IV Priming/IV Medications

IV PrimingChapter 27 (Perry & Potter)IV PrimingWhy do clients need an IV?

Replacing fluids

Correct or prevent nutritional imbalances

Provide IV medication therapyNursing ResponsibilitiesKnow the correct solution & equipment needed & how to initiate the infusion

Regulate the infusion (with or without a pump)

Care for and maintain the system

Indentify and correct problems

Discontinue the infusion

Categories of IV solutionsIsotonic HypotonicHypertonic

Determined by serum electrolyte values and fluid volume balance

RN must understand the rationale for IV fluid administration and the type of solution ordered

Establish IV AccessIV catheter can remain in place for 96 hrs (check hospital policy, most are 72 hours), 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 systemSuppliesAdministration set (IV lines)Correct IV solutionAntiseptic swabsTapeIV pole, rolling or ceiling mountedHospital gown with snaps1-3 ml normal saline, 3 ml syringe (or larger)pre-filled n/s syringes may be available, to flush IV catheter prior to initiating infusionNursing DiagnosisRisk for imbalanced fluid volume

Deficient fluid volume

Excess fluid volume

Risk for infectionAssessmentReview physicians 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

ImplementationChange gown

Prepare tubing and solutionCheck solution (6 rights)ColorClarityExpiration dateLeaks

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 bagPriming: Compress drip chamber, fill 1/3 to

Remove cap on end of tubing, KEEP and maintain sterility

Slowing 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 establish IV access, pictureA)

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 q8-12 h, and before & after each drug infusion (hospital policy)

Saline or heparinized saline (hospital policy)

Sterile techniqueRegulating 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/mlCalculating drip rate:

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

ml x gtt x 1 hr = drops/minhr 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 ml15 min 60 min hr

Or

50 ml x ? = 200 ml0.25 hr 1 hr hrExample: (infusion over 4 hrs)

1000 ml x ? = 250 ml4 hr 1 hr hr

Example:Order: D5W @ 75 ml/hrDrop factor: 15 gtt/mlCalculate 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 Ringers Lactate over 4 hoursDrop factor: 15 gtt/mlCalculate 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 RateCount 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 .EvaluationMonitor infusion at least q1h (note volume, rate)

Assess for S&S of overhydration or dehydration, response, lab values

Assess S&S of infiltration, inflammation, clot in catheter, kink or knot in tubing etc

Recording and ReportingRate 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 shiftPractice PrimingIV MedicationSecondary LinesChapter 21 (Perry & Potter)Piggyback (p. 737)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 indicationDrugs prescribed 1 to 6 times per day, dissolved in small volumes of IV fluid

Usual infusion time : 30 to 60 minutes

Check compatibility of drug to solutionWhen mixing powders for injections, remember:Check the type of fluid recommended to dissolve the powderThe amount of fluid to addThe strength of the solution made (i.e. mg/ml)Further dilution for infusionInfusion timeThe label of the vialPackage insert inside the vial packageNursing Drug bookCompendium of Pharmaceuticals and Specialties ( CPS) Parenteral drug manual

Where to find information regarding reconstitution of the powder

Medication CalculationExample:Order: Drug 0.65 g QID IVLabel directions : Add 2.5 ml water for injection. Provides approx volume of 3 ml (325mg/ml) Note : the manufacturer gives the strength of the solutionDesire 0.65gHave: 325 mg/mlStock : in every ml

Desire X Stock = AmountHave650 mg X 1ml = 2mL325 mgConvert: 0.65g to mg1g = 1000 mg ( therefore answer should be bigger)1000mg = Three zeros Therefore move decimal point three spaces to the right0.65 g = 650 mg

Desire: 0.65 gHave: 325 mg/mlStock : in every mlCalculation of Drip RateExample: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 5 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 8 ml penicillin=108 mlDuration: Give over 30 minutesCalculate rate: ? ml/hr

Answer: 108 ml x ? = 216 ml 0.5 hr 1 hr hr

Lets Practice (vial containing a powder) p.706Reconstitution of medication

Adding to secondary bag

Attaching secondary line to primary line

Regulating rateFollow 6 rights and 3 checks

Wash hands

Gather suppliesMedication, 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, MAROrderAmpicillin 500 mg IV, q6hSee 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 minutesHow 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

PreparationRemove 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 withdrawal desired amount (follow same steps as withdrawing dilutant (inject equal volume of air (i.e.1 ml) as medication to be removed)Add 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 endComplete 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 pumpObserve for S&S of reactionAssess IV site frequentlyOrderAmpicillin 500 mg IV, q6hSee vial for directions: 500 mg/ml add 5.6 ml solutionIV 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 LabSubcutaneous Injection & InsulinChapter 21