IV Priming/IV Medications by M34fxMy

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									Chapter 28 (Perry & Potter)
IV Priming
 Why do clients need an IV?

   Replacing fluids


   Correct or prevent nutritional imbalances


   Provide IV medication therapy
Nursing Responsibilities
1.   Know the correct solution & equipment needed & how
     to initiate the infusion

2.   Regulate the infusion (with or without a pump)

3.   Care for and maintain the system

4.   Indentify and correct problems

5.   Discontinue the infusion as ordered
Categories of IV solutions
1.   Isotonic
2.   Hypotonic
3.   Hypertonic

    Determined by serum electrolyte values and
     fluid volume balance

    RN must understand the rationale for IV fluid administration
     and the type of solution ordered
Isotonic solution: same osmolarity as plasma. Prevents fluid shifts.
   (0.9% NS)

*Hypotonic solution: lesser conc of solutes than plasma. Fld shifts into
  cell. (0.45%NS)

*Hypertonic solutions: greater conc of solutes than plasma. Draws
  fluid out of the cells. (5% Dextrose .45 NS)
HYPOTONIC vs. HYPERTONIC
 Solution of lower osmotic           Solution of higher osmotic
  pressure                             pressure
 Less salt or more water than        3% sodium chloride is example
  isotonic                            If infused into blood, water moves
                                       out of cells & into solution (cells
 If infused into blood, RBCs
                                       wrinkle or shrivel)
  draw water into cells (can swell
                                      Solutions pull fluid from cells
  & burst )
 Solutions move into cells
  causing them to enlarge
Establish IV Access
 IV catheter & tubing can remain in place for 72 hours (check
  hospital policy), IV solution replaced every 24 hours

 Palpate insertion site daily and prior to initiating infusion

 Inspect site if client c/o pain at site or developed S&S of
  infection

 Change transparent dressing if becomes damp, soiled, loose

 Clean injection port with antiseptic before accessing system
Supplies
 Administration set (IV lines)
 Correct IV solution
 Antiseptic swabs
 Tape
 IV pole, rolling or ceiling mounted
 Hospital gown with snaps
 1-3 ml normal saline, 3 ml syringe (or larger)…pre-
 filled n/s syringes may be available, to flush IV
 catheter prior to initiating infusion
Assessment
 Review physician’s order (type, amount and/or rate)


 6 medication rights (medication, dose, client, route, time,
  documentation)

 Physical assessment pertaining to IV fluid administration


 Understand rationale and purpose of IV fluid, potential
  incompatibilities, and potential side effects
Nursing Diagnosis
 Risk for imbalanced fluid volume


 Deficient fluid volume


 Excess fluid volume


 Risk for infection
Implementation
 Change gown


 Prepare tubing and solution
   Check solution (6 rights)
   Color
   Clarity
   Expiration date
   Leaks
 Open infusion set (maintaining sterility of each end)


 Place roller clamp 2-5 cm below drip chamber and move to
  OFF position

 Remove sheath over port on IV solution bag


 Remove tubing spike (DO NOT TOUCH)


 Insert spike into IV bag
 Priming:
    Compress drip chamber, fill 1/3 to ½

    Remove cap on end of tubing, KEEP and maintain sterility

    Slowly open roller clamp and prime tubing with fluid,
     return roller clamp to OFF position

    Inspect for air bubbles, tap tubing where bubbles are visible,
     and invert ports and tap to fill and remove air

    Replace cap from end of tubing

    Label tubing and bag with date and time
 Prepare N/S (1-3 ml) to flush intermittent infusion device
  (saline lock, PIID, clave) (p. 749/750 – establish IV
  access)

 Saline lock is attached to end of IV catheter which is then
 attached to the primary line
    Has a port or stopper (needleless)

    Must be irrigated (flushed) q8-12 h, and before & after each drug
     infusion (hospital policy)

    Saline or heparinized saline (hospital policy & dependent on IV
     access Line/ site)

    Sterile technique
Regulating IV Flow Rate
(Gravity)
 Flow rate established using pump (ml/hr) or gravity
  (gtt/min)

 If line patent and IV infusion initiated, flow rate must
  be established

 Educate client regarding positioning

 Inspect site often
 What is the drop factor: number of drops per ml (gtt/ml)
  IV tubing provides:

  Microdrip: 60 gtt/ml

  Macrodrip: Abbott: 15 gtt/ml
            Travenol: 10 gtt/ml
            McGaw: 15 gtt/ml
Calculating drip rate:

ml/hr x gtt/ml        =   drops/min
   60 min
                 Or

ml x     gtt     x    1 hr = drops/min
hr       ml           60 min
If ml/hr unknown:


 ml/hr = total infusion (ml)
        hours of infusion (hr)
Remember: if infusion is not exactly 1 hour
(15 min, 30 min, 2 hrs, 4 hrs etc…) you must calculate
hourly rate.
Example: (infusion over 15 mins)

50 ml x ?           =    200 ml
15 min  60 min               hr

              Or

50 ml x ?    =       200 ml
0.25 hr 1 hr             hr
Example: (infusion over 4 hrs)

1000 ml   x   ?    =     250 ml
4 hr          1 hr           hr
 Example:
Order: D5W @ 75 ml/hr
Drop factor: 15 gtt/ml
Calculate drip rate: ? gtt/min

Answer: 75 ml/hr x 15 gtt/ml = 18.75 gtt/min
          60 minutes             (18-19 gtt/min)
 Example:
Order: Give 1 L Ringer’s Lactate over 4 hours
Drop factor: 15 gtt/ml
Calculate drip rate: ? gtt/min

Answer:       1000 ml x      ?       =    250 ml
              4 hr           1 hr             hr

             250 ml/hr x 15 gtt/ml = 62.5 gtt/min
                 60 minutes        (62- 63 gtt/min)
Establishing Drip Rate
 Count drops in drip chamber for 1 minute (with second
  hand), adjust roller clamp as needed (2-5 cm below drip
  chamber)

 If very fast or very slow, count for 30 sec (x 2) and adjust
  roller clamp. Count for 1 full minute once clamp is
  adjusted .
Evaluation
 Monitor infusion at least q1h (note volume, rate)


 Assess for S&S of over hydration or dehydration,
  response, lab values

 Assess S&S of infiltration, inflammation, clot in catheter,
  kink or knot in tubing etc…
Recording and Reporting
 Rate of infusion, gtt/min, and ml/hr in nursing notes or IV
  fluid form

 Document any ordered changes in IV fluid rates


 Report rate, solution, volume remaining to the nurse
  assuming care of client at break or change of shift
Practice Priming
Chapter 22 (Perry & Potter)
                 p.604-609
Piggyback (p.609)
A small IV bag connected to short tubing
that is connected to the upper Y port of a
primary infusion line. The small bag is set
higher than the primary infusion bag. Upon
completion of the secondary solution when
the solution in the tubing falls below the
primary drip chamber the primary solution
begins again.
IV Medication
Secondary line (piggyback)
 Prepare medications: 6 rights and 3 checks


 Medical history & allergies


 Review medication indication
 Drugs prescribed 1 to 6 times per day, dissolved in
  small volumes of IV fluid (mini-bag: 50mL, 100mL,
  250mL)

 Usual infusion time : 30 to 60 minutes


 Check compatibility of drug to solution
When mixing powders for injections, remember:

•Check the type of fluid recommended to
dissolve the powder

•The amount of fluid to add

•The strength of the solution made (i.e. mg/ml)

•Further dilution for infusion

•Infusion time
Where to find information regarding reconstitution
of the powder

•The label of the vial

•Package insert inside the vial package

•Nursing Drug book

•Compendium of Pharmaceuticals and Specialties ( CPS)

•Parenteral drug manual

•Ottawa General (most common & you should know where
this is on your unit)
Medication Calculation
Example:
 Order: Drug 0.65 g QID IV
 Label directions : Add 2.5 ml water for injection. Provides
  approx volume of 3 ml (325mg/ml)
 Note : the manufacturer gives the strength of the solution
 Desire 0.65g
 Have: 325 mg/ml
 Stock : in every ml
 Desire: 0.65 g
 Have: 325 mg/ml
 Stock : in every ml

Convert: 0.65g to mg
1g = 1000 mg ( therefore answer should be bigger)
1000mg = Three zeros
Therefore move decimal point three spaces to the right
0.65 g = 650 mg
        Desire X       Stock = Amount
        Have
         650 mg    X    1ml   =   2mL
         325 mg
Calculation of Drip Rate
Example:
Order: Flagyl 500mg/100 ml normal saline IV BID
           (administered over 1 hour)
Drop factor: 15 gtt/ml
Calculate drip rate: ? gtt/min

Answer:           100 ml
                    1 hr

             100 ml/hr x 15 gtt/ml = 25 gtt/min
                 60 minutes
 When calculating IV rates, if the medication volume exceeds
  10 ml, add this into calculations (i.e. 10% rule, 5 ml 10% 50
  ml, 10 ml 10% of 100 ml)


Example:
Amount: 100 ml NS plus 10 ml penicillin=110 ml
Duration: Give over 30 minutes
Calculate rate: ? ml/hr

            Answer:         110 ml x ?   = 220 ml
                             0.5 hr 1 hr      hr
Let’s Practice
(vial containing a powder) p.585

   Reconstitution of medication


   Adding to secondary bag


   Attaching secondary line to primary line


   Regulating rate
 Follow 6 rights and 3 checks


 Wash hands


 Gather supplies
    Medication, secondary line,10 ml syringe, 18-22 gauge
     needle (filtered if indicated), alcohol swabs, dilutant (saline
     or sterile water), mini bag (medication bag), medication
     label, MAR
Order
Ampicillin 500 mg IV, q6h
     See vial for directions: to have 500 mg/ml add 5.6 ml dilutant
     IV drug manual indicates: add to 50 - 100 ml normal saline and
      infuse over 60 minutes
     How many ml of medication will you add to your minibag?
     What is the rate (ml/hr)?
     What is the drip rate with drop factor of 15 gtt/ml?


Answers: 50 ml    50 ml/hr X 15 gtt/ml = 12.5 gtt/min (12-13)
          hr             60 min

        100 ml    100 ml/hr X 15 gtt/ml = 25 gtt/min
          hr             60 min
Preparation
 Remove cap covering medication and dilutant (6 rights, 3
  checks), swab both rubber seals with alcohol swab and allow to
  dry

 Attach needle (or needleless device) to syringe, pull back on
  plunger drawing the equivalent amount of air (i.e. 5.6 ml) as
  solution and inject into solution (hold plunger firmly, vial on
  flat surface)

 Invert vial and allow pressure from the vial to fill syringe with
  solution (5.6 ml), pull back gently if required. Keep tip of
  needle in fluid. Place vial on flat surface to remove needle

 Inject dilutant into medication vial, remove needle and recap
  (scoop technique)
 Roll in palms (DO NOT SHAKE)
 Wait until medication is clear, swab medication bottle again,
    and withdraw desired amount (follow same steps as
    withdrawing dilutant (inject equal volume of air (i.e.1 ml) as
    medication to be removed)
   Adding medication to secondary bag: wipe port with alcohol
    swab, lay medication bag on flat surface, insert needle and
    inject. Discard needle (no need to recap)
   Mix medication turning gently end to end
   Complete medication label (apply to back of medication bag)
   Spike bag with secondary IV tubing, ensure clamp is CLOSED
 Clean port of main line and connect secondary tubing to
  medication bag, squeeze and fill drip chamber.
 Back prime: drop medication bag below level of primary
  drip chamber, open secondary line roller clamp, prime
  line, hang medication bag above primary fluid bag (use
  hook to lower main bag)
 Regulate flow by adjusting regulator clamp or using IV
  pump
 Observe for S&S of reaction
 Assess IV site frequently
Order
Ampicillin 500 mg IV, q6h
    See vial for directions: 500 mg/ml add 5.6 ml solution
    IV drug manual indicates: add to 50 - 100 ml normal saline
     and infuse over 60 minutes

Answers: 50 ml     50 ml/hr X 15 gtt/ml = 12.5 gtt/min (12-13)
          hr              60 min

        100 ml     100 ml/hr X 15 gtt/ml = 25 gtt/min
          hr              60 min
Next Lab
   Subcutaneous Injection & Insulin
              Chapter 22
             (p.573-598)

								
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