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Sunday, April 19, 2009

Fundamentals of Nursing: Intravenous Therapy

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Intravenous Therapy - Presentation Transcript

1. thus verifying that the needle is really in a vein; INTRAVENOUS THERAPY then the tourniquet is removed before injecting. This is the most common method of intravenous therapy?cat=health drug use for euphoriants such as heroin, or in any case where a person must self-administer Intravenous therapy or IV therapy is the intravenous medication at home. It is also a administration of liquid substances directly into a convenient way to deliver life-saving medications vein. It can be intermittent or continuous; in an emergency. However, in a controlled continuous administration is called an health-care setting, direct injection is rarely used intravenous drip. The word intravenous since it only allows delivery of a single dose of simply means \"within a vein\", but is most medication. commonly used to refer to IV therapy. Therapies administered intravenously are often called Peripheral IV lines specialty pharmaceuticals. This is the most common intravenous access method in both hospitals and paramedic services. Compared with other routes of administration, A peripheral IV line consists of a short catheter the intravenous route is the fastest way to deliver (a few centimeters long) inserted through the fluids and medications throughout the body. skin into a peripheral vein. A peripheral vein is Some medications, as well as blood transfusions any vein that is not in the chest or abdomen. and lethal injections, can only be given Arm and hand veins are typically used although intravenously. leg and foot veins are occasionally used. On infants the scalp veins are sometimes used. Part of the catheter remains outside the skin, with a hub that can be connected to a syringe or an An intravenous infusion line, or capped with a bung intravenous between treatments. The caliber of cannulae is drip in a commonly indicated in gauge, with 14 being a hospital very large cannula (used in resuscitation settings) and 24-26 the smallest. The most common sizes are 16-gauge (midsize line used for blood donation and transfusion), 18- and 20- gauge (all-purpose line for infusions and blood draws), and 22-gauge (all-purpose pediatric line). 12 and 14-gauge peripheral lines actually deliver equivalent volumes of fluid faster than central lines, accounting for their popularity in emergency medicine; these lines are frequently called \"widebores\" or \"trauma lines.\" Photo Courtesy of: Blood can be drawn from a peripheral IV if necessary, but only if it is in a relatively large vein and only if the IV is newly inserted. Blood Intravenous access devices draws are typically taken with specialized IV access sets known as phlebotomy kits, and once Needle and syringe the draw is complete, the needle is removed and the site is not used again. If a patient needs The simplest form of intravenous access is a frequent venous access, the veins may scar and syringe with an attached hollow needle. The narrow, making any future access extremely needle is inserted through the skin into a vein, difficult or impossible; this situation is known as and the contents of the syringe are injected a \"blown vein,\" and the person attempting to through the needle into the bloodstream. This is obtain the access must find a new access site most easily done with an arm vein, especially one proximal to the \"blown\" area. of the metacarpal veins. Usually it is necessary to use a tourniquet first to make the vein bulge; Originally, a peripheral IV was simply a needle once the needle is in place, it is common to draw that was taped in place and connected to tubing back slightly on the syringe to aspirate blood, rather than to a syringe; this system is still used for blood donation sets, as the IV access will only
2. be needed for a few minutes and the donor may Central IV lines – Hickman Line not move while the needle is in place. Today, hospitals use a safer system in which the catheter is a flexible plastic tube that originally contains a needle to allow it to pierce the skin; the needle is then removed and discarded, while the soft catheter stays in the vein. The external portion of the catheter, which is usually taped in place or secured with a self-adhesive dressing, consists of an inch or so of flexible tubing and a locking hub. Many sets contain a small amount of the anticoagulant heparin to keep the line from clotting off, and frequently are called \"heparin locks\" or \"hep-locks.\" Photo courtesy of: A peripheral IV cannot be left in the vein indefinitely, because of the risk of insertion-site infection leading to phlebitis, cellulitis and bacteremia. Hospital policies usually dictate that Peripherally inserted central catheter every peripheral IV be replaced (at a different (PICC) location) every three to four days to avoid this PICC lines are used when intravenous access is complication. required over a prolonged period of time, as in the case of long chemotherapy regimens, Central IV lines extended antibiotic therapy, or total parenteral Central IV lines flow through a catheter with its nutrition. tip within a large vein, usually the superior vena cava or inferior vena cava, or within the right The PICC line is inserted into a peripheral vein, atrium of the heart. This has several advantages usually in the arm, and then carefully advanced over a peripheral IV: upward until the catheter is in the superior vena cava or the right atrium. This is usually done by It can deliver fluids and medications that feel and estimation; an X-ray then verifies that • would be overly irritating to peripheral the tip is in the right place. veins because of their concentration or chemical composition. These include some A PICC may have two parallel compartments, chemotherapy drugs and total parenteral each with its own external connector (double- nutrition. lumen), or a single tube and connector (single- Medications reach the heart immediately, • lumen). From the outside, a single-lumen PICC and are quickly distributed to the rest of resembles a peripheral IV, except that the tubing the body. is slightly wider. There is room for multiple parallel • compartments (lumens) within the The insertion site must be covered by a larger catheter, so that multiple medications can sterile dressing than would be required for a be delivered at once even if they would peripheral IV, due to the higher risk of infection if not be chemically compatible within a bacteria travel up the catheter. However, a PICC single tube. poses less of a systemic infection risk than other Caregivers can measure central venous • central IVs, because bacteria would have to pressure and other physiological variables travel up the entire length of the narrow catheter through the line. before spreading through the bloodstream. Central IV lines carry higher risks of bleeding, The chief advantage of a PICC over other types of bacteremia, and gas embolism (see Risks below). central lines is that it is easy to insert, poses a relatively low risk of bleeding, is externally There are several types of central IVs, depending unobtrusive, and can be left in place for months on the route that the catheter takes from the to years for patients who require extended outside of the body to the vein. treatment. The chief disadvantage is that it must travel through a relatively small peripheral vein and is therefore limited in diameter, and also
3. somewhat vulnerable to occlusion or damage from movement or squeezing of the arm. Peripherally inserted central catheters Courtesy of : Port-a-cath 083s.jpg Central venous lines Forms of intravenous therapy There are several types of catheters that take a more direct route into central veins. These are Intravenous drip collectively called central venous lines. An intravenous drip is the continuous infusion of fluids, with or without medications, through an In the simplest type of central venous access, a IV access device. This may be to correct catheter is inserted into a subclavian, internal dehydration or an electrolyte imbalance, to jugular, or (less commonly) a femoral vein and deliver medications, or for blood transfusion. advanced toward the heart until it reaches the superior vena cava or right atrium. Because all of IV fluids these veins are larger than peripheral veins, There are two types of fluids that are used for central lines can deliver a higher volume of fluid intravenous drips; crystalloids and colloids. and can have multiple lumens. Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules. Colloids Another type of central line, called a Hickman line contain larger insoluble molecules, such as or Broviac catheter, is inserted into the target gelatin; blood itself is a colloid. vein and then \"tunneled\" under the skin to emerge a short distance away. This reduces the The most commonly used crystalloid fluid is risk of infection, since bacteria from the skin normal saline, a solution of sodium chloride at surface are not able to travel directly into the 0.9% concentration, which is close to the vein; these catheters are also made of materials concentration in the blood (isotonic). Ringer's that resist infection and clotting. lactate or Ringer's acetate (ASERING, patented brandname of Otsuka Indonesia) is another Implantable ports isotonic solution often used for large-volume fluid A port (often referred to by brand names such as replacement. A solution of 5% dextrose in water, Port-a-Cath or MediPort) is a central venous line sometimes called D5W, is often used instead if that does not have an external connector; the patient is at risk for having low blood sugar instead, it has a small reservoir implanted under or high sodium. The choice of fluids may also the skin. Medication is administered depend on the chemical properties of the intermittently by placing a small needle through medications being given. the skin into the reservoir. Ports cause less inconvenience and have a lower risk of infection Intravenous fluids must always be sterile. than PICCs, and are therefore commonly used for patients on long-term intermittent treatment. Effect of Adding One Litre Change in Change in Solution ECF ICF D5W 333 mL 667 mL 2/3D & 1/3S 556 mL 444 mL Half-normal 667 mL 333 mL
4. the injection to push the medicine into the saline bloodstream more quickly. Normal saline 1000 mL 0 mL Risks of intravenous therapy Ringer's lactate 900 mL 100 mL Intravenous therapy has many risks and should therefore only be performed by trained personnel Infusion equipment under medical supervision, using proper A standard IV infusion set consists of a pre-filled, equipment. sterile container (glass bottle, plastic bottle or plastic bag) of fluids with an attached drip Infection chamber which allows the fluid to flow one drop Any break in the skin carries a risk of infection. at a time, making it easy to see the flow rate Although IV insertion is a sterile procedure, skin- (and also reducing air bubbles); a long sterile dwelling organisms such as Coagulase-negative tube with a clamp to regulate or stop the flow; a Staphylococcus or Candida albicans may enter connector to attach to the access device; and through the insertion site around the catheter, or connectors to allow \"piggybacking\" of another bacteria may be accidentally introduced inside infusion set onto the same line, e.g., adding a the catheter from contaminated equipment. dose of antibiotics to a continuous fluid drip. Infection of IV sites is usually local, causing An infusion pump allows precise control over the easily visible swelling, redness, and fever. If flow rate and total amount delivered, but in cases bacteria do not remain in one area but spread where a change in the flow rate would not have through the bloodstream, the infection is called serious consequences, or if pumps are not septicemia and can be rapid and life-threatening. available, the drip is often left to flow simply by An infected central IV poses a higher risk of placing the bag above the level of the patient and septicemia, as it can deliver bacteria directly into using the clamp to regulate the rate; this is a the central circulation. gravity drip. Phlebitis A rapid infuser can be used if the patient requires Phlebitis is irritation of a vein that is not caused a high flow rate and the IV access device is of a by infection, but from the mere presence of a large enough diameter to accommodate it. This is foreign body (the IV catheter) or the fluids or either an inflatable cuff placed around the fluid medication being given. Symptoms are swelling, bag to force the fluid into the patient or a similar pain, and redness around the vein. It does not electrical device that may also heat the fluid necessarily mean the IV device must be being infused. removed; warmth, elevation of the affected limb, or a change in the rate of flow may resolve the Intermittent infusion symptoms. Intermittent infusion is used when a patient Due to frequent injections and recurring phlebitis, requires medications only at certain times, and the peripheral veins of intravenous drug addicts, does not require additional fluid. It can use the and of cancer patients undergoing chemotherapy, same techniques as an intravenous drip (pump or become hardened and difficult to access over gravity drip), but after the complete dose of time. medication has been given, the tubing is disconnected from the IV access device. Some Infiltration medications are also given by IV push, meaning This occurs when the tip of the IV catheter that a syringe is connected to the IV access withdraws from the vein or pokes through the device and the medication is injected directly vein into surrounding tissue, or when the vein's (slowly, if it might irritate the vein or cause a wall becomes permeable and leaks fluid (in this too-rapid effect). Once a medicine has been instance it is said that the cannula has 'tissued'). injected into the fluid stream of the IV tubing It occurs frequently with peripheral IVs, and there must be some means of ensuring that it requires replacement of the IV at a different gets from the tubing to the patient. Usually this location. The symptoms of pain and swelling are is accomplished by allowing the fluid stream to temporary and not dangerous, unless giving a flow normally and therby carry the medicine into highly irritating medication, such intravenous the bloodstream; however, a second fluid contrast or amiodarone. Additionally it can injection is sometimes used, a \"flush\", following become dangerous if the person monitoring the IV site fails to recognize that an infiltration has
5. occurred and fluid continues to drip in the tissue under the skin. It can cause a compression injury. This known as an infiltration injury. Fluid overload This occurs when fluids are given at a higher rate or in a larger volume than the system can absorb or excrete. Possible consequences include hypertension, heart failure, and pulmonary edema. Electrolyte imbalance Administering a too-dilute or too-concentrated solution can disrupt the patient's balance of sodium, potassium, magnesium, and other electrolytes. Hospital patients usually receive blood tests to monitor these levels. Embolism A blood clot or other solid mass, or an air bubble, can be delivered into the circulation through an IV and end up blocking a vessel; this is called embolism. Peripheral IVs have a low risk of embolism, since large solid masses cannot travel through a narrow catheter, and it is nearly impossible to inject air through a peripheral IV at a dangerous rate. The risk is greater with a central IV. Air bubbles of less than 30 milliliters generally dissolve into the circulation harmlessly. A larger amount of air, if delivered all at once, can cause life-threatening damage to pulmonary circulation, or, if extremely large (3-8 milliliters per kilogram of body weight), can stop the heart. One reason veins are preferred over arteries for intravascular administration is because the flow will pass through the lungs before passing through the body. Air bubbles can leave the blood through the lungs. A patient with a heart defect causing a right-to-left shunt is vulnerable to embolism from smaller amounts of air. Fatality by air embolism is vanishingly rare, in part because it is also difficult to diagnose. Extravasation Extravasation is the accidental administration of IV infused medicinal drugs into the surrounding tissue, either by leakage (e.g. because of brittle veins in very elderly patients), or directly (e.g. because the needle has punctured the vein and the infusion goes directly into the arm tissue).

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