AMA 116 IV Theory

1. AMA 116 IV Theory

2. Objectives of IV Therapy: • Restore and maintain fluid and electrolyte balance • Provide medications and chemotherapy • Transfuse blood and blood products • Deliver parenteral nutrients and nutritional supplements

3. Benefits of IV Therapy: • Allows more accurate dosing • Medications can act instantaneously • Can be used to administer fluids, medications and nutrients when the patient cannot take them orally

4. Risks of IV Therapy: • Bleeding • Infiltration (when fluids are infused into the surrounding tissue instead of the vein) • Infection • Overdose (fluid overload, speed shock) • Anaphylaxis, Syncope

5. Fluids and Electrolytes The body is made up of mostly liquid. Two-thirds of total body weight in an adult and three-fourths of the body weight in an infant consist of fluid. Body fluids are composed of water and solutes (dissolved substances) which are electrolytes and non-electrolytes. Electrolytes There are six major electrolytes: • Sodium • Potassium • Calcium • Chloride • Phosphorous • Magnesium

6. Fluids and Electrolytes • Electrolytes are contained either intracellularly (potassium, magnesium and phosphorous) or extracellularly (sodium and calcium). • Osmosis is a term for this movement of fluids and electrolytes and the fluid movement gradient. Water flows from higher to lower concentration. When the solute concentration is equal on both sides of a membrane the osmosis stops. It is possible for the osmosis to create an equal concentration if the concentration isn’t optimal, then the balance must be corrected.

7. Osmotic pressure is based on solute concentration which is referred to as osmolarity (or how much solid is dissolved in the water). The prefixes “iso” (equal), “hyper” (higher) and “hypo” (lower) denote the “tonicity” or osmolarity of a solution. In the picture above, side “A” is hypertonic to side “B” in the left picture, but isotonic to side “B” in the right picture. IV solutions all have a tonicity; therefore they can have an osmolar effect on the human body. Isotonic IV solutions (iso-osmolar to the blood) will go in to the person without causing any osmotic effect between the plasma, extracellular, or intracellular spaces in the body.

8. Solutions There are three types of IV solutions: • Isotonic- this has the same osmolarity as serum and other body fluids. It will not cause any osmotic effect on the body. Examples: lactated ringers, ringers, normal saline, dextrose 5% in water and 5% albumin. • Hypertonic- this has a higher osmolarity than serum. It will pull fluid from the interstitial and intracellular compartments into the blood vessels. Examples: dextrose 5% in half-normal saline, dextrose 5% in normal saline, dextrose 5% in lactated ringers, 3% sodium chloride, 25% albumin and 7.5% sodium chloride. • Hypotonic- this has a lower osmolarity than serum. Fluid moves from the blood vessels and into the cells and interstitial spaces. Examples: Sterile water, half-normal saline, 0.33% sodium chloride and dextrose 2.5% in water.

9. Delivery Methods There are two types of IV administration: • Peripheral • Central There are three basic methods to infuse IV fluids and medications via both delivery methods: • Continuous infusion- this allows a carefully regulated amount of fluid to be given over a long period of time, helping maintain a constant drug level and is used for fluid therapy and parenteral nutrition. • Intermittent infusion- this is the most common and flexible method of IV therapy. Drugs can be administered over a specific period of time at intervals and can be infused through a primary line or a secondary line that has been connected (or “piggybacked”) to the primary line. • Direct injection- the most direct method. This gets the medication or fluid right into the patient right away. It is also called giving a bolus or an IV push.

10. Central Venous Therapy This is IV therapy using major veins instead of those in the limbs and other peripheral veins. It is most useful when a patient needs infusion of a large amount of fluid, requires multiple infusions, and /or requires long-term therapy. A central line may be inserted directly into the superior or inferior vena cava or the right atrium of the heart. In addition, one can be inserted into a peripheral vein and threaded up into the vena cava. There are additional risks to central venous therapy including: • Perforation of the vein and adjacent organs • Requires more time and skill than peripheral IV’s • Air embolism or thrombus • Sepsis • Pneumothorax

11. Types of access devices include: Non-tunneled and tunneled catheters Peripherally inserted central catheters (PICCs) Implanted vascular access ports (VAPs) Access Devices

12. Supplies and Equipment • The tubing for an IV is called an administration set. Which set you choose depends on the type of infusion needed, the infusion container, and whether you are using a volume control device or not. • Administration sets can be vented for bottles or un-vented for IV bags. Other items and features include ports for infusion of additional medications, filters for blocking particulates in the fluid, tubing which is designed to enhance devices in regulating flow or for continuous or intermittent infusion or for blood and nutrition. • There are also various types of clamps for stopping the flow through the tubing as well as pumps that automatically deliver fluids and medications.

14. Orders • When the physician orders IV administration, it may be a standard or standing order (to be followed for certain illnesses and needs) or it may be an individualized order. They may be limited in the duration of time they are effective for, such as a 24-hour period, when a new order must be given. • All orders should include the type and amount of solution to be administered, any additives and their concentration, rate and volume of infusion and the duration of the infusion therapy.

15. Flow Rates Two basic types of flow rates are: • Microdrip • Macrodrip. Each one delivers a certain amount of drops per milliliter (gtts/mL) and each uses the same calculation formula: • Volume of infusion (milliliters) X drip factor (gtts/mL) = flow rate (gtts/minute) • Time of infusion (minutes) • When calculating the flow rate, the number of drops needed to deliver 1mL will vary on whether you are using the macrodrip (delivers 10, 15, or 20 gtts/mL) or the microdrip (delivers 60 gtts/mL) administration set. • After the flow rate has been calculated, use your watch while checking the drops per minute. Adjust the clamp or roller to slow or speed the flow until the correct number of drops per minute has been achieved. Always count for one full minute. There are also pumps that automatically deliver the medication at the correct rate provided it has been set accurately.

16. Programmable IV Pump

17. Risks, Complications and Disadvantages There are numerous risks and complications in various aspects of IV therapy. This list is a majority, but is not necessarily all-inclusive: • All risks related to phlebotomy • Infection • Infiltration • Irritation at the site or along the vein • Incompatibility of drugs • Restricted mobility • Clotting • Too rapid or too slow flow rate can cause many problems for the patient • Wrong medication given • Using the wrong syringe when multiple syringes are required • Allergic response or adverse reaction • Hematoma • Vasovagal reaction • Nerve, tendon or ligament damage • Spasm of the vein

18. Patient Teaching Having an IV is frightening to many patients and it is a little painful. You will need to explain the procedure and try to decrease the patient’s anxiety. Some things to include are: • What intravenous means, and that a plastic catheter will be inserted and left in the vein, not a needle. • What fluid or medications they are receiving and why. (Most times the provider will do this). • How long the IV will be in. • Admit that there may be some discomfort (do not say pain) that should stop once the IV is in place. • Explain any sensations the fluid or medication may cause such as coldness, a feeling of it going up the arm, a burning sensation, etc… Tell them to report any pain or discomfort once the IV is placed. • Explain the restrictions as needed such as ambulating, showering, etc… • Teach them how to help care for the IV such as not pulling on it, not to remove the medication from the pole, not to crimp or kink the tubing and to report any redness or irritation at the site or numbness in the fingers etc…

19. For the insertion of an IV it must include: Size and type of device Name of the person administering (inserting) Date and time Site location Type of solution and any additives Flow rate Whether a pump is used Complications and patient response Patient teaching Number of attempts Maintenance of an IV is also charted and should include: Condition of the site Site care provided Dressing changes Site changes Tubing and solution changes Additional patient teaching Documentation Discontinuing an IV is charted as well as insertion and maintenance. When you discontinue an IV, include in your documentation: • Date and time • Reason for stopping the therapy • Assessment of the site before and after removal • Complications • Patient reaction • Integrity of the device upon removal • Any follow-up tasks such as a dressing or insertion in another site

20. Legal Issues Administering fluids and medications by IV therapy • one of the most legally risky tasks performed in the medical setting. • especially risky for the medical assistant who works under the physician-employer’s license, whereas nurses have their own license. • Errors in medication dosage, incorrect placement of an IV line, and failure to monitor adverse reactions, infiltration, and dislodgement of IV equipment are the common problems. • The medical assistant CANNOT place, start, monitor or remove an IV unless they are fully trained to the full extent of their State laws and only when your physician-employer has allowed you to do so. (**See the State laws of Washington called the Healthcare Assistant Law in another assignment of the checklist in your packet for more information on this). • The medical assistant must be fully knowledgeable about the laws that govern their right to practice within their scope of training. Be fully aware of the policies in your office/clinic and follow all Federal and State laws for infection control when performing tasks that involve body fluids (OSHA, WISHA, CDC, Bloodborne Pathogen Standard, Standard Precautions).

21. Central and Peripheral Veins

22. IV insertion Memory Tool A simple tool to remember the major steps for completing a venipuncture properly is the acronym BLATS. • B Blood return enters the flashback chamber. • L Level the catheter. • A Advance the catheter. • T Tourniquet is removed. • S Stylet is removed.

23. Obtain and check the IV order Gather the appropriate equipment Wash your hands Identify the patient and assess the condition of the patient’s arm Apply the tourniquet Select appropriate vein Prep with alcohol in an upward manner Put on gloves Hold the catheter bevel up, at the appropriate angle Retract the skin Insert until the blood return is visible in the flashback chamber Level off the angle of entry Advance the catheter slightly Remove the tourniquet Remove the stylet Attach the IV tubing Open the flow control clamp Retract the skin Advance the catheter to the hub Regulate the flow rate Remove gloves Center the transparent dressing over the site to anchor the catheter in place Loop the IV tubing and tape in place Document the procedure in the patient chart Review of Main Steps:

24. Positioning and Hand Placement

25. IV Arm Placement