Indications for Intravenous Therapy

1. Indications for Intravenous Therapy

2. Purpose of IV Therapy • To provide maintenance and replacement of • acid-base balance or • fluid and electrolyte balance • When rapid absorption is necessary (bypasses hepatic system) • Access for blood sampling and blood transfusion • TPN: Total Parenteral Nutrition (nutritional therapy)

3. Purpose of IV Therapy • Chemotherapy • Avenue for continuous or intermittent medications e.g. antibiotics, vasopressors, analgesics, electrolytes, vitamins and diuretics

4. Nursing Responsibilities for IV Therapy • To have a thorough knowledge of fluids and drugs, their effects, dosage, recommended rate, incompatibilities, contraindications, and allergic reactions, prior to administration • To have good judgment and assessment skills prior to, during, and post administration LPN

5. Nursing Responsibilities for IV Therapy • To have the ability to interpret physician’s orders • To have good documentation and communication skills • To know your own scope of practice

6. Nursing Responsibilities for IV Therapy • Choose the most appropriate vascular access deviceby selecting a device that • has the potential for providing access throughout the course of therapy , • ensures the best possible outcome, • has the least risk to the patient and the health care provider. • Collect and document relevant patient data • Manage venous access cost-effectively

7. The Skin • First line of defense • Fertile ground for bacterial growth • Warmth • Moisture • 10,000 organisms per square centimeter • Three layers • epidermis • dermis • subcutaneous tissue

8. The Skin • Resident Flora • Permanent residents • Not readily removed by handwashing • Can be inhibited with use of antimicrobial soaps

9. The Skin • Transient Flora • Not normally present on the skin • Survive poorly on skin surfaces • Noncolonizing flora, vary from day to day • Present from touch contamination • Can be eradicated by good handwashing • Staphylococcus aureus

10. Handwashing • 50% of nosocomial infections could be eliminated by handwashing alone • Hands are only washed 50% of the times indicated • Wearing gloves does not eliminate need to wash hands before or after patient contact • 15-20 second hand wash vigorously with soap and running water Don’t forget to clean yourpen!

11. Skin Cleansing and Disinfecting Disinfectant Types

12. 10% Iodophors • Iodine fixed to a carrier molecule reducing the amount of free iodine released on the skin which reduces irritation to the skin • Two minutes of contact before effective • Must be allowed to air dry • Residual activity, if reservoir left on the skin • Effectiveness is affected by organic material, wash skin with soap and water if needed or alcohol swabs if available • Ensure no allergy to iodine

13. 70% Alcohol • Recommended agent for iodine allergy • When used alone requires 1 minute scrub • Provides immediate kill • Has no residual activity • Must be allowed to air dry • Repeated use is drying to skin

14. Antimicrobial Skin Prep • 70% Ethyl Alcohol & 10% Povidone-iodine combination • One-step prep • 5-7 day efficacy beneath sterile transparent film dressings

15. 2% Chlorhexidinevs Iodine options • Chlorhexidine has comparable effectivenessand is safer, cheaper, and preferred by staff, so it is an alternativeto iodine tincture. Journal of Clinical Microbiology, May 2004, p. 2216-2217, Vol. 42, No. 5 • Applied in a scrubbing motion both horizontally and vertically

16. Layers of the Vein

17. Tunica Intima • Characteristics • Innermost layer • Smooth elastic lining • Recognizes foreign material • Prostaglandin & heparin mast cells. . .mediators for inflammatory process • Stage for phlebitis

18. Tunica Media • Characteristics • Middle layer • Smooth muscle & elastic tissue • Nerve fibers • dilation/constriction • muscle tone • Clinical indications • Affects efforts of vasodilation

19. Tunica Adventitia • Characteristics • Outer layer • Fibrous connective tissue • Vein support • Vein nourishment • Clinical indications • “Pop” • Sclerosis, scarring

20. Those Pesky Venous Valves • Damage may lead to thrombus formation • Incomplete catheter insertion can lead to leaking, variable IV rate and/or early removal

21. Comparison of Arteries and Veins

22. Artery Lie deep in tissue Thicker connective tissue: prevents collapsing or distending with pressure Protected by muscles Vein Superficially located Collapses under pressure Muscle layer may spasm with pain More numerous than arteries Differentiating Arteries and Veins

23. Artery There are some areas where the arteries are superficial Supply single area Pulsate Color bright red Vein Inner layer has one-way valves If spasms, other veins compensate Darker color, bluish Differentiating Arteries and Veins

24. Associated Nerve Structures

25. Radial nerve • Posterior cutaneous nerve of forearm arises in spiral grove • Branches to brachoradialis and exteral radial • Deep branch perforates supinator to form posterior interosseous nerve which supplies extensor compartment • Superficial branch supplies skin on dorsum of hand and digits proximal to nail beds

29. Assessing Patient for IV Therapy

30. Psychological preparedness Age specific Purpose of therapy Possible duration (peripheral/central) Method of administration Insertion procedure Mobility limitations or restrictions Long-term alternatives to peripheral IV may be nec. Patient Preparation/Education

31. ‘Informed’ Consent • Requires • Sufficient information to make a decision • Capacity to make a decision • No coercion • Refusal of treatment • Assault and Battery: Coercion of rational patient into having an IV.

32. Special Considerations

33. Disease States/Conditions • Immunosuppression • Increased risk of infection • Dehydration • Decreased intravascular volume • Mastectomy • May have compromised circulation, but vascularization has likely been rebuilt. Some pts will be “No IV” “No BP” on affected limb.

34. Disease States/Conditions • Heart disease/edema • Obscures veins • Irritating cardiac meds • Fluid overload • Anticoagulation therapy • Diabetes • Peripheral neuropathy • Infection risks, slow to heal • Cancer • Chemotherapy • Decreased cell counts

35. Disease States/Conditions • Renal Dialysis • Hemodialysis grafts • Obesity • Veins deep or pushed to surface • Sclerotic Veins • Tendency to roll

36. Osmolarity of Fluid • Osmolarity = the osmotic concentration of a solution expressed as osmoles of solute per liter of solution • Osmole = the molecular weight of a solute • Normal osmolarity of blood/serum is about 300-310 mOsm/L.

37. Osmolarity of Fluid • The tonicity of an IV fluid dictates whether the solution should be delivered via the peripheral or central venous route. Hypotonic and hypertonic solutions may be infused in small volumes and into large vessels, where dilution and distribution are rapid. • When solutions with extremes of tonicity are infused, fluids shift into or out of cells, including endothelial cells of the tunica intima near the catheter tip and blood cells. The resulting changes in the cell size of the vein wall causes the inflammatory and clotting processes to occur, leading to phlebitis and thrombophlebitis.

38. Allergy Assessment • Medication history • First dose considerations • Risk analysis • Iodine allergy (note shellfish allergy) • Use alcohol or chlorhexidine • Latex allergy • Local anesthetics

39. Nursing Assessment • Consider the following • Patient condition, age, diagnosis & activity level • Vein condition, size & location • Associated structures • Skin integrity • Type & duration of therapy • Drugs that affect skin integrity • Corticosteroids • Heparin/Coumadin • Chemotherapy • Prednisone

40. Veins: So many to pick from!

41. Antecubital Fossa • Large veins • Tendency to “roll” • Because the veins in this area are visible and easily accessed, the antecubtial is ideal for blood samples and bolus drugs • Unless joint is immobilized, cannula could kink or move in and out of the vein damaging the vein. Discuss cannula, what, why, rigid?

42. Infants only (Up to 2 years old)

43. Dangers Associated with Lower Extremities • Thrombosis • Varicosity • Immobility • Increase risk of Pulmonary Embolism a travelling clot 

44. By understanding the physiology of veins, the IV therapist can use vasoconstriction and vasodilation to increase the vein size, increase visibility and decrease venous spasm. Distending Techniques • Tourniquet (just enough to restrict venous return but not impede arterial flow) • Dependent Position, (works well for elderly with tortuous veins instead of tourniquet) • Warm moist heat compress • Blood pressure cuff (40-50 mm HG below systolic—check for pulse) • Clenching fist (muscles pump veins up)

45. Intravenous Supplies and Equipment

46. The Right Device to Start • Greatest likelihood of surviving anticipated length of therapy • Accommodates therapy requirements • Is the least invasive • Utilizes the fewest number of catheters • Meets a benefit vs. risk assessment

47. Short-term Peripheral Catheters • Most commonly inserted catheter • Any appropriate peripheral vein • Usual dwell time (P&P) • 48-72 hours • Heparin lock - 96 hours • Peripheral solutions only • “Clean” vs. sterile technique

48. Short-termAcute Catheters • Tip located in the SVC or IVC • Dwell time varies 7-14 days • Used for all types of solutions • X-ray required (why?) • Sterile technique • Inserted subclavicular region by specialty nurse or physician, with imaging assistance- ultrasound

49. Midline Tip • Tip placement in proximal portion of the upper extremity • Lower extremity may be used in the neonate and infant • Dwell time • 2-4 weeks avg • Peripheral solutions only • Sterile technique • No X-ray required

50. Peripherally Inserted Central Catheters (PICC) • Tip located in the SVC (superior vena cava) or IVC • Dwell time indeterminate • Consider in patients requiring therapy up to one year • Used for all types of solutions • X-ray required • Maximum sterile barrier precautions *