AMA 116 IV TheoryAMA 116 IV Theory

Objectives of IV Therapy:Objectives of IV Therapy:

Restore and maintain fluid and electrolyte Restore and maintain fluid and electrolyte balancebalance

Provide medications and chemotherapyProvide medications and chemotherapy

Transfuse blood and blood productsTransfuse blood and blood products

Deliver parenteral nutrients and nutritional Deliver parenteral nutrients and nutritional supplements supplements

Benefits of IV Therapy:Benefits of IV Therapy:

Allows more accurate dosingAllows more accurate dosing

Medications can act instantaneouslyMedications can act instantaneously

Can be used to administer fluids, Can be used to administer fluids, medications and nutrients when the medications and nutrients when the patient cannot take them orallypatient cannot take them orally

Risks of IV Therapy:Risks of IV Therapy:

BleedingBleeding

Infiltration (when fluids are infused into the Infiltration (when fluids are infused into the surrounding tissue instead of the vein)surrounding tissue instead of the vein)

InfectionInfection

Overdose (fluid overload, speed shock)Overdose (fluid overload, speed shock)

Anaphylaxis, SyncopeAnaphylaxis, Syncope

Fluids and ElectrolytesFluids and Electrolytes

The body is made up of mostly liquid. Two-thirds of total body weight in The body is made up of mostly liquid. Two-thirds of total body weight in an adult and three-fourths of the body weight in an infant consist of an adult and three-fourths of the body weight in an infant consist of fluid. fluid.

Body fluids are composed of water and solutes (dissolved substances) Body fluids are composed of water and solutes (dissolved substances) which are electrolytes and non-electrolytes. which are electrolytes and non-electrolytes.

ElectrolytesElectrolytesThere are six major electrolytes:There are six major electrolytes:

SodiumSodiumPotassiumPotassiumCalciumCalciumChlorideChloridePhosphorousPhosphorousMagnesiumMagnesium

Fluids and ElectrolytesFluids and Electrolytes

Electrolytes are contained either intracellularly Electrolytes are contained either intracellularly (potassium, magnesium and phosphorous) or (potassium, magnesium and phosphorous) or extracellularly (sodium and calcium). extracellularly (sodium and calcium).

Osmosis is a term for this movement of fluids Osmosis is a term for this movement of fluids and electrolytes and the fluid movement and electrolytes and the fluid movement gradient. Water flows from higher to lower gradient. Water flows from higher to lower concentration. When the solute concentration is concentration. When the solute concentration is equal on both sides of a membrane the osmosis equal on both sides of a membrane the osmosis stops. It is possible for the osmosis to create an stops. It is possible for the osmosis to create an equal concentration if the concentration isn’t equal concentration if the concentration isn’t optimal, then the balance must be corrected. optimal, then the balance must be corrected.

IV solutions all have a tonicity; therefore they can have an osmolar effect IV solutions all have a tonicity; therefore they can have an osmolar effect on the human body. Isotonic IV solutions (iso-osmolar to the blood) will on the human body. Isotonic IV solutions (iso-osmolar to the blood) will go in to the person without causing any osmotic effect between the go in to the person without causing any osmotic effect between the plasma, extracellular, or intracellular spaces in the body.plasma, extracellular, or intracellular spaces in the body.

Osmotic pressure is based on Osmotic pressure is based on solute concentration which is solute concentration which is referred to as osmolarity (or referred to as osmolarity (or how much solid is dissolved in how much solid is dissolved in the water). The prefixes “iso” the water). The prefixes “iso” (equal), “hyper” (higher) and (equal), “hyper” (higher) and “hypo” (lower) denote the “hypo” (lower) denote the “tonicity” or osmolarity of a “tonicity” or osmolarity of a solution. In the picture above, solution. In the picture above, side “A” is hypertonic to side side “A” is hypertonic to side “B” in the left picture, but “B” in the left picture, but isotonic to side “B” in the right isotonic to side “B” in the right picture. picture.

SolutionsSolutionsThere are three types of IV solutions:There are three types of IV solutions:

Isotonic- this has the same osmolarity as serum and other body Isotonic- this has the same osmolarity as serum and other body fluids. It will not cause any osmotic effect on the body. Examples: fluids. It will not cause any osmotic effect on the body. Examples: lactated ringers, ringers, normal saline, dextrose 5% in water and lactated ringers, ringers, normal saline, dextrose 5% in water and 5% albumin. 5% albumin.

Hypertonic- this has a higher osmolarity than serum. It will pull fluid Hypertonic- this has a higher osmolarity than serum. It will pull fluid from the interstitial and intracellular compartments into the blood from the interstitial and intracellular compartments into the blood vessels. Examples: dextrose 5% in half-normal saline, dextrose 5% vessels. Examples: dextrose 5% in half-normal saline, dextrose 5% in normal saline, dextrose 5% in lactated ringers, 3% sodium in normal saline, dextrose 5% in lactated ringers, 3% sodium chloride, 25% albumin and 7.5% sodium chloride. chloride, 25% albumin and 7.5% sodium chloride.

Hypotonic- this has a lower osmolarity than serum. Fluid moves Hypotonic- this has a lower osmolarity than serum. Fluid moves from the blood vessels and into the cells and interstitial spaces. from the blood vessels and into the cells and interstitial spaces. Examples: Sterile water, half-normal saline, 0.33% sodium chloride Examples: Sterile water, half-normal saline, 0.33% sodium chloride and dextrose 2.5% in water. and dextrose 2.5% in water.

Delivery MethodsDelivery MethodsThere are two types of IV administration:There are two types of IV administration:

PeripheralPeripheralCentralCentral

There are three basic methods to infuse IV fluids and medications via There are three basic methods to infuse IV fluids and medications via both delivery methods:both delivery methods:

Continuous infusion- this allows a carefully regulated amount of fluid to be Continuous infusion- this allows a carefully regulated amount of fluid to be given over a long period of time, helping maintain a constant drug level and given over a long period of time, helping maintain a constant drug level and is used for fluid therapy and parenteral nutrition. is used for fluid therapy and parenteral nutrition.

Intermittent infusion- this is the most common and flexible method of IV Intermittent infusion- this is the most common and flexible method of IV therapy. Drugs can be administered over a specific period of time at therapy. Drugs can be administered over a specific period of time at intervals and can be infused through a primary line or a secondary line that intervals and can be infused through a primary line or a secondary line that has been connected (or “piggybacked”) to the primary line. has been connected (or “piggybacked”) to the primary line.

Direct injection- the most direct method. This gets the medication or fluid Direct injection- the most direct method. This gets the medication or fluid right into the patient right away. It is also called giving a bolus or an IV push. right into the patient right away. It is also called giving a bolus or an IV push.

Central Venous TherapyCentral Venous Therapy

This is IV therapy using major veins instead of those in the limbs and This is IV therapy using major veins instead of those in the limbs and other peripheral veins. It is most useful when a patient needs other peripheral veins. It is most useful when a patient needs infusion of a large amount of fluid, requires multiple infusions, and infusion of a large amount of fluid, requires multiple infusions, and /or requires long-term therapy. A central line may be inserted /or requires long-term therapy. A central line may be inserted directly into the superior or inferior vena cava or the right atrium of directly into the superior or inferior vena cava or the right atrium of the heart. In addition, one can be inserted into a peripheral vein and the heart. In addition, one can be inserted into a peripheral vein and threaded up into the vena cava. threaded up into the vena cava.

There are additional risks to central venous therapy including:There are additional risks to central venous therapy including:

Perforation of the vein and adjacent organsPerforation of the vein and adjacent organsRequires more time and skill than peripheral IV’s Requires more time and skill than peripheral IV’s Air embolism or thrombusAir embolism or thrombusSepsisSepsisPneumothoraxPneumothorax

Access DevicesAccess Devices

Types of access Types of access devices include:devices include:

Non-tunneled and Non-tunneled and tunneled catheterstunneled catheters

Peripherally inserted Peripherally inserted central catheters central catheters (PICCs)(PICCs)

Implanted vascular Implanted vascular access ports (VAPs)access ports (VAPs)

Supplies and EquipmentSupplies and EquipmentThe tubing for an IV is called an administration set. The tubing for an IV is called an administration set. Which set you choose depends on the type of infusion Which set you choose depends on the type of infusion needed, the infusion container, and whether you are needed, the infusion container, and whether you are using a volume control device or not. using a volume control device or not.

Administration sets can be vented for bottles or un-Administration sets can be vented for bottles or un-vented for IV bags. Other items and features include vented for IV bags. Other items and features include ports for infusion of additional medications, filters for ports for infusion of additional medications, filters for blocking particulates in the fluid, tubing which is blocking particulates in the fluid, tubing which is designed to enhance devices in regulating flow or for designed to enhance devices in regulating flow or for continuous or intermittent infusion or for blood and continuous or intermittent infusion or for blood and nutrition. nutrition.

There are also various types of clamps for stopping the There are also various types of clamps for stopping the flow through the tubing as well as pumps that flow through the tubing as well as pumps that automatically deliver fluids and medications. automatically deliver fluids and medications.

OrdersOrders

When the physician orders IV administration, it When the physician orders IV administration, it may be a standard or standing order (to be may be a standard or standing order (to be followed for certain illnesses and needs) or it followed for certain illnesses and needs) or it may be an individualized order. They may be may be an individualized order. They may be limited in the duration of time they are effective limited in the duration of time they are effective for, such as a 24-hour period, when a new order for, such as a 24-hour period, when a new order must be given. must be given.

All orders should include the type and amount of All orders should include the type and amount of solution to be administered, any additives and solution to be administered, any additives and their concentration, rate and volume of infusion their concentration, rate and volume of infusion and the duration of the infusion therapy. and the duration of the infusion therapy.

Flow RatesFlow RatesTwo basic types of flow rates are:Two basic types of flow rates are:

Microdrip Microdrip Macrodrip. Macrodrip.

Each one delivers a certain amount of drops per milliliter (gtts/mL) and each uses the Each one delivers a certain amount of drops per milliliter (gtts/mL) and each uses the same calculation formula:same calculation formula:

Volume of infusion (milliliters)Volume of infusion (milliliters) X drip factor (gtts/mL) = flow rate X drip factor (gtts/mL) = flow rate (gtts/minute)(gtts/minute)

Time of infusion (minutes)Time of infusion (minutes)

When calculating the flow rate, the number of drops needed to deliver 1mL will vary When calculating the flow rate, the number of drops needed to deliver 1mL will vary on whether you are using the macrodrip (delivers 10, 15, or 20 gtts/mL) or the on whether you are using the macrodrip (delivers 10, 15, or 20 gtts/mL) or the microdrip (delivers 60 gtts/mL) administration set. microdrip (delivers 60 gtts/mL) administration set.

After the flow rate has been calculated, use your watch while checking the drops per After the flow rate has been calculated, use your watch while checking the drops per minute. Adjust the clamp or roller to slow or speed the flow until the correct number of minute. Adjust the clamp or roller to slow or speed the flow until the correct number of drops per minute has been achieved. Always count for one full minute. There are also drops per minute has been achieved. Always count for one full minute. There are also pumps that automatically deliver the medication at the correct rate provided it has pumps that automatically deliver the medication at the correct rate provided it has been set accurately. been set accurately.

Programmable IV PumpProgrammable IV Pump

Risks, Complications and Risks, Complications and DisadvantagesDisadvantages

There are numerous risks and complications in various aspects of IV therapy. This There are numerous risks and complications in various aspects of IV therapy. This list is a majority, but is not necessarily all-inclusive:list is a majority, but is not necessarily all-inclusive:

All risks related to phlebotomyAll risks related to phlebotomyInfectionInfectionInfiltrationInfiltrationIrritation at the site or along the veinIrritation at the site or along the veinIncompatibility of drugsIncompatibility of drugsRestricted mobilityRestricted mobilityClottingClottingToo rapid or too slow flow rate can cause many problems for the patientToo rapid or too slow flow rate can cause many problems for the patientWrong medication givenWrong medication givenUsing the wrong syringe when multiple syringes are requiredUsing the wrong syringe when multiple syringes are requiredAllergic response or adverse reactionAllergic response or adverse reactionHematomaHematomaVasovagal reactionVasovagal reactionNerve, tendon or ligament damageNerve, tendon or ligament damageSpasm of the veinSpasm of the vein

Patient TeachingPatient TeachingHaving an IV is frightening to many patients and it is a little painful. You will need to explain Having an IV is frightening to many patients and it is a little painful. You will need to explain

the procedure and try to decrease the patient’s anxiety. Some things to include are:the procedure and try to decrease the patient’s anxiety. Some things to include are:

What intravenous means, and that a plastic catheter will be inserted and left in the vein, not a What intravenous means, and that a plastic catheter will be inserted and left in the vein, not a needle.needle.

What fluid or medications they are receiving and why. (Most times the provider will do this).What fluid or medications they are receiving and why. (Most times the provider will do this).

How long the IV will be in.How long the IV will be in.

Admit that there may be some discomfort (do not say pain) that should stop once the IV is in Admit that there may be some discomfort (do not say pain) that should stop once the IV is in place. place.

Explain any sensations the fluid or medication may cause such as coldness, a feeling of it going Explain any sensations the fluid or medication may cause such as coldness, a feeling of it going up the arm, a burning sensation, etc… Tell them to report any pain or discomfort once the IV is up the arm, a burning sensation, etc… Tell them to report any pain or discomfort once the IV is placed. placed.

Explain the restrictions as needed such as ambulating, showering, etc…Explain the restrictions as needed such as ambulating, showering, etc…

Teach them how to help care for the IV such as not pulling on it, not to remove the medication Teach them how to help care for the IV such as not pulling on it, not to remove the medication from the pole, not to crimp or kink the tubing and to report any redness or irritation at the site or from the pole, not to crimp or kink the tubing and to report any redness or irritation at the site or numbness in the fingers etc…numbness in the fingers etc…

DocumentationDocumentation

Discontinuing an IV is charted as well as Discontinuing an IV is charted as well as insertion and maintenance. When you insertion and maintenance. When you discontinue an IV, include in your discontinue an IV, include in your documentation:documentation:Date and timeDate and time

Reason for stopping the therapyReason for stopping the therapy

Assessment of the site before and after removalAssessment of the site before and after removal

ComplicationsComplications

Patient reactionPatient reaction

Integrity of the device upon removalIntegrity of the device upon removal

Any follow-up tasks such as a dressing or insertion in Any follow-up tasks such as a dressing or insertion in another siteanother site

For the insertion of an IV it For the insertion of an IV it must include:must include:

Size and type of deviceSize and type of deviceName of the person administering Name of the person administering (inserting)(inserting)Date and timeDate and timeSite locationSite locationType of solution and any additivesType of solution and any additivesFlow rateFlow rateWhether a pump is usedWhether a pump is usedComplications and patient responseComplications and patient responsePatient teachingPatient teachingNumber of attemptsNumber of attempts

Maintenance of an IV is also charted Maintenance of an IV is also charted and should include:and should include:

Condition of the siteCondition of the siteSite care providedSite care providedDressing changesDressing changesSite changesSite changesTubing and solution changesTubing and solution changesAdditional patient teachingAdditional patient teaching

Legal IssuesLegal IssuesAdministering fluids and medications by IV therapyAdministering fluids and medications by IV therapy

one of the most legally risky tasks performed in the medical setting. one of the most legally risky tasks performed in the medical setting. especially risky for the medical assistant who works under the physician-employer’s especially risky for the medical assistant who works under the physician-employer’s

license, whereas nurses have their own license. license, whereas nurses have their own license. Errors in medication dosage, incorrect placement of an IV line, and failure to monitor Errors in medication dosage, incorrect placement of an IV line, and failure to monitor

adverse reactions, infiltration, and dislodgement of IV equipment are the common adverse reactions, infiltration, and dislodgement of IV equipment are the common problems. problems.

The medical assistant CANNOT place, start, monitor or remove an IV unless they are The medical assistant CANNOT place, start, monitor or remove an IV unless they are fully trained to the full extent of their State laws and only when your physician-fully trained to the full extent of their State laws and only when your physician-employer has allowed you to do so. employer has allowed you to do so.

(**See the State laws of Washington called the Healthcare Assistant Law in another (**See the State laws of Washington called the Healthcare Assistant Law in another assignment of the checklist in your packet for more information on this).assignment of the checklist in your packet for more information on this).

The medical assistant must be fully knowledgeable about the laws that govern their The medical assistant must be fully knowledgeable about the laws that govern their right to practice within their scope of training. Be fully aware of the policies in your right to practice within their scope of training. Be fully aware of the policies in your office/clinic and follow all Federal and State laws for infection control when performing office/clinic and follow all Federal and State laws for infection control when performing tasks that involve body fluids (OSHA, WISHA, CDC, Bloodborne Pathogen Standard, tasks that involve body fluids (OSHA, WISHA, CDC, Bloodborne Pathogen Standard, Standard Precautions).Standard Precautions).

Central and Peripheral VeinsCentral and Peripheral Veins

IV insertion Memory ToolIV insertion Memory Tool

A simple tool to remember the major steps A simple tool to remember the major steps for completing a venipuncture properly is for completing a venipuncture properly is the acronym BLATS.the acronym BLATS.

B Blood return enters the flashback chamber.B Blood return enters the flashback chamber.L Level the catheter. L Level the catheter. A Advance the catheter. A Advance the catheter. T Tourniquet is removed.T Tourniquet is removed.S Stylet is removed. S Stylet is removed.

Review of Main Steps:Review of Main Steps: Obtain and check the IV orderObtain and check the IV order Gather the appropriate equipmentGather the appropriate equipment Wash your handsWash your hands Identify the patient and assess the Identify the patient and assess the

condition of the patient’s armcondition of the patient’s arm Apply the tourniquetApply the tourniquet Select appropriate veinSelect appropriate vein Prep with alcohol in an upward Prep with alcohol in an upward

mannermanner Put on glovesPut on gloves Hold the catheter bevel up, at the Hold the catheter bevel up, at the

appropriate angleappropriate angle Retract the skinRetract the skin Insert until the blood return is Insert until the blood return is

visible in the flashback chambervisible in the flashback chamber Level off the angle of entryLevel off the angle of entry

Advance the catheter slightlyAdvance the catheter slightly Remove the tourniquetRemove the tourniquet Remove the styletRemove the stylet Attach the IV tubingAttach the IV tubing Open the flow control clampOpen the flow control clamp Retract the skinRetract the skin Advance the catheter to the hubAdvance the catheter to the hub Regulate the flow rateRegulate the flow rate Remove glovesRemove gloves Center the transparent dressing Center the transparent dressing

over the site to anchor the over the site to anchor the catheter in placecatheter in place

Loop the IV tubing and tape in Loop the IV tubing and tape in placeplace

Document the procedure in the Document the procedure in the patient chartpatient chart

Positioning and Hand PlacementPositioning and Hand Placement

IV Arm PlacementIV Arm Placement