Chapter 27 (Perry & Potter)

Chapter 27 (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 an maintain the system
4.
Indentify and correct problems
5.
Discontinue the infusion
Categories of IV solutions
1.
2.
3.
Isotonic
Hypotonic
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
Establish IV Access
 IV 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 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)…prefilled n/s syringes may be available, to flush IV
catheter prior to initiating infusion
Nursing Diagnosis
 Risk for imbalanced fluid volume
 Deficient fluid volume
 Excess fluid volume
 Risk for infection
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
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
 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 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
60 min
=
drops/min
If ml/hr unknown:
ml/hr = total infusion (ml)
hours of infusion
Remember: if infusion is not exactly 1 hour
(15 min, 30 min, 120 min, etc…) you must calculate
hourly rate.
50 ml x ?
15 min 60 min
=
200 ml
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 ?
240 min
60 min
=
250 ml
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 overhydration 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 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 indication
 Drugs 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 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 (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
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
325 mg
X
1ml
=
2mL
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 x ?
60 min
60 min
=
100 ml/hr x 15 gtt/ml = 25 gtt/min
60 minutes
100 ml
hr
 When calculating IV rates, if the medication volume exceeds
5 – 10 ml, add this into calculations
Example:
Amount: 100 ml NS plus 8 ml penicillin=108 ml
Duration: Give over 30 minutes
Calculate rate: ? ml/hr
Answer:
108 ml x ?
= 216 ml
30 min 60 min
hr
Let’s Practice
(vial containing a powder) p.706
 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/min?
Answers: 50 ml X ?
= 50 ml
60 min 60 min
hr
gtt/min = 50 ml/hr X 15 gtt/min = 12.5 gtt/min
60 min
(12-13)
100 ml X ?
= 100 ml
60 min 60 min
hr
gtt/min = 100 ml/hr X 15 gtt/min = 25 gtt/min
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 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 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 X ?
= 50 ml
60 min 60 min
hr
gtt/min = 50 ml/hr X 15 gtt/min = 12.5 gtt/min
60 min
(12-13)
100 ml X ?
= 100 ml
60 min 60 min
hr
gtt/min = 100 ml/hr X 15 gtt/min = 25 gtt/min
60 min
Next Lab
Subcutaneous Injection & Insulin
Chapter 21