MEDICATION ADMINISTRATION: ADMINISTERING PARENTERAL MEDICATIONS (IV PUSH, INITIATING IV ACCESS, IV FLUID ADMINISTRATION)
INTRAVENOUS INJECTIONS
The intravenous (IV) route is used when a rapid drug effect is desired or when the medication is irritating to tissue. IV administration provides immediate release of medication into the bloodstream; consequently, it can be dangerous. IV medications are administered by one of the following methods:
• Intravenous fluid container
• Volume-control administration set
• Intermittent infusion by piggyback or partial fill
• Intravenous push (IVP or bolus)
ADDING DRUGS TO AN INTRAVENOUS FLUID CONTAINER
When administering IV medications, regardless of the method used, the nurse should assess the patency of the infusion system and the condition of the injection site for signs of complications such as infiltration (swelling and discomfort at the IV site) and phlebitis (inflammation of a vein).
Some IV medications or solutions with high or low pH or high osmolarity are irritating to veins and can cause phlebitis.
Before administering any IV medication, the nurse should note the client’s allergies, drug or solution incompatibilities, the amount and type of diluent needed to mix the medication, and the client’s general condition to establish a baseline for administering medication.
Examples of drugs that can be added to an IV fluid container that is infusing are potassium chloride, an electrolyte, and Solu-B, a vitamin (Figure 29-26).
The nurse should check for drug compatibilities of drug additives before injecting a medication into an infusion bag. Drug incompatibilities cause an undesired chemical or physical reaction between a drug and a solution, between two drugs, or between a drug and the container or tubing. For example, diazepam (Valium) and chlordiazepoxide hydrochloride (Librium) must not come into contact with a saline solution; insulin should not be added to an infusion bag because the insulin adheres to the inside of the solution bag.
ADDING DRUGS TO A VOLUME-CONTROL ADMINISTRATION SET
A volume-control set is used to administer small volumes of IV solution (Figure 29-27).
These devices have various names as determined by the manufacturer, such as Soluset, Metriset, VoluTrol, or Buretrol. To administer a drug by this method, the nurse should:
• Withdraw the prescribed amount of medication into a syringe that is to be injected into the volume-control set.
Cleanse the injection port of a partially filled volumecontrol set with an alcohol swab.
• Inject the prepared medication into the port of the volume-control set (Figure 29-28).
• Gently mix the solution in the volume-control chamber.
After injecting the medication into the volume-control chamber, the nurse should check the infusion rate and adjust as necessary to the prescribed rate of infusion.
ADMINISTERING MEDICATIONS BY INTERMITTENT INFUSION
A common method of administering IV medications is by using a secondary, or partial-fill additive bag, often referred to as an IV piggyback (IVPB). A secondary line is a complete IV set (fluid container and tubing with either a microdrip or macrodrip system) connected to a Y–port of a primary line (see Procedure 29-28)
The primary line maintains venous access. The IVPB is used for medication administration.
When the IVPB medication is incompatible with the primary IV solution, the nurse must flush the primary IV tubing with normal saline before and after administering the medication.
Intermittent Infusion Devices When the client requires only the administration of IV medications without the infusion of solutions, an intermittent infusion device is inserted into a peripheral needle or catheter in the client’s vein (Figure 29-30).
This device is commonly referred to as a heparin or saline lock depending on the agency’s policy regarding the device’s maintenance. A lock provides continuous access to venous circulation, eliminating the need for a continuous IV, and it increases the client’s mobility.
The device can be used to infuse intermittent IVPB or IV push medications, or it can be converted to a primary IV. A major consideration for inserting a heparin lock device is that it provides venous access in case of an emergency. Lock devices are routinely used with cardiac clients.
Locks are generally flushed every 8 hours to maintain patency (patency refers to being freely opened). Some agencies require a diluted dose of heparin (100 units/ml) to be injected into the lock; other agencies use normal saline to keep the device patent. When heparin is used, the devise must be flushed with normal saline solution before and after administration of a medication.
ADMINISTERING IV PUSH MEDICATIONS
The method of medication administration by IV bolus or IV push injection is determined by the type of IV system. For example, an IV push medication can be injected into a saline or heparin lock (Figure 29-31) or into a continuous infusion line.
When giving an IV push medication into a continuous infusion line, the nurse must stop the fluids in the primary line; the nurse usually pinches the IV tubing closed to inject the drug (see Figure 29-32).
This technique is safe and prevents the nurse from having to recalculate the drip rate of the primary infusion line.
IV push medications can also be given into a central line or directly into the vessel by venipuncture. The five rights of medication administration are implemented when administering an IV bolus. The nurse must know the specific time interval to inject the medication and the specific reactions of the infused drug. The client must be monitored closely during and after injection for drug reactions.
Intravenous (IV) therapy is the administration of fluids, electrolytes, nutrients, or medications by the venous route. The health care practitioner prescribes IV therapy to treat or prevent fluid and electrolyte or nutritional imbalances. The nurse has specific responsibilities relative to IV therapy (see the accompanying Nursing Process Highlight).
The Intravenous Nurses Society (INS) is the professional organization that establishes standards of practice to promote excellence in intravenous nursing to ensure the highest quality, cost-effective care for all individuals requiring infusion therapies (INS, 2000). INS standards of practice direct the development of agency policy/protocols in accordance with state and federal regulations and should complement the manufacturer’s direction for usage. The nurse should review the agency’s protocols before gathering the equipment. IV therapy requires parenteral fluids (solutions) and special equipment: administration set, IV pole, filter, regulators to control IV flow rate, and an established venous route.
PARENTERAL FLUIDS
The nurse confirms the type and amount of IV solution by reading the health care practitioner’s prescription in the medical record. IV solutions are sterile and packaged in plastic bags or glass containers. Solutions that are incompatible with plastic are dispensed in glass containers.
Plastic IV solution bags collapse under atmospheric pressure to allow the solution to enter the infusion set.
Plastic solution bags are packaged with an outer plastic bag, which should remain intact until the nurse prepares the solution for administration. When the plastic solution bag is removed from its outer wrapper, the solution bag should be dry. If the solution bag is wet, the nurse should not use the solution. The moisture on the bag indicates that the integrity of the bag has been compromised and that the solution cannot be considered sterile. The bag should be returned to the dispensing department that issued the solution. Glass containers are discussed in the section on equipment.
IV solutions are usually packaged in quantities ranging from 50 to 1,000 ml. The nurse should select a container that has the prescribed amount of solution or select several containers that together contain the prescribed volume. At no time should the nurse select a container whose volume is greater than that prescribed. For example, if the client is to receive 600 ml of normal (0.9%) saline, the nurse must not select a 1000 ml container, but rather two containers, 100 ml and 500 ml (containers are not prepared in volumes of 600 ml). Crystalloids (electrolyte solutions with the potential to form crystals) are used to replace concurrent losses of water, carbohydrates, and electrolytes. Sodium chloride and Ringer’s lactate are commonly used crystalloid solutions. There are three types of parenteral fluids that are classified in accord with the tonicity of the fluid relative to normal blood plasma. As previously discussed, an osmolar solution can be hypotonic, isotonic, or hypertonic.
type of solution is prescribed on the basis of the client’s diagnosis and the goal of therapy.
The normal osmolarity of blood is between 280 and 295 mOsm/L, so the desired effect of the tonicity of the fluid is determined as follows:
1. Hypotonic fluid (hypo-osmolar, less than 290 mOsm/L) lowers the osmotic pressure and causes fluid to move into the cells; if fluid is infused beyond the client’s tolerance, water intoxication may result.
2. Isotonic fluid (iso-osmolar, 290 mOsm/L) increases extracellular fluid volume; if fluid is infused beyond the client’s tolerance, cardiac overload may result.
3. Hypertonic fluid (hyperosmolar, greater than 290 mOsm/L) increases the osmotic pressure of the blood plasma, drawing fluid from the cells; if fluid is infused beyond the client’s tolerance, cellular dehydration may result (Bulechek & McCloskey, 1999).
The common types of intravenous solutions in terms of their tonicity, contents, and clinical usage.
Crystalloid solutions can be isotonic (equal to the sodium chloride concentration of blood, 0.9%); hypotonic (less than the sodium chloride concentration of blood); and hypertonic (greater than the sodium chloride concentration of blood) (Kee & Paulanka, 2000).
Colloids (nondiffusable substances) function like plasma proteins in blood by exerting a colloidal pressure to replace intravascular volume only. Examples of colloidal solutions are albumin, dextran, Plasmanate, and hetastarch (artificial blood substitute). During the administration of these solutions, the nurse should monitor the client for hypotension and allergic reactions (Bulechek & McCloskey, 1999; Kee & Paulanka, 2000). Blood transfusions are discussed later in this chapter.
EQUIPMENT
IV equipment is sterile, disposable, and prepackaged with user instructions. The user instructions are usually placed on the outside of the package, with a schematic that labels the parts, allowing the user to read the package prior to opening. The following discussion regarding intravenous equipment, inclusive of the frequency when to change disposal intravenous therapy equipment, is based on the revised 2000 Infusion Nursing Standards of Practice developed by INS. All intravenous equipment must be inspected by the nurse to determine the integrity of the IV product before, during, and after use. Product integrity refers to the sterility of the equipment. Products are assessed for integrity by visual examination of the product and checking the expiration date on the equipment. All products identified with a defect must be returned to the appropriate department within the agency with a written report identifying the defect.
Since intravenous therapy provides a direct access into the vascular system, the nurse must understand the basic epidemiology principles and common organisms that may cause an infection and implement infection control measures to minimize the potential for infectious complications. The nurse uses aseptic technique and standard precautions when assembling and changing intravenous equipment. To decrease the risk of pathogen transmission, handwashing is required before and immediately after all IV procedures and upon removal of gloves. The frequency of changing sterile intravenous equipment not only reflects the national standards of practice but the agency’s established infection control policies.
INFECTION
Infection data allow the agency to increase the time interval beyond the recommended standard provided the data verifies low infection rates. INS (2000) recommends that an organization that exhibits an increased rate of catheter-related bloodstream infection with the practice of 72-hour administration set changes should return to a 48-hour administration set change interval.
ADMINISTRATION SET
The administration set (infusion set) refers to the plastic disposal tubing that provides for the infusion of a solution. There are several types of infusion sets to accommodate the solution and the mode of administration: primary continuous; secondary; primary intermittent; and special tubing for certain solutions such as blood/blood components. There are several add-on devices, such as extension sets, filters, stopcocks, PRN adaptor, and needleless devices that are used in conjunction with the administration set and changed whenever the set is changed. Administration sets are changed at established time intervals and immediately upon suspected contamination or when the integrity of the set has been compromised. The administration set contains an insertion spike with a protective cap, a drip chamber, tubing with a slide clamp and regulating (roller) clamp, a rubber injection port, and a protective cap over the needle adapter (Figure 37-10).
The protective caps keep both ends of the infusion set sterile and are removed only just before usage. The insertion spike is inserted into the port of the IV solution container.
Infusion sets can be vented or nonvented. The nonvented type is used with plastic bags of IV solutions and vented bottles. The vented set is used for glass containers that are not vented (Figure 37-11).
Glass containers require an air vent so that air can displace fluid from the container into the IV tubing. Some glass bottles are vented with an inside tube that exits the bottle into a rubber stopper in the neck of the bottle; if the bottle is not vented, then the nurse needs to select a vented infusion set.
The drip chamber is calibrated to allow a predictable amount of fluid to be delivered. There are two types of drip chambers: a macrodrip, which delivers 10 to 20 drops per milliliter of solution, and a microdrip, which delivers 60 drops per milliliter. The drip rate varies with the manufacturer as indicated on the package.
The administration set has a manual flow-control device such as a slide clamp (Figure 37-10), a roller clamp, or a screw to regulate a prescribed infusion rate.
Follow the manufacturer’s guidelines when using the manual flow-control device to regulate the prescribed infusion rate. The end of the IV tubing contains a needle adapter that attaches to the sterile device inserted in the client’s vein. Extension tubing may be used to lengthen the primary tubing. A primary continuous administration set is used to administer routine solutions prescribed to infuse continuously over a 24 hour period.
The primary administration set, inclusive of the add-on devices, is changed every 48 to 72 hours in conjunction with the peripheral cannula change. A bag of intravenous solution should not hang longer than 24 hours. Secondary administration sets are often referred to as “piggyback” administration sets.
The secondary tubing is connected into the primary tubing at an injection site (see Figure 37-11) and allows for the administration of a second solution such as medication. Secondary administration sets are also changed every 48 to 72 hours.
Secondary administration sets are also changed every 48 to 72 hours.
Primary intermittent administration sets are used to deliver medications at prescribed intervals through an injection/access port and are changed every 48 to 72 hours; all add-on devices such as extension sets, filters, PRN adaptors, and stopcocks are changed with the intermittent administration set. A sterile needle/ needleless device should be aseptically attached to the intermittent administration set prior to administering the medication and removed immediately after each use.
INTRAVENOUS FILTERS
Intravenous filters prevent the passage of undesirable substances such as particulate matter and air from entering the vascular system. Particulate matter filters are utilized when preparing infusion medications for administration to prevent obstruction in the vascular/pulmonary systems, irritation and phlebitis (inflammation of a vein). Aireliminating filters are used for the delivery of infusion therapy to decrease the potential of air emboli; the filter should be located as close as possible to the cannula site.
IV filters come in various sizes; the finer the filter, the greater is the degree of solution filtration. Although studies have shown that IV filters reduce the risk of bacteremia and phlebitis as much as 40%, some agencies do not use IV filters because of cost. Many IV catheters contain an in-line filter; if the catheter has an in-line filter, it is not necessary to add a filter to the tubing.
NEEDLES AND VENOUS PERIPHERAL-SHORT CATHETERS
Needles and peripheral-short catheters provide access to the venous system. A variety of devices are available in different sizes to complement the age of the client, the type and duration of the therapy, and to protect the user from injury (Figure 37-12).
As with any gauge needle, the larger the number, the smaller the lumen. The nurse considers the client’s age, body size, and the type of solution to be administered when selecting the gauge of the needle or catheter:
ü Infants and small children, 24 gauge
1. Preschool through preteen, 24 or 22 gauge
2. Teenagers and adults, 22 or 20 gauge
3. Geriatric, 22 or 24 gauge
Butterfly (scalp vein or wing-tipped) needles are short, beveled needles with plastic flaps attached to the shaft.
The flaps (which are flexible) are held tightly together to facilitate ease of insertion and then flattened against the skin to prevent dislodgement during infusion. These needles are commonly used for short-term or intermittent therapy and for infants and children.
There are several types of short catheters used to access peripheral veins. Short peripheral venous catheters vary in length from 3/4 to 1 1/4 inches.
During insertion, some of these catheters are threaded over a needle, and others are threaded inside a needle. Intracath is a term used to refer to a plastic tube inserted into a vein. An angiocatheter is a type of intracath with a metal stylet to pierce the skin and vein, after which the plastic catheter is threaded into the vein and the metal stylet is removed, leaving only the plastic catheter in the vein. Short venous catheters can have safety devices to reduce the risk of accidental needlesticks. These devices are designed to allow for easy insertion of the catheter while providing a built-in safety feature for the user. As the catheter is threaded over the needle and advanced into the vein, the built-ieedle guard advances forward toward the tip of the needle; when the catheter hub is removed from the device, the entire needle is encased within the needle guard.
PERIPHERAL INTRAVENOUS (PI) AND HEPARIN LOCKS
Peripheral intravenous (PI) and heparin locks are devices that establish a venous route as a precautionary measure for clients whose condition may change rapidly or who may require intermittent infusion therapy. A butterfly needle or peripheral catheter is inserted into a vein and the hub is capped with a lock port, also called a Luer lock (Figure 37-13).
NEEDLE-FREE SYSTEM
Safety is a concern associated with IV therapy; refer to Chapter 31. Accidental needle-stick injuries and puncture wounds with contaminated devices increase the employee’s risk for infectious diseases such as AIDS, hepatitis (B and C), and other viral, rickettsial, bacterial, fungal, and parasitic infections. Most health care agencies now use totally needle-free IV systems (Figure 37-14) to decrease the risk of employee injuries.
VASCULAR ACCESS DEVICES
Vascular access devices (VAD) include various catheters, cannulas, and infusion ports that allow for long-term IV therapy or repeated access to the central venous system. The kind of VAD used depends on the client’s diagnosis and the type and length of treatment (see Table 37-6).
Site selection and insertion of central catheters, other than peripherally inserted central catheters, is a medical act performed by a practitioner. Although there are many types of catheter materials, insertion techniques and kinds of central catheters, all central catheters must be radiopaque to allow for radiographic verification of placement of the catheter and its tip prior to the administration of any solution.
Central catheters are usually inserted into the internal jugular and subclavian veins with the distal tip located in the superior vena cava to minimize vessel irritation and sclerosis. The femoral vein can be used for central venous access when there is thrombosis of the internal jugular or subclavian veins; correct tip location should be in the inferior vena cava. Insertion of a central catheter can be performed either percutaneously or surgically. Surgically, a central catheter is either placed entirely under the skin (implanted), or the catheter partially exits the skin (tunneled).
A tunneled catheter is inserted through the subcutaneous tissue, usually between the nipple and clavicle, with the catheter tip inserted through the cephalic or external jugular vein and threaded to the right atrium.
An implantable port is a device made of a radiopaque silicone catheter and a plastic or stainless steel injection port with a self-sealing silicone-rubber septum. The health care practitioner inserts the device into a subcutaneous pocket, usually over the third or fourth rib, lateral to the sternum. The distal tip of the catheter is surgically tunneled in the cephalic or external jugular vein, with the proximal end of the catheter tunneled through the subcutaneous tissue into the injection port of the device.
Implanted ports and pumps are vascular access devices that provide for the delivery of prescribed parenteral therapies. Accessing these devices requires the use of aseptic technique. Noncoring needles such as a Huber needle are used to access an implanted port/pump and should be changed at least every 7 days.
The smallest gauge noncoring needle that can deliver the prescribed therapy should be used when accessing the port/pump. Nurses caring for clients with implanted ports/pumps must have a thorough knowledge of the design features of the device, as explained in the manufacturer’s guidelines, to ensure correct access and administration techniques, maintenance, and potential complications.
Implanted pumps have a reservoir designed to continuously infuse a specific volume of solution over a preset period of time; the pump must be routinely emptied and refilled at established intervals. Some pumps have an additional feature, a side port designed for administration of intermittent medication. The flow rate of some pumps is sensitive to changes in atmospheric pressure, body temperature, blood pressure and the viscosity of the medications. Clients are instructed to report changes in their lifestyle and physical condition that may affect the pump’s flow rate. Only nurses who have been specially trained are allowed to access an implanted port/pump because of the risk of infiltration into the tissue if needle placement is incorrect.
A peripherally inserted central catheter (PICC) is the generic name for 11 different devices. A PICC is a silicone or polyurethane catheter inserted into one of the major veins in the antecubital fossa. Although the length of the catheter varies, on an average a PICC is
PREPARING AN INTRAVENOUS SOLUTION
To prepare an IV solution, read the agency’s protocol and gather the necessary equipment. Because IV equipment and solutions are sterile, check the expiration date on the package prior to usage. The solution can be prepared at the nurses’ work area or in the client’s room (Procedure 37-2).
The nurse prepares and applies a time strip to the IV solution bag to facilitate monitoring of the infusion rate as prescribed by the health care practitioner (Figure 37-19).
The IV tubing is tagged with the date and time to indicate when the tubing replacement is necessary. IV tubing is changed every 48 to 72 hours in accord with the agency’s protocol. The nurse initials the time strip and IV tubing tag.
INITIATING IV THERAPY
When initiating IV therapy, the nurse should assess for a venipuncture site. Figure 37-20 presents the common peripheral sites for starting IV therapy in pediatric, adult, and geriatric clients (see Chapter 28, Procedure 28-1, Venipuncture).
When assessing clients for potential sites, consider their age, body size, clinical status and impairments, and the skin condition (see the accompanying display for contraindications when selecting a site). Lower-extremity veins are used for IV therapy only when so prescribed by the health care practitioner; circulating blood in the lower extremities is likely to pool and clot, which may result in an embolism. Because contact with blood is likely, venipuncture requires the implementation of Standard Precautions. Refer to Chapter 31 for a complete discussion of Standard Precautions.
Select a vein for puncture at its most distal end to maintain the integrity of the vein, because venous blood flows with an upward movement toward the heart.
When a vein is punctured with an instrument, such as a needle, fluids can infiltrate (leak from the vein into the tissue at the site of puncture). If IV therapy has to be discontinued for any reason, such as infiltration, it can be restarted above the initial puncture site only.
VEIN FINDER
A vein finder is a device used to locate hard-to-find veins. It is helpful, for example, in working with obese clients whose superficial veins are difficult to locate.
A Venoscope (Figure 37-21) is a type of vein finder with adjustable fiberoptic arms that reveal veins.
The room is dimmed, and the disposable skids are placed flush against the skin. The nurse slowly moves the Venoscope along the extremity until a dark, shadowy line is seen between the fiberoptic arms.
Once the vein is identified, it can also be checked to determine whether it is sclerotic. To assess for sclerotic veins, apply a downward pressure over the fiberoptic arms and observe the vein when pressure is applied then released. A nonsclerotic vein will disappear with pressure and reappear when pressure is released.
ADMINISTERING IV THERAPY
Once the solution is prepared for administration, the nurse calculates the rate and explains the procedure to the client (see Procedure 37-3 for the administration of IV therapy). There are three ways to administer solutions:
1. Initiate the infusion by performing a venipuncture.
2. Use an existing IV system: catheter, heparin or PI lock, central line, or implanted port.
3. Add a solution to a continuous-infusion line.
Fluid administration can be continuous, ongoing over a 24-hour period, or intermittent, 1000 ml ordered once in a 24-hour period. Although fluids may be continuous, the type of fluids can alternate over a 24-hour period; for example, an order might be add 40 mEq of KCl to first bag of 1000 ml of normal saline.
IV medications may be piggybacked, added to an existing intravenous solution to infuse concurrently. IV solutions and medications that have been refrigerated should be warmed to room temperature before administration (usually 30 minutes) to increase client’s comfort.
The type of solution and frequency of flushing an intermittent intravenous cannula is determined by the agency’s policy/protocol. According to the INS (2000), flushing a cannula at established intervals with saline (0.9% sodium chloride injection) is the accepted solution to ensure and maintain patency of an intermittent PI cannula, while a heparin flush solution is the accepted solution to maintain patency of an intermittent central venous devices. The volume of flush is equal to the volume capacity of the cannula and add-on devices times two (INS, 2000). Consideration is also given to the volume and frequency of heparin flush in order to prevent an alteration in the client’s clotting factors.
When flushing a cannula positive pressure within the lumen of the catheter must be maintained to prevent the reflex of blood into the cannula lumen. Use the manufacturer recommended maximum pressure limits (pounds per square inch) when selecting the size of the syringe to use for flushing since the smaller the syringe the greater the pressure generated; excessive internal pressures in the device increase the potential for cannula damage and/or progressive internal cannula weakening over the life of the device (INS, 2000). If resistance is met when flushing a cannula, do not exert pressure in an attempt to restore patency of an occluded cannula since this action may result in the dislodgement of a clot into the vascular system and/or rupture of the catheter.
REGULATING IV SOLUTION FLOW RATES
Infusion sets with macrodrip chambers are often used for adult clients, whereas microdrip chambers are used for volume-sensitive clients, such as geriatric or pediatric clients. Pediatric and geriatric clients usually require some type of device to regulate the fluids as a safety factor to prevent overload. Devices such as controllers and pumps are commonly used to regulate the rate of infusion.
FLOW-CONTROL DEVICES
Flow-control devices are used to regulate the infusion at the prescribed administration rate. Safety factors such as the client’s age and condition, prescribed therapy, and setting are considered when selecting a flow-control device. There are two basic types of flow-control devices: manual flow-control devices and electronic infusion devices. Manual flow-control devices include roller, screw, and slide clamps and may include volume control devices such as Buretrol. These devices are used routinely to regulate the accurate delivery of most pre-
scribed IV therapy.
Electronic infusion devices are operated either by electricity or battery and are used to administer IV fluids and medications and should be considered on all central access devices (INS, 2000). Electronic infusion pumps have audible alarms that sound when the solution has infused, the infusion tubing contains air or is kinked, or the cannula is clotted. There are two types of electronic infusion devices: controllers and pumps.
Controller infusion devices generate flow by gravity and are capable of maintaining a constant preset flow rate either by drop counting or volumetric delivery. The nurse sets the flow rate, and the specific gravity of the solution and the height of the bag determine the maximum delivery pressure. Fluids with low-viscosity are usually infused by electronic controllers.
Infusion pumps maintain the flow rate under positive pressure. Pumps counter the effects of resistance in the delivery system and pressure fluctuations at the infusion site (McConnell, 1999). Positive pressure infusion devices are classified as either volumetric or syringe pumps, and are used to deliver viscous fluids or large volumes of fluids. Volumetric pumps use either a peristaltic pumping action or a pumping cassette or chamber to delivery a fixed volume over a specified period of time. Syringe infusion pumps rely on a syringe or cartridge to deliver the fluid at a specific set rate.
MANAGING IV THERAPY
IV therapy requires frequent client monitoring by the nurse to ensure an accurate flow rate and other critical nursing actions; refer to Procedure 37-4.
These other actions include ensuring client comfort and positioning; checking IV solution for correct solution, amount, and timing; monitoring expiration dates of the IV system (tubing, venipuncture site, dressing) and changing as necessary; and being aware of safety factors.
Coordinate client care with the maintenance of IV lines. Clients with IV therapy usually require assistance with hygienic measures, such as changing a gown (see Procedure 37-4). Change IV tubing when doing site care to decrease the number of times the access device is manipulated, thereby decreasing the risk for infiltration and phlebitis. PI devices are changed every 72 hours as directed by the Centers for Disease Control and Prevention (CDC) guidelines.
If a solution infuses at a rate greater than prescribed, decrease the rate to keep vein open (KVO) and immediately notify the health care practitioner. Report the amount and type of solution that infused over the exact time period and the client’s response.
INFILTRATION
Infiltration may be caused by inserting the wrong type of device, using the wrong-gauge needle, or dislodgement of the device from the vein. When a drug or solution is administered under high pressure by a pump, it may also cause infiltration or vein irritation.
Infiltration results in the leaking of fluids or medications into the surrounding tissue. The client usually complains of discomfort at the IV site. Inspect the site by palpating for swelling, and feel the temperature of the skin (coolness and paleness of skin are indications of infiltration).
The nurse confirms that the needle is still in the vein by pinching the IV tubing; this action should cause a flashback (blood should rush into the tubing if the needle is still in the vein). If a flashback does not occur, aspirate the injection port nearest the device as explained in Procedure 37-4. Discontinue the needle or catheter if it cannot be aspirated and apply a sterile dressing to the puncture site. After the IV has been removed, the puncture site may ooze or bleed (especially in clients receiving anticoagulants).
If oozing or bleeding occurs, apply pressure and reapply a sterile dressing until it stops. Accurately assess and document the degree of edema.
Clients may be injured by infiltration. If the IV site becomes grossly infiltrated, the edema in the soft tissue may cause a nerve compression injury with permanent loss of function to the extremity. If a vesicant (medication that causes blistering and tissue injury when it escapes into surrounding tissue) infiltrates, it may cause significant tissue loss with permanent disfigurement and loss of function.
PHLEBITIS
Phlebitis may result from either mechanical or chemical trauma. Mechanical trauma may be caused by inserting a device with too large a gauge, using a vein that is too small or fragile, or leaving the device in place for too long. Chemical trauma may result from infusing too rapidly, or from an acidic solution, hypertonic solution, a solution that contains electrolytes (especially potassium and magnesium), or other medications.
Phlebitis may be a precursor of sepsis. Listen for client complaints of tenderness, the first indication of an inflammation. Inspect the IV site for changes in skin color and temperature (a reddened area or pink or red stripe along the vein, warmth, and swelling are indications of phlebitis).
If phlebitis is present, discontinue the IV infusion. Before removing and discarding the venous device, check the agency’s protocol to see whether the tip of the device needs to be cultured and sent to the laboratory for a culture and sensitivity. After removing the device, apply a sterile dressing to the site and wet warm compresses to the affected area. Document in the nurses’ notes the time, symptoms, and nursing interventions.
Hypertonic solutions may cause irritatioecessitating frequent IV site changes. Observe site for symptoms of postinfusion phlebitis following IV removal. This may occur in response to either chemical or mechanical factors of the preexisting IV. Postinfusion phlebitis is treated with hot compresses to the site and elevation of the extremity.
INTRAVENOUS DRESSING CHANGE
IV dressing changes require the use of Standard Precautions and aseptic technique; refer to Procedure 37-4. Institutional protocol and the type of intravenous access device and dressing determine the frequency of care:
1. Nontransparent (gauze) dressing may be used for a PI. It is changed every 24 hours.
2. Transparent dressings (Bioclusive, OpSite, Tegaderm) allow visualization of the IV site; these dressings are changed every 48 hours.
3. Persistent drainage at the IV site may require dressing changes more frequently or necessitate changing the IV site.
INITIATING INTRAVENOUS FLUIDS INTO AN EXISTING IV SITE
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1. *Verify order and gather equipment: IV solution, IV tubing (micro tubing if hourly rate 50ml/hr. or less), alcohol wipes, clean gloves, saline flush, 3ml syringe, blunt cannula, tape and watch with second hand. |
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2. *Wash hands. |
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3. *Correctly interpret IV math for ml/hour and gtts./min. |
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4. *Using three checks and the five rights to compare solution with the physician’s order on the MAR |
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5. Remove outer wrapper from IV bag and assess the expiration date and check for any leaks or impurities in the bag. |
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6. Label the bag with client’s name, solution type, date, time and your initials. Label IV tubing with date and time. Place time strip on side of bag with hourly rate. |
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7. Prepare the IV tubing for spiking into bag by sliding roller clamp to the top of the tubing and closing it completely. |
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8. Invert IV bag and remove outer cap. Remove cap off IV tubing spike and insert spike into the IV bag while keeping tips sterile. |
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9. Place bag on IV pole and squeeze drip chamber to fill half full. |
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10. Remove IV tubing cap, place adapter on IV tubing end and while holding IV tubing at waist level slowly open roller clamp to prime IV tubing until all air is removed. Recap tubing and hang on IV pole while you prepare IV flush. |
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11. To prepare IV flush cleanse saline vial with alcohol. Draw up 2 ml of air into 3ml syringe and inject into saline vial. Invert vial and draw up 2 ml of saline flush. Recap and label syringe. |
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12.*If you have prepared IV in the medication room then gather your supplies and at client’s bedside use two identifiers to validate the correct patient against the MAR. |
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13.Apply clean gloves. Assess site for signs of infiltration and phlebitis. |
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14. After cleansing IV site with alcohol slowly inject saline flush. Set syringe aside and connect IV tubing to site. |
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15. Open roller clamp slowly and assess patency of IV flow rate. |
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16. Secure IV tubing with tape. Lower bed and using second hand timer set IV to ordered rate. |
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17. *Wash hands and document. |
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ADMINISTERING IVP MEDICATIONS VIA INT/PRN ADAPTER/LOCK DEVICE
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Yes |
No |
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1. Gather supplies: MAR, vial or ampule of ordered medication, watch with second hand, clean gloves, alcohol swabs, saline flush, 2-3ml syringes with blunt cannulas and appropriate size syringe to withdraw medication. |
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2. *Check for any allergies. Calculate the correct amount of drug to be given. Wash hands. |
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3. *Using the five rights check medication against MAR. Complete three checks of medication, as you retrieve medication, after preparing medication and prior to medication administration. |
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4. Prepare a pre and post flush of saline by withdrawing 2 ml of saline in each syringe. Label syringes. |
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5. Prepare medication according to dosage and administration section of drug reference. Label medication. |
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6. *Identify client by using two identifiers found on MAR and ID bracelet. Recheck five rights. |
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7. *Apply clean gloves and assess IV site patency by observing for any redness or swelling at site. (Note: Some institution’s policy requires aspirating on syringe and assessing for a blood return to ensure IV patency.) |
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8. Cleanse INT with alcohol swab and slowly flush with normal saline solution. Assess INT patency by noting if any discomfort or resistance while flushing. |
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9. Remove flush, cleanse site with alcohol and connect medication syringe. Using second hand on watch administer medication at recommended rate. |
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10. Remove medication syringe, cleanse site with alcohol and administer post-saline flush at the same rate at which medication was administered. |
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11. Dispose of syringe in sharps and container and remove gloves. |
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12. *Wash hands and document medication administration. |
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