than 310 mOsm (+ 50 mOsm); increase osmotic

pressure of blood plasma, thereby drawing fluid from cells.

a. Ten percent dextrose in normal saline

Administered in large vein to dilute and prevent venous trauma.Indications:

Nutrition

Replenish Na and Cl.Possible side effects:

Hypernatremia (excess Na)

Acidosis (excess Cl)

Circulatory overload.b. Sodium Chloride solutions, 3% and 5%

Indications: Slow administration essential to prevent overload (100 mL/hr)

Water intoxication

Severe sodium depletion

3. Hypotonic solutionsFluids whose osmolarity is significantly less than that of blood plasma (-50 mOsm);

these fluids lower plasma osmotic pressure, causing fluid to enter cells.

a. 0.45% sodium chlorideUsed for replacement when requirement for Na use is questionable.

b. 2.5% dextrose in 0.45% saline, also 5% in 0.2 % NaCl

Common rehydrating solution.

Indications: Fluid replacement when some Na replacement is also necessary.

Encourage diuresis in clients who are dehydrated.

Evaluate kidney status before instituting electrolyte infusions.Possible side effects:

Hypernatremia

Circulatory overload


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Used with caution in clients who are edematous, appropriate electrolytes should be

given to avoid hypokalemia.

Table of Commonly Used IV SolutionsName of

Solution

Type of Solution Ingredients in

1-Liter

Uses Complications

0.45% Sodium

Chloride

Shorthand

Notation:

NS

Hypotonic

pH 5.6

77 mEq Sodium

77 mEq Chloride

hypotonic hydration; replace

sodium and chloride;

hyperosmolar diabetes

If too much is mixed with blood cells

during transfusions, the cells will pull wat

into them and rupture

0.9% Sodium

Chloride

Shorthand

Notation:

NS

Isotonic

pH 5.7

154 mEq Sodium

154 mEq Chloride

isotonic hydration; replace

sodium and chloride;

alkalosis; blood transfusions(will not hemolyze bloodcells)

None known

3% Sodium

Chloride

Hypertonic

pH 5.0

513 mEq Sodium

513 mEq Chloride

symptomatic hyponatremia

due toexcessive sweating,vomiting, renal impairment,

and excessive water intake

rapid or continuous infusion can result in

hypernatremia or

hyperchloremia5% Sodium

Chloride

Hypertonic

pH 5.8

855 mEq Sodium

855 mEq Chloride

5% Dextrose inWater

Shorthand

Notation:

D5W

Isotonic

pH 5.0

5 grams dextrose

(170 calories/liter)

isotonic hydration; providessome calories

water intoxication and dilution of bodys

electrolytes with long, continuous infusion

10% Dextrose

in Water

Shorthand

Notation:

D10W

Hypertonic

pH 4.3

10 grams dextrose


may be infused peripherally;

hypertonic hydration;

provides some calories


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5% Dextrose in

1/4 Strength (or

0.25%) Saline

Shorthand

Notation:

D5N

Hypertonic

pH 4.4

5 grams Dextrose

34 mEq Sodium

34 mEq Chloride

fluid replacement;replacement of sodium,

chloride and some calories

vein irritation because of acidic pH, caus

agglomeration (clustering) if used with

blood transfusions; hyperglycemia withrapid infusion leading to osmotic diuresi

5% Dextrose in

0.45 Sodium

Chloride

Shorthand

Notation:

D5NS

Hypertonic

pH 4.4

5 grams Dextrose

77 mEq Sodium

77 mEq Chloride

hypertonic fluid replacement;replace sodium, chloride, and

some calories

5% Dextrose in

Normal Saline

Shorthand

Notation:

D5NS

Hypertonic

pH 4.4

5 grams Dextrose

154 mEq Sodium

154 mEq Chloride

hypertonic fluid replacement;

replace sodium, chloride and

some calories

Ringers

Injection,

U.S.P.

Isotonic

pH 5.8

147 mEq Sodium

4 mEq Potassium

4 mEq Calcium

155 mEq Chloride

electrolyte replacement;

hydration; often used to

replace extracellular fluid

losses

rapid administration leads to excessive

introduction of electrolytes and leads to

fluid overload and congestive conditions;

provides no calories and is not an adequat

maintenance solution if abnormal fluid

losses are present

LactatedRingers

Shorthand

Notation:

LR

Isotonic

pH 6.6

130 mEq Sodium

4 mEq Potassium

3 mEq Calcium

109 mEq Chloride

28 mEq Sodium Lactate

(provides 9

calories/liter)

isotonic hydration; replaceelectrolytes and extra-

cellular fluid losses; mild to

moderate acidosis (the lactate

is metabolized into

bicarbonate which

counteracts the acidosis)

not enough electrolytes for maintenance;

patients with hepatic disease have trouble

metabolizing the lactate; do not use if lacti

acidosis is present


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5% Dextrose in

Lactated

Ringers

Injection

Shorthand

Notation:

D5LR

Hypertonic

pH 4.9

5 grams Dextrose


130 mEq Sodium

4 mEq Potassium

3 mEq Calcium

109 mEq Chloride

28 mEq Sodium Lactate

(provides 9

calories/liter)

hypertonic hydration;provides some calories;

replace electrolytes and

extra-

cellular fluid losses; mild to

moderate acidosis (the lactate

is metabolized intobicarbonate which

counteracts the acidosis), the

dextrose minimizes glycogen

depletion

VENIPUNCTURE TECHNIQUE

Methods of vein entry

There are different methods of vein entry for needles or over needle catheters; indirect, direct,

direct, and bevel position either up or down. Use of over the needle cannula requires a different

threading technique than a wing tip or scalp vein needle. With the wing tip usually use the bevel

down position.

The Bevel

The bevel up method usually causes fewer traumas to the vein and is less painful for the

patient; however, sometimes the bevel down position is better. If the needle and vein are

approximately the same diameter, this position is likely to perforate the opposite wall of the vein

on insertion causing a hematoma. This problem is less likely to occur in the bevel down position.

Entering a vein successfully doesnt guarantee that the vein wont collapse and block the bevel

when removing the tourniquet. In that case, manipulating the needle slight within the vein may

relieve the blockage. A greater risk of perforating the opposite wall of the vein when the needles

bevel is facing up. It is a good idea when entering a small vein with a large bore needle to use the

bevel down position.

Remember, a needle that is properly placed in the vein can be palpated. If not, probably it has

gone through the vein. Remove the needle promptly and reinsert.

Indirect method

The first movement, penetrate the skin at a 54 degree angle to side of the vein about

below the point of the venipuncture, then decrease the needle angle until the is almost parallel to

the skin surface.


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The second movement , penetrate the vessel wall and advance the needle cautiously while

lifting the vein with slight upward pressure. Watch for the backflow to confirm proper placement

of the needle/catheter. If using the catheter, over the needle, advance the catheter while removing

the needle. Never reinsert the needle into the catheter which may cause shearing off of the tip of

the catheter leading to catheter embolus. Since the needle protrudes further than the catheter,

need to be sure that the catheter itself is in the vein, not just the needle.

Direct method

In the direct method the needle is at 30 degree angle over the vein and is inserted in the

direction of the blood flow. The vein is penetrated in one movement by approaching the vessel

from the top or side. This method of venipuncture requires considerable more skill then the

indirect method, but it is less painful for the patient when done correctly.

When trying to penetrate the skin, be sure to hold the skin taught. This will cause fewer

trauma and less pain. Before insertion, measure the cannula against the vein to be sure thecannula will clear joints and nodules to ease threading. Some veins have a tendency to roll or

move away. Pull down on them slight and hold tension for easier penetration. Do not spend too

much time probing. Gently feel for the tip of the cannula in relation to the vein to give some idea

if it is below, to the right, or left of the vein. If cannot stabilize the vein or if it disappears,

remove the cannula and attempt venipuncture in another vein.

Methods of stabilizing the venipuncture site

Chevron method

Using a strip of tape to wide apply sticky side up in a V formation.Apply a piece of 1 tape across the two wings of the chevron. The loop the tubing and secure it

with another piece of 1 tape. This method can be used with both plastic cannula/ catheter and

wingtip needle.

U method

Using a strip of tape to wide place with a sticky side up under the hub

folding each tape tail over each corresponding wing in the U formation. Use this method with

wingtip needle.

H method

Place one strip of 1 tape over each wing. Then place another piece of 1 tape

horizontally over the first two forming the letter H. This method is suitable for securing the

wingtip needle.


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INTRAVENOUS THERAPY COMPLICATIONS

1. LOCAL COMPLICATIONS

a. Infiltration

b. Extravasation

c. Thrombosis

d. Thrombophlebitis

e. Phlebitis

2. SYSTEMIC COMPLICATIONS

a. Embolism

b. Pulmonary embolism

c. Air embolism

d. Catheter embolism

e. Hematoma

f. Systemic infection

g. Speedshock

h. Circulatory overload

i. Allergic reaction

INFILTRATION

Results when the infusion cannula becomes dislodged from the vein and fluids are

infused into the surrounding tissues.

Cause

Device dislodged from vein or perforated veinSigns & Symptoms

Increasing edema at the site of the infusion

Discomfort, burning, pain at site

Feeling of tightness at site


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Decreased skin temperature around site

Blanching at site

Absent backflow of blood

Slower flow rate

Nursing intervention

Remove the device

Apply warm soaks to aid absorption

Elevate the limbNotify the doctor if severe

Assess circulation

Restart the infusionDocument the patient's condition and your interventions

Prevention

Check the I.V site frequentlyDon't obscure area above site with tape

Teach the patient to report discomfort, pain, swelling

EXTRAVASATION

It occurs when fluids seep out from the lumen of a vessel into the surrounding tissue.

Causes

Damage to the posterior wall of the vein

Occlusion of the vein proximal to the injection site

Signs & Symptoms

Swelling

Discomfort

Burning

Tightness

Coolness in the adjacent skin

Slow flow rate

Nursing Interventions


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Immediately stop the infusion and remove the device

Elevate the affected limb

Apply cold compress to decrease edema and pain

Apply moist heat to facilitate the absorption of fluid at grossly infiltrated sites

DRUGS ASSOCIATED WITH EXTRAVASATION NECROSIS

Generic Name Brand Name

Calcium chloride Various

Calcium gluconate Various

Dacarbazine DTIC

Dactinomycin Cosmogen

Daunorubicin Cerubidine

Dopamine Various

Doxorubicin Adriamycin

Idarubicin Idamycin

Mechlorethamine Mustargen

Mitomycin C Mutamycin

Plicamycin Mithracin Streptozocin Zanosar

Teniposide Vumon

Vancomycin Various

Vinblastine Velban

Vincristine Oncovin

Vinorelbine Navelbine

THROMBOSIS

Occurs when blood flow through a vein is obstructed by a local thrombus. Catheter-

related thrombosis arises as a result of injury to the endothelial cells of the venous wall.

Cause


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Injury to endothelial cells of vein wall, allowing platelets to adhere and thrombus form

Signs & Symptoms

Painful, reddened, & swollen vein

Sluggish or stopped I.V flow


Remove the device; restart the infusion in the opposite limb if possible

Apply warm soaksWatch for I.V therapy related infection

Prevention

Use proper venipuncture techniques to reduce injury to the vein

THROMBOPHLEBITIS

Occurs when thrombosis is accompanied by inflammation. Infusions allowed tocontinue after thrombophlebitis develops will slow and eventually stop, indicating progression

to an obstructive thrombophlebitis. All thrombotic complications have the associated danger of

embolism, especially in cases where the thrombus is not well attached to the wall of the vein.

Signs & Symptoms

Local tendernessSwelling

Induration

A red line detectable above the IV site.

Recommendations to Reduce the Risk of Thrombotic Complications

1. Use veins in the upper extremities

2. Avoid placing catheters over joint flexions

3. Select veins with adequate blood volume for solution characteristics

4. Anchor cannulas securely5. Avoid multiple venipunctures

PHLEBITIS

inflammation of a vein that may be caused by infection, the mere presence of a foreign

body (the IV catheter) or the fluids or medication being given.


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Causes:

Injury during Venipuncture

Prolonged use of the same IV site

irritating./incompatible IV additives

Use of vein that is too small for the flow rate

Use of needle size too large for the vein size

Signs & Symptoms

Pain

Vein that is sore, hard, cord like and warm to touch

Red line above the site

Signs of infection

Phlebitis Rating

0 = No symptoms

1 = Erythema at site with or without pain2 = pain at site, erythema and/or edema; no streak, no palpable cord

3 = pain at site, erythema and/or edema; streak present; palpable cord

4 = pain at site, erythema and/or edema; streak present; palpable cord > 1 inch; purulentdrainage

Common Medication that can cause Phlebitis

Phenytoin

Diazepam

Erythromycin

Tetracycline

Vancomycin

Amphothericin B

40 mEq/L or more doses of KCL


Upon assessment of phlebitis, removal the needle

Avoid multiple insertion

Application of warm compress

Continuously monitor the patient- vital signs


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PULMONARY EMBOLISM

It associated with venous access devices is usually the result of a thrombus that has

become detached from the wall of the vein. It is carried by the venous circulation to the right side

of the heart and then into the pulmonary artery.Circulatory and cardiac abnormalities are caused by full or partial obstruction of the

pulmonary artery, with possible progression to pulmonary hypertension and right-sided heart

failure.

AIR EMBOLISM

Occurs most frequently with the use of central venous access devices. Occur with the

insertion of an IV catheter, during manipulation of the catheter or catheter site when the device is

removed, or when IV lines associated with the catheter are disconnected.

CATHETER EMBOLISM

This can occur during the insertion of a catheter if appropriate placement techniques are

not strictly adhered to. The tip of the needle used during the placement of the catheter can shear

off the tip of the catheter. The catheter tip then becomes a free-floating embolus. This can occurwith both over-the-needle and through-the-needle catheters. If this happens, cardiac

catheterization may be required to remove the embolus.

Signs & Symptoms

Sudden vascular collapse with the hallmark symptoms of cyanosis, hypotension, increased

venous pressures, and rapid loss of consciousness.Respiratory distress

Unequal breath sounds

Weak pulse

Causes

Empty solution container

Solution container empties; next container pushes air down line

Tubing disconnected from venous access device or I.V bag


Discontinue the infusionPlace the patient in Trendelenburg position on his left side to allow air to enter the right atrium

and disperse through the pulmonary artery.

Administer oxygenNotify the doctor

Document the patient's condition and your interventions.


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HEMATOMA

Blod accumulation resulting from the infiltration of blood into the tissues at the

venipuncture site

Causes::

Coagulation defects

Inappropriate use of tourniquet

Unsuccessful insertion attempts

Little pressure upon removal of cannula

Discoloration of the tissue at the IV site


Frequent assessment of the site

Upon insertion, slowly advance the needle to prevent puncturing both vein walls

Discontinue therapy if with edema

Apply pressure for at least 5 minutes upon removal

SYSTEMIC INFECTION

If bacteria do not remain in one area but spread through the bloodstream, the infection

is calledsepticemiaand can be rapid and life-threatening. An infected central IV poses a higher

risk of septicemia, as it can deliver bacteria directly into the central circulation.

Caused by: Staphylococcuaureus, Klebsiella, Serratia, Pseudomonas Aeruginosa

Signs & symptoms

Fever, chills, & malaise for no apparent reason

Contaminated I.V site, usually with no visible signs of infection at site

Causes

Failure to maintain aseptic technique during insertion or site care

Severe phlebitis, which can set up ideal conditions for organisms growth

Poor tapingProlonged indwelling time of device

Immunocompromised patient
http://en.wikipedia.org/wiki/Septicemiahttp://en.wikipedia.org/wiki/Septicemia


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Notify the doctor.Administer medications as prescribed

Culture the site and the device

Monitor the patient's vital signsPrevention

Use scrupulous aseptic techniqueSecure all connections

Change I.V solutions, tubing and venous access device at recommended times

Use I.V filters

Management and Prevention Tips

Assess catheter site daily

Accurately document visual inspection and palpation data.

Refer to physician for any suspected infection.

Use maximal sterile-barrier precautions during insertion (sterile technique)

Practice good hand hygiene before and after palpating, inserting, replacing, or

dressing any intravascular device.

If any part of the system is disconnected, dont rejoin it

Remove at first sign of infection

Replace site, tubings and bags per policy example: change set= 72 hours, TPN

and single use of antibiotics=24 hrs

SPEEDSHOCK

Rapid introduction of a foreign substance, usually a medication, into the circulation.

Signs & Symptoms

Flushed face

Headache

Tight feeling in the chest

Irregular pulse

In extreme cases:

Loss of consciousness


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STOP the infusion

Careful monitoring of IV flow rate and patient response. Maintain prescribed

rate.

Know the actions and side effects of the drug being administered


Use of IV pumps when indicated

Begin infusion of 5% dextrose at a KVO rate in emergency cases

Evaluate circulatory and neurologic statusNotify the physician

CIRCULATORY OVERLOAD

An excess of fluid disrupting homeostasis caused by infusion at a rate greater than the

patients system is able to accommodate

Signs & Symptoms

Shortness of breath

Elevated blood pressure

Bounding pulse

Jugular vein distention

Increased Respiratory rate

Edema

Crackles or rhonchi upon auscultation

Causes

Roller clamp loosened to allow run on infusion

Flow rate too rapid

Miscalculation of fluid requirements


Raise the head of the bed

Slow the infusion rate

Administer oxygen as needed


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Notify the doctor

Administer medications as ordered

ALLERGIC REACTION

Maybe a Local or generalized response to tape, cleansing agent, medication, solutionor intravenous device

Signs & Symptoms

SYSTEMIC

Runny nose

Tearing

Bronchospasm

Wheezing

Generalized rash

LOCAL

Wheal

Redness

Itching at the site


If reaction occurs, stop the infusion immediately and infuse normal saline

solution.

Maintain a patent airway.

Notify the doctor.

Administer antihistaminic steroid, anti inflammatory, & antipyretic drugs, as

ordered.

Give 0.2 to 0.5ml of aqueous epinephrine subcutaneously. Repeat at 3-minute

intervals and as needed, as ordered

FLUID OVERLOAD


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This occurs when fluids are given at a higher rate or in a larger volume than the system

can absorb or excrete. Possible consequences includehypertension,heart failure, andpulmonary

edema.

INFECTION CONTROL

Infection at the venipuncture site is usually causd by a break in aseptic technique during

the procedure. The following measures reduce patients risk:

Wash hands before starting an IV or before handling any of the IV equipment.

Use a approved antiseptic ( as per hospitals protocol) to clean the patients skin.

Cut/ clip the hairs of the venipuncture site if necessary. Do not share.
http://en.wikipedia.org/wiki/Hypertensionhttp://en.wikipedia.org/wiki/Hypertensionhttp://en.wikipedia.org/wiki/Heart_failurehttp://en.wikipedia.org/wiki/Heart_failurehttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Hypertensionhttp://en.wikipedia.org/wiki/Heart_failurehttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Pulmonary_edema


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Documentation of IV therapy

Proper documentation provides:

An accurate description of care that can serve as legal protection.

A mechanism for recording and retrieving information.

A record for health insurers and retrieving information documenting the insertion of a

venipuncture devise or the beginning of therapy

a. The following information of acre that can serve as legal protection:

Size, type, and length of cannula/needle

Name of person who inserted the IV catheter

Date and time of insertion

b. Label the IV solution specifying:

Type of IV fluid

Medication additives and flow rate

Use of any electronic infusion devise

Duration of therapy and nurses signature

c. In additional documentation following information is documented in the patients chart:

Location of and condition of insertion site

Complications, patients response and nursing interventions

Patient teaching and evidence of patient understanding (for example ability to explain

instruction or perform a return demonstration).

Signature of nurse

Other observations

IV THERAPY PROCEDURE

A. Setting up

B. Inserting IV utilizing the dummy arm

C. Changing an IV solution


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D. Discontinuing an IV infusion

Steps

A. Setting up

1. Verify written prescription and make IV label

2. Observe ten (10) Rs when preparing and administering IVF.

3. Explain procedure to reassure patient and/or significant others, secure consent if necessary.

4. Assess patients vein; choose appropriate site location, size/ condition.

5. Do hand hygiene before and after the procedure.

6. Prepare necessary materials for procedure (IV tray with IV solution, administration set, IV

cannula, forceps soaked in antiseptic solution, alcohol swabs or cotton balls soaked in alcohol

with cover (this should be exclusively used for IV), plaster, tourniquet, glove, splint, ad IVhook, sterile 2x2 gauze or transparent dressing.

7. Check the sterility and integrity of the IV solution, IV set and other devices.

8. Place IV label on IVF bottle duly signed by RN who prepared it (patients name, room no.,

solution, drug incorporation, bottle sequence and duration, time and date).

9. Open the seal of the IV infusion aseptically and disinfect rubber port with cotton ball with

alcohol.

10.Open IV administration set aseptically and close the roller clamp and spike the infusate

container aseptically.

11. Fill drip chamber to at least half and prime it with IV fluid aseptically.

12.Expel air bubbles if any and put back the cover to the distal end of the IV set (get ready for

IV insertion).

B. Inserting IV utilizing the dummy arm

1. Verify the written prescription for IV therapy; check prepared IVF and other things needed.

2. Explain procedure to assure the patient and significant others and observed the 10 Rs.

3. Do hand hygiene before and after the procedure.

4. Choose site for IV

5. Apply tourniquet 5 to 122 cm (2-6 inches) above injection site depending on condition of

patient.

6. Check for radial pulse below tourniquet.


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7. Prepare site with effective topical antiseptic according to hospital policy or cotton balls with

alcohol in circular motion and allow 30 seconds to dry. ( no touch technique)

Note: CDC Universal precaution: always wear gloves when doing any venipuncture.

8. Using the appropriate IV cannula, pierce skin with needle positioned on a 15-30 degree angle.

9. Upon flashback visualization decrease the angle, advance the catheter and stylet (1/4 inch)

into the vein, check if tip of catheter can be rotated freely inside the vein...

10.Position the IV catheter parallel to the skin. Hold stylet stationary and slowly advance the

catheter until the hub is 1 mm to the puncture site.

11.Slip sterile gauze under the hub. Release the tourniquet; remove the stylet while applying

digital pressure over the catheter with one finger about 1-2 inches from the tip of the inserted

catheter.

12. Connect the infusion tubing of the prepared IVF aseptically to the IV catheter.

13. Open the clamp, regulate the flow rate, reassure patient.

14. Anchor needle firmly in place with the use of:

a. Transparent tape/ dressing directly on the puncture site.

b. Tape ( using any appropriate anchoring style)

c. Band-aid

15. Tape a small loop of IV tubing for additional anchoring ; apply splint ( if needed)

16.Calibrate the IVF bottle and regulate flow of infusion according to prescribed duration.

17. Label on IV tape near the IV site to indicate date of insertion, type and gauze of IV catheter

and countersign.

18. Label with plaster on the IV tubing to indicate the date when to change the IV tubing.

19. Observe patient and report any untoward effect.

20. Document in the patients chart and endorse to incoming shift.

21.Discard sharps and waste according to Health Care Waste Management (DOH/ DENR).

C. Changing an IV solution

1. Verify doctors prescription in doctors order sheet; countercheck IV label, IV card, infusate

sequence, type, amount, additives (if any), and duration of infusion.

2. Observe ten (10) Rs.


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3. Explain procedure to reassure the patient and significant other and assess IV site for redness,

swelling, pain and etc.

4. Change IV tubing and cannula if 48-72 hrs. Has lapsed after IV infusion.

5. Wash hands before and after the procedure.

6. Prepare necessary materials; place on IV tray.

7. Check sterility and integrity of IV solution.

8. Place IV label on the IV bottle.

9. Calibrate new IV bottle according to duration of infusion as per prescription.

10. Open and disinfect rubber port of IV solution to follow.

11. Close the roller clamp and spike the container aseptically.

12. Regulate the flow based on the prescribed infusion rate of infusion. Expel air bubbles (if

any).

13. Reiterate assurance to patient and significant others.

14. Discard all waste materials according to health care waste management.

15. Document and endorse accordingly.

D. Discontinuing an IV infusion

1. Verify written doctors order to discontinue IV including IV medicines.

2. Observe ten (10) Rs.

3. Assess and inform the patient of the discontinuation of IV infusion and of any medicine.

4. Prepare the necessary materials; IV tray or injection tray with sterile cotton balls with

alcohol, plaster, pick-up forceps in antiseptic solution, kidney basin band aid.

5. Wash hands before and after procedure.

6. Close the roller clamp of the IV administration set.

7. Moisten adhesive tapes around the IV catheter with cotton ball with alcohol; remove plastergently.

8. Use pick-up forceps to get cotton balls with alcohol and without applying pressure, remove

needle or IV catheter then immediately apply pressure over the venipuncture site.

9. Inspect IV catheter for completeness.


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10. Place dressing over the venipuncture site.

11.Discard all waste materials including the IV cannula according to health care waste

management (DOH/DENR).

12. Reassure patient.

13. Document time of discontinuance, status of insertion site integrity of IV catheter and endorse

accordingly.

Documents

Intravenous Parenteral Therapy Lecture