IV Therapy

Advantages:
- Large volume of fluids can be rapidly administered into vein for volume depletion
- More rapid onset of medication, especially in an emergency
- More comfortable for patient if repeated doses of medication needed over time
Reasons for IV Therapy:
- Maintenance therapy: provides basic nutrients and meets daily fluid requirements. Some
examples may be patients who are NPO or have limited oral intake, prior to surgery or
procedures, or post‐operatively
-Replacement Therapy: This replaces fluids and/or repairs imbalances from conditions such as
dehydration, blood loss, trauma, vomiting, diarrhea, draining wounds, nasogastric suctioning,
or burns
Types of IV access:
1. Central: PICC or tunneled CVP catheters (Hickman, Broviac, or Groshong);
a. allows for tip of catheter to be typically in superior vena cava to allow for maximal
mixing with large volumes of blood;
b. usually in for 2-4 weeks, but can stay in up to 1 year; uses either NS or Heparin
flushes
c. PICC lines can be single or double lumen; other CVP catheters can be up to triple
lumen
d. used when using large volumes of medication, irritating medications, or
hypertonic solution such as TPN
e. usually safe for home infusion
f. needs x-ray to verify location
2. Peripheral:
a. short-term use into peripheral veins in hand and arm; can be Hep-locked; needs
flushes per protocol
b. usually changed every 72-96 hours, except in children, to prevent infection and
phlebitis;
c. cannot draw blood from these but may administer blood and blood products with
an 18-gauge needle
3. Implantable venous infusion ports (Porta-a-cath):
a. long-term use; can stay in for years; must flush with each use and/or at least
monthly
b. placed in central veins
c. can be used for IV fluids, medications, TPN, chemotherapy and blood products
 d. uses a special needle (Huber) for access
e. needs x-ray to verify location and check for pneumothorax
Infusion Pumps:
Advantages:
1. Safety for certain therapeutic medications (i.e., Heparin, chemotherapy, etc.
2. Monitoring medications for toxicity (nephrotoxicity, ototoxcity)
Types:
1. Programmable Infusion Pumps: programmed for a specific volume over time and
more accurate infusion rate; have an alarm system which detects when IV unable to
infuse at correct rate
2. Syringe Pumps: able to deliver a specific volume of medicine over a set time. Used
mostly for small volumes. Could be used for pain medications, insulin, PCA. Can be
taught for use in home.

Types of IV Solutions: see cheat sheet of IV solutions

- Isotonic: osmolality is same as blood
- Hypotonic: has fewer particles than blood
- Hypertonic: higher concentration of particles than blood
IV Catheters/ Sites: see slides
- Adult
- Pediatric
Monitoring patient and IV sites: should be monitored at established intervals to insure these
devices are working properly. This inspection includes both equipment and site inspection. It is
recommended that fluids and IV sites should be monitored every one to two hours, as well as
with any physical assessment; please check your facility’s policy. Assessment should include:
 The catheter itself for migration
 All connections are secure
 Condition of the insertion site
 Fluids being infused
 Pump function and flow rate
 Keep accurate I/O
 Patient’s report of pain or discomfort at access site
 Patient’s Vital signs and lung sounds
  Signs of IV‐related infections or complications, such as
- discoloration (i.e. blanching, erythema),
- disruption of sensation (i.e. pain, tenderness, numbness),
- edema or localized swelling, exudate,
- increase in skin or body temperature,
- induration (i.e. sclerosis) with palpable cord
Procedures with IV lines:
1. Central Line Dressings: done per facility’s P&P
a. Usually a transparent semipermeable membrane dressing done under sterile
technique
b. Stabilize catheter prior to removing old dressing
c. Always label dressing with time, date, gauge and length of needle and initials

2. Changing of tubing:
a. All mainline and secondary peripheral and central line tubing is changed every
24 hours to help maintain asepsis; When hanging new tubing there should be a
date and time sticker on tubing to indicate when it was done so know when next
needs to be changed
b. Tubing is changed with each unit of blood/ blood products using tubing
recommended per facility’s P&P
c. Pediatric tubing should have a filter

3. Flushing of catheters: Use SASH method

4. Insertion of catheters: check MD order

a. Gather supplies:
i. use mostly 18 or 20-gauge IV catheters for adults;
ii. there are different types: butterfly wings, over needle catheter, retractable
needle/ catheter
iii. collect tubing: Hep-Lock with cap vs continuous
b. Prepare patient for IV insertion
c. Prepare supplies at side of bed
d. Apply tourniquet and select site (depends on length of therapy.): usually start at
hand and work upwards in most adults. Avoid hands in elderly due to fragility of
veins and skin: usually try antecubital space due to size of veins.
 e. Clean area with alcohol prep pad: starts at anticipated injection site and go in
circular direction outward
f. Anchor skin and insert needle bevel up at 10-30 angle
g. Once see blood in flashback chamber can remove inner needle and thread
catheter
h. Apply pressure over catheter end site and hub and remove tourniquet and
immediately apply tubing.
i. Secure needle and tubing per facility protocol.
When IV insertion completed document needle size/gauge, location, attempts
needed, and IV solution and rate, or Hep-Lock with flush. Also document how patient
tolerated procedure. If done on child need to document how child was restricted
during procedure (i.e., papoose, mom held child, etc.)

5. Removal Peripheral catheters: should be removed per unit protocol or by physician

order when therapy is completed, during routine site rotation, when contamination or
IV‐ related complication is suspected, or when the tip location is no longer appropriate
for the prescribed therapy.
Minimal equipment is needed, including an alcohol wipe, sterile gauze, and adhesive
bandage. Steps for Removal
a. Discontinue the administration of all infusions.
b. Wash your hands and don gloves.
c. Carefully remove the dressing from the IV site ensuring the cannula remains in
place and inspect the cannulation site.
d. Remove the catheter securement device and cleanse the cannulation site with an
alcohol wipe, using aseptic technique.
e. Place the first two fingers of your non‐dominant hand lightly above the
catheter‐ skin junction site with the gauze between the fingers.
f. Use your other hand to withdraw the catheter slowly and smoothly, keeping it
parallel to the skin.
g. Inspect the catheter tip. Apply pressure to site for a minimum of 30 seconds or
until bleeding has stopped.
h. Apply a new gauze or adhesive bandage to the insertion site per facility policy.
i. Remove your gloves and wash your hands.
j. Change the dressing as needed every 24 hours until site is healed
Complications: As with any invasive procedure, there are potential complications that can
occur with IV therapy. These complications will be reviewed, including assessment and
management.
 Phlebitis/ Thrombophlebitis/ Local Infection: Phlebitis is the inflammation of a vein.
Most common complication of peripheral IV therapy.
o Signs and symptoms: redness/warmth, swelling, burning/pain, and/or drainage at
the insertion site and/or along the vein. See page 170, Table 11-2 for Phlebitis
Assessment Scale
o Causes: irritation of vein, chemical irritation from medicines, improper aseptic
technique with insertion, dressing changes, or long-term catheter
o Treatment:
 if peripheral line, removal of the catheter, application of warm moist
compresses and analgesia.
 Notification of provider if central line for treatment.
 If purulent drainage, then culture of drainage and possibly blood cultures
and tip of catheter
o A picture should also be taken to document the injury.

 Infiltration/ Extravasation: Catheter dislodgement occurs when the catheter backs out
of the vein. The IV solution may infiltrate. Infiltration is the inadvertent leakage of
solution into surrounding tissue. Extravasation is when caustic medication, etc.
infiltrates into surrounding tissue causing injury to tissues.
 See age 171, Table 11-3 for Infiltration scale
o Causes: improper insertion of the IV catheter, damage or swelling of the vein, clot
formation in the vein, or when the cannula punctures or erodes through the
opposite wall of the vein
o Signs and symptoms: include cool skin temperature at the IV site, skin that looks
blanched, taut, or stretched, edema, discomfort; redness, warmth, and
tenderness/pain at puncture site, change in quality and flow of the infusion, or IV
fluid leaking from the insertion site.
o Treatment:
 Infiltration: immediately stopping the infusion due to severe tissue
damage can occur depending on infusate, elevate the limb, check for
capillary refill, apply warm compress, remove the catheter and apply
dressing to site and restart the IV
 Extravasation: turn off flow, but leave needle in place; provider may order
nurse to try to aspirate solution and/or instill antidote to area; elevate limb
and apply cold compress to area; restart IV in new site
o A picture should also be taken to document the injury, and an incident or variance
report completed.

 Air Embolism: when air gets into tubing;

 o small bubble is not a concern;
o s/s: chest pain, difficulty breathing, change in LOC, and decreased BP
o treatment: turn patient on left side with head in dependent position, give oxygen,
and notify physician, monitor VS;
o prevent by clamping tubing whenever changing tubing or injection caps, not
allowing IV containers to run dry, and removing all air from tubing or syringes
before connecting to patient

 Circulatory Overload/ Pulmonary Edema: caused by infusing fluids too fast or giving too
much fluids
o s/s: engorged neck veins, dyspnea, reduced urine output, edema, bounding or
thready pulse, and shallow, rapid respirations with cough and frothy sputum;
crackles in lungs
o Treatment: slow IV to TKO, raise HOB, and notify provider ASAP; usually given
diuretics with vasodilators, and MS

 Pulmonary Embolism: foreign materials travel to lungs; treat as you would normally
treat PE;
o can be prevented by using filter with solutions, using proper diluent, and make
sure complete dissolution noted prior to administration;
o we use filters with all pediatric IV medications to prevent proper since most meds
need to be mixed for proper dosage

 Speed Shock: occurs when a foreign substance is given too quickly into blood stream;
o prevent this by timing IV push medications so not given too fast, using IV infusion
pumps with verifying rate per drips, and making sure IV piggybacks are run over
adequate time, and monitoring patient frequently when new medications are
given.
o s/s: same as shock: dizziness/syncope, flushing, rapid, irregular pulse,
hypotension, and possible cardiac arrest
o If occurs, decrease IV to TKO, monitor VS, and notify provider immediately
o Treat like any other shock

 Vasovagal Reaction: Vasovagal reactions can occur when the patient experiences
vasospasm from anxiety or pain.
o s/s: The vein suddenly collapses during venipuncture and causes the patient to
become pale, diaphoretic, faint, dizzy, and nauseated. The patient may also have
a sudden drop in blood pressure.
 o Treatment: If this occurs, lower the head of the bed and have the patient take
slow deep breaths while you monitor vital signs. The reaction should resolve
quickly
o An incident or variance report should be completed.

Blood and Blood Products

Purpose of Blood Transfusion:
- To supply and/or restore the blood volume
- To correct anemia, maintain HGB level and oxygen carrying capacity of RBCs
- To supply plasma protein to increase plasma protein and maintain colloid osmotic
pressure
- To supply clotting factors and platelets to prevent or treat hemorrhagic disease
- To supply antibodies and alexin (a protective substance that exists in the serum or other
bodily fluid and is capable of killing microorganisms) to resist the infection
Types of Blood Products
1. Whole blood: usually in case of severe hemorrhage
2. Packed RBCs: To increase oxygen transporting RBCs which may occur after surgery or
acute hemorrhage
3. Platelets: used in thrombocytopenia, serious bleeding disorders, or platelet deficiencies
4. Fresh frozen plasma: does not contain any RBCs. Used for pts with clotting factors or in
need of increased blood volume. It does not have to be typed and crossmatched
because it has no antigen carrying RBCs.
5. Albumin: For blood expansion or need for plasma proteins
6. Clotting factors or cryoprecipitate: for clotting factors and anyone lacking fibrinogen
Complications:
1. Acute Hemolytic Reaction/ Hemolysis: from blood breaking down from a compatibility
issue
a. Usually occurs within the first 15minutes of start
b. s/s:
i. CP with drop in BP,
ii. wheezing with tachypnea,
iii. fever and chills,
iv. n/v,
v. headache,
vi. flank pain over kidneys with hematuria
c. Treatment:
 i. stop blood,
ii. send blood and tubing to blood bank;
iii. maintain NS IV with new tubing
iv. notify PMD: will give directions on medications to give
2. Anaphylaxis
a. Allergy reaction occurring in first 15minutes
b. s/s: wheezing, SOB, chest tightness, cyanosis
c. Treat:
i. stop blood and take blood, tubing, etc to blood bank;
ii. continue with NS IV with new tubing
iii. maintain airway/ administer O2
iv. contact PMD
v. antihistamines
vi. vasopressors
vii. steroids
3. Febrile Reaction: most common
a. Can occur at any time through transfusion
b. s/s: fever/chills/flushing, nausea, anxiety
c. Treatment:
i. Continue transfusion
ii. Administer antipyretic if order available
iii. Notify PMD for further orders
iv. Possible WBC filter added to tubing
4. Mild Allergic Reaction
a. Can occur at any time during transfusion
b. s/s: Itching, hives, swelling of lips, mouth, and tongue
c. Treatment:
i. Continue transfusion
ii. Notify PMD
iii. Administer antihistamine and steroid
Documentation for Administration:
- The date and time that transfusion began
- The name of 2nd nurse who verifies product
- The name and amount of the specific type of transfusion (i.e., 1 unit of PRBC)
- The number of blood product
- Where the site was
- Size of the angiocath used
- Duration of transfusion
 - Vital signs that were taken and when they were taken (facility may have a transfusion VS
record
- The fact that the patient was notified of s/s to report to nurse after the initial 15-minute
monitoring period
Show video on blood and blood products
Math Calculations
1. Drip factors:
- Macrodrip= 20 drips per minute
- Microdrip= 60 drips per minute

2. Calculations:
𝑇𝑜𝑡𝑎𝑙 𝑉𝑜𝑙𝑢𝑚𝑒 (𝑚𝑙)
- Infusion rate=
𝑇𝑜𝑡𝑎𝑙 𝑇𝑖𝑚𝑒 (𝑚𝑖𝑛𝑠)

𝑇𝑜𝑡𝑎𝑙 𝑉𝑜𝑙𝑢𝑚𝑒 (𝑚𝑙)

- Infusion rate=
𝑇𝑜𝑡𝑎𝑙 𝑡𝑖𝑚𝑒 (ℎ𝑟𝑠)

𝑇𝑜𝑡𝑎𝑙 𝑣𝑜𝑙𝑢𝑚𝑒 (𝑚𝑙) 𝑑𝑟𝑖𝑝 𝑓𝑎𝑐𝑡𝑜𝑟

- Infusion Rate drips/min= X
𝑇𝑜𝑡𝑎𝑙 𝑇𝑖𝑚𝑒 (𝑚𝑖𝑛𝑠) 1