Intravenous Therapy

Regulating Flow Rates

The ability to establish accurate infusion rates in IV therapy is essential to deliver prescribed infusion volumes and medications Complications include: Infiltration Phlebitis Clotting Circulatory Overload

Regulating Flow Rates

Alteration in Flow Rates Client; Change in client positions Flexion of involved extremity Partial or complete occlusion of IV devices Venous spasm Vein trauma Manipulated by client or visitor

Regulating Flow Rates

Mechanical; Height of parenteral container (36 inches above heart) Positional access device Viscosity or temperature of IV solution Occluded air vent Occluded in-line filter Improperly placed restraints Crimped administration set tubing Tubing dangling below bed Low battery of an electronic device

Regulating Flow Rates

Observation of the flow rate and IV system should occur hourly to achieve the desired therapeutic response Methods used to ensure an accurate hourly infusion rate for IV therapy; Gravity (flow control/regulator clamp) Electronic infusion device or rate controller (mechanical pump set at the prescribed rate)

Regulating Flow Rates

Infusion pumps are necessary when administering low, hourly volumes to pediatric clients or clients who are at risk for volume overload Infusion pumps are necessary when administrating high volume IV fluids to clients with impaired renal clearance, older adults, or pediatric clients or when infusing drugs or IV fluids that require specific hourly volumes

Regulating Flow Rates Equipment: Watch with a second hand Paper and Pencil IV tubing, macro drip or micro drip Electronic infusion control device Volume control device Tape Label

 Assessment: Review medical record for physician order, stating type, amount, rate or duration of IV fluid order or IV med Assess client's understanding Identify client risk Determine the presence of any client or mechanical factor that may alter ordered fluid rates Obtain info from pharmacology references Assess patency of IV device (make sure not infusing into sq area, phlebitis or bleeding at site) is so, assess first & may need to discontinue Check for infection (assess site daily) Make sure have I & O (nursing judgment) Need to make sure no emboli ( prevention need to back flush)

-Make sure have I & O (nursing judgment) need to make sure no emboli ( prevention need to back flush) - Assess for fluid overload; (check for I & O, listen to lung sounds, weight client) - If IV slows down after insertion, check to make the site, check position of extremity and fluid ( is it empty), - Need to check IV on a pump every hour to make sure that pump is working correctly

 Important footnotes to remember about IVs

Back flushing when hanging a piggy back Primary always low and Piggback high Check for signs of infection, thrombophlebitis ( d/c IV and apply moist heat) Appropriate technique for implementation when changing IV solution is to have the next solution at bed side and labels correctly 30 minutes to 1 hours in advance, so as not to have IV run dry Backflushing not only clears the line but also helps to remove any air bubbles If client has a reaction or tell you that she maybe allergic to the IV medication. Always stop the IV and notify MD immediately

 Blood transfusion
Always check MD order Take explain procedure to client Make sure you have equipment (blood tubing, Saline ( NO DEXTROSE) ,and have saline connected to Y filter of blood tubing, and a 18 gauge angiocath or needle - Make sure saline is running - Take temperature if above 100 0 notify MD immediately - Take order, and blood papers to lab to get blood - Get blood & return to floor, get another RN to do the three check, Blood itself, paper and clients ID which will contain (Blood type, RH factor, ID numbers)

IF blood is not correct must be returned to blood bank in 20 minutes Take a set of vital signs Initial set before starting blood Stay in room the first 15 minutes Must take vital signs for 1 hour every15 minutes or hospital policy Stop NSS solution and hang blood and start the blood Remember when the blood hits the clients blood vessel it will slow down and the client may chill for a few minutes ( blood is very cold) If reaction to blood stop immediately ( constantly feeling cold, temp elevated, shivering, pain in back, headache, vomiting, tachycardia, respiratory distress, skin rash, hypotension)

 Clamp off blood and NSS Call for help Disconnect tubing from site and deposit it into a sealed back ( the tubing with the Blood and NSS MUST all stay together) Hang a NEW NSS saline Notify MD , and monitor closely, take vital signs

Regulating Flow Rates

Outcomes: Client receives correct volume within correct time frame (moist mucous membranes, adequate skin turgor, and balanced I&O) Medications are administered over correct time frame with therapeutic response

Regulating Flow Rates

Obtain IV fluid and appropriate tubing Macro: >100 ml/hr 10-15 gtts/ml Micro: <100 ml/hr 60 gtts/ml

Regulating Flow Rates

Calculate desired flow rate or infusion Flow Rate (ml/hr) Total infusion vol in ml) Hours of infusion (time to be infused) Calculate the drop rate based on drops per minute Gtt factor X Flow Rate = Drop Rate 60

Regulating Flow Rates

Steps Time tape the IV bottle Close rate controlling clamp on IV tubing Insert infusion set into fluid bagremove protective cover from IV bag without touching openingremove cap from spike and insert spike into opening of IV baghang bag from pole Fill drip chamber of tubing till half full Open rate controlling clamp and fill remainder of tubinginvert Y connector sites to displace air Close rate controlling clamp Perform venipuncture and attach catheter to end of IV tubing With IV fluid bag a minimum of 36 in. above IV insertion site, adjust rate controlling clamp to deliver drops per minute

Regulating Flow Rates

Options: Attach to electronic infusion device or rate controller Attach IV tubing to volume control device

Instruct client about the following Avoid raising hand or arm to a position that will affect flow rate Avoid manipulation of rate control clamp Purpose and significance of alarms

Regulating Flow Rates

Monitor and Document IV infusion hourly for proper rate of infusion Therapeutic response to medication Client and client lab values for signs and symptoms of over hydration or dehydration Client during ADL's for proper position of extremity and care of infusion tubing

Administering IV Meds
Gloves Two 3 ml syringes filled with NS One 3 ml syringe filled with dilute heparin Alcohol Tape IV pole MAR

Administering IV Meds

Equipment:
IV med Vial or ampoule Small volume admixture Container for admixture diluent Sterile 19-21 gauge needle, 1" - 1 1/2" Label Syringe pump Secondary administration set

Administering IV Meds Assessment Check physician order Review drug information with client Assess lab values Steps: Assemble medications Check client info Explain procedure

Administering IV Meds
IV PUSH THROUGH EXISTING LINE Select injection port closest to client Prepare injection site and cleanse Connect syringe to IV line Occlude IV system by pinching tubing above injection port Aspirate gently on syringe plunger Continue to occlude IV tubing and inject med slowly Release tubing Remove gloves Dispose properly

Administering IV Meds
IV PUSH THROUGH IV LOCK Fill two 3 ml syringes with NS Attach blunt cannula or remove needle from syringe Cleanse with alcohol Insert syringe through injection port of IV lock Aspirate Flush Detach NS syringe and swab with alcohol Inject med

Administering IV Meds

Remove med syringe Recleanse cap or port with antiseptic swab and attach syringe with 1 ml NSflush Check org policy about heparin Remove gloves Dispose properly

Administering IV Meds IV PIGGYBACK Attach tubing of administration set to prepared admixture container Tandem (50-100 ml) Syringe (10-60 ml) Fill tubing with IV fluid (see specific instructions on page 716)

Administering IV Meds

Administer IVPB (Tandem)

Attach needle to end of IV minibag tubing and insert into injection port farthest away from client after cleansing
Lower primary line Open clamp Regulate flow After med has infusedcheck flow rate of primary Re-regulate primary Leave secondary bag and tubing in place for future drug admin or discarddiscard needle appropriately

Administering IV Meds
SYRINGE PUMP Place syringe with primed tubing into infusor Attach end of tubing to designated port after cleansing Hang mini infusor pump with syringe on IV pole with primary IV line After med infuses, turn off pumpcheck flow rate of primary IV infusion and regulate to desired rate Leave infusor tubing attached to primary linedisconnect and cover end with sterile cap, or disconnect and discard in appropriate container

Administering IV Meds
IVPB: HEP LOCK Take minidrip IV tubing and insert spike into minibag Close roller clamp and squeeze drip chamber to fill half full Open roller clamp and fill remaining tubing Attach sterile needle to tubing Prepare injection port Insert 3 ml syringe filled with 1 ml NS and gently aspirate Re-prepare port or stopper with antiseptic swabattach end of tubing to port or insert sterile needle Open clamp and regulate IV med to infuse 20-90 minutes

Administering IV Meds
Continue to observe infusion Prepare injection port with antiseptic swab, insert syringe with 1 ml NS and flush Re-prepare and inject dilute heparin concentration per agency and procedure, repeating procedure and using positive pressure Apply new sterile needle and cap to minibag tubing and retain for next administration Dispose of syringe and needles in appropriate container

Administering IV Meds Monitor and Document Infusion for proper rate IV site condition Therapeutic drug levels Symptom of allergic response

Three checks Five rights + Two Remember I&O Document: drug dose, route, amount, type of diluent, time of administration Always remember the basics!!!

Patient Controlled Analgesia

Purpose: To meet the needs of patients who require an effective
method of pain management.

Criteria
Clients requiring parenteral analgesic treatment Clients requiring postoperative pain relief. Trauma clients who have clear sensorium. Clients suffering from chronic pain. Clients who are mentally alert and able to understand and comply with procedure instructions. Clients without a handicap that impairs ability to use PCA Clients with no prior addiction to drugs or alcohol. Eighteen years of age is the usual minimum age for PCA use, but it has been used in children as young as 7 years of age.

Patient Controlled Analgesia

Equipment
Specific physicians orders for PCA PCA infuser pump IV administration set IV pole IV narcotic as ordered IV tubing for drug cartridge (PCA microbore) Minibore extension tube with one injection site, if needed. Extension set with Luer-Lok Analgesic medication cartridge and injector (vial injector) PCA administration record.

Patient Controlled Analgesia

Definition of Terms: Patient Controlled Analgesia (PCA) PCA pump is a device with computerized programming delivered intravenously or subcutaneously over a specified time period in four different modes. These are patient control continuous, patient control bolus or continuous clinician control bolus. The pump can allow a patient who is experiencing pain to selfadminister analgesia as needed by pushing a button.

Patient Controlled Analgesia

Assessment and Intervention: 1. Confirm presence and patency of infusion 2. Check and Document: Concentration of medication. Assess patient and document per physician order following PCA flow sheet guidelines. Patients pain perception using most appropriate pain scale. With every documentation of medication usage, clear shift total is specific to pump. 3. Assess and document vital signs and level of consciousness as per physician order or more frequently as patients condition indicates.

Patient Controlled Analgesia

Analgesics: Drugs that relieve pain. PCA analgesics most frequently used are morphine sulfate, Demerol (meperidine) and Dilaudid (hydromorphone).

Expected Patient Outcomes: 1. Patient will demonstrate/verbalize understanding of PCA and use of equipment 2. Patient will demonstrate/verbalize adequate pain management. 3. Vital signs will remain within baseline parameters. 4. Any side effects will be appropriately managed.

Patient Controlled Analgesia

If vital signs fall below patients normal range and the patient is difficult to arouse, Stop PCA and call ordering physician. 5. Assess for dizziness, slurred speech and pinpoint pupils every four hours. If this is assessed, notify ordering physician. 6. Nausea and vomiting: Medicate as per PCA orders If medication not effective notify ordering doctor for change in antiemetic, change narcotic or discontinuation of PCA. 7. Bowel function. Auscultate for bowel sounds Observe abdomen for distension. Inquire every shift about passage of flatus or BM. Ambulate per physician order. 4.

Patient Controlled Analgesia

8. Urinary bladder function if no urinary catheter present: Void within 6-8 hours of initiation of PCA Document volumes. Frequency of voiding (Question patient if bladder feels empty after voiding. Assess for urinary retention/bladder distention after voiding). Obtain physician order for in and out catheterization if patient not fully emptying bladder or has not voided in a 6-8 hours. 9. Assess indications for discontinuing IV

Patient Controlled Analgesia

Patient Teaching 1. Discuss with patient the purpose, type of medication and effects of medication as well as use of device. 2. Instruct patient/family to report any untoward effects of narcotic, (especially itching). 3. Reinforce need for only patient to press button, if using patient controlled mode not parent/family/staff. 4. Review indication for discontinuing PCA device. 5. Discuss with patient reporting of pain, using the pain intensity rating scale and effect on outcomes.