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NURSE ROLE IN

INTRAVENOUS THERAPY
CNED
Clinical Instructor

Objective
Knowledge about the role of nurses
with intravenous therapy.
Able to know the policy and
procedure regarding Intravenous
therapy
Insertion, Changing & Discontinuing
Therapy

Learn about Intravenous


Calculations.

Purpose
Is designed to guide nursing staff
their responsibilities in caring for
patients receiving treatment and
medications though intravenous
route and for diagnostic test.

Policy
Intravenous therapy requires:
Doctors order
Accurate Documentation in patients medical records.

Physician shall be responsible to supervise the proper


administration of intravenous therapy.
Procedure can be performed by a trained nurse with the
physicians supervision.
Venous Cut down shall be performed by an experienced
physician with assistance from a trained nurse.
Intravenous therapy shall be performed under aseptic
technique.
Infection control measures have to adhered in
administering intravenous therapy

Site of insertion must be properly and


securely applied with an adhesive tape and
splint to prevent limb movement and keeping
the cannula from dislodging from the vein.
Insertion sites must be checked frequently for
complications.
Consent for venous cut down and blood
transfusion when required.
Phlebotomy site should be changed with in 72
hours even if the cannula is still intact, and
when there are complications.
IV tubing set should be changed with in 24
hours.

Indication of IV therapy
Restore and maintain fluids and electrolyte
balance.
Provide medication and chemotherapeutic
agent.
Transfuse blood and blood products.
Deliver parenteral nutrients and supplements.
IV therapy can be used if patient is unable to
take oral substances.
Provides also as access in withdrawing blood
for lab work.

Initiations Of IV Therapy
Shall provide peripheral intravascular access for
therapeutic indications.
This requires physicians order.

Physicians Prescribed Treatment


Type and amount of solution
Flow rate
Type, dose and frequency of medication to be
incorporated/ pushed
Others affecting the procedures (x-rays, treatment to the
extremities, etc.)

Documentation of IV
Therapy
Proper documentation provides
Accurate description of care that can
serve as legal protection.
A mechanism for recording and retrieving
information.
A record for health insurance of
equipment and supplies used when
documenting the insertion of venipuncture
device or the beginning of the therapy.

The following should be documented in


the patients chart.
Location and condition of insertion
site.
Complication, patients response and
nursing interventions.
Patient teaching and evidence of
patient understanding.
Other observations.

The following should be written on the IV tape


Size, type and length of cannula/ needle.
Initials of the person who inserted the IV
catheter.
Date and time of insertion.
Label the IV solution
Type of fluid and volume
Medication additives.
Flow rate
Date and time started, date and time to finished.
Patients name and file number
Nurses signature
Nurses shift

Intravenous Fluid
Complication

Objective
Enumerate the kinds of intravenous
therapy complications.
Identify the types of each kind of
intravenous therapy complications and
describe them according to the following:
Definition
Causes
Signs & symptoms
Nursing intervention

Intravenous Therapy
Complication
Local Complications

Systemic
complication
Embolism

Infiltration
Extravasations
Thrombosis
Thrombophlebitis
phlebitis

Pulmonary embolism
Air embolism
Catheter embolism

Hematoma
Systemic infection
Speed shock
Circulatory overload
Allergic Reaction.

Local Complication

Infiltration
Extravasations
Thrombosis
Thrombophlebitis
Phlebitis

Infiltration
Results when the
infusion cannula
becomes dislodged
from the vein and
fluids are infused
into the
surrounding tissue.

Sign and Symptoms


Increasing edema at the site of the
infusion
Discomfort, burning pain at the site
Feeling of tightness at site
Decreased skin temperature around
the site
Blanching at site
Absent backflow of blood
Slower flow rate

Cause
Device dislodged from the vein or
perforated vein.

Nursing Interventions

Remove the device


Apply warm compress to aid absorption
Elevate the limb
Notify the doctor if severe
Assess circulation
Restart the infusion
Document the patients condition and
your interventions

Prevention
Check the I.V site frequently
Dont obscure area above site with
tape
Teach the patient to report
discomfort, pain, swelling.

Extravasations
It occurs when fluids seep out from
the lumen of a vessel into the
surrounding tissue
Causes:
Damage to the posterior wall of the
vein
Occlusion of the vein proximal to the
injection site

Sign & Symptoms


Swelling
Discomfort
Burning
Tightness
Coolness in the
adjacent skin
Slow flow rate

Truth about common


MISCONCEPTION:
Extravasations doesnt always cause a
hard lump
Patient may not always experience
coldness or discomfort with
extravasations

Nursing Intervention
Immediately stop the infusion and
remove the device
Elevate the affected limb
Apply cold compress to decrease
edema and pain
Apply moist heat to facilitate the
absorption of fluid at grossly
infiltrated sites.

Thrombosis
Occurs when blood flow through a
vein is obstructed by a local
thrombus
Catheter- related thrombosis arises
as a result of injury to the endothelial
cells of the venous wall.
Sign & Symptoms
Painful, reddened, & swollen vein.
Sluggish or stopped I.V flow

Cause
Injury to endothelial cells of vein wall, allowing
platelets to adhere and thrombus form.
Nursing Interventions
Remove the device; restart the infusion in the
opposite limb if possible
Apply warm soaks
Watch for I.V therapy- related infection
PREVENTION
Use proper venipuncture techniques to reduce
injury to the veins.

Thrombophlebitis
Occurs when thrombosis is
accompanied by inflammation.
Infusions allowed to continue after
thrombophlebitis develops will slow
and eventually stop, indicating
progression to an obstructive
thrombophelbitis.
Various terms can be used to
distinguish the type of phlebitis a
patient experiences.

Signs & Symptoms

Local tenderness
Swelling
Induration
A red line
detectable above
the I.V. Site.

Thrombophlebitis
All thrombotic complications have
the associated danger of embolism,
especially in cases where the
thrombus is not well attached to the
wall of the vein.
The risk for the development of
thrombotic complications can be
greatly reduced when certain
preventive measures are taken.

Recommendations to reduce the risk


of thrombotic complications
Use veins in the upper extremities
Avoid placing catheters over joint
flexions
Select veins with adequate blood
volume for solution characteristics
Anchor cannulas securely
Avoid multiple venipunctures

Phlebitis

Injury during venipuncture


Prolonged use of the same IV site
Irritating/incompatible IV additives
Use of vein that is too small for the
flow rate
Use needle size too large for the vein
size.

Sign & Symptoms


Pain
Vein that is sore, hard, cord like and warm to
touch
Red line above the site
Signs of infection
NURSING INTERVENTION
Upon assessment of phlebitis, removal the needle
Avoid multiple insertion
Application of warm compress
Continuously monitor the patient vital signs

Systemic Complications
Embolism
Hematoma
Systemic infection
Circulatory overload
Allergic reaction

Pulmonary Embolism
It associated with venous access devices is
usually the result of a thrombus that has
become detached from the wall of the vein. It
is carried by the venous circulation to the
right side of the heart and then into the
pulmonary artery.
Circulatory and cardiac abnormalities are
caused by full or partial obstruction of the
pulmonary artery, with possible progression to
pulmonary hypertension and right-sided heart
failure.

Air Embolism
Occurs most frequently with the use
of central venous access devices.
Occur with the insertion of an IV
catheter, during manipulation of the
catheter or the catheter site when
the device is removed, or when IV
lines associated with the catheter are
disconnected.

Catheter Embolism
This can occur during the insertion of a catheter if
appropriate placement techniques are not strictly
adhered to.
The tip of the needle used during the placement of
the catheter can shear off the tip of the catheter.
The catheter tip then becomes a free-floating
embolus
This can occur with both over-the-needle and
through-the-needle catheters. If this happens,
cardiac catheterization may be required to remove
the embolus.

Sudden vascular collapse with the


hallmark symptoms of cyanosis,
hypotension, increased venous
pressures and rapid loss of
consciousness.
Respiratory distress
Unequal breath sounds
Weak pulse

Nursing Intervention
Discontinue the infusion
Place in trendelenburg position on his
left side to allow air to enter the right
atrium and disperse through the
pulmonary artery.
Administer oxygen
Notify the doctor
Documents the patient condition

hematoma
The seepage of blood into the extravascular tissue
CAUSES:
Coagulation defects
Inappropriate use of torniquet
Unsuccessful attempts
Little pressure upon removal of cannula
NURSING INTERVENTION
Frequent assessment
Discontinue therapy if with edema
Apply pressure for at least 5 minutes upon removal.

Systemic Infection

Is the successful transmission or encounter of host with


potential pathogenic organism.
SIGN & SYMPTOMS
Fever, chills, & malaise for no apparent reason
Contaminated IV site, usually with no visible signs of
infection at site.
CAUSES
Failure to maintain aseptic technique during insertion or
site care
Severe phlebitis, which can set up ideal conditions for
organisms growth
Poor taping
Prolonged indwelling time of device
Immuno compromised patient

Nursing Intervention
Notify the doctor
Administer medications as prescribed
Culture the site and the device
Monitor patients vital sign
PREVENTION
Use scrupulous aseptic technique
Secure all connections
Change IV solutions, tubing and venous
access device at recommended times.

Circulatory Overload
An Excess of fluid disrupting homoestasis caused
by infusion at a rate greater than the patients
system is able to accommodate.
SIGNS & SYMPTOM
Shortness of breath
Elevated blood pressure
Bounding pulse
Jugular vein distention
Increased resp. rate
Edema
Crackles or rhonchi upon auscultation.

CAUSES:
Roller clamp loosened to allow run-on
infusion
Flow rate too rapid
Miscalculation of fluid requirements
NURSING INTEVENTION
Raise the head of the bed
Slow the infusion rate
Administer oxygen as needed
Notify the doctor

Allergic Reaction
Maybe a local or generalized to tape,
cleansing agent, medication, solution or
intravenous device.
LOCAL
SYSTEMIC
Wheal
Runny nose
Redness
Tearing
Itching at the site
Bronchospasm
Wheezing
Generalized rash
NURSING INTERVENTION
IF REACTION OCCURS, STOP the infusion
immediately and infuse normal saline
Maintain patent airway
Notify the doctor
Administer medicines as ordered (i.e. antiinflammatory, antihistamines, anti pyretic,

Intravenous Cannulation, Peripheral

Policy
IV cannulation and competency should be re-assessed as
determined.
There should be a physicians order.
The nurse shall not make more tan 2 attempts to insert a
cannula. If unsuccessful, a person with more experience will
be requested to make further 2 attempts. If still unsuccessful,
the physician will be notified.
Adult patient should have cannula inserted in the upper
extremities only.
In peadiatric patients the upper and the dorsum of the foot
can be used as the cannula insertion sites.
A cannula inserted under emergency conditions with possible
breaks in aseptic techniques should be removed within 24
hours and a new cannula inserted at a different site.

NEVER use limb that has


a fistula or graft for hemodialysis.
With affected side in cases of paralysis or
mastectomy.
Has a fracture or dislocation proximal to the site.

ALWAYS remember:
Choose a vein that is most distal
If a patient is in cardiac arrest, choose one that
is as close to the patients heart as possible and
ideally is a large vein to infuse fluids quickly.
Similarly, Adenosine (treatment for SVTs) must
be given from a site as close to the heart as
possible.

Procedure

Confirm the physicians order.


Gather all equipment
Identify the patient
Wash hands and put on gloves
Locate appropriate peripheral site for
cannulation.
Apply torniquet approxiamtely 5-12 cm above
puncture site to promote vasodilation.
Clean the skin with approved solution using an
outward/ vigorous moving circular motion. Allow to
dry for 30 seconds.

Stabilize vein below the site of insertion and pull the skin taut.
Hold the cannula at the sides to allow viewing of flashback chamber.
Insert cannula smoothly through the skin at 15-20 degrees angle
with bevel facing up.

When backflow of blood is visible, remove the torniquet


advance the catheter tip slightly, then gradually thread the
supported cannula into the vein up to the hub.
Remove stylet and apply dressing dispose of sharps in sharps
container.
Ensure patency of cannula using at least 2mls of normal saline
to flush, in pediatric 1ml.
Secure with transparent dressing.
Splint if necessary.
Label the site
Dispose the equipment in a safe manner
Wash hands.
Document on your nurses notes.

Changing Intravenous solution and


tubing
POLICY:
Review the file for the diagnosis and
medical plan for IV Therapy.
The nurse must check the type of
solution, additives, and infusion rate
against the physician order.
Every IV infusion bag must have
label.

Procedure
Wash Hands thoroughly
Check the IV fluids to be administered against the doctors
order. Adhere to 5 rights of medication administration.
Check the IVF for the expiry date, sediment, cracks or color.
Label the bottle with date time and rate
Remove the covers from the solution bottle with out
touching the rubber top.
Open new tubing package, keeping protective covers on
spike and catheter adapter.
Adjust roller clamp on new tubing to fully closed position.
Position the IV Bottle upright and insert IV set into rubber
top observing aseptic technique.

Hang container and prime drip chamber fill one half full
Remove protective cap from catheter adapter and adjust
roller clamp to flush tubing with fluid. Replace protective
cap.
Close roller clamp of old tubing.
Place towel or disposable under pad under extremity. Don
clean, disposable gloves.
Hold catheter hub with fingers of one hand.
Grasp new tubing, remove protective catheter cap and
insert tightly into the needle hub.
Adjust roller clamp to start solution flowing according to
the prescribed rate.
Discard gloves
Secure tubing with tape. if dressing is removed apply new
one.
Label your new bottle.
Documentation

Thank you