jcmendiola_Achievers2013

Care of Clients in Cellular Aberrations,

Acute Biologic Crisis (ABC), Emergency and Disaster Nursing
(NCM106)
Intravenous Therapy

Intravenous Therapy
Goals of Intravenous Therapy:
Restores FLUID and ELECTROLYTE Balance
o FVD DHN
o Electrolyte Imbalance - Na, K, Cl
Maintains HYDRATION and FLUID replacement
Supplements CALORIES and NUTRIENTS Nutrient solution
Correct electrolyte IMBALANCE
Restores ACID-BASE BALANCE
AVENUE to administer medications
o Rapid response and absorption (fastest action)
Administration of BLOOD PRODUCTS whole blood and its components

Basic Nursing Competencies
1. Hand washing To prevent transfer
of microorganisms
2. Assess vital signs
3. Principle of aseptic technique
4. Medication calculation
5. Medication administration

Laws, Rules and Regulations
- Board of Nursing Resolution Number 8, Series of 1994
- Section 27, Article V of the Republic Act 7164 The Philippine Act of 1991
o Intravenous injection is within the scope of nursing, and that in the administration of intravenous
injection, special training shall be required according to protocol established
- Section 28, Article V
o A Registered Nurse is prohibited from administering intravenous injection to a patient unless he /
she has undergone a special training at least under a nursing administrator who is a member of
ANSAP(Association of Nursing Service Administrators of the Philippines)
- Section 30, Article VII / Section 2, Article III
o Any Registered Nurse without such training who administered injection to patients whether
causing or not an injury or death to the patient shall be held liable either criminally /
administratively

Association of Nursing Service Administrators of the Philippines
Aims for a quality and safe nursing practice which has the expertise to conduct such specialized training
program in the administration of intravenous injection for nurses
Nursing organization that provides certification of intravenous therapy for a continuous and safe

Nursing Roles and Responsibilities in Administering Intravenous Therapy
1. Health Teaching
2. 10 Rights in Nursing Administration
3. Preparation of Intravenous Therapy Set and Solution
4. Monitoring IV Infusion
5. Changing Prescribed IV Infusion
6. Discontinuing IV Fluid
7. Documentation
LOOKY
HERE
Topics Discussed Here Are:
1. Intravenous Therapy
(Introduction)
a. Competencies
b. Ethico-moral
Issues
c. Nursing Roles
and
Responsibilities
2. Implementation of
Intravenous Therapy
3. Types of Intravenous
Therapy Solutions
4. Complications of IV Therapy
5. Blood Transfusion
6. Drugs Commonly Used in
IVT
Administration of IV Drug
1. Direct Injection IV Push
2. Intermittent Infusion
Volumetric Chamber
Piggyback, Soluset
Dobutamine, Nicardipine
3. Continuous Infusion
Infusion Pump
Basis of Nursing Scope and Practice
Independent Individual
professional accountability,
professional competency
Dependent Legal of a
licensed Physician
Invasive Collaborative M
HCT, network, linkages, blood
bank
jcmendiola_Achievers2013
HEALTH TEACHING
o Teaching ways to maintain the infusion system
1) Avoid sudden movement of the arm with the IV catheter
2) Avoid placing tension on tubing
3) Try to keep tubing from dangling below the needle level
4) Avoid regulating the flow rate
5) Notify the nurse: If IV solution is nearly empty
6) Notify the nurse: Pain, swelling, blood on the IV site

10 Rights in Drug Administration (RIGHT)
- Patient
- Dosage
- Route
- Refuse
- Interaction
- Education
- Drug-Drug Interaction, Drug-to-Food
Interaction
- Documentation
- Time and Frequency (30 Minutes
AC/PC)
- Drug Medication (Analgesic 1
st
Before
antibiotic)

Preparation of the Intravenous Therapy (Basic IV Setup)
Drip Chamber
1) Measures the speed of a manual IV set-up
2) Counts the number of drops we see per minute
3) Determines the IV infusion / flow rate
Roller Clamp
- Controls the flow rate at which the intravenous fluid infuses
Infusion Rate
- Synonym: IV Flow Rate, IV Infusion Rate
The specific rate at which an intravenous fluid infuses
Slide Clamp
- Completely stops the IV from flowing without having to adjust the roller clamp
Injection Port
- A place where medications can be injected, pushed and administered so that they will
infuse into the patients vein through the IV tubing

STARTING AN INTRAVENOUS THERAPY
Purpose:
` Supply fluid
` For electrolyte balance
` Provides glucose
` Provides nutrients
` Administration of
medication
Assessment:
1. Vital Signs
2. Skin Turgor
3. Allergy
4. Bleeding tendency
5. Injury to extremity
6. Status of vein
Planning
1. Verify Physicians Order
2. Prepare the following
equipment:
Infusion Set
IV Pole
IV Solution
Adhesive Tape
Gloves
Tourniquet
Gloves
Antiseptic Swab
IV Catheter
Sterile Gauze
Arm Splint





Note:
OD, BID, QID Px is AWAKE
q Drugs Px is NOT AWAKE (RTC)
jcmendiola_Achievers2013


INSERTING AN IV THERAPY
IMPLEMENTATION
1. Verify Doctors orders and countercheck
O AOR: Legal Responsibility
2. Observe 10 Rights
O AOR: Safe Quality Care
3. Explain Procedure to Patient and Purpose to
alleviate anxiety,
O AOR: Communication
4. Assess patients vein. Choose site
O AOR: Safe Quality Care
5. Hand Hygiene (- for clearness of bottle, order)
6. Prepare materials (Assemble all at bedside)
= IV Bottle, infusion set, IV cannula,
cotton ball with alcohol, tegaderm,
tourniquet (used once), gloves, arm
board/splint, IV stand)
7. Check IV Bottle and solution
8. Label the bottle (Before the procedure, with
the IV card)
9. Open IV Administration Set Aseptically
10. Close the roller clamp
11. Spike the infusate container aseptically
12. Fill drip chamber
13. Expel air bubbles put back cover getting
ready for insertion
14. Choose IV Site (Principles in Choosing)
1) Distal veins of arms first
2) Non-dominant hand
3) Vein Easily palpated, large, soft,
non-visible
4) Avoid VEIN Flex areas, highly
visible, damaged, distorted/injured
15. Apply tourniquet above injection site (2 -6
inches above site of insertion)
16. Check for radial pulse below tourniquet
17. Pierce skin with IV cannula
18. Continue inserting catheter into vein while
checking for blood backflow
19. Position IV catheter parallel to skin and
advance the catheter to the puncture site
20. Slip a gauze under the hub
21. Release the tourniquet (Occlude the vein
with thumb)
22. Connect infusion tubing aseptically to the IV
catheter
23. Open clamp and regulate the flow rate
24. Anchor needle firmly in place
25. Open clamp and regulate the flow rate
26. Anchor needle firmly in place Ulit?
27. Tape a small loop of IV tubing. Apply splint
(Usually children)
28. Calibrate the IV Bottle and Regulate
infusion rate
29. Label the IV Tape
O AOR: Ethico-moral
30. Observe patient for untoward effect
31. Document (AOR: Records) and endorse
accordingly (AOR: Collaboration)
32. Discard sharp and waste appropriately
O AOR: Management of Resources

CHANGING AN IV
IV container is not allowed to hand over 24
hours (Unsterile)
Check for cracks, leaks and cloudiness
Check for discoloration, turbidity and
particulates
Check for expiration date
Change the complete IV administration set
Routine IV Site rotation
o If from 48 72 hours, may cause
complication, so ROTATE!

PURPOSE
Maintain flow rate
Maintain Sterility of IV system
Prevent Complication
Maintain Patency

ASSESSMENT
1. IV Site
2. Allergies
3. Infusion rate
4. Dressing

IMPLEMENTATION
1. Verify Doctors order and countercheck
O AOR: Legal Responsibility
2. Observe 10 Rights
O AOR: Safe Quality Care
3. Explain procedure to the patient
O AOR: Communication
4. Change IV System
5. Prepare equipment and place on tray
6. Check the IV Bottle
7. Label the IV Bottle
8. Hand Hygiene
9. Close Roller Clamp
10. Open and Connect Tubing to the IV Bottle
11. Regulate the flow rate
12. Reiterate assurance to patient
13. Discard Waste materials
14. Document and endorse accordingly
Quick Notes:
Introduce
Rapport
Explain procedure
Explain purpose
Assess for
ALLERGIES/
BLEEDING
Skin prep with
cotton ball
with alcohol
(From inner to
outer)
jcmendiola_Achievers2013
MONITORING IV THERAPY
PURPOSE
Maintains prescribed flow rate
Prevents complications

ASSESSMENT
1. IV Site
2. Patency of IV System
3. Infusion Rate
4. Type of IV Fluid
5. Patients Response
Intravenous Drip Rate
A. ml/hr
The total number or milliliters ordered, divided by number of hours to run



B. gtt/min
The number of milliliters per hour multiplied by tubing drip factor divided by number of minutes



DISCONTINUING IV THERAPY
PURPOSE
To discontinue IV Infusion
Completion of therapy
IV site needs to be changed

ASSESSMENT
1. IV Site
2. Total Amount of fluid infused
3. Appearance of IV catheter

PLANNING
1. Verify Physicians Orders
2. Prepare the following equipment:
Clean gloves
Swabs
Sterile dressing
Tape

IMPLEMENTATION
1. Verify Doctors orders and countercheck
2. Observe 10 Rights
3. Assess patient
4. Explain procedure to patient
5. Prepare equipment and place on tray
6. Hand hygiene
7. Close roller clamp
8. Moisten tape. Remove plaster gently
9. Remove the IV catheter or needle
10. Apply cotton balls immediately and apply
pressure over IV site
11. Inspect IV catheter for completeness
12. Discard waste materials
13. Document and endorse accordingly


Documentation
+ The nurse ensures accurate reporting, recording and documentation
Name and type of IVF
Infusion site by vessel/extremity
Infusion flow rate
Date and Time infusion started
Date and Time end/due
Amount of fluid remaining in
present solution
Ordinal number of the bottles
Status of venipuncture site
Changing of IV Solution
Name and Signature of RN

ml Ordered
____________
hours to Run
=
ml ___
hr
ml/hr x drop factor
_______________
=
___
gtt
jcmendiola_Achievers2013
Types of Intravenous Therapy Solutions
Isotonic
Hypotonic
Hypertonic

ISOTONIC SOLUTION
e Total osmolality is the same as blood/body fluid
e Total electrolyte content is equal to 310 mEq/L

Purpose: To replace extracellular volume, and to EXPAND vascular membrane
Examples:
o D
5
W / D5W = Provides free water, replaces ICFV, expander CI: To ICP = May cause CEREBRAL EDEMA
o 0.9 Sodium Chloride / NSS
Plain NSS / NSS
0.9% Na Cl
0.9% NSS
***ONLY SOLUTION COMPATIBLE WITH BLOOD TRANSFUSION
***CAN CAUSE FLUID VOLUME EXCESS: Cause Na attracts WATER :o
o Lactated Ringers (LR)
Also known as Plain LR
Provides important electrolytes like Na, Cl, Ca, K, and Lactate
Indication: Burns, trauma, casualties, requires fluid resuscitation, Dehydration
(Ex. Dengue)
e Nursing Management:
o Assess for Signs and Symptoms of HYPERVOLEMIA (PR RR; Bounding and Crackles)
o Remain in vascular compartment, expands vascular volume

HYPOTONIC SOLUTION
Total osmolality is less than the blood / body fluid
Total electrolyte content is lesser than 250 mEq/L
Total osmotic pressure is less than the extracellular fluid

Purpose:
` To replace the cellular fluid
` Provides free water to excrete body wastes
` Treatment for HYPEROSMOLAR Conditions (Like Hypernatremia)
Examples:
1. 0.45 Na Cl (Half strength normal saline)
= Contraindicated to patients with ICP = May cause 3
rd
space fluid shift
2. 1/3 NSS 0.33% NaCl
Nursing Management:
` WOF: Signs / Symptoms of HYPERVOLEMIA
` Give carefully, may lead to PULMONARY EDEMA

HYPERTONIC
Total osmolality is less than the blood / body fluid
Total electrolyte content is less than 375 mEq/L
Osmotic pressure exceeds the extracellular fluid

Example:
D
10
W; 3% - 5% NaCl; D5% LR and D
5
% in 0.45% NaCl
D
5
LR = Provides calories used for ECF Deficit (FVD), Burn, Bleeding, DHN)
D
5
in NSS = Can be used before and after infusion of blood products. For ECF deficit and provides calories
D
5
in 0.45% in NaCl = Used as initial fluid for hydration. Provides more water than Na, provides calories

Provides basic Na and Chloride (i.e. Hyponatremia)
jcmendiola_Achievers2013
Complications of Intravenous Therapy
Localized Systemic
1. Infiltration
2. Extravasation
3. Thrombosis
4. Phlebitis
5. Thrombophlebitis
6. Bleeding / Hematoma
1. Fluid volume excess
2. Circulatory overload
3. Embolism
4. Pulmonary Embolism
5. Air Embolism
6. Catheter Embolism

LOCALIZED
INFILTRATION
Definition: Intravenous fluid enters the
surrounding space around the venipuncture site
Clinical Manifestation: Swelling, Pallor,
Coolness, Blanching, Pain and Edema, Slow IV
Rate
Nursing Management:
1. Stop infusion and discontinue IV
2. Elevate / raise the affected arm with
pillow
3. Provide warm and moist compress for
20 minutes
4. Notify the physician immediately
5. Restart new IV as prescribed /
indicated

EXTRAVASATION
Definition: Leakage of VESICANT IV
solution or MEDICATION into the
extravascular tissue
Clinical Manifestations: Swelling, Pallor,
Coolness, Blanching, Pain and Edema, Slow IV
Rate, TISSUE SLOUGHING
Nursing Management:
1. Stop infusion and discontinue IV
2. Elevate / raise the affected arm with
pillow
3. Provide warm and moist compress for
20 minutes
4. Notify the physician immediately
5. Restart new IV as prescribed /
indicated
6. Administer antidote
7. Aspirate residual drug if possible
8. Administer IV push slowly, dilute
drug, provide soluset as needed
PHLEBITIS
Definition: Inflammation of the vein due to
MECHANICAL, CHEMICAL and
BACTERIAL factors
Clinical Manifestations: Pain, Edema,
Erythema, Vein becomes TENDER and
Increased Skin Temperature
Nursing Management
1. Stop infusion and discontinue IV
2. Elevate / raise the affected arm with pillow
3. Provide warm and moist compress for 20
minutes
4. Notify the physician immediately
5. Restart new IV as prescribed / indicated
6. Practice hand hygiene and aseptic
technique
7. Choose small / appropriate gauge catheter
8. Stabilize IV site with arm board (avoid
flexion)
9. Adequately secure the catheter
10. Instruct patient to avoid excess physical
activity of extremities


jcmendiola_Achievers2013
THROMBOSIS
Definition: The presence of blood clot inside
the vein
Factors: Multiple/Traumatic venipuncture
attempts, FVD, USE OF LARGE
CATHETERS
Clinical Manifestations: Pain, Erythema,
Tender/ Engorged Vein, Swollen Extremity,
Difficulty Moving the NECK/JAW, STOP
INFUSION
Nursing Management:
1. Stop infusion immediately
2. Apply cold then warm compress
3. Elevate extremities
4. Good venipuncture technique
5. Small gauge catheter
6. Secure catheter adequately
Use splint
7. Warfarin (Coumadin) and
thrombolytic agent as prescribed
8. Adequate hydration
THROMBOPHLEBITIS
Definition: The presence of blood clot and vein
inflammation
Factors: Multiple/Traumatic venipuncture
attempts, FVD, USE OF LARGE
CATHETERS, MECHANICAL, CHEMICAL
and BACTERIAL ETIOLOGY
Clinical Manifestations: Pain, edema,
erythema, vein becomes TENDER AND
INCREASE in SKIN TEMPERATURE,
TENDER/ENGORGED VEIN, SWOLLEN
EXTREMITY, difficulty moving NECK/JAW,
STOP INFUSION
Nursing Management:
1. Stop infusion immediately
2. Apply cold then warm compress
3. Elevate extremities
4. Good venipuncture technique
5. Small gauge catheter
6. Secure catheter adequately
Use splint
7. Warfarin (Coumadin) and
thrombolytic agent as prescribed
8. Adequate hydration

BLEEDING/HEMATOMA
Definition: Blood leakage into the surrounding tissues of the IV insertion site
Factors:
O Perforation of vein during venipuncture
O Needle slips out of the vein
O Lack/excessive pressure to IV site after removal of catheter
O Disconnected/inpatient catheter needle
O Patient has a bleeding disorder
Clinical Manifestations: Bleeding-slow, NOT SERIOUS, CONTINUOUS SEEPAGE, Ecchymosis,
Swelling, Blood leakage, Bruising
Nursing Management:
1. Determine the patency / intact of cannula
2. Change the dressing and apply new gauze dressing over the IV insertion site
3. Apply light direct pressure
4. Advise the patient not to overbend extremity
5. Good venipuncture technique

SYSTEMIC
FLUID VOLUME EXCESS
Factors: Too rapid administration of IV
solution, overloading the circulatory system
with excess IV Fluids
Clinical Manifestations: Dyspnea, DOB,
shortness of breath, crackles, RR, PR, BP and
CVP, Edema, Weight gain
Nursing Management:
1. Proper regulation of IV infusion
2. Slow the rate of infusion
3. High fowlers position
CIRCULATORY OVERLOAD
Definition: Disruption of fluid hemostasis with
excess fluid in the circulatory system
Factor: Rapid IV infusion flow rate
Clinical Manifestations: DOB, cough,
hypertension, eye-puffiness, edema, engorged
neck vein
Nursing Management:
1. Remove the catheter
2. Slow IV Flow rate
3. Monitor vital signs and intake and
Quick Notes: PSP-DB
Perforation
Slipping
Pressure
Disconnection
Bleeding
jcmendiola_Achievers2013
4. Monitor vital signs frequently
5. Assess the breath sounds
6. Contact physician immediately
output. Notify imbalances
4. Raise patient upright position
5. Administer diuretics and oxygen
therapy as prescribed

CATHETER EMBOLISM
Definition: Piece of catheter breaks off and
floats freely in the blood vessel
Factors: Needle is reinserted / inadvertently
pulled back in the catheter
Clinical Manifestations: Hypotension,
Tachycardia, Thready PR, Cyanosis, Loss of
LOC
Nursing Management:
1. Remove the catheter
2. Apply tourniquet high on limb
3. Inspect catheter for rough uneven
surfaces
4. Expect for X-ray and surgery
5. Never reinsert the needle into the
catheter
AIR EMBOLISM
Definition: Air enters the central venous
system
Factors: Air is inserted in the catheter during:
Catheter Insertion
IV Push
Tubing Change
Catheter Removal
Clinical Manifestations: Chest pain, DOB,
Hypoxia, Nausea, Dizziness, Anxiety,
Tachycardia, Hypotension, Loud Churning
over the Heart (Auscultation)
Nursing Management:
1. Clamp catheter immediately
2. Position patient to left lateral
Trendelenburg
3. Notify doctor
4. Oxygen therapy
5. Expect for ECG and ABG
6. Perform valsalva maneuver

Blood Transfusion
Synonym: Blood Replacement, Replacement Therapy
Definition: Intravenous Administration of whole blood products or Blood components
Functions:
1. To increase circulating blood volume
2. To increase number of erythrocytes and maintain hemoglobin levels
3. To prevent life-threatening complications associated with blood loss
4. To provide cellular components of replacement therapy

BLOOD PRODUCTS
1. Whole Blood Check Blood type and cross MATCH!
Indication: Acute hemorrhage, shock
Purpose: Replaces blood volume and all blood products (RBC Plasma)
Hazards: Hemolysis (Incompatibility reaction Destroys RBCs, Viral contamination Hepatitis,
HIV, Circulatory overload, Pyrogenic / Allergic Reactions)
2. Packed RBC
Indication: Anemia, Surgery, Bleeding, Bone Marrow Suppression
Purpose: Increases oxygen carrying capacity of the blood
3. Platelet
Indication: Platelet deficiency, bleeding disorders, viral infection
Purpose: Fragment of cytoplasm that functions in blood coagulation (Blood clotting)

BLOOD EXPANDERS
1. Plasma (Dextran)
Purpose:
Expands the blood volume
Increases the level of
clotting factors
2. Albumin
Purpose:
Expands the blood volume
Provides the plasma
protein

Functions of BT:
Blood volume
Erythrocytes
Life threatening
complication
Give components
Quick Notes: I-CPR
Insertion
Push
Change
Removal
jcmendiola_Achievers2013
3. Clotting Factor
Indication: Clotting factor deficiency
Purpose:
Provides the different factors involved in clotting pathway
Provides CRYOPRECIPITATE Associated with clotting factors

Blood Transfusion Nursing Considerations
Nursing Management
1. Proper blood typing and blood matching
2. Ensures signing of informed consent
3. Careful assessment before, during and after transfusion
4. Obtaining baseline vital signs
5. Checking right patient, right blood product and compatibility
6. Checking of the patency of IV catheter
7. Ensures large gauge of catheter (gauge 18 19)
8. Proper labeling of blood products
9. Explains the procedure to the patient and their family
10. Determine cultural background
11. Requires another nurse to double-check the blood product and patient identification
12. Use of appropriate Intravenous fluid solution (Plain Normal Saline Solution)
13. Remain with the patient throughout the duration of the blood transfusion
14. Assessment for the risk of allergic transfusion reaction
15. Proper regulation of blood transfusion
16. Assesses and instructs patient to report any untoward side effects once transfusion begins
17. Promptly records and documents all findings and management done

Drugs Most Commonly Used in Intravenous Therapy
Epinephrine
Atropine
Sodium Bicarbonate
Morphine
Dobutamine
Dopamine
Furosemide
Streptokinase
Nitroglycerin









Parts of an IV!

*** SORRY NAMAN KUNG ANG
PANGET NG DRAWING KO
XD
WALA KASI AKONG
MAHANAP SA NET NA PIC
SOOO GUMAWA AKO
YEY~ XD
jcmendiola_Achievers2013
DRUG DRUG CLASSIFICATION INDICATION MECHANISM OF ACTION NURSING MANAGEMENT
Epinephrine Bronchodilator Bronchospasm
Asthma Attack
Cardiac Arrest
Anaphylaxis
Relaxes the bronchial smooth
muscles
Monitor BP, HR, ECG
Compatible with
isotonic Intravenous
Fluids
Atropine Anti-arrhythmia Bradycardia
Bradyarrythmia
Preoperative to
Secretions
Anticholinergic that blocks
VAGAL effects that enhances
heart conduction and
PR/HR
Give into a large vein
Give IV for 1 minutes
Avoid slow IV push
Sodium Bicarbonate Acidifier/Alkalinizer Metabolic Acidosis
Antacid
Cardiac Arrest
Restores bodys buffering
capacity and neutralizes
excess acid
Monitor lab results
regularly
Morphine Opioid Analgesic Moderate Pain
Severe Pain
Postoperative Meds
Bind with opiate receptor to
alter perception and
emotional response to pain
Dilute 4-5 ml sterile
water
Administer IV slowly
for 4-5 minutes
Dobutamine
**Put in intermittent solution
Adrenergic-
Sympathomimetics
Heart failure
Cardiac Surgery
Depressed cardiac
contractility
Stimulates heart receptor to
myocardial contractility,
volume and cardiac output
Note discomfort in IV
site
Compatible with
isotonic/hypotonic IVF
Dilute concentration
Dopamine Adrenergic-
Sympathomimetics
Shock
Hemodynamic
Imbalance
Hypotension
Stimulates dopaminergic
reception in the SNS
Dilute with isotonic IVF
Use infusion pump

Furosemide Diuretic Acute Pulmonary Edema
Hypertension
Inhibits Na and Cl
reabsorption at loop of Henle
and kidney tubules
Infused with isotonic
solution
Give 1-2 minutes
Streptokinase
(Hematolytic)
Thrombolytic Enzyme Thrombosis
P. Embolism
Acute MI
Cannula Occlusion
Activates plasminogen and
converts it to plasmin for
FIBRINOLYSIS
Reconstitute / Dilute
Drug
Check for heparin
Use filter solution 0.8
micron.
Nitroglycerin Antianginal Anginal Attacks
A. Pectoris
HTN, Heart Failure
Surgery
Nitrate reduces cardiac
oxygen demand by
decreasing preload and
afterload
Dilute the drug
Use infusion pump as
necessary

DRUGS COMMONLY USED IN INTRAVENOUS THERAPY