Parenteral/Intravenous Therapies (Nursing)

00:01 Hi! My name is Jill Beavers-Kirby. And today we’re going to be talking about intravenous and parenteral therapies. So, why do we need to give IV therapy? First of all, let me just point out that starting an IV is not a test that you can delegate to somebody who’s unlicensed. This is true in all 50 states. So, the registered nurse will have to start the IV. So, why do we need an IV? Well, sometimes we need it for fluid replacement, or sometimes we need it for electrolyte replacement such as potassium. The purpose of the IV will determine the type of the IV that’s inserted, the size also known as the gauge, and what type of tubing you’ll need. So, what kind of personal protective equipment do we need when we start an IV? Gloves are always worn when you start an IV or when you stick somebody with a needle. And gloves are always worn when you’re stopping the IV or discontinuing. The gloves are clean gloves. They don’t have to be sterile gloves for a peripheral IV. So, basic nursing facts, you’re going to want to remember to look at the IV site every two hours. Is there any edema or swelling or redness or tenderness around the IV site? Is there any drainage around the IV site? Is there any bleeding at the IV site? These are all abnormal signs that you’ll want to stop the IV for and do something about. As I said before, you want to wear clean gloves, not sterile, when stopping your IV. After you stopped the IV and you pulled the catheter out, you’ll want to hold manual pressure for about one to three minutes to make sure the bleeding has stopped. So, what are some complications of IV therapy? One is occlusion.

01:45 This simply means that something is occluding, the tubing, or the infusion from going in.

01:51 This can be like a crimped tubing or something a patient even bending their arm if the IV site is in their elbow. Another complication can be an infiltration. This is when IV fluids will seep into the subcutaneous tissue around the IV site. Depending on the fluid, you might see the skin turn like a whitish color which is called pallor, or it might be cool because of the temperature of the IV fluid. Another complication is phlebitis, and probably a lot of people have heard of this. This is irritation and inflammation along the vein of the actual arm or body part that the IV is in. You’ll see erythema, redness, and it can be a little tender. And then, the last complication is skin damage. This is usually seen with toxic medication such as chemotherapies. The skin may be really white or it may be really red and you can get blisters around the site. And it is usually almost always painful. Another IV fluid that we infuse frequently is called total parenteral nutrition or TPN. So, what is the purpose of TPN? This is used to give patients nutrients who can’t keep up with their own nutritional needs. You’ll see this in patients who have chronic nausea and vomiting, patients with stomach cancers.

03:17 There is a lot of reasons why a patient might need TPN. But TPN has to be infused through a large catheter that goes centrally into the system. You can’t infuse TPN through a small little peripheral IV in somebody’s hand or somebody’s arm because there is a lot of sugar in this medication, and it can cause damage to your skin. So, it will contain glucose, other nutrients. It can even contain lipids which are body fats, and it will make the TPN look sort of like a milky color.

03:50 So, why do we use TPN? This is needed for nutrition and to provide somebody electrolytes when they can’t keep up with their own nutritional needs. What type of personal protective equipment do we need? As stated before, TPN goes centrally into somebody’s system, so you have to wear sterile gloves and use sterile technique any time you work with TPN. So, the flow rate of the TPN is usually determined by the pharmacist. It can’t be given too fast because the patient can’t get an overload of glucose, especially, or other electrolytes like potassium.

04:27 And it can’t be given too slow because this will cause the IV line to clog off from this heavy sugary solution. So, the goal is to usually give one to two liters over 24 hours. And as stated before, your pharmacist will figure out the flow rate.

04:42 So, how do we care for the patient who is receiving TPN? Our biggest concern is to prevent infection with these patients. We want to maintain sterility. I cannot express that enough. Remember sterile technique and sterile gloves. Once again, you have to assess your IV site every two hours. Remember, we’re looking for erythema, redness, leakage, phlebitis, pain at the site. Anything that looks abnormal, you need to let the physician know right away.

05:14 We also do sterile dressing changes on TPN and central line IV sites. So your hospital or your institution that you’re working at will have their own policy about how frequently to change these central line dressing sites. The standard is usually every 48 to 72 hours, about every two to three days. Obviously, if the site gets soiled or if there’s leakage or bleeding or anything, you’ll change the site sooner. Just remember, you have one IV line for your TPN. Nothing else can be infused with this. You can’t piggyback any other IVs into this. You cannot give blood through the same line that you’re giving TPN.

05:55 And you can’t give any medications in the same line that you’re giving a TPN.

05:59 That’s because there are so many nutrients and other electrolytes in the solution that it just doesn’t mix with other medications or blood. Never ever, ever, ever can you do this, never.

06:10 If you need to give a medication or blood, you’re going to have to get another IV access point. So, how do we maintain the TPN system? First thing is we prevent complications.

06:22 The nurse will often assist the physician in putting in these lines. These lines can be put in at the bedside or in an official OR suite. So, one of the potential complications is correct placement. These lines are often placed in large veins, such as the subclavian vein or the internal jugular vein. So, correct placement has to be verified by a chest X-ray.

06:46 Just because you get blood return from the line does not mean that the line is in the correct place. Please remember that. You have to have a chest X-ray verifying the placement before you put anything into this line. Always, always, always.

07:00 Another potential complication is an air embolus. Air emboli can occur during insertion because once again, we’re going into the large veins or it can occur after insertion if you don’t have the connections on your IV tubing tightened down. A patient can get an air embolus.

07:19 So, what is another complication of TPN? Hyperglycemia which is when the patient’s blood glucose level is greater than 150. This can be caused from the amount of dextrose solution in the actual TPN, or from running the solution too fast, or from infection. Infection in a person’s body feeds off a glucose so your body will make more glucose thinking that the glucose level is low if you have an active infection. Or some medications that the patient is taking can also lead to elevated blood glucose levels when you’re giving a sugary solution in the veins. Some of these medications are blood pressure pills. And as we know, a lot of our patients are going to be on blood pressure pills. So, for the hyperglycemia, it’s usually a standing order to monitor somebody’s blood glucose every six hours or four times a day.

08:12 You’ll have to get your institution’s policy to see which one you need to do.

08:16 On the reverse side, another potential complication is hypoglycemia. This is when your blood glucose level falls below 70. This is usually caused from too much insulin in the TPN solution because you have to have insulin in the TPN solution because you have glucose in the TPN solution, so they have to balance each other out. Another way that hypoglycemia is caused is if you just suddenly go in and stop the TPN. So say, for example, the physician says, “Okay. We can stop this patient’s TPN. Here, she’s eating well and we’ll be able to get rid of this.” Well, you don’t just go and stop it. You usually will cut the rate in half. So for example, if somebody is getting 84 ml of TPN an hour, you’ll cut the rate in half to 42 ml an hour for the next two hours, and then you can turn the solution off. You have to taper down the solution. You can’t just stop it because the patient’s blood sugar will crash. It’s not a very fun picture.

09:17 So, what is the nursing assessment for IVs and TPN? Well, we look at the site how often? Every two hours. You want to make sure that there’s no redness, no drainage, no edema, no tenderness, no erythema. The IV site should look just as good as it did the day the IV was put in. Peripheral sites, they can stand for about 72 to 96 hours. That’s three to four days. Most institutions will say 72 hours. On a rare occasion, they’ll say, “Okay.

09:51 This person has a hard stick. We’ll go ahead and leave it in for another day as long as the site looks okay.” That is rare and you need to make sure that you’re reading your institution’s policy so you understand what your institution wants you to do. My name is Jill Beavers-Kirby, and this has been your lecture on intravenous and parenteral therapy. Thank you.