Unit 5:
Module 2:

Page 1
Nursing Re-entry Program
     

Nursing Implications for IV Infusion and IV Medication Administration

 

Complications of IV Therapy:

  • Infiltration: Occurs when IV fluid enters the SQ space, can range from mild to severe, is usually due to catheter dislodgement, and manifestations include swelling, pain, cool skin, pallor, and decreased flow in gravity administration.  Nursing implications include discontinuing the IV, elevate the extremity, warm compresses (depending on the medication infiltrated) to the affected site, notify the MD, and restart the IV in the opposite extremity or above the infiltrated site.
  • Phlebitis:  Inflammation of the vein caused by a chemical irritant or a mechanical irritant (catheter).  The wrist is the most common site for phlebitis.  Manifestations include pain, redness/hardness along the vein path, warmth at the IV site, and can progress to thrombophlebitis.  The IV site will need to be discontinued and restarted in the opposite extremity. 
  • Infection/Septicemia:  Direct entrance into circulatory system of microorganisms due to poor skin prep, poor asepsis, and prolonged catheter dwell time.  Manifestations include fever/chills, drainage at the IV site, warmth to touch.  Nursing implications include notifying the MD, discontinuing the IV site (catheter tip may need to be cultured), and patient may be placed on antibiotic therapy.
  • Allergic reactions:  Usually related to latex or medications and is manifested by itching, teary eyes, wheezing, edema, rash, and shortness of breath. Nurses should STOP the infusion, maintain airway, notify MD, and stay with the patient monitoring VS.

 

 

IV Flow Rates:  It is critical to monitor IV flow rates.  Too fast can cause fluid volume excess and too slow can cause cardiac/circulatory collapse.  Always use a pump if possible, especially in patients with congestive heart failure, renal failure, and pediatrics (buretrols) to prevent overload.  Table 5-1 highlights the common signs and symptoms associated with fluid volume excess as well as the nursing implications:

 

Table 5-1 Fluid Volume Excess

Signs and Symptoms

Nursing Interventions

 

Shortness of breath (SOB)

Elevate head of bed (HOB)

Flushed skin

Apply O2

Tachycardia                                                             

Notify MD

Intake greater than output

Monitor VS

Elevated BP

 

 

Maintaining the Infusion:  IV infusions are closed systems and are sterile, therefore nurses should remember when handling IV tubing and solutions to wash hands, use gloves and alcohol wipes.  General time frames for tubing changes are noted on page 1004 of skills book. Nurses should check institutional policy as well.  Additional nursing care will include:

 

  • Assisting the patient in self care (changing the gown; procedure on page 1017 of skills book) to prevent disruption of the closed system.
  • Teaching the patient the signs and symptoms of infiltration: pain, swelling, redness, and warmth at the site.
  • If administering IV fluids via a pump, the rate in ml/hr must be entered.
  • Request an in-service on the pump at the facility to ensure safety

 

IV Medication Administration Principles:

  • Remember to follow the 5 + 1 rights with +1 referring to documentation, write it!
  • Know the correct dilution
  • Be familiar with adverse affects/side effects
  • Have antidote nearby if applicable
  • A current IV drug guide should always be consulted prior to giving an IV medication
  • If there is not a current IV drug guide available, consult the pharmacist.  Note incompatibilities.
  • Administration of IV medication is within the scope of practice of LVNs in most states (know the institutional policy as well).
  • Mixing and administering IV medications are sterile procedures and introduction of bacteria into the bloodstream can lead to FATAL consequences.
  • Use filter needles when drawing up medications with sharps or from ampules.
  • Integrity of IV site is a pre-requisite to all IV medication administration.

 

Incompatibility:

  • Two incompatible solutions or medications must never come in contact with one another in an IV line.
  • KCl is incompatible with many medications.
  • When in doubt about compatibility flush, flush, flush with NS.

 

Pumps:

  • Pumps use ccs/hr not gtts/min.
  • Do not clear the pump before the change of shift. The number of cc's infused is used to calculate intake and output.

 

Piggybacks:  An intermittent volume-controlled infusion (small volume 25-100 ml) connected to a secondary (shorter) tubing that is inserted into the upper Y-port of the primary infusion tubing.  The primary infusion does not infuse at the same time as the piggyback but will resume infusion after the piggyback infusion is completed.  The piggyback must always be higher than the primary to infuse and the piggyback tubing should be primed by back flushing if the medication is compatible with the IV solution that is infusing.  Most nurses set IV pump piggyback volumes 5 cc's greater than the amount indicated on the bag so that all the solution in the piggyback tubing will infuse, leaving the tubing empty.  Some nurses use a different set of piggyback tubing for each IV. This is not necessary if the medications are compatible.  If the medications are incompatible back flushing make this unnecessary.  If different sets of piggyback tubing are used the access device on the end of the piggyback tubing must be changed each time.

 

IV Push/Bolus:  Administration of a concentrated dose of medication directly into the systemic circulation and is the most dangerous method of medication delivery.  Nursing principles include:

  • May be given via saline/heparin lock. Remember, flush with saline first, follow with medication, flush with saline after, and if using heparin to maintain patency, flush with heparin.
  • May be given via injection port closest to the IV site in the primary infusion tubing.  Know compatibility with primary infusion and remember to continually flush with primary infusion.
  • Dilute the drug whenever possible according to the drug book (check with the pharmacist).
  • Monitor patient for reactions to the IV bolus (pain, swelling, complaints of not feeling well) while administering the medication.