Intravenous infusion-NURSES OUTLOOK

INTRAVENOUS INFUSION

                                           

OBJECTIVES:

At the end of the demonstration, the students will be able to:

·       Enumerate the purposes of infusion.

·       Discuss physiological mechanism of infusion.

·       List the types of fluid used for infusion.

·       Describe the procedure used for infusion.

·       Discuss the complications of I.V infusion.

INTRODUCTION:

Fluid is an essential component required for a living being. Both fluids and electrolytes are essential for a person to maintain good health and their homeostasis. Fluid balance depends on the balance between the fluid intake and fluid output, that is, gain in the body fluid must be equal to the fluid loss. When the fluid intake is less than the fluid loss, it causes fluid imbalance. Excess fluid loss causes dehydration. An average adult having moderate activity requires about 2600 ml of fluid. The body may lose fluid by vomiting, diarrhoea, hemorrhage, gastric and intestinal suction, etc, dehydration and Hypovolemia, that is characterised by dryness of skin, mucus membrane, acute weight loss, coated tongue, decreased urinary output, loss of skin texture, sunken eye balls etc. To overcome this loss, fluids have to be replaced in body through the intravenous route called infusion.

DEFINITION:

It is an introduction of a large amount of fluid into the body through veins.

PURPOSE:

·       

     To restore the body fluids in case of bleeding and dehydration.

·       To meet the basic requirement of the body e.g. calorie, water, minerals and vitamins.

·       To overcome and prevent shock and collapse.

·       To supply the body, an adequate amount of electrolyte, nutrients, when the patient is unable to take orally in case of oral surgery, oral cancer.

·       To restore acid-base balance.

·       To monitor central venous pressure.

TYPES OF FLUID AND SITES OF INFUSION:

Types of fluids:

SOLUTION	ACTION	NURSING INTERVENTIONS AND CONCERNS
Hypotonic solutions (less than 250 mOsm/L) ·       2.5% dextrose in water. ·       0.25% sodium chloride solution. ·       0.33% sodium chloride solution. ·       0.45% sodium chloride solution.	Will hydrate the cells; pulls fluid from the vascular space into the cellular space.	These solutions may further exaggerate hypotension due to fluid shifting out of vascular space; do not administer these fluids to hypotensive patients.
Isotonic solutions (250-375 mOsm/L) ·       5% dextrose in water. ·       0.9% sodium chloride solution. ·       Ringer’s injection. ·       Lactated ringer’s solution.	Will hydrate the extracellular compartment; replace fluid volume without disrupting the intracellular and interstitial volumes.	5% dextrose is isotonic when infused but becomes hypotonic when the dextrose has been metabolised. Use cautiously in patients who is fluid overloaded or who would be compromised if vascular volume would increase, such as renal and cardiac patients.
Hypertonic solutions (greater than 375 mOsm/L) ·       5% dextrose in 0.45% sodium chloride solution. ·       5% dextrose in 0.9% sodium chloride solution. ·       5% dextrose in lactated ringer’s lactate solution.	Will draw out fluid of intracellular space, leading to increased extracellular volume both in vascular and interstitial space.	These solutions can be very irritating to the veins, so observing the IV site for inflammation is imperative; may cause circulatory overload , so these solutions should be infused slowly to prevent this in vulnerable patients; may increase serum glucose in patients with glucose intolerance, which would make more frequent glucose monitoring an important intervention.
Plasma expanders ·       Dextran 70 (isotonic) ·       10% mannitol (hypertonic) ·       20% mannitol (hypertonic) ·       5% albumin ·       25% albumin ·       0.9% sodium chloride ·       10%  hetastarch in 0.9% sodium chloride.	Increases volume in the vascular space. Will draw fluid out of intracellular space, leading to increased extracellular volume both in vascular and interstitial space.	Monitor patients carefully for circulatory overload; monitor for hypersensitivity reactions; medications should not be given with or added to these solutions. These solutions can be very irritating to the veins, so observing the IV site for inflammation is imperative; may cause circulatory overload, so these solutions must be infused slowly to prevent this in vulnerable patients; may increase serum glucose in patients with glucose intolerance, which would make frequent glucose monitoring an important nursing intervention.

Composition of fluids:

·       Saline solution – water and electrolytes.

·       Dextrose solution – water or saline and sugar.

·       Ringer’s lactate – water and electrolyte and sugar.

·       Balance isotonic – water, electrolytes and some sugar.

·       Whole blood and blood components.

·       Plasma expanders – albumin, dextrin, plasma protein fraction (plasmanate).

Sites:

When selecting a site for I/V check:

·       Condition of the vein.

·       Characteristics of the tissue over the vein.

·       Purpose and duration of infusion.

·       Type and amount of fluid prescribed.

·       Diagnosis and general condition of the patient.

Most commonly used veins are:

·       Veins of the forearm (basilic and cephalic veins).

·       Veins in ante cubital (median cubital, cephalic and basilic veins).

·       Veins in radial area (radial veins).

·       Veins in hand (dorsal metacarpal veins).

·       Veins in the foot (dorsal).

·       Femoral and saphenous veins.

·       Veins in the scalp (for infants).

CALCULATION OF THE FLOW RATE OF I/V INFUSION:

Flow rate of the fluid is calculated by using a formula

Flow rate = total volume infused in ml    X   drops per ml

                      Total time of infusion in minutes

e.g. total volume infused = 3000 ml in 24 hrs

1 ml = 15 drops (depends on the lumen of the needle)

Total time in minutes = 24 X 60 = 1440 minutes

Flow rate = 3000 X 15 = 31 drops per minute

                        1440

COMPLICATIONS OF I/V INFUSION:

1.     Circulatory overload.

2.     Infiltration.

3.     Extravasation of blood (hematoma).

4.     Thrombophlebitis.

5.     Air embolism.

6.     Pyrogenic reaction.

7.     Infection.

8.     Allergic reaction.

9.     Serum hepatitis.

10.  Nerve damage.

11.  Osmotic diuresis.

General instructions for I/V infusion:

·       Have a clearly written prescription, before starting I/V infusion.

·       Follow a strict aseptic technique throughout the procedure.

·       Maintain the prescribed rate of flow.

·       Observe the patient constantly for any unfavourable symptoms, dislodgement of needle, fluid level of bottle, Thrombophlebitis.

·       Check and recheck the solutions used for infusion for the expiry date, sediments, suspended particles, colour and cloudy appearance.

·       Observe five rights – right patient, right medicine, right dose, right route and right time.

·       Make sure that the drip set is sterile and in a good working order.

·       Select the proper site for infusion.

·       Check the rate of flow, if it is slow or stopped check for

a)       Displacement of needle.

b)       Spasm of vein.

c)       Kinking of tube.

d)       Low pressure within the I/V fluid.

·       Never allow the bottle to get empty completely to prevent entry of air, if I/V has to be continued have a new bottle ready at hand.

·       Always use isotonic saline before blood and after blood transfusion to prevent haemodialysis of blood cell in the tubing.

·       Keep the patient warm and comfortable.

·       If the needle is in place near a joint, use splints to immobilize the joint.

·       Observer the vital signs throughout the procedure to prevent complications.

·       Offer a bedpan or urinal before infusion.

·       Reassure the patient often, and keep an attendant near the bed side.

PREPARATION OF THE PATIENT:

·       Identify the patient’s name bed no. And diagnosis.

·       Check the purpose of infusion.

·       Check the physicians prescription for the type of infusion fluid, strength, amount rate of the flow, duration.

·       Check the condition of the patient to see his ability to follow the instructions,

·       Check the site of infusion.

·       Check the limitation of the patient.

·       Observe the need for an additional restraint or an attendant.

·       Check the articles for their working order.

PREPARATION OF ARTICLES:

ARTICLES A tray containing:	RATIONALE
I.V solutions or fluid bottles.	To administer fluids without any interruption or delay.
A sterile scalp vein or butterfly with a vein flow.	It is used for a suitable vein and allows free movement.
A sterile I/V set with tubing.	To supply fluid into the patient.
A sterile syringe with needle no. 20-22.	To add medication to the I/V drip or initiate or start the procedure.
Sterile cheatle forceps.	To handle the sterile supplies.
Sterile cotton swabs and gauze pieces in a sterile container.	To clean the skin at the site of infusion.
A bowl with a disinfectant.	To discard the used syringes.
Tourniquet, splint with bandage, mackintosh and towel.	To occlude venous return and to make the vein visible.
A kidney tray and a paper bag.	To discard the used swabs.
Methylated spirit in a container	To clean the skin.
An I/V pole.	To hang the bottle at the desired height.
A needle crusher.	To crush the used needles.
An adhesive plaster roll.	To fix the needle and set.

STEPS OF THE PROCEDURE:

1.     Explain the procedure to the patient.

2.     Wash hands with soap and water.

3.     Check the physician’s order for the type and amount of fluid to be introduced.

4.     Prepare the I/V solution carefully. Open the bottle seal and clean the top with a sterile swab holding the bottle upright. Insert the needle drip set and air vent into the bottle opening.

5.     Close the screw clamp to prevent fluid loss.

6.     Hang the bottle on the I/V stand about 18-20” high from the bed to facilitate flow of fluid through gravity.

7.     Connect the needle to the I/V tubing and remove the protective covering.

8.     Open the clamp, flush I/V infusion fluid throughout tubing and needle into the kidney tray until all air is removed. Clamp the tubing and reapply the protective cap over the needle.

9.     Prepare a few strips of adhesive tape and keep ready for use.

10.  Prepare the site for giving infusion.

11.  Place the extremity in a proper position for easy introduction of the needle.

12.  Apply tourniquet firmly 6-8” proximal to the site.

13.  Massage or stroke the vein distal to the knot and in the direction of venous flow to the heart.

14.  Encourage the patient to close and open the fist rapidly to distend the vein.

15.  Lightly tap the vein with finger tips.

16.  Clean the area with a spirit swab and dry.

17.  Grasp the arm distally.

18.  Hold the needle at 30^o with the bevel up and puncture the skin laterally. Once the needle enters the skin it becomes parallel with the skin. Then pierce the site of the vein.

19.  When the backflow of blood occurs into the needle and tubing, insert the needle further.

20.  Release the tourniquet and open thee clamp to allow the fluid to flow in.

21.  Secure the needle and tubing in place.

22.  Secure the needle with H method.

23.  Apple one adhesive strip beneath the needle and one cross to the opposite.

24.  Use splint to immobilize the site or joint.

TERMINATION OF THE PROCEDURE:

·

           After care of the patient and articles.

  ·       Remove the mackintosh and towel.

·       Make the patient comfortable.

·       If the patient is conscious, instruct him not to move the site.

·       Dismantle all the articles.

Record the following:

·       Time of starting the fluid.

·       Type of fluid.

·       Concentration of the solution.

·       Amount of fluid.

·       Rate of flow.

·       Any medicine added to the bottle.

·       Any reaction noted in the patient.

Observe frequently for the following:

·       Fluid chamber is not dripping.

·       Quantity of I/V fluid in the bottle before it gets empty.

·       Any back flow of the blood from the needle site.

·       Needle and connection of the tubing are intact.

·       Swelling of tissue around the needle site.

·       Any unusual symptoms e.g. chills, rigor, restlessness.

Discontinuing infusion:

·       Clamp the tubing.

·       Loosen the adhesive tape.

·       Withdraw the needle by the hub in line with the vein and hold a dry sterile swab over the needle site. When the needle is out, apple firm pressure over the site.

·       Discard the bottle and tubing.

·       Record the total amount of fluid infused.

·       Watch the general condition of the patient after the fluid has been discontinued.

·       Record the termination of infusion with relevant observations.

Storage of articles:

Collect all the articles used for the infusion, carry them to the treatment room, clean them first with cold water, rinse thoroughly, disinfect them and store them in the right place. Discard the needle, I/V bottle with tubing – all disposable items.