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

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 • Flowrate • 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 – 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