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Title: LPN-C Unit Five Peripheral Intravenous Therapy ..


1
LPN-C
  • Unit Five
  • Peripheral Intravenous Therapy

2
Nursing Interventions R/T Anxiety Discomfort
with IV Infusion
  • Individuals typically experience anxiety related
    to intravenous therapy
  • Illness
  • Unfamiliar environment
  • Need for complex services and procedures
  • Extreme anxiety can have physiological effects
  • Spasm or constriction of veins due to the
    sympathetic response
  • Blood shunted from peripheral circulation to
    vital organs
  • Inhibits venous access
  • Syncope related to the vasovagal response

3
Anxiety Discomfort (contd)
  • Psychological preparation increases coping
    ability
  • Relaxes the client
  • Facilitates initiation of IV therapy for the
    nurse
  • Client teaching
  • Time
  • Building rapport and relaying caring
  • Allowing time for questions
  • Explanations
  • Overcoming communication barriers
  • Honesty
  • How long the IV may be in place
  • Why IV access is needed
  • Acknowledge associated pain and discomfort

4
Anxiety Discomfort (contd)
  • Pain reduction
  • Advise patient of measures that may decrease
    distress
  • Assure patient that you will be as efficient as
    possible
  • Employ appropriate physical, pharmacological, and
    psychological measures to minimize discomfort
  • Professionalism
  • Express confidence and expertise
  • Reinforce positive aspects of the procedure

5
Latex Allergy Precautions
  • Patients at risk for latex-related reactions
  • Women constitute 75 of all reported cases
  • Asthma
  • Allergy history
  • Occupational exposure to latex
  • Fruit and vegetable allergies
  • Avocados
  • Bananas
  • Chestnuts
  • Kiwis and other tropical fruits
  • Intermittent catheterization
  • Chronic genitourinary or abdominal conditions
    requiring multiple surgeries

6
Latex Allergy Precautions (contd)
  • Report incidents of adverse reactions to latex or
    other materials used in medical devices to the
    FDA
  • FDA recommendations to health professionals --
  • Assess latex sensitivity while obtaining history
    for all patients
  • Use devices made with alternative materials
  • Be alert for an allergic reaction whenever
    latex-containing devices are used, especially
    when in contact with mucus membranes
  • Alert clients with suspected allergic reaction to
    latex to possible latex sensitivity, and advise
    them to consider immunologic evaluation

7
Latex Allergy Precautions (contd)
  • FDA recommendations to health professionals
    (contd) --
  • Advise clients to tell health professionals and
    emergency personnel about latex sensitivity
  • Consider advising clients with a latex allergy to
    wear a medical identification bracelet
  • Other allergies
  • Must assess for allergies to foods, animals and
    insect matter, and environmental substances
  • Iodine
  • Often used in skin antisepsis
  • Client may only recognize this as a shellfish
    allergy
  • Adhesive
  • Used in dressing tape

8
Caring for an IV at Home
  • Many clients receive IV therapy at home
  • Limitations by 3rd party payers
  • Personal preference
  • Several types of IV therapy can be maintained
    outside of the hospital
  • Antibiotics
  • Chemotherapy
  • Hydration and hyperalimentation
  • Pain control
  • HIV-related therapies
  • Growth hormone and immunoglobulins
  • Dobutamine (for severe CHF)
  • Tocolytic therapy (to ? premature contractions)

9
Caring for an IV at Home (contd)
  • Arm/hand movement may be limited, so client may
    need to relearn ADLs
  • Ambulation with infusion equipment
  • Instruct client against tampering with IV tubing,
    clamp, or dressing
  • Advise client to keep the IV dry to minimize risk
    of infection
  • Staphylococcus epidermis
  • Staphylococcus aureus
  • Teach client how to assess IV site for signs and
    symptoms of infection
  • Provide list of symptoms or conditions for which
    client would need to call the doctor

10
IV Preparation
  • Physical preparation of the client for
    initiation of intravenous therapy includes
    safety, comfort, and positioning
  • Safety
  • Verify IV order
  • Verify correct patient identification
  • Validate that the ordered infusion is appropriate
    for the patient
  • Confirm that the patient is not allergic to
    anything that is to be administered
  • Review documentation of significant laboratory
    and diagnostic reports
  • Maintain strict asepsis when preparing all
    products to be used for venipuncture/infusion

11
IV Preparation (contd)
  • Safety (contd) --
  • Ensure that all supplies and equipment for
    venipuncture are sterile
  • Check expiration dates
  • Provide a safe environment for the patient during
    infusion therapy
  • Bedrails
  • Restraints
  • Movement
  • Ambulation
  • Assess/select the vessel that is appropriate for
    the type of infusion ordered
  • Instruct the client about what to report in terms
    of activity, discomfort, or signs/symptoms
    associated with a reaction

12
IV Preparation (contd)
  • Comfort
  • Restrictions in mobility and sustaining ADLs
  • Prevent dislodgement of the cannula
  • Avoid disconnection of any part of the infusion
    setup
  • If any portion of the closed IV system were
    disrupted, contamination and infection could
    occur
  • Use nondominant hand for IV access
  • Avoid using veins in areas of flexion unless
    immobilized
  • Allow completion of ADLs prior to IV insertion
  • Provide loose-fitting clothing/hospital gown
  • Allows for less restricted movement
  • Does not impede fluid flow
  • Easily removed for changing
  • Provide for privacy

13
IV Preparation (contd)
  • Correct positioning
  • Fowlers position
  • Maintain intended venipuncture site below heart
    level to promote venous filling
  • Follow institutional protocol with regards to
    armboards, restraints, or stabilization devices
  • Can cause nerve and muscle damage
  • Must be removed at frequent intervals to assess
    circulatory status
  • Protect insertion site from moisture and
    contamination
  • Hair may need to be removed prior to initiating
    IV therapy if it impedes vessel visualization,
    site disinfection, cannula insertion, or dressing
    adherence

14
IV Preparation (contd)
  • Correct positioning (contd)
  • Hair removal (contd)
  • Hair is to be removed by gently clipping it close
    to the skin
  • Do not scratch the skin
  • Do not shave the hair because of the potential
    for microabrasion and the introduction of
    contaminants
  • Do not apply depilatories due to the possibility
    for skin irritation or allergic reactions
  • An electric shaver may be used
  • Check your institutional policy
  • If the shaver does not belong to the patient, the
    shaving heads would need to be changed or
    disinfected between patient use

15
IV Preparation (contd)
  • IV preparation involves using the correct site
    preparation/maintenance materials
  • Obtain the appropriate dressing materials
  • Sterile gauze
  • Sterile transparent, semipermeable dressing
  • Cleanse the skin
  • Use an antimicrobial barrier
  • 2 chlorhexidine or per institutional policy
  • Available in the form of swab sticks, prep pads,
    or plastic, cotton-tipped squeezable vials
  • These are one-time use only!
  • Allow barrier to air dry

16
Vein Selection
  • Intravascular access refers to entrance into
    arteries, veins, or capillaries
  • The selected access site should provide the most
    appropriate access to the vessel
  • Needs to be appropriate for intended therapy
  • Must accommodate administration of the prescribed
    infusion
  • Endeavor to minimize associated risks or
    complications
  • Factors to consider with vein/site selection
  • Patients age, health status, and diagnosis
  • Condition of the site to be accessed
  • Purpose, duration, and possible side effects of
    therapy

17
Vein Selection (contd)
  • Peripheral intravenous routes should be achieved
    in an upper extremity
  • Venous cannulation should begin at the
    distal-most area of the upper extremity and
    proceed proximally
  • Examine the upper extremities
  • Predict the ease or difficulty of venous access
  • Predetermine measures to facilitate successful
    venipuncture
  • Inspect the patients skin
  • Assess for damaged areas
  • Apply a tourniquet
  • Use a flashlight for enhanced visualization

18
Vein Selection (contd)
  • Peripheral intravenous routes (contd)
  • Palpate the patients veins
  • Determine condition of the vessel
  • Locate deeper, larger veins that are stronger and
    more suitable for initiation of IV therapy
  • The nurse needs to know which veins to avoid
    when preparing to perform venipuncture for
    purposes of peripheral intravenous therapy
  • Do not use veins in an area with a recent
    infiltration
  • Do not use veins in an area that has sustained
    3rd degree burns

19
Vein Selection (contd)
  • Veins to avoid (contd)
  • Avoid veins in the antecubital fossa
  • Do not use veins that are irritated or sclerosed
    from previous use
  • For a vein to be viable, it must be able to be
    blanched
  • To check for blanching, apply downward pressure
    over, or on each side of, a vein
  • If the vein disappears with the pressure, then
    reappears when the pressure is removed, the vein
    is viable
  • A sclerotic vein will not blanch
  • Avoid veins in an extremity that is partially
    amputated

20
Vein Selection (contd)
  • Veins to avoid (contd)
  • Do not use veins in the lower extremities in
    ambulatory adults and children
  • Use lower extremity sites only in an emergency
  • Must have a written order
  • Ensure agency has policy in place that upholds
    this procedure
  • Never access an arteriovenous fistula, graft, or
    shunt that has been surgically placed for
    hemodialysis
  • Do not use the affected arm itself for IV therapy
  • Do not use veins in an extremity that is impaired
    as a result of a CVA

21
Vein Selection (contd)
  • Veins to avoid (contd)
  • Do not use veins on the side of the body where a
    radical mastectomy with lymph node
    dissection/stripping has been performed
  • Bypass veins in an extremity that has undergone
    reconstructive or orthopedic surgery
  • Avoid edematous extremities

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27
Cannula Selection
  • Types of peripheral venous devices
  • Steel needles
  • Winged needles
  • Catheters
  • Steel needles are very rarely used anymore
  • Winged needles, referred to as butterflies, have
    one or two wings
  • Connect with a needle on one side and a segment
    of infusion tubing that ends in a hub and
    protective cap on the other
  • Tubing varies in length from 3½ to 12 inches
  • Tubing is primed with NS prior to insertion to
    prevent entry of air into the circulation

28
Cannula Selection (contd)
  • Butterflies (contd)
  • Wings are held upright during insertion to
    facilitate movement into the vein
  • Once the needle is in the vein, the wings are
    taped to the skin to secure the device
  • If secured properly, winged needles stay in the
    vein well
  • Good means of venous access under certain
    circumstances
  • Short-term infusions (24 hours or less)
  • Seldom used for adult infusion therapy
  • Can be used for one-time IV push medications
  • May be used to draw blood

29
Cannula Selection (contd)
  • Peripheral venous access catheters are the most
    commonly used IV device
  • Used to enter superficial or deep veins
  • Extremity
  • Neck
  • Head
  • Two-part flexible cannula in tandem with a rigid
    needle or stylet
  • Stylet is used to puncture and insert the
    catheter into the vein
  • Connects with a clear chamber
  • Allows for visualization of blood return
  • Indicates successful venipuncture
  • Facilitates removal of the needle

30
Cannula Selection (contd)
  • Catheters (contd) --
  • Color-coded plastic cannula hub
  • Indicates length and gauge of catheter
  • Length ranges from ¼ inches to 12 inches
  • Catheter is radiopaque
  • Easily detected by radiology in case of embolus
  • Types of catheters include the over-the-needle
    peripheral catheter (ONC) and the
    through-the-needle peripheral catheter (TNC)
  • The ONC is a flexible cannula that encases a
    steel needle or stylet device
  • Most commonly used peripheral IV device

31
Cannula Selection (contd)
  • Types of catheters (contd) --
  • ONC (contd)
  • Once the vein is accessed, the catheter is
    threaded into the vessel and the stylet is
    withdrawn
  • The TNC is the opposite of the ONC, as the
    flexible cannula is encircled by the steel needle
  • Infrequently used
  • The needle is withdrawn once venous access is
    achieved
  • Secured in a protective shield outside the body
    on the skin

32
Cannula Selection (contd)
  • Factors to consider when selecting a cannula
  • Use the smallest cannula that will deliver the
    prescribed infusate
  • Adequate blood flow and hemodilution
  • Causes minimal discomfort
  • Delivery rate
  • 24 gauge cannula ? approx 15-25mL/min
  • 22 gauge cannula ? approx 26-36mL/min
  • 20 gauge cannula ? approx 50-65mL/min
  • 18 gauge cannula ? approx 85-105mL/min

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35
Achieving Venous Distention
  • Apply a tourniquet
  • A tourniquet is an encircling device consisting
    of a segment of rubber tubing that temporarily
    arrests blood flow to or from a distal vessel
  • Apply tightly enough that venous blood flow is
    suppressed, but not so tight that it obstructs
    arterial flow
  • Should be able to palpate pulse distal to the
    tourniquet
  • Do not leave a tourniquet in place longer than
    four to six minutes
  • Tourniquet paralysis from injury to a nerve can
    occur if the tourniquet is applied too tightly or
    left for too long a period
  • Apply warm compresses for 10-15 minutes

36
Achieving Venous Distention (contd)
  • Place the extremity intended for venipuncture
    below the level of the patients heart for
    several minutes
  • Have the patient open and close his or her fist,
    or squeeze and release the lowered bedrail
  • Use an alcohol pad to gently rub the skin over
    the vein intended for venipuncture
  • Alcohol and friction creates heat
  • Enhances venous distention
  • Pat the area of skin over the intended vein using
    light to moderate force to engorge the vein with
    blood

37
IV Equipment and Supplies
  • Infusate containers and IV administration sets
  • Infusate containers
  • Flexible plastic
  • Semirigid plastic
  • Glass
  • IV administration set tubing that delivers
    fluid/medication from the infusate container to
    the patient
  • All administration sets have a spike insert that
    fits into the administration set port of the
    infusate container, as well as a drip chamber,
    clamps, and an adapter

38
IV Administration Sets
  • On an administration set, the drip chamber is
    where the solution flows after leaving the
    infusate container and before entering the tubing
  • A screw and roller clamp allows for flow
    regulation
  • A slide clamp functions as an on-off clasp
  • A cannula hub can be attached to the sterile
    adapter at the end of the tubing
  • The adapter can be straight, fitting directly
    into the cannula hub with a push OR
  • The adapter can be screwed on to the cannula hub,
    providing a firm attachment (Luer-Lok)

39
IV Administration Sets (contd)
  • The administration set determines the rate at
    which fluid can be delivered to the patient (i.e.
    the drop factor)
  • Specialized tubings are used in specific settings
    and circumstances
  • Extra large (macrobore) tubings
  • Used in emergency surgical and trauma situations
  • Rapid infusion of large volumes of blood or fluid
  • Extra small (microbore) tubings
  • Used for the delivery of small amounts of
    precisely controlled fluid or medication
  • Special volume restriction (neonatal care,
    epidural infusions)

40
IV Administration Sets (contd)
  • Types of administration sets
  • Vented systems
  • Used for vacuum infusate containers that dont
    have their own built-in mechanisms for air
    displacement
  • Glass and some semirigid bottles
  • Nonvented systems
  • Used with flexible plastic bags and other
    nonvacuum receptacles
  • Primary administration sets
  • Secondary administration sets
  • Primary administration sets are also known as
    basic, or standard, sets
  • Carries fluid directly to the patient through one
    tube

41
IV Administration Sets (contd)
  • Primary administration sets (contd) --
  • Spiked into one (single line) or two (Y-type)
    main infusate container(s)
  • May terminate in straight, flashtube, or Luer-Lok
    male adapters
  • Available in macrodrip or microdrip in varying
    lengths
  • Available with or without check valves, which
    prevent retrograde blood flow
  • May contain one or several injection ports
  • Can accept attachments
  • Secondary administration tubings, extension
    tubings, flow control devices, filters, adapters

42
IV Administration Sets (contd)
  • Single line primary administration sets have one
    spike that is inserted into one infusate
    container the tubing terminates with an adapter
    that connects to the cannula hub at the IV access
    site
  • Y-type primary administration sets have two
    equal-length tubings that can each access an
    infusate container
  • Access can be simultaneous or alternately
  • Each tubing has its own roller clamp
  • Each tubing may or may not have its own drip
    chamber
  • Frequently used in emergency, surgical, and
    critical care situations

43
IV Administration Sets (contd)
  • Y-type administration sets (contd)
  • The solution reaches the patient via one common
    tubing
  • Necessitates compatibility between the infusates
  • Blood administration tubings are Y-type sets, but
    differ from standard Y-type primary
    administration sets
  • Should be used only with nonvacuum, flexible
    infusion containers where venting is unnecessary
  • If vented containers are used, air can be drawn
    into the circulatory system, resulting in an air
    embolism

44
IV Administration Sets (contd)
  • Secondary administration sets are referred to as
    piggyback sets
  • Used to deliver continuous or intermittent doses
    of fluid or medication
  • Widely used because they negate the need for
    additional venipunctures and interruption of the
    primary infusion
  • Usually connected with a needle or needleless
    adapter into an injection port immediately distal
    to the back-check valve of the primary tubing
  • Some primary administration sets have a
    closed-system connection to a second line

45
IV Administration Sets (contd)
  • Whenever an infusion line is breached, the
    possibility for introduction of contaminants
    exists
  • IV line should not be broken to add accessory
    equipment unless absolutely necessary
  • Refer to your institutions policy for adding
    equipment such as filters, extension sets,
    adapters, and connectors to infusion lines
  • Needleless systems and needlestick safety
    systems are state-of-the-art in IV therapy
  • Used to connect IV devices, administer fluids and
    medications, and sample blood

46
IV Administration Sets (contd)
  • Needleless systems (contd)
  • Eliminates up to 80 of needles
  • Other than the initial stick to insert the
    cannula into the patients vein, there is no need
    for needles during IV therapy
  • Blood exposure protocol
  • Wash needlestick punctures with soap water
  • Flush splashes to the nose, mouth, or skin with
    water
  • Irrigate splashes to the eyes with clean water,
    NS, or sterile ophthalmic irrigants
  • Report the incident to the department responsible
    for managing exposures
  • Start post-exposure treatment ASAP

47
Mechanical Gravity Control Devices
  • Mechanical gravity control devices are
    flow-regulating mechanisms that attach to the
    primary infusion administration set
  • Manually set to deliver specified volumes of
    fluid per hour
  • Available as dials or cylindrical controls
  • Includes approximate flow markings that must be
    verified (i.e. counting gtt/min)
  • Accuracy varies
  • Discrepancies can be up to 25
  • Dependent upon patients condition, activity
    level, positioning, and venous pressure

48
Mechanical Gravity Control (contd)
  • Should generally be used for only short periods,
    such as transporting the patient
  • IV tubing kinking/obstruction can restrict fluid
    flow
  • Must be checked frequently for infusion accuracy

49
Electronic Infusion Control Devices (EID)
  • EIDs are state-of-the-art infusion-regulating
    mechanisms that deliver fluids and medications
  • Powered by electricity and/or battery
  • Safe and accurate ( 5)
  • Programmable for several infusates at different
    rates and volumes at the same time
  • Sensors detect air in the line and pressure
    changes
  • Signals infusion termination
  • Alerts the nurse to problems via readouts,
    alarms, and flashing lights

50
EIDs (contd)
  • Most newer EID models have built-in safety flow
    mechanisms
  • Prevents unintended free flow of infusate into
    the patient if the administration set were to be
    removed from the machine
  • NOTE No EID is a substitute for regular patient
    observation and evaluation

51
Initiation of Infusion Therapy
  • Gather the necessary equipment/supplies to be
    optimally prepared for venipuncture
  • Check the order
  • Identify that the order is for the right patient
  • Read the label on the infusate container to
    verify correct medication and dose
  • Container should be compared directly with the
    physicians order to be sure it is correct
  • Verify pharmacy admixtures
  • Verify infusate compatibility
  • Check the expiration date of the infusate
  • Evaluate the infusate container to ensure seals
    are intact

52
Initiation of Infusion Therapy (contd)
  • Gather equipment/supplies (contd)
  • Check the infusate fluid for clarity and presence
    of particulate matter
  • Equipment preparation and setup should be
    completed away from the patients room in an
    environment that minimizes the chance for
    contamination
  • Prior to starting an infusion, the correct
    infusate should be set up with a primary
    administration set (Skill 9-2, page 205)
  • If secondary infusions are ordered or
    anticipated, choose a primary set with a check
    valve and injection ports

53
Initiation of Infusion Therapy (contd)
  • Equipment preparation(contd)
  • The interior of the tubing, both ends of the
    tubing, and the infusate must be kept sterile
  • NOTE The nurse must obtain permission from the
    adult patient before performing venipuncture or
    it may constitute assault and battery

54
Venipuncture
  • Step 1 Introduce yourself to the patient
  • Step 2 Ask the patient to state his/her full
    name, verifying identity with chart and ID
    bracelet
  • Step 3 Provide privacy
  • Step 4 Explain proposed procedure in terms the
    patient can understand
  • Step 5 Elevate the bed to prevent strain
  • Step 6 Place the patient in a semi- Fowlers or
    Fowlers position
  • Step 7 Protect clothing/bedding with a pad or
    towel
  • Step 8 Wash your hands

55
Venipuncture (contd)
  • Step 9 Set up all necessary supplies near the
    bed in the order they will be used
  • Step 10 Select an appropriate vein based on the
    type of therapy and anticipated duration
  • Step 11 Apply a tourniquet 2-3 inches below
    the antecubital fossa for venous access in the
    arm or hand
  • Step 12 Prepare the site
  • Step 13 Apply gloves while the final
    antiseptic is drying
  • Step 14 Cannulate the vein

56
Catheter Immobilization
  • Once in place, the IV device must be secured
  • Must allow for regular site assessment
  • Need to prevent cannula movement or dislodgement
  • Maintain asepsis
  • Prevent catheter-related infection
  • Transparent, semipermeable dressings are most
    common
  • Secures the vascular access device
  • Allows for continuous visual inspection of site
  • Allows bathing without saturating the dressing
  • Requires less frequent changes than others

57
Special Considerations
  • Patients with altered skin and vessels
  • Burns, fragile veins
  • Do not use a tourniquet
  • Use alternative measures per institutional policy
    for skin antisepsis to prevent further irritation
    and discomfort
  • Patients with peripheral edema
  • May need to use landmarks to identify a vein
  • Client is at risk for unidentified infiltration
    due to edema
  • Vein may collapse due to pressure from excess
    fluid
  • Obese patients
  • May have deeply imbedded vessels

58
Special Considerations (contd)
  • Obese Patients (contd) --
  • May need to use landmarks to identify a vein
  • May need to employ a longer cannula to reach an
    appropriate vein
  • Patients receiving anticoagulant therapy
  • Avoid using a tourniquet, or, if necessary, apply
    as loosely as possible
  • Avoid excess pressure when applying the skin
    preparation
  • Use the smallest cannula that will accommodate
    the vein and deliver the ordered infusate
  • Remove dressings gently and use an adhesive
    solvent

59
Converting a Peripheral IV
  • Converting a peripheral IV to an intermittent
    access device is necessary when discontinuing
    peripheral infusions while retaining venous
    patency
  • IV access remains available in case it is needed
  • Administration of intermittent medications
  • Conversion is completed by attaching an
    intermittent infusion plug to the hub of the
    cannula (Refer to page 234, Skill 9-9)
  • Also called a male adapter plug
  • Formerly referred to as a heparin lock
  • Heparin is no longer recommended for intermittent
    flushing because bacterial growth on the catheter
    may be intensified in its presence

60
Converting a Peripheral IV (contd)
  • Intermittent line maintenance is achieved by
    assessing the IV site, checking for cannula
    patency, and flushing with 2cc NS every 8-12
    hours
  • Check for patency of the intermittent line by
    attaching the syringe to the intermittent plug
    and pulling back the plunger to elicit blood
    return
  • If there is no blood return, gently inject the
    saline while palpating the infusion site
  • If the cannula is out of the vein, the saline
    will infiltrate the surrounding tissue, causing
    it to rise and be cool to the touch
  • If the cannula is placed correctly, the saline
    will enter the cannula and vein, maintaining
    patency

61
Converting a Peripheral IV (contd)
  • When any medication is administered into an
    intermittent infusion device, the protocol to be
    followed is the S-A-S method
  • Slowly instill 2mL NS to clear the lock (S)
  • Administer the prescribed medication (A)
  • Flush with NS to clear the lock (S)
  • Prior to implementing the S-A-S method
  • Wash your hands
  • Assess the IV access site
  • Don gloves
  • Disinfect the cannula port
  • Verify cannula and venous patency
  • If resistance is met, do not exert pressure on
    the syringe plunger to restore patency

62
Converting a Peripheral IV (contd)
  • Multiple medication orders
  • Instill NS between the administration of each
    medication
  • Always flush with NS after all medications are
    injected in order to clear the cannula and
    maintain patency
  • Maintain positive pressure during and after
    saline flushes
  • Achieved by withdrawing the blunt cannula or
    needle as the last 0.5mL of NS is flushed inward
  • Prevents the reflux of blood

63
Adding a Fluid/Medication
  • During infusion therapy, fluids or medications
    can be added in the following ways
  • Added to the primary infusate container
  • Via secondary administration set
  • Through an injection port in the primary
    administration tubing
  • By direct injection into a vein that is not
    concurrently receiving infusates (bolus)
  • NOTE For all but the last method, the nurse must
    check for chemical, physical, and therapeutic
    compatibility between the medications and
    delivery systems

64
Adding a Fluid/Medication (contd)
  • Adding fluid/medication to the primary infusate
    container
  • This is usually done as an admixture by the
    pharmacy under asepsis
  • If the nurse would need to add a medication, you
    would need to check for compatibility, additive
    concentration, and stability of the new solution
  • Refer to page 229 (Skill 9-6)
  • Never add a medication to an existing infusion
    container while it is hanging and infusing
  • Drug would be delivered to the base of the
    container
  • Bolus dose would be infused to the patient
  • May result in serious complications, or even death

65
Adding a Fluid/Medication (contd)
  • Adding fluid/medication via secondary
    administration set (piggyback)
  • This method involves administering a medication
    or fluid that is initiated after the primary
    infusion is already in progress
  • This is the most common means to administer
    intravenous medications concurrently with the
    primary infusion
  • The piggyback line is coupled to the primary
    infusion line at the first injection port below
    the check valve
  • The secondary infusion is able to function
    concurrently with the primary infusion only when
    suspended higher than the primary line

66
Adding a Fluid/Medication (contd)
  • Adding fluid/medication via piggyback (contd)
  • The primary line must have a back-check valve
  • By opening the clamp on the secondary line, the
    primary infusion temporarily stops flowing
  • When the piggyback infusion is complete and the
    infusate in its tubing falls below the level of
    the primary line drip chamber, the back-check
    valve opens and the primary infusion resumes
  • Refer to page 231 (Skill 9-7)

67
Adding a Fluid/Medication (contd)
  • Adding fluid/medication through an injection port
    in the primary administration tubing (Refer to
    page 233, Skill 9-8)
  • This is termed an IV push medication
  • Intravenous medications that would normally be
    delivered directly into the vein by bolus
    injection can be delivered through an injection
    port in the primary administration set if the
    patient already has a running IV
  • The nurse must check for compatibility between
    the product already and the drug to be
    administered by IV push
  • Failure to do so could cause a precipitate to
    form
  • Precipitate could obstruct the infusion line,
    damage the vein, or embolize

68
Nonfunctioning IV Lines
  • Checklist for determining the cause of a
    nonfunctioning peripheral IV line
  • Check IV site for infiltration, patency
  • Check the infusate container
  • Fluid level
  • Height
  • Check the tubing for kinking
  • Check the air vent and filter
  • Ensure the clamp is open
  • Check the positioning of the patient
  • Check the temperature of the solution
  • Ensure the tubing is correct for the infusate

69
Documentation
  • IV documentation includes labeling
  • The main purpose for labeling is to denote IV
    start, stop, and discontinuation times
  • Labels must be affixed to infusate containers,
    administration set tubing, and dressing sites
  • Placement of labels
  • IV site
  • Place next to the dressing
  • Include the date and time of cannulation
  • Indicate the type of device used
  • Length
  • Gauge
  • Identification (nurses initials)

70
Documentation (contd)
  • Placement of labels (contd) --
  • Allergy labels
  • On and in the patients chart
  • In the patients room and on the patients bed
  • All communication with other personnel and
    departments regarding allergies and drug
    reactions
  • Attach appropriate identification bracelet to the
    patient
  • Administration set tubing
  • Include date and time of initiation/change
  • Infusate container(s)
  • Start date and time
  • Flow level strips
  • Added medications
  • Never write directly on an IV bag (use label
    instead)

71
Documentation (contd)
  • Accurate charting for intravenous infusions
    should include these components
  • Date and time of insertion
  • Which vein was cannulated
  • Be specific (know your peripheral venous
    anatomy!)
  • Document why you chose a particular vein if
    necessary
  • Document the condition of the vein in terms of
    its softness or hardness and resiliency
  • Device used
  • Brand name and style
  • Gauge and length

72
Documentation (contd)
  • What to include in your charting (contd)
  • Infusate administered
  • Name of medication/fluid
  • Rate of infusion
  • Method of infusion
  • Gravity
  • EID
  • Controller or pump mode
  • Name brand and model number
  • Type of dressing applied
  • Remedial information
  • Number/location of attempted cannulations
  • Condition of the failed site(s)

73
Documentation (contd)
  • What to include in your charting (contd)
  • Patients response to the procedure
  • Reaction/comments
  • Be sure to document in these areas --
  • MAR
  • Nurses notes
  • Infusion and equipment flow sheets
  • Nursing care plan
  • Intake and output records
  • Laboratory, radiology, and other ancillary
    department requisitions

74
Local and SystemicComplicationsof IV Therapy
75
Local Complications of IV Therapy
  • Local complications adverse reactions that
    occur at or close to the IV insertion site
  • Constitutes the majority of complications in IV
    therapy
  • Usually less serious than systemic problems
  • Types of localized infusion-related
    complications include infiltration, thrombosis,
    phlebitis, thrombophlebitis, and allergic
    reaction to the IV catheter
  • Infiltration refers to the inadvertent
    administration of nonvesicant solution into the
    surrounding tissue

76
Local Complications (contd)
  • Causes of infiltration
  • Dislodgement of the cannula from the vein
  • Puncture of the vein wall during venipuncture
  • Friction of the catheter against the vein wall
  • Use of a high pressure infusion device
  • Irritating infusate that weakens the veins
  • Signs and symptoms of infiltration
  • Skin is taut and/or cool to the touch
  • Dependent edema
  • Absence of blood backflow
  • Pinkish blood return
  • Slowing of the infusion rate

77
Local Complications (contd)
  • Infiltration complications
  • Ulceration may appear after days/weeks
  • Compartment syndrome
  • Fluid builds up inside an inflexible compartment
  • Pressure on nerves, muscles, and vessels
  • Functional muscle changes occur within 4-12 hours
  • Ischemic nerve damage occurs within 24 hours
  • Preventing infiltration
  • Assess IV site (blood return is not an indicator)
  • Pain may or may not be present
  • Extremity comparison
  • Infusion should stop running if pressure is
    applied 3 inches above the catheter site

78
Local Complications (contd)
  • Treatment of infiltration
  • Infuse antidote through the IV if applicable,
    then remove the IV
  • Apply warm compresses for antineoplastic agents,
    and cool compresses for most other medications
  • Notify the physician
  • Elevate the extremity if this promotes comfort
    for the patient
  • Extravasation is the inadvertent administration
    of vesicant medication or solution into the
    surrounding tissue
  • Requires an incident report

79
Local Complications (contd)
  • Treatment of extravasation
  • Dependent on a variety of factors
  • Pharmaceutical manufacturers labeled uses and
    directions
  • Properties and severity of extravasated agent
  • Treatment determined before IV removed
  • Do no apply excessive pressure to the site to
    avoid establishment of perfusion
  • Ongoing observation and assessment of site (i.e.
    motion, sensation, circulation)
  • Do not use extremity for subsequent IV placement
  • Notify the physician

80
Local Complications (contd)
  • Infiltration documentation
  • Use the INS Infiltration Scale
  • Extravasation always graded at 4
  • Document written and verbal communication
  • Chart nursing and medical interventions
  • Document patients response to incident and
    treatment
  • Drugs associated with extravasation necrosis
    include
  • Calcium chloride Calcium gluconate
  • Dopamine Vancomycin
  • Vincristine Streptozocin

81
Infusion Nurses Society Infiltration Scale
  • May have circulatory impairment and severe pain
    with infiltration of blood product, irritant, or
    vesicant

82
Local Complications (contd)
  • Thrombosis occurs when blood flow through the
    vein is obstructed by a local thrombus
  • If thrombosis is IV-related, it has resulted from
    injury to the endothelial cells of the venous
    wall
  • Injury leads to platelet aggregation at the site
    of injury, which forms the thrombus
  • Major complication of central venous catheters
  • Signs and symptoms of thrombosis
  • Earache or jaw pain
  • Edema, redness at insertion site
  • Tachycardia, tachypnea

83
Local Complications (contd)
  • S/S of thrombosis (contd)
  • Malaise
  • Unilateral arm or neck pain
  • Absence of pulse distal to the obstruction
  • Digital coldness, cyanosis, and/or necrosis
  • Treatment of thrombosis
  • Never flush with force to remove an occlusion
  • Discontinue IV and restart with a new catheter at
    a different site
  • Notify the physician for assessment of
    circulatory status

84
Local Complications (contd)
  • Phlebitis inflammation of the vein
  • Endothelial cells in the venous wall become
    irritated and rough, allowing platelets to adhere
  • Capillary permeability increases, and protein
    leaks out into the interstitial space
  • Area more susceptible to mechanical or chemical
    irritation
  • Signs and symptoms of phlebitis
  • Localized redness and swelling
  • Warm and tender to the touch
  • Palpable cord along the vein
  • Sluggish infusion rate
  • Increased temperature

85
Local Complications (contd)
  • Prevention of phlebitis
  • Use of larger veins for hypertonic solution
    infusions
  • Use of central line for long-term IV therapy
  • Use of the smallest IV cannula appropriate for
    the ordered infusate
  • Rotation of IV sites per agency protocol
  • Change IV bag per agency protocol
  • Appropriate stabilization of the catheter
  • Correct venipuncture technique
  • Good handwashing
  • Phlebitis is graded according to INS scale

86
Infusion Nurses Society Phlebitis Scale
87
Local Complications (contd)
  • INS practice criteria for phlebitis requires
    established guidelines for treatment in Policy
    and Procedures Manual
  • All vascular access sites should be routinely
    assessed for signs or symptoms of phlebitis
  • Discontinue IV at first sign of phlebitis and
    remove the intravenous device
  • Grade 2 report to physician and file incident
    report
  • Observe peripheral catheter site for 48 hours
    after device has been removed
  • Document incident, intervention, treatment,
    corrective action, and patient education

88
Local Complications (contd)
  • Types of phlebitis
  • Mechanical
  • Chemical
  • Bacterial
  • Causes of mechanical phlebitis
  • Insertion of a cannula that is too small for the
    vein
  • Improper taping of the cannula hub so that the
    catheter tip rubs the vein wall
  • Manipulation of the catheter during infusion
  • Causes of chemical phlebitis
  • Excessively rapid infusion

89
Local Complications (contd)
  • Causes of chemical phlebitis (contd)
  • Infusion of irritating substances
  • Acidic solutions (Dextrose, KCL, antibiotics)
  • pH level falls the longer the solution is stored
  • Improperly mixed medications
  • Presence of particulate matter in the solution
  • Causes of bacterial phlebitis
  • Poor aseptic technique
  • Incorrect cannula insertion procedure
  • Inadequate stabilization of cannula hub
  • Lengthy catheter dwell time

90
Local Complications (contd)
  • Thrombophlebitis occurs when thrombosis is
    accompanied by inflammation
  • May become obstructive if IV not discontinued
  • Complications of thrombophlebitis
  • Embolism
  • Septicemia
  • Acute bacterial endocarditis
  • Causes of thrombophlebitis
  • Use of leg veins for venipuncture
  • Use of hypertonic or highly acidic infusates
  • Signs and symptoms of thrombophlebitis
  • Local tenderness and warmth

91
Local Complications (contd)
  • S/S of thrombophlebitis (contd)
  • Appearance of a red line above the IV site
  • Hardening of the vessel
  • Sluggish flow rate
  • Edema in the limbs
  • Diminished arterial pulses
  • Mottling or cyanosis of the extremities
  • Treatment of thrombophlebitis
  • Notify the physician, remove IV catheter and
    restart in opposite extremity using new equipment
  • Apply warm, moist compresses to the area for 20
    minutes for comfort

92
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93
Local Complications (contd)
  • Documentation of thrombophlebitis
  • Chart all observable symptoms
  • Document patients complaints/reactions
  • Chart nurses actions
  • Document information regarding new venipuncture
  • Allergic reaction to the IV catheter
  • Symptoms include red streak over the vein
  • Treatment of a localized allergic reaction
  • Discontinue the IV
  • Notify the physician
  • Use different material for new IV in another site

94
Systemic Complications of IV Therapy
  • Septicemia
  • Embolism
  • Pulmonary
  • Air
  • Catheter
  • Pulmonary Edema
  • Speed Shock
  • Allergic Reaction
  • Septicemia a febrile disease caused by
    microorganisms in the circulatory system
  • Major complication that occurs from cannula or
    infusate contamination

95
Systemic Complications (contd)
  • Signs and symptoms of septicemia
  • Fever, flushing, profuse diaphoresis
  • Altered mental status
  • Nausea/vomiting, abdominal pain
  • Tachycardia, hypotension
  • Treatment of septicemia
  • Monitor patient
  • Culture IV catheter per order/agency protocol
  • Administer antimicrobial therapy as ordered
  • Administer oxygen if needed
  • Administer IV fluids
  • Observe for bleeding (all body orifices)

96
Systemic Complications (contd)
  • Prevention of septicemia
  • Good handwashing
  • Careful inspection of IV solutions
  • Appropriate infusion site dressing
  • Rotate IV sites
  • Pulmonary embolism is associated with IV-related
    thrombus
  • Dislodged from the wall of the vein
  • Carried by the venous circulation through the
    right side of the heart to the pulmonary artery
  • Signs and symptoms include shortness of breath,
    cyanosis, chest pain, tachypnea

97
Systemic Complications (contd)
  • Prevention of a pulmonary embolism
  • Manage local complications immediately
  • Do not apply pressure to regain IV patency
  • Inspect medication/fluid for particulate matter
  • Avoid venipuncture in lower extremities
  • Treatment of a pulmonary embolism
  • Position patient on the left side, trendelenburg
  • Administer oxygen
  • Transfer to ICU
  • Air embolism is most frequent in central lines,
    and results from small amounts of air in the
    circulatory system

98
Systemic Complications (contd)
  • Causes of an air embolism
  • Incorrect IV insertion
  • Excessive catheter manipulation
  • Loose connections in the IV tubing
  • Complications of an air embolism
  • Accumulation of small bubbles forms larger
    bubbles that can block pulmonary capillaries
  • Blockage may be fatal due to sudden vascular
    collapse
  • Symptoms of an air embolism
  • Cyanosis, hypotension, ? venous pressure
  • Rapid loss of consciousness

99
Systemic Complications (contd)
  • Treatment of air embolism
  • Immediately place the client on the left side
    with head down
  • Air becomes trapped in the right atrium
  • Prevents air from entering the pulmonary artery
  • Administer oxygen
  • Notify the physician ASAP
  • May need to administer CPR
  • Catheter embolism can occur during catheter
    insertion if appropriate placement technique is
    not observed
  • Catheter tip can shear off and become a
    free-floating embolus
  • Can occur in both OTC and TNC

100
Systemic Complications (contd)
  • Treatment of catheter embolism
  • Apply a tourniquet high on the extremity to
    impede venous flow
  • Cardiac catheterization may be needed to remove
    the tip
  • Notify the physician and radiologist
  • Start an IV in the opposite arm to prepare for
    angiography for visualization
  • Symptoms of catheter embolism
  • Hypotension
  • Tachycardia, chest pain
  • Cyanosis
  • Loss of consciousness

101
Systemic Complications (contd)
  • Prevention of a catheter embolism
  • Never place an IV over a joint
  • Flexing may cause the catheter to break
  • If unavoidable, use splint to prevent bending
  • Documentation of catheter embolism
  • Vital signs, symptoms, level of consciousness
  • Appearance of catheter upon removal
  • Pulmonary edema is caused by rapid
    administration of large volumes of fluid that
    leads to circulatory overload
  • Prevention of pulmonary edema includes monitoring
    the patient frequently and using an EID for IV
    therapy

102
Systemic Complications (contd)
  • Symptoms of pulmonary edema
  • Increased blood pressure
  • Distended neck veins
  • Shortness of breath, rales
  • Orthopnea (sensation of breathlessness in the
    recumbent position)
  • Copious frothy sputum
  • Speed shock systemic reaction to rapid or
    excessive infusion that overloads the system may
    result in cardiac arrest
  • Symptoms of speed shock
  • Flushing of the head and neck
  • Severe headache, chest pain

103
Systemic Complications (contd)
  • Causes of speed shock
  • Leaving the flow clamp open on the IV tubing
  • IV pump programming error
  • Incorrect drip rate calculation
  • Prevention of speed shock
  • Always dilute IV push medications to the
    appropriate concentration
  • Always administer IV push medications over the
    amount of time recommended per agency protocol
  • Allergic reaction at the systemic level is
    considered a hypersensitivity reaction that can
    be mild or severe

104
Systemic Complications (contd)
  • Symptoms of an allergic reaction
  • Localized pain, edema, and/or redness
  • Wheezing, bronchospasm
  • Headache
  • Palpitations, agitation, confusion
  • Intestinal cramping, nausea/vomiting
  • Development may vary from rapid to delayed
  • Treatment of an allergic reaction
  • Stop the infusion
  • Keep the vein open with NS
  • Administer oxygen if needed
  • Ensure emergency equipment is available

105
Systemic Complications (contd)
  • Complications of an allergic reaction
  • Severe hypersensitivity to IV therapy
  • Profound physiological response to an antigen
  • Abnormal immune response to an allergen
  • May include anaphylaxis
  • Anaphylaxis severe allergic reaction
  • Immune response to allergen
  • Large quantities of histamine released
  • Massive peripheral dilation occurs
  • Decreased blood flow to vital organs
  • May lead to shock and death within minutes if
    untreated

106
Medication/Fluid Interactions
  • Incompatibility unintended effects from mixing
    fluids and/or medications
  • Action may be neutralized, intensified, or
    weakened
  • Precipitation may occur
  • Crystallization of particles
  • Occlusion of the IV line
  • Vessel injury
  • Significant drug-drug interactions involve
    medications that are incompatible with other
    products
  • Sodium bicarbonate
  • Phenytoin (Dilantin)

107
Medication/Fluid Interactions (contd)
  • Drug-drug interactions (contd)
  • Aminoglycosides (gentamicin, neomycin)
  • Digitalis glycoside
  • Barbiturates
  • Secobarbital (Seconal)
  • Pentobarbital (Nembutal)
  • Phenobarbital (Luminal)
  • Chlordiazepoxide (Librium)
  • Diazepam (Valium)
  • Theophylline
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