RN Skills Laboratory

1. 1 RN Skills Laboratory Intravenous Therapy West Coast University Week 7

2. Objectives IV therapy overview Type of fluids IV drop factors & calculations IVPBs IVPs Central Lines Blood and Blood Products TPN

3. IV Therapy IV therapy – peripheral Admission criteria in hospital Surgical, transfusion patients Hydration, restoring fluids/electrolyte imbalance Administration of drugs Side affects Bleeding, infiltration, infection, hearing loss, bone marrow suppression, kidney and heart damage Is not long-term therapy and more expensive than other routes

4. Fluid Management Thin people 50-70% water Obese people 50% water Elder 46-52% water Two main compartments Intracellular (64%) Extracellular (36%) ¾ interstitial ¼ plasma

5. Fluid Management Physiological homeostasis Fluid movement done by osmotic pressure (holding on) Hydrostatic pressure (letting go) Plasma uses osmotic pressure (why?) Kidneys are the primary regulator of fluids Usually produces 1-2L/24h Must produce a minimum of 500-600mL/24h

6. Fluid Management Homeostatic Mechanisms Thirst to CNS Illness, LOC, age changes thirst mechanism Antidiuretic hormone (ADH) – hypothalamus Extracellular volume is concentrated Fluid retention by hemorrhage, cardiac output, trauma, pain, fear, surgery, dehydration Aldosterone – adrenal cortex Reabsorbs Na & H2O = changes electrolytes Na exchanges for K or H Kidneys and the angiotensin system Renin – angiotensin I – angiotensin II Renin circulates in the body, converts plasma proteins to in the liver to vasoconstrictor called angiotensin I, this enters the lungs and converts to angiotensin II – this works on the adrenal cortex to secrete AldosteroneRenin circulates in the body, converts plasma proteins to in the liver to vasoconstrictor called angiotensin I, this enters the lungs and converts to angiotensin II – this works on the adrenal cortex to secrete Aldosterone

7. Fluid Management - Tonicity Renin circulates in the body, converts plasma proteins to in the liver to vasoconstrictor called angiotensin I, this enters the lungs and converts to angiotensin II – this works on the adrenal cortex to secrete AldosteroneRenin circulates in the body, converts plasma proteins to in the liver to vasoconstrictor called angiotensin I, this enters the lungs and converts to angiotensin II – this works on the adrenal cortex to secrete Aldosterone

8. Venipuncture Site selection Gauge needle Supplies Procedure Charting – location and identify vein used Renin circulates in the body, converts plasma proteins to in the liver to vasoconstrictor called angiotensin I, this enters the lungs and converts to angiotensin II – this works on the adrenal cortex to secrete AldosteroneRenin circulates in the body, converts plasma proteins to in the liver to vasoconstrictor called angiotensin I, this enters the lungs and converts to angiotensin II – this works on the adrenal cortex to secrete Aldosterone

9. Supplies The pump The drip factor (varies by manufacturer) Microdrop 60gtt/mL Macrodrop 20gtt/mL 15gtt/mL 10gtt/mL The volume control set The filter Renin circulates in the body, converts plasma proteins to in the liver to vasoconstrictor called angiotensin I, this enters the lungs and converts to angiotensin II – this works on the adrenal cortex to secrete AldosteroneRenin circulates in the body, converts plasma proteins to in the liver to vasoconstrictor called angiotensin I, this enters the lungs and converts to angiotensin II – this works on the adrenal cortex to secrete Aldosterone

10. Formulas Flow rate Drops per minute

11. Secondary Infusions Piggybacks - IVPB Used for mediations Check medication Check capability Stop primary, flush, infuse, flush and restart primary Bactrim – don’t mix (usually D5W) Dilantin – only in NS

12. Intravenous Line Injection Pushes - IVPs Dilute whenever possible KNOW YOUR DRUG Digitalis – usually monitored Benzodiazepines (do not mix or dilute) Clamp, flush, push, flush, unclamp Flush, push, flush SASH

13. Central Venous Access Types Peripherally Placed PICC Tunneled Groshong (same as PICC only tunneled) Triple Lumens Hickmans, Boviacs Ports

14. Insertion Sites Neck Jugular Chest Subclavian Arm Bacilic Cephalic Anticubital

15. SAFETY NO SCISSORS ONCE INSERTED PREVENT INFECTION

16. Site Care First 7 days (or if discharge) Use 2x2 gauze NO betadine ointment Then q72h or if soiled Check policy

17. Tubing & Cap changes Both q72h with fluids Blood change both After 2-3 units TPN (PPN) change both q24h Change caps q blood draws NO LABEL – change both

18. Blood drawing Access line with prefilled 10cc NS Flush Draw back 10cc blood in same syringe (discard) New syringes – draw up sample Change cap Flush with 10cc NS (heparin??)

19. CVC Side Effects Phlebitis mechanical vs bacterial Infection Pheumothorax Superior vena cava syndrome

20. Flushing Know the following for all Manufactures Guidelines Policy/Protocol Peripheral Lines 3cc NS Central Lines PICC: 10cc NS (No Heparin) Central Line: 10cc NS & Heparin 100u/cc (3cc) Tunneled: Same as Central Line (Groshong see PICC) Ports (Should have primary line) Needles -Huber (non-coring) -Change every Friday -Flush when needle remove and not reinserted -use Heparin 100u/cc (5cc)

21. Blood Administration Have saline infusing with Y-set up Use 170 micron filter Double check At lab/blood bank At bed side Monitoring Prior, 5min after start, 15min after start then q30m until completed Should infuse over 1-2 hours

22. The Blood System ABO blood group system Universal Donor O lacks A & B antigen Universal Recipients AB lacks anti-A & anti-B antibodies

23. Blood Products Whole blood Packed red cells Granulocyte concentrates Platelet concentrates Fresh frozen plasma Cryoprecipitate Clotting factors - Factor VIII / IX

24. Complications of Transfusions Complications of blood transfusion Haemolytic reactions (immediate or delayed) Bacterial infections from contamination Allergic reactions to white cells or platelets Pyogenic reactions Circulatory overload Air embolism Thrombophlebitis Clotting abnormalities

25. Anaphylaxis Reaction Usually occurs soon after start of transfusion Presents with circulatory collapse and bronchospasm Management Discontinue transfusion and remove giving set Maintain airway and give oxygen

26. Autologous transfusion Is the use of the patients own blood Particularly useful in elective surgery Accounts for 5% of transfusions in USA Reduces the need for allogeneic blood transfusion Reduces risk of postoperative complications (e.g. infection, tumor recurrence)

27. Total Parenteral Nutrition Pharmacist may do formulation If dextrose >10% - need CVC Monitor blood glucose Monitor electrolytes Weigh qd Use filters 1.2micron with lipids .2micron without lipids Know who to “ramp up and down”

28. TPN precautions Check compatibility of medications Don’t play “catch-up” No blood