IV THERAPY

Definition:

Intravenous therapy or IV therapy is the giving of liquid substances directly into a

vein. It can be intermittent or continuous; continuous administration is called an
intravenous drip. The word intravenous simply means "within a vein", but is most
commonly used to refer to IV therapy. Therapies administered intravenously are often
called specialty pharmaceuticals.

Compared with other routes of administration, the intravenous route is one of the fastest
ways to deliver fluids and medications throughout the body. Some medications, as well
as blood transfusions and lethal injections, can only be given intravenously.

When are IV Lines Used?

Intravenous lines are useful in many cases, because they allow medications or fluids to
be dispensed at a steady, controlled pace. Once an IV line is inserted, it can be used
repeatedly without the need for a new injection. IV lines can be helpful for patients who
need long-term antibiotics, chemotherapy, pain management medications, total
parenteral nutrition and for drawing blood. An IV also may be used for maternity patients
to relieve pain during labor and delivery.

Indications

• Establish or maintain a fluid or electrolyte balance

• Administer continuous or intermittent medication

• Administer bolus medication

• Administer fluid to keep vein open (KVO)

• Administer blood or blood components

• Administer intravenous anesthetics

• Maintain or correct a patient's nutritional state

• Administer diagnostic reagents

• Monitor hemodynamic functions
 IV Devices

Steel Needle

Example: Butterfly Catheter. They are named after the wing-like plastic tabs at the base
of the needle. They are used as to deliver small quantities of medicine, to deliver fluids
via the scalp veins of infant, and sometimes to draw blood samples (although not
routinely, since the small diameter may damage blood cells). These are small gauge
needles (i.e. 23 gauge).

Over the Needle Catheter

Example: Peripheral IV catheter. This is the kind of catheter you will be primarily using

A Word About Gauges

And now, a word about gauges: Catheters (and needles) are sized by their diameter,
which is called the gauge. The smaller the diameter, the larger the gauge. Therefore, a
22-gauge catheter is smaller than a 14-gauge catheter. Obviously, the greater the
diameter, the more fluid can be delivered. To deliver large amounts of fluid, you should
select a large vein and use a 14 or 16-gauge catheter. To administer medications, an 18
or 20-gauge catheter in a smaller vein will do.
 IV Fluid

There are three main types of fluids:

Isotonic fluids
Close to the same osmolarity as serum. They stay inside the intravascular
compartment, thus expanding it. Can be helpful in hypotensive or hypovolemic patients.
Can be harmful. There is a risk of fluid overloading, especially in patients with CHF and
hypertension. Isotonic fluids contain an approximately equal number of molecules (blue
dots) as serum so the fluid stays within the intravascular space. Remember that fluid
flows from an area of lower concentration of molecules to an area of high concentration
of molecules (osmosis) to achieve equilibrium (fluid balance). In this example, there is
no fluid flow into or out of the intravascular space.

Examples: Lactated Ringer's (LR), NS (normal saline, or 0.9% saline in water).

Hypotonic fluids

Have less osmolarity than serum (i.e., it has less sodium ion concentration than serum).
It dilutes the serum, which decreases serum osmolarity. Water is then pulled from the
vascular compartment into the interstitial fluid compartment. Then, as the interstitial fluid
is diluted, its osmolarity decreases which draws water into the adjacent cells. Can be
helpful when cells are dehydrated such as a dialysis patient on diuretic therapy. May
also be used for hyperglycemic conditions like diabetic ketoacidosis, in which high
serum glucose levels draw fluid out of the cells and into the vascular and interstitial
compartments. Can be dangerous to use because of the sudden fluid shift from the
intravascular space to the cells. This can cause cardiovascular collapse and increased
intracranial pressure (ICP) in some patients.

Example: D5NS.45 (5% dextrose in 1/2 normal saline).

Contain a lower number of molecules than serum so the fluid shifts from the
intravascular space to the interstitial space (represented by the green arrows). This
decreases the interstitial space osmolarity (because of the increase of fluid and
constant number of molecules within it) which then causes fluid to move into the cells.
Note that the green arrows represent fluid movement, not molecule movements.
 Hypertonic fluids
Have a higher osmolarity than serum. Pulls fluid and electrolytes from the intracellular
and interstitial compartments into the intravascular compartment. Can help stabilize
blood pressure, increase urine output, and reduce edema. Rarely used in the
prehospital setting. Care must be taken with their use. Dangerous in the setting of cell
dehydration.

Examples: 9.0% NS, blood products, and albumin.

Contain a higher number of molecules than serum so the fluid shifts from the interstitial
space to the intravascular space (represented by the green arrows). This increases the
interstitial space osmolarity (because of the loss of fluid and constant number of
molecules within it) that then causes fluid to leak out of the cells.

There Are Two Main Groups Of Fluids

Crystalloid Are isotonic and remain isotonic and are therefore, effective volume expanders
for a short period of time. However, both the water and the electrolytes in the solution can
freely cross the semipermeable membranes of the vessel walls (but not the cell
membranes) into the interstitial space, and will achieve equilibrium in two to three hours.
They are ideal for patients who need fluid replacement.

When using an isotonic crystalloid for fluid replacement to support blood pressure from
blood loss, remember that 3 mL of isotonic crystalloid solution are needed to replace 1 mL
of patient blood. This is because approximately two thirds of the infused crystalloid
solution will leave the vascular spaces by about one hour.

Generally, a good rule of thumb is that initial crystalloid replacement should not exceed
three liters before whole blood is instituted. Continued use of crystalloids runs the very
real risk that the fluid that has leaked into the interstitial space will result in edema,
primarily in the lungs (pulmonary edema).Examples: Lactated Ringer's (LR), NS (normal
saline).Colloid These contain molecules (usually proteins) that are too large to pass out of
the capillary membranes and therefore remain in the vascular compartment. The large
protein molecules give colloid solutions a very high osmolarity. As a result, they draw fluid
from the interstitial and intracellular compartments into the vascular compartment. They
work well in reducing edema (as in pulmonary or cerebral edema) while expanding the
vascular compartment.

Colloids can produce dramatic fluid shifts and place the patient in considerable danger if
they are not administered in a controlled settings.Examples: albumin and steroids
 Vein Selection

Veins of the Hand Veins of the Forearm

1.Digital Dorsal veins 1. Cephalic vein

2. Dorsal Metacarpal veins 2. Median Cubital vein
3. Dorsal venous network 3. Accessory Cephalic vein
4. Cephalic vein 4. Basilic vein
5. Basilic vein 5. Cephalic vein
6. Median antebrachial vein

Generally speaking, it is better to try to cannulate the most distal veins first. If for
example, the antecubital veins are ruined as a result of failed cannulation attempts this
can cause problems in the event of a successful cannulation further down. Any drugs or
fluids put through the cannula may extravasate at the failed cannula site.

The cepahlic vein is one of the best veins available. It tends to be large, and the forearm
provides a natural splint (Weinstein, 1997). If you place the cannula too far distally along
the vein, you can run into problems with the wrist joint, and are getting close to the
radial nerve. Also the tendons that control the thumb can obscure the vein (Hadaway,
1995). These problems can usually be avoided by moving a little further proximally
along the vein.
The basilic vein is often overlooked, hiding as it does along the ulnar border of the hand
and forearm. On the plus side, it's often fairly large - on the minus side it can roll like a
tanker in a rough sea and can have more valves than a submarine.

The dorsal veins are often quite handy (excuse the pun) as the metacarpals splint
cannulae well (Weinstein, 1997), but they can be quite small. If the patient is elderly,
look elsewhere. The lack of turgor in the skin and loss of subcutaneous tissue make it
quite difficult to cannulate these veins in the chronologically gifted (Whitson, 1996).

Cannulation of the antecubital veins can also cause problems as the cannula may
occlude as the patient bends their arm. Avoid, if you can, areas where cannulation or
venipuncture has previously taken place. Repeated puncture of the vein wall can result
and is painful (Ahrens et al., 1991)

In general, locate the vein section with the straightest appearance. Choose a vein that
has a firm, round appearance or feel when palpated. Avoid areas where the vein
crosses over joints.

If the IV treatment is for a life-threatening illness or injury, your choice may be limited to
an area that remains open during hypoperfusion. Otherwise, limit IV access to the more
distal areas of the extremities.

Technique

It is important to point out that starting an IV is an art-form which is learned with

experience accumulated after performing many IVs. Some patients are easy but many
are difficult.

Preparation: It is important to gather all the necessary supplies before you begin. You
will need:

• Absorbent disposable sheet

• 1 alcohol prep pad
• 1 betadine swab
• Tourniquet
• IV catheter
• IV tubing
• Bag of IV fluid
• 4 pieces of tape (preferably paper tape or easy to remove tape which has been
precut to approximately 4 inches (10cm) in length and taped conveniently to the
table or stretcher.
• Disposable gloves
• Gauze (several pieces of 4x4 or 2x2)
Prepare the IV fluid administration set

• Inspect the fluid bag to be certain it contains the desired fluid, the fluid is clear,
the bag is not leaking, and the bag is not expired.
• Select either a mini or macro drip administration set and uncoil the tubing. Do not
let the ends of the tubing become contaminated.
• Close the flow regulator (roll the wheel away from the end you will attach to the
fluid bag).
• Remove the protective covering from the port of the fluid bag and the protective
covering from the spike of the administration set.
• Insert the spike of the administration set into the port of the fluid bag with a quick
twist. Do this carefully. Be especially careful to not puncture yourself!
• Hold the fluid bag higher than the drip chamber of the administration set.
Squeeze the drip chamber once or twice to start the flow. Fill the drip chamber to
the marker line (approximately one-third full). If you overfill the chamber, lower
the bag below the level of the drip chamber and squeeze some fluid back into the
fluid bag.
• Open the flow regulator and allow the fluid to flush all the air from the tubing. Let
it run into a trash can or even the (now empty) wrapper the fluid bag came in.
You may need to loosen or remove the cap at the end of the tubing to get the
fluid to flow although most sets now allow flow without removal. Take care not to
let the tip of the administration set become contaminated.
• Turn off the flow and place the sterile cap back on the end of the administration
set (if you've had to remove it). Place this end nearby so you can reach it when
you are ready to connect it to the IV catheter in the patient's vein.

Perform the venipuncture

• Be sure you have introduced yourself to your patient and explained the
procedure.
• Apply a tourniquet high on the upper arm. It should be tight enough to visibly
indent the skin, but not cause the patient discomfort. Have the patient make a fist
several times in order to maximize venous engorgement. Lower the arm to
increase vein engorgement.
• Select the appropriate vein. If you cannot easily see a suitable vein, you can
sometimes feel them by palpating the arm using your fingers (not your thumb)
The vein will feel like an elastic tube that "gives" under pressure. Tapping on the
veins, by gently "slapping" them with the pads of two or three fingers may help
dilate them. If you still cannot find any veins, then it might be helpful to cover the
arm in a warm, moist compress to help with peripheral vasodilatation. If after a
meticulous search no veins are found, then release the tourniquet from above the
elbow and place it around the forearm and search in the distal forearm, wrist and
hand. If still no suitable veins are found, then you will have to move to the other
arm. Be careful to stay away from arteries, which are pulsatile.
• Don disposable gloves. Clean the entry site carefully with the alcohol prep pad.
Allow it to dry. Then use a betadine swab. Allow it to dry. Use both in a circular
 motion starting with the entry site and extending outward about 2 inches. (Using
alcohol after betadine will negate the effect of the betadine) Note that some
facilities may require an alcohol prep without betadine.
• To puncture the vein, hold the catheter in your dominant hand. With the bevel up,
enter the skin at about a 30 to 45 degree angle and in the direction of the vein.
Use a quick, short, jabbing motion. After entering the skin, reduce the angle of
the catheter until it is nearly parallel to the skin. If the vein appears to "roll" (move
around freely under the skin), begin your venipuncture by apply counter tension
against the skin just below the entry site using your nondominant hand. Many
people use their thumb for this. Pull the skin distally toward the wrist in the
opposite direction the needle will be advancing. Be carefully not to press too hard
which will compress blood flow in the vein and cause the vein to collapse. Then
pierce the skin and enter the vein as above.
• Advance the catheter to enter the vein until blood is seen in the "flash chamber"
of the catheter.

If not successful If you are unsuccessful in entering the vein and there is no flashback,
then slowly withdraw the catheter, without pulling all the way out, and carefully watch for
the flashback to occur. If you are still not within the vein, then advance it again in a 2nd
attempt to enter the vein. While withdrawing always stop before pulling all the way out to
avoid repeating the painful initial skin puncture. If after several manipulations the vein is
not entered, then release the tourniquet, place gauze over the skin puncture site,
withdraw the catheter and tape down the gauze. Try again in the other arm.

Otherwise, After entering the vein, advance the plastic catheter (which is over the
needle) on into the vein while leaving the needle stationary. The hub of the catheter
should be all the way to the skin puncture site. The plastic catheter should slide forward
easily. Do not force it!!

• Release the tourniquet.

• Apply gentle pressure over the vein just proximal to the entry site to prevent
blood flow. Remove the needle from within the plastic catheter. Dispose of the
needle in an appropriate sharps container. NEVER reinsert the needle into the
plastic catheter while it is in the patient's arm! Reinserting the needle can shear
off the tip of the plastic catheter causing an embolus. Remove the protective cap
from the end of the administration set and connect it to the plastic catheter.
Adjust the flow rate as desired.
• Tape the catheter in place using the strips of tape and/or a clear dressing. It is
advisable not to use the "chevron" taping technique.
• Label the IV site with the date, time, and your initials.
• Monitor the infusion for proper flow into the vein (in other words, watch for
infiltration).

Occasionally, you may inadvertently enter an artery. You'll recognize this because bright
red blood is quickly seen in the IV tubing and the IV bag because of the high pressure
that exists. If this occurs, stop the fluid flow, remove the catheter, and put pressure on
the site for at least 5 minutes.

It is sometimes helpful to draw blood after you have entered the vein and before you
have connected the IV tubing and bag. You can easily withdraw blood into a 15 or 20
mL syringe and then inject it into blood vials. Be sure to fill the vials to at least three
quarters full. To recall the order of the blood tubes, remember the pneumonic Red Blood
Gives Life for red, blue, green, lavender top tubes. Gently rock the tubes back and forth
a few times to mix the blood with the additives. There is no need to rock the red top
tube, however, the blood in this tube will clot quickly because it contains no additives. It
should not be shaken because this will destroy the sample.

To discontinue an IV

Remember to observe universal precautions. Start by clamping off the flow of fluids.
Then gently peel the tape back toward the IV site. As you get closer to the site and the
catheter, stabilize the catheter and remove the rest of the tape from the patient's skin.
Then place a 4 x 4 gauze over the site and gently slide the plastic catheter out of the
patient's arm. Use direct pressure for a few minutes to control any bleeding. Finally,
place a band aide over the site.

How to correctly apply a warm, moist compress Put a bath towel under hot water and
wring it out. Then fold it in half (by width not length) and enclose the arm from fingertips
to elbow in the towel. Now place the towel-wrapped arm into a plastic bag and seal the
open end of the bag near the elbow. While the pack is working (using heat to cause
venous dilation), you can be setting up your supplies and be ready to perform the
venipuncture as soon as you remove the pack. It works wonders! Many professional,
experienced IV Therapy nurses would not even consider performing a venipuncture on
patient with limited venous access without using a pack first.

Problems With IV Therapy

Infusion Phlebitis - inflammation of the vein associated with infusion phlebitis.

Careful/regular monitoring of intravenous access sites is recommended.

Infection - adhering to aseptic technique is vital in the prevention of intravenous related

infections. Asepsis should be maintained at insertion, during clinical use and at removal
of the device.

Bruising - may occur at any time during an episode of intravenous therapy.

Extravasation - the inadvertent administration of a vesicant substance into the tissues

can have disastrous outcome.
Infiltration- regular monitoring of infusion sites, choice of correct access
device/intravenous dressing and the use in-line pressure monitors may help to reduce
the extent to which infiltration occurs.

Systemic Complications:

1. Fluid overload

à same as circulatory overload. Too much, too fast.

S&S: SOB, edema, increased RR, abnormal lung sounds, increased BP, cough,
neck vein distention, variance for I&O (more in than out).

Prevention: monitor I&O, be aware of client history. Carefully monitor infusion

flow rates, may need to use pump or volutrol or hang smaller bags.

Treatment: slow IV down, do assessment, elevate HOB, call MD. MD may order
Lasix.

2. Air Embolism

à caused by air bubbles that accumulate and block pulmonary capillaries.

Associated commonly with central lines. Important to get air out. Can cause
shock and death.
S&S: dyspnea, cyanosis, hypotension, weak rapid pulse, loss of consciousness,
chest, choulder or low back pain.

Prevention: be sure connections are tight, lure locks should be tight.

Treatment: clamp central line and get new tubing.

3. Septicemia

à presence of pathogenic bacteria that invades the blood stream. Caused by a

break in aseptic technique or contaminated equipment.
S&S: chills, fever, general mallaise, h/a, backache, increased pulse and resps.

Prevention: sterile technique, inspect fluids, don’t hang over 24 hours, use sterile
technique for add mixtures, good handwashing.

Treatment: symptomatic.

4. Speed shock

à speeding it up when it is behing, may be a bolus.

S&S: facial flushing, h/a, chest tightness, symptoms of shock.

Prevention: use a pump.

Treatment: show IV down and call MD.

The Five Rights

Remember the five rights: The minimum standard of practice for medication
administration is checking the “five rights” (right drug, right patient, right dose, right time
and right route) to provide patient safety.

Do I have the right drug?

Do I have the right patient?
Do I have the right dose?
Do I have the right time?
Do I have the right route?

Now add to this:

Do I have the right solution?
Flow Rates

You will often need to calculate IV flow rates. The administration sets come in two basic
sizes:

Microdrip sets: Allow 60 drops (gtts) / mL through a small needle into the drip chamber.
Good for medication administration or pediatric fluid delivery.

Macrodrip sets: Allow 10 to 15 drops / mL into the drip chamber. Great for rapid fluid
delivery. Also used for routine fluid delivery and KVO

Fluid may be ordered at a KVO rate. This means to Keep the Vein Open, or run in fluids
very slowly, enough to keep the vein open, but not really deliver much volume. At times,
you may desire a faster flow rate. This is usually expressed in mLs / hour. In other
words, how much fluid do you want your patient to receive each hour? A common
"maintenance" amount, for instance, would be "run it in at 125 an hour". Your patient
would receive 125 mL of fluid every hour. Unless you are using an electronic pump to
deliver the fluid at precise amounts, you will need to learn how to set a flow rate
yourself. This is usually done by counting the number of drops that fall into the clear drip
chamber on the IV administration set in one minute. To do this, you must know what
size administration set you are using (micro or macrodrip). Plug the numbers into the
following formula and you've got it!

(Volume in mL) x (drip

gtts
set)
------------------------------
= ------
------
(Time in minutes) min

Let's say you want your patient to receive 250 mL of normal saline (NS) over a 90
minute time period. You decide to use a macrodrip (10gtt / mL) administration set. The
formula will now look like this:

(250 mL) x (10

gtts
gtts/min)
------------------------------
= ------
------
(90 min) 1 min

Which becomes:

2500 gtts
------------------------------
= ------
------
90 1

Then solving for gtts:

gtts
27.7 = ------
1

Or, gtts = 28

Sometimes you will need to know how many milligrams of a medication to give a patient
based on their weight. Let's say you need to give the patient some D 50. You look up the
medication and see that it should be given in a concentration of 0.5 mg / kg. The patient
weighs 220 pounds. The first thing to do is convert the weight to kilograms. Then we
can express all of this as simple ratios. We now have:

0.5 mg ? mg
--------- = ------
1 kg 100 kg

Solving for? Give us 50 mg ((0.5 mg x 100) kg / 1 kg) Fortunately for you; 50 mg is

exactly what is in one amp of D50.

Want to try this yourself? Let's say you want your patient to have 500 mL of NS given
over a two-hour period using a microdrip administration set. Use the first formula above.

Here's how it's done. First, the formula...

(Volume in mL) x (drip

gtts
set)
------------------------------
= ------
------
(Time in minutes) min

Plug the numbers in...

(500 mL) x (60

gtts
gtts/min)
------------------------------
= ------
------
(120 min) 1 min

Which becomes:

30000 gtts
------------------------------
= ------
------
120 1

Which becomes:

gtts
250 = ------
min
RESEARCH STUDY
ON
IV THERAPY

Submitted to:

Maria Luisa Dela Cruz

( Clinical Instructor )

Submitted by:

Reyes, Mari Rigel M.

Rianzares, Ervinne Mei A.

BSN – 3A2-6
Group 24