IV THERAPY

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 Needles
Example: Butterfly catheter. They are named after the wing-like plastic tabs at the base of the needle. They a
medicines, to deliver fluids via the scalp veins in infants, and sometimes to draw blood samples (although no
damage blood cells). These are small gauge needles (i.e. 23 gauge).

Over the Needle Catheters

Example: peripheral IV catheter. This is the kind of catheter you will primarily be 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).

Hypotonic fluids
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 movement.
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.

Hypertonic fluids
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.

Some of this text was modified and the pictures borrowed from an unknown nursing
website.

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