IV and MEDS

Objective One

Explain the legalimplications of

intravenous therapy

The Five Rights of Medication

Administration

Right patientRight medicationRight doseRight routeRight time

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The Three Checks of Medication Administration1. Read the label of the medication as it is removed from the shelf, unit dose cart, refrigerator, or dispensing system

2. Read the label of the medication when comparing it with the MAR

3. Read the medication label again before administering the medication to the patient

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LOOK at the label for verification of the medication name, dosage, route, and expiration date

CHECK the medication itself, NOT just the pharmacy label

Be overly cautious with regards to dose, proper dilution, and administration rate

Watch decimal pointsBe aware of the unit

Is the medication dispensed in mcg or mg?

What is ordered in comparison? 5

Risk Management forInfusion Therapy

Know venous anatomy and physiologyKnow appropriate vein selectionUse infusion equip. appropriatelyClarify unclear ordersRefuse to follow orders that you know are

not within the scope of safe nursing practiceKnow the infusion indications, side effects,

and special considerations for IV medicationsAdminister medications and/or infusions at

the proper rate and within the ordered intervals

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Risk Management (cont’d)Assess the patient and monitor the IV site

for complicationsUse proper IV care and maintenanceNotify physician promptly of IV

complicationsKnow and give appropriate treatments for

complicationsProvide proper patient educationDocument all aspects of IV therapy,

including patient educationFollow your institution’s policy/proceduresAbide by Nebraska’s Nurse Practice Act and

standards of IV practice7

Objective Two

Apply the concepts of standard precautions in

infusion therapy

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Updated CDC Guidelines for Preventing Infusion Device-

Related InfectionsPrepping the skin

Use 2% chlorhexidine, which is more effective in lowering catheter-related bloodstream infection rates than 10% povidone-iodine and 70% isopropyl alcohol

Chlorhexidine persists on the skin longer, which is important because it kills organisms that could repopulate the insertion site from deeper skin layers

Use “back and forth” scrubbing motion rather than outwardly radiating concentric circles

Allow solution to dryIt has not been determined if chlorhexidine should

be used on infants less than 2 months of age

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Peripheral IV site recommended for only 72 to 96 hours to prevent phlebitis

Maintain peripheral IV in place in pediatric patients as long as neededEnsure site is free from complicationsIf catheter was placed in an emergency

situation, replace within 48 hoursFollow hand antisepsis protocols (i.e.

handwashing and alcohol-based hand rubs)Use clean gloves to insert a peripheral

catheter; do not touch access site after skin prep has been applied

Observe hand hygiene before and after palpating catheter insertion sites; before and after inserting an IV; and before and after replacing, accessing, repairing, or dressing an IV site

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Occupational HIV ExposurePreventing exposures to blood and body

fluids is the primary means of preventing occupationally acquired human immunodeficiency virus (HIV) infectionUniversal precautionsHandwashingProper use of safety equipment

Follow institutional policy/proceduresRecommendations for post-exposure

prophylaxis (PEP) include urgent medical treatment to ensure timely initiationPrompt reporting of exposure4-week regimen of two antiretroviral

medications to prevent seroconversion of HIV infection in health care workers

Counseling

Objective Three

Discuss the risks, complications, and

adverse reactions of intravenous therapy

Extravasation

Phlebitis

Hematoma

Infiltration

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*Infiltration refers to the inadvertent administration of nonvesicant solution into the surrounding tissueCauses of infiltration include 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, and 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 or pinkish blood return Slowing of the infusion rate

Complications of infiltration may include ulceration (after days/weeks) and compartment syndrome

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*Infiltration (cont’d):Prevention of infiltration involves comparing

extremities, assessing if infusion stops running when pressure applied 3 inches above catheter site

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 Elevate the extremity if this promotes comfort for the

patient

*Extravasation is the inadvertent administration of vesicant medication or solution into the surrounding tissueRequires an incident reportDetermine treatment BEFORE removing IVDo not apply excessive pressure to the site

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*Thrombosis occurs when blood flow through the vein is obstructed by a local thrombusS/S include earache/jaw pain, edema/redness at

insertion site, tachycardia/tachypnea, malaise, unilateral arm/neck pain, absence of pulse distal to the obstruction, digital coldness/cyanosis/necrosis

Treatment of thrombosis involves discontinuing and restarting IV at a different site (never flush with force to remove an occlusion)

*Phlebitis = inflammation of the veinS/S include localized redness/swelling,

warmth/tenderness, palpable “cord” along the vein, sluggish infusion rate, increased temperature

Prevention includes using smallest cannula appropriate, stabilizing the catheter, and correct venipuncture technique

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*Septicemia = a febrile disease caused by microorganisms in the circulatory system; septicemia is a major complication that occurs from cannula or infusate contaminationS/S include fever, flushing, profuse diaphoresis, altered

mental status, nausea/vomiting, abdominal pain, tachycardia, hypotension

Treatment includes culturing IV catheter per order/agency protocol, administering oxygen if needed, antimicrobial therapy, IV fluids

Prevention of septicemia includes good handwashing, appropriate infusion site dressing, rotation of IV sites

*Pulmonary embolism is associated with IV-related thrombusS/S = shortness of breath, cyanosis, chest pain,

tachypneaPrevent by avoiding venipuncture in lower extremities

and not applying pressure to regain IV patency

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*Pulmonary embolism (cont’d)–Treated by positioning patient in left-sided

trendelenburg, administer oxygen, and transfer to ICU

*Air embolism is most frequent in central lines, and results from small amounts of air in the circulatory systemCauses include incorrect IV insertion, excessive catheter

manipulation, and loose connections in the IV tubing Accumulation of small bubbles can block pulmonary capillaries Blockage may be fatal due to sudden vascular collapse

Symptoms include cyanosis, hypotension, ↑ venous pressure, and rapid loss of consciousness

Treatment includes immediately placing client in left-sided trendelenburg so that air becomes trapped in the right atrium and is prevented from entering the pulmonary artery; administer oxygen; notify the physician ASAP

Objective Four

Identify central and peripherally placed

vascular access devices utilized for various

patient needs

Central Lines

PICC Line

POWER PICC

Huber needles for port access

Objective Five

Identify the pharmacological principles and

administration of intravenous medications

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Vein SelectionDo not use veins in ambulatory lower extremitiesNever access an arteriovenous fistula, graft, or

shuntDo not use veins in an extremity that is impaired as

a result of a CVADo not use veins on the side of the body with

radical mastectomy with lymph node dissection/stripping

Bypass veins in an extremity that has undergone reconstructive or orthopedic surgery

Do not use veins in an area with a recent infiltrationDo not use veins at or near 3rd degree burnsAvoid veins in an extremity that is partially

amputatedDo not use veins that are irritated or sclerosed from

previous use

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Tourniquet ApplicationApplying a tourniquet assists in venous distention

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

Contraindicated in some patients

http://www.youtube.com/watch?v=wul7KsoRdnQ

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Cannula Selection*Winged needles, referred to as butterflies, have

one or two “wings” that 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

*Peripheral venous access catheters are the most commonly used IV deviceTwo-part flexible cannula in tandem with a rigid

needle or stylet, which is used to puncture and insert the catheter into the vein

Connects with a clear chamber that allows for visualization of blood return, indicates successful venipuncture, and facilitates removal of the needle

Catheter is radiopaque so that it can be easily detected by radiology in case of embolus

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IV Administration SetsThe IV administration set determines the rate at

which fluid can be delivered to the patient (i.e. the drop factor)Extra large (macrobore) tubings are used in

emergency surgical and trauma situations for rapid infusion of large volumes of blood or fluid

Extra small (microbore) tubings are used for the delivery of small amounts of precisely controlled fluid or medication for special volume restriction (neonatal care, epidural infusions)

Primary administration sets carry fluid directly to the patient through one tube

Secondary administration sets (also referred to as piggyback sets) are used to deliver continuous or intermittent doses of fluid or medication

http://www.youtube.com/watch?v=tfQbbCx6xFU&feature=related

Objective Six

Demonstrate peripheral venipuncture and

discontinuation of IV push

(*Lab Practice)

Objective Seven

Demonstrate calculation of IV drip rates and IV dosages

The IV flow rate is the speed at which the IV fluid infuses into the bodyOften measured in drops per minute (abbreviated

“gtt/min”)Factors affecting the flow rate include:

The amount of fluid to be infusedThe time over which it is to be infusedThe size of the tubing

The number of drops required to deliver 1 ml of fluid varies with the type of IV administration set (tubing) used; the size of the tubing is called the drop factor

There are 2 types of IV administration sets:Macrodrip = 10, 15, or 20 gtt/mlMicrodrip = 60 gtt/ml

In calculating the flow rate, ratio/proportion cannot be used because there are more than two components to calculate

The dosage calculation formula cannot be used because a dosage is not being calculated

When calculating the flow rate, all rates should be rounded to the nearest whole number

IV Flow Rate Formula:volume of infusion (in mL) x drop factor =

Flow rate time of infusion (in minutes) (in gtt/min)*Note that time must be converted to minutes,

and that the drop factor is in gtt/mL

IV Calculation ExamplesAdminister D5 ½ NS at 30 mL/h. The drop factor is a microdrip.

30mL x 60gtt/mL = 30gtt/min 60min

An IV medication in 60 mL of 0.9% NS is to be administered in 45 minutes. The drop factor is a microdrip.

60mL x 60gtt/mL = 80gtt/min45min

Examples (cont’d)Administer 3,000 mL D5 ½ NS in 24 hours. The drop factor is 10 gtt/mL.

3000mL x 10gtt/mL = 21gtt/min 1440min

Administer Lactated Ringer’s at 125 ml/h. The drop factor is 15 gtt/mL.

125mL x 15gtt/mL = 31gtt/min60min

Examples (cont’d)1,000 mL of Lactated Ringer’s solution is to infuse in 16 hours. The drop factor is 15 gtt/mL.

1000mL x 15gtt/mL = 16gtt/min 960min

Infuse 2,000 mL D5W in 12 hours. The drop factor is 15 gtt/mL.

2000mL x 15gtt/mL = 42gtt/min720min

Electronic Flow RateWhen using an electronic infusion device (IV

pump), the flow rate is calculated in milliliters per hour (mL/h)

To find mL/h, you must divide the total milliliters by the total hours

You would then round your final answer to the nearest whole

Examples --1000 mL in 8 hours = 1000/8 = 125mL/h500 mL in 24 hours = 500/24 = 21mL/h

If an order is given without total milliliters, this becomes a dose calculation; you would use ratio-proportion, dimensional analysis, or the Formula

Recalculating the Flow RateSometimes the IV infusion rate changes due

to a change in the patient’s positionIf you notice that the flow rate needs to be

adjusted, assess the client and determine the percentage of change needed to correct the infusion

Please note that you can adjust the infusion flow rate by no more than 25% without consulting the physician or practitioner

In order to determine the percentage of increase or decrease of the flow rate:Determine the actual change in the flow rateDivide by the original flow rateMultiply by 100

Examples of IV RecalculationOriginal infusion order : 1000mL D5W IV to infuse over the next 10 hours.Infusion start time: 1300 hours. Drop factor = 10. Hourly rate = 100mL/h. Flow rate = 17gtt/min.At 1430 hours, the infusate level is at 900mL. 150mL should have already infused, leaving 850mL remaining to infuse over the next 8 ½ hours. The IV would be recalculated as follows:900mL = 106mL/h – 100mL/h = 6mL/h 8.5h 6mL/h = 0.06 x 100 = 6% increase 100mL/h

Recalculation Examples (cont’d)

Original infusion order : 1000mL D5W IV to infuse over the next 8 hours.Infusion start time: 0900 hours. Drop factor = 15. Hourly rate = 125mL/h. Flow rate = 31gtt/min.At 1200 hours, the infusate level is at 850mL. 375mL should have already infused, leaving 625mL remaining to infuse over the next 5 hours.

The IV would be recalculated as follows:850mL = 170mL/h – 125mL/h = 45mL/h 5h

45mL/h = 0.36 x 100 = 36% increase 125mL/h

Titrating MedicationsTitrating means to adjust the medication

until it brings about the desired effectAlways start with the low end of “safe” and

increase dosage from thereFollow institutional protocol for titrating

medicationsTitrated medications are calculated in the

same way as non-titrated drugsAn example of a titration order would be:

A client weighing 50 kg is to receive a Dobutrex solution of 250 mg in 500 mL D5W ordered to titrate between 2.5–5 mcg/kg/min

Titration Calculation Examples

In the previous order, the initial dose would be set at the low end of safe. Therefore, the client will receive 2.5mcg/kg/min of the ordered medication, and will receive no more than 5mcg/kg/min.The client’s weight is 50kg.50 x 2.5 = 125mcg/min safe range of drug50 x 5 = 250mcg/min Per IV pump, the client would receive the minimum dosage of 7500mcg/h, or 7.5mg/h:250mg = 500mL = 250 X mg/mL = 7.5mg(500mL) 7.5mg X mLX = 3750mg/mL = 15mL (initial dose is 15mL/h) 250mg

Objective Eight

Demonstrate safe administration of

medications and IV piggyback medications

(*Lab Practice)