RN Skills Laboratory

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

7
Fluid Management - Tonicity
Hypertonic Increased solutes in relationship to plasma D5.9NS D5LR D5.45NS
Hypotonic Decreased solutes in relationship to plasma .25NS .45NS 2.5Dextrose
Isotonic Same tonicity as plasma .9NS D5W LR
8
Venipuncture

• Site selection
• Gauge needle
• Supplies
• Procedure
• Charting location and identify vein used

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

10
Formulas

• Flow rate
• Drops per minute

Total Solution

mL/hr
of hours to run
mL/hr x gtt factor
gtts/min

60 mins
11
Secondary Infusions

• Piggybacks - IVPB
• Used for mediations
• Check medication
• Check capability
• Stop primary, flush, infuse, flush and restart
  primary
• Bactrim dont 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 gt10 - 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
• Dont play catch-up
• No blood