SUBCUTANEOUS INJECTION

- 1 mL syringe

- 25-27 gauge needle

- Outer upper arms, abd, anterior thighs, upper buttocks below waist

- pinch

- 45-90 degree angle

- Aspiration optional

- Do not massage

- Not with Heparin or Insulin

INTRAMUSCULAR INJECTION

- Deliver drug to muscle layer below SC

- Rapid systemic, lg doses

- muscles have fewer sensory nerves

- Z-track

- Dart-like

- Always aspirate

INTRAMUSCULAR INJECTION SITES

-Ventorgluteal - hand on side of waist

- Vastus Lateralis - mid lateral portion of thigh

- Deltoid Muscle - Triangle upper arm

- Dorsogluteal -

CRITERIA FOR CHOOSING EQUIPMENT AND INJECTIONS

- Route of administration

- Viscosity of the solution

- Quantity to be administered

- Body Size

- Type of Medication

- Condition of patient's muscle mass

INTRAMUSCULAR INJECTIONS

- 1-3 mL syringe

         - 0.5 - 1mL is deltoid

         - 3 mL in Vastus, Ventrogluteal

- Less than 1 mL, use TB or IM needle

- Gauge 21-23

         - determined by viscosity

- Length 1 1/2"

               - length by muscle mass

Z TRACK

- Deliver All Injections With Responsibility

- Displace

- Aspirate

- Inject (wait 10 seconds

- Withdraw

- Release

DELTOID SITE

- Immunizations and non-irritating meds

- Less than 2 mL

- Risk injury to brachial artery and radial nerve

- Acromium process

- Index and middle finger

- 1-2" below acromium in center of triangle

VENTROGLUTEAL SITE

- Free of major blood vessels or nerves

- Less fatty tissue

- Safest and least painful

- Thumb towards front

VASTUS LATERALIS

- Safe, rapid absorption

- Middle third of the muscle

- Mid-lateral portion of the thigh

- Infants, children, adults

- Needle 1" or less

DORSOGLUTEAL SITE

- Least preffered

- Risk of injection into fatty tissue

- Not for infants and toddlers

- imaginary line bet. superior iliac spine and greater trochanter

- superior and lateral to line several inches below iliac crest

DRAWING UP MEDS FROM AMPULES

- Flick, tap or twirl ampule

- Break away

- Attach filter needle

- Invert and withdraw med

- Draw 0.2 mL of air into syringe

- Attach needle for injection

- Dispose ampule and needles

DRAWING UP MEDS FROM VIALS

-Roll between hands

- Place on flat surface

- Air into syringe = to med

- Insert needle or cannula at 45-60 degrees

- Inject air into air in vial

- Invert vial and w/d med

- tap air bubbles back into vial

- hold at eye level to recheck dose

SUBCUTANEOUS INJECTION

- Fastest from Abd, then arms, thighs, back

- If adipose greater than 2", use 90 degree angle and spread

- Rotate 1" from previous site

MIXING INSULINS

- Make sure insulins are compatible

- Rotate insulin bet. hands 1 minute

- Inject amt of air = to med

- Air in long acting, then regular

- Draw up regular first

- Draw up long acting = to dose

- Give w/in 5 minutes

ADMINISTERING HEP SC

- Deep in abd

- Extra 0.2 mL of air to ensure all med injected

- Do not aspirate

- Do not massage

- Rotate site

- Avoid NSAIDS, falls

INTRADERMAL MEDICATIONS

- 1 mL syringe

- 25-28 gauge, 1/4 - 5/8" needle

- Small dose 0.01-0.1 mL

- Ventral surface of forearm, upper back, upper chest

- Easy to read area - no hairs, scars, pigmentation, less fat

- Syringe at 5-15 degree angle

- Relax muscle

- Do not aspirate

- Inject slowly to create bleb or wheal

TEN RIGHTS

Right Med

Right Dose

Right Patient

Right Route

Right Time

Right Documentation

Right to Refuse

STAT - IMMEDIATELY

NOW - W/IN HOUR

ON CALL - WHEN REQUIRED

AC - BEFORE MEALS

PC - AFTER MEALS

PRN - AS NEEDED

ON MED ORDER

- Patients full name

- Date order written

- Date expires (if applicable)

- Drug name

- Appropriate dose

- Frequency or timing

- Reason (for PRN meds)

- Prescibers Signature

WHAT TO

ASSESS BEFORE GIVING MED

- Allergies

- Patient's knowledge of med

- Ability to take med

- Factors that may interfere w/ drug absorption

- Vital signs and labs

- NPO restrictions, I&O

SUBQ - 45-90 DEGREE

INTRAMUSCULAR - 72-90 DEGREE

INTRADERMAL - 15 DEGREE

IF LIQUID DOSE IS LESS THAN 5 Ml - PULL BACK INTO SYRINGE TO MEASURE

IF LESS THAN 1 ML, USE TB SYRINGE FOR INJECTION

INSULIN MEASURED IN UNITS - NOT ML

IF CELLULITIS, EDEMA OR SCARRING - NO INJECTION AT THAT SITE

EYE OINTMENT

- Rest dominant hand on patient forehead

- Expose conjunctival sac

- After applying, have patient close eyes for 2-3 minutes

EAR DROPS

- Warm solution

- Use gloves

- Straighten ear canal

- Instill w/o touching ear

- Massage or press on tragus of ear

- Remain on side for 5-10 minutes

EAR IRRIGATION

- Clean pinna and auditory canal

- Warm solution

- Steady, slow stream of solution

- Place cotton ball in ear

- Assess in 10-15 minutes

NASAL MEDICATIONS

- Explain effects

- Postion patient

- Have patient blow nose, occlude one nostril, and exhale

- Administer spray or drops while inhaling

- Repeat for other nostril

- Assess effectiveness

VAGINAL MEDICATIONS

- Dorsal recumbant or Sims position

- Gloves

- Inspect and clean

- Water soluble lubricant

- Spread labia w/ non-dominant hand

- Insert along posterior vaginal wall about 3"

- Client maintains position for 5 - 15 minutes

VAGINAL IRRIGATION

- Warm solution to 105 degrees

- Hand 1-2' above vagina

- Dorsal recumbant on waterproof pad and bedpan

- Clear tubing of air

- Lubricate nozzle

- Insert 3" and start flow

- If labia reddened, clean w/ solution

- Clean and dry perineum

- Appy peri-pad if indicated

- Assess

RECTAL SUPPOSITORY

- Assess for contraindictions

- Ask patient if need to defecate

- Left lateral SIMS

- Lubricate smooth end of suppository

- Insert beyond internal sphincter along rectal wall

- Wipe anus w/ toilet tissue

ASPIRATION THROUGH ENTERAL TUBE

- Check placement

- Check residual volume

- Flush tube

- Instill med through gravity or plunger

- Flush tube

- Give each med seperately

- Sitting position for 30 min afterwards

METERED DOSE INHALERS

- Use bronchodilator b4 anti-infammatory

- Remove cap and shake

- Poition mouthpiece 1 1/2 - 2" from mouth

- Press down on canister while inhaling

- Close mouth and hold 10 seconds

- Allow 1 min. between puffs

- Rinse mouth if indicated

Infusion Nurses Society

- Develops standards of practice

- Professional certification

- Advocates for public

- Professional development and education

PURPOSES OF IV THERAPY

- Maintain or replace fluids

- Replace electrolytes

- Assess for med administration

- Administer blood products

- Provide calories

- Administer total parenteral nutrition (TPN)

- Administer contract dyes and isotopes during tests

- Administer anesthesia

- Venous access for emergencies

NURSING DIAGNOSES

FOR IV THERAPY

-Deficient Fluid Volume

- Risk for Imbalanced Fluid Volume

- Nausea

- Ineffective Tissue Perfusion

- Impaired Swallowing

IV NURSING ASSESSMENT

- Age

- Medical condition

- Skin integrity (infant and elderly skin more fragile)

- Current fluid status

- Sources of fluid gain or loss

- Reasons for fluid

- Condition of cardiac, renal, respiratory and neurological system

- Vitals

- Lab data (potassium, magnesium, chloride)

- Lung sounds

ASSESSMENT OF FLUID VOLUME

- Heart rate

- Blood pressure

- Body weight

- Intake and output

- Mucous membranes

- Skin turgor

INFUSION METHODS

- Continuous Primary

- Secondary piggyback infusion

- Intermittent Infusion

- Intravenous push/bolus (in syringe over time)

- Gravity vs Mechanical pump

Chlorhexadine is the most effective antimicrobial. 6 hr kill time - keeps working

CHANGING IV DRESSING

- Transparent occlusive - every 7 days

- Sterile Gauze - every 48 hours

IV CALCULATIONS

(Volume in Ml) x drip factor   = gtts

      Time in minutes         minutes

Total Volume    =  mL

Hours           Hour

VEIN SELECTION SITE

- Accessible - prominant near surface

- Spring when palpated

- Well fixed - doesn't roll

- Straight

- As distal as possible (hand)

- Consider type of fluid and duration of infusion

- Avoid sclerotic veins, near joint, near injury, areas of edema, palpable pulse, surgical site

TYPES OF ACCESS

- Peripheral IVs

- Peripherally Inserted Central Catheter (PICC)

- Nontunneled Catheter

- Tunneled Central Lines (Hickman, Broviac)

- Implantable Port

PERIPHERAL IV'S

- Short term use - fluid replacement post-op, short term antibiotics

- Rotate every 72 hrs and PRN

- Intermittent flush; 1 mL .9% normal saline before and after medication

- Use metacarpal, cephalic (radial side of wrist), basilic

PICC

(Peripherally Inserted Central LIne Catheter)

- Therapy over 7 days - up to 1 year

- Basilic, Cephalic, Median cubital

- Tip placement lower 1/3 SVC (Superior Vena Cava)

- Low risk for infection

- Can be used for hypertonic, vesicant, irritant drugs

- RN's may remove

- Groshog valve - no Heparin

- Arm circumference and cath measurement each dressing change

Vesicant Medication

- If it gets out of the vein, it destroys the tissue

CENTRAL VENOUS CATHETER

DIRECT

- Poor peripheral access

- Therapy less than 1 month

- Multiple drug rx

- Frequent blood draws

- Multiple lumens 2,3,4

- Inserted at bedside

CENTRAL VENOS CATHETER

- Poor Peripheral access

- Therapy over 6 months

- Frequent blood draws

- Cuff and tunnel impede migration of organisms

- Surgical procedure

- Single, dual, triple lumen

IMPLANTED SUBCUTANEOUS PORTS

(PORT O' CATH)

- Lowest risk of infection

- Can draw blood from these

- Poor peripheral access

- Therapy greater than 6 months

- Frequent blood draws

- Surgical procedure

- Single or dual lumen

- Placement can be arm, chest or abd.

MANAGEMENT OF CENTRAL LINES

- Weekly dressing changes

- Sterile technique

- Weekly cap changes

- Maintenance flushing with Heparin unless Groshong

- Chest x-ray confirms placemen

- S.A.S.H. - Saline/Administer Drug/Saline flush/Heparin per order

You want to use a larger syring for less pressure

IMPLANTABLE PUMPS

- Peak and valley effect eliminated

- Constant drug administration

- Cannot use large volume

- Not used for infection

TYPES OF FLUIDS

- Crystalloids (can see through it)

       - Isotonic - 0.9% saline; Lactated Ringers (LR)

       - Hypotonic - 0.45 NS (1/2 NS); D5W (5% DW)

       - Hypertonic - D5NS, D5LR; 10% DW

Colloids (Blood - blood products)

      - Plasma

      - Blood

     -  Albumin

IV DOCUMENTATION

- Date and time of insertion

- Specific Vein chosen

- Gauge and type of needle

- Solution infusing

- Patient education

- Untoward effects

MONITORING IV THERAPY

- Check site every 2 hrs or PRN

- Monitor rate q 1 hour and PRN

- Check IV solution for precipitants

- Change IV site q 3 days or PRN

- Proper skin prep - up/down, side to side, circular from in to out

- Monitor for untoward effects

- Know policies and procedures

- I & O

- Vitals

IV PATIENT TEACHING

- Activity restictions

- Call if: Air in tubing

               Solution stops dripping

               Blood in tubing or lock

               IV insertion starts leaking

               Site swollen, painful, red or burning

                Pump alarm

IV COMPLICATIONS

- Phlebitis

- Infiltration

- Extravasation

- Speed shock

- Septicemia

- Occlusion

PHLEBITIS

(IV COMPLICATION)

1+  Pain at site, erythma or edema, no streak, no palpable cord

2+ Pain at site, erythma, streak formation, no palpable cord

3+ Pain at site, erythma or edema, streak formation, palpable cord

INFILTRATION

(IV COMPLICATION)

1  Skin blanched, , 1" edema, with/w/o pain

2  Skin blanched, edema 1-6", cool to touch, with/w/o pain

3  Skin blanched/translucent, gross edema >6", cool to touch, mild/mod pain, possible numbness

4  Fluid leaking out of IV site, blanched/translucent/tight/leakinh/discolored, gross pitting edema > 6", circulatory impairment, mod/severe pain, infiltration blood, irritant, vesicant any amt

CELLULITIS

(IV COMPLICATION)

- Diffuse circular pattern radiating from insertion site

- Causative organisms S. Aureus, S. Epidermis

- RX with antibiotic RX

- Warm compress

- If cath related sepsis suspected, will need culture of cath.  Clean site with alcohol; 10 cm of cath into sterile cup (central line)

EXTRAVASATION

(IV COMPLICATION)

Should be using Central Line

- Drugs with extreme pH infiltrate into tissue causing tissue destruction

- Beware of these drugs:

    Vancomycin

    Doxycycline

    Morphine

    Gentamycin

    Ampicillin

    Cipro

    Chemotherapy

FLUID OVERLOAD

(IV COMPLICATION)

- Fluid excess

- Isotonic (CHF) - Only ECF is expanded

- Hypertonic - rare - excessive Na+ intake; fluid shifts from ICF to ECF

- Hypotonic - water intoxication; life threatening; fluid moves in ICF and all compartments expand

CATHETER OBSTRUCTION

(IV COMPLICATION)

- Unable to flush or absence of blood return

- Remove catheter

- Do not force flush

- Relocate IV

- Prevent by appropriate flushing after med admin and blood draws

PROCEDURE FOR DISCONTINUING PERIPHERAL IV THERAPY

- Verify order

- Explain procedure/Burning sensation

- Hand hygeine/clean gloves

- Close roller pump or shut off IV

- Loosen dressing while stabilizing catheter

- Inspect condition of site

- Clean site with antimicrobial swap/let dry

- Apply sterile gauze over site

- Remove needle at angle of insertion

- Apply pressure for 1-2 mins, or 5-10 if bleeding risk

- Inspect cath for length and defects

- Document

IV PUSH MEDS

- Verify patency of site

- IV push meds carry the greatest risk for infection

- Some meds require diluting

- Too fast or undiluted can cause speed shock

- Check compatibility with existing IV solution'

- Beware IV Potassium (must always be diluted, straigh Potassium will cause cardia arrest)

IMPLEMENTATION OF BLOOD TRANSUSION

- No smaller than 20 gauge needle

- Prime tubing with .9% saline

- Informed consent

- Baseline vitals

- Double checking with another RN

- Slow inititation

- Remain w/client for 15 minutes

- Continue to monitor vitals

- Infuse over 2 hours; max 4 hours

TRANSUSION REACTIONS

- Acute Hemolytic

- Febrile

- Mild Allergic

- Anaphylactic

- Circulatory Overload

- Sepsis

MGMT OF TRANSFUSION REACTIONS

- Stop transfusion immed.

- .9% normal saline directly into line

- Immed. notify MD

- Remain with client

- Vitals every 5 min

- Prep for emergency

- Obtain urine specimen

- Blood and equipment to lab

ADMINISTERING TPN

- Hypertonic

- Infused through cenral vein

- Consists of Dextrose, Amino acids, electrolytes, vitamins, minerals, trace elements

- Always use infusion pump

- Tubing change every 24 hrs

- Do not abruptly discontine - causes hypoglycemia

- Sterile mask/gloves dressing change

METABOLIC COMPLICATIONS OF PN

- Electrolyte Imbalance

- Hypoglycemia

- Hyperglycemia

NORMAL LABS ON FLUIDS/ELECTROLYTES

- Sodium 135-145 mEq/L

- Potassium 3.5 - 5.0 mEq/L

- Calcium 4.5 - 5.5 mg/dl

- Magnesium 1.5 - 2.5 mEq/L

- Chloride 95-105 mEq/L

- Biocarbonate 22 -26 Arterial mEq/L

- Phosphate 2.8 - 4.5 mg/dl

PRIMARY FUNCTIONS OF WATER IN THE BODY

- Provides a medium for transporting nutrients to cells

- wastes from cells

- transporting substances such as hormones, enzymes, blood platlets, blood cells

- Facilitates cellular metabolism and proper cellular chemical functioning

- Acts as a solvent for electrolytes and non-electrolytes

PRIMARY FUNCTION OF WATER

- Maintains normal body temp

- Facilitates digestion and promotes elimination

- Acts as tissue lubricant

- Largest component of the boy - 60%

- Lower proportion in women, elderly, obese

- Higher proportin in children

TOTAL BODY FLUID IS 50-60% OF BODY WEIGHT

CELL FLUID 35-40% BODY WEIGHT

PLASMA 5%

INTERSTITIAL FLUID 10-15%

EXTRACELLUILAR FLUID 15-20%

IONS

(ELECTROLYTES)

An atom or a molecule carrying an electric charge

- Cation  +

- Anion  -

ELECTROLYTES

Substances capable of breaking into electrically charged ions when dissolved in solution

SODIUM 135-145 mEq/L

POTASSIUM 3.5-5.0 mEq/L

CALCIUM 4.5-5 mg/dl

MAGNESIUM 1.5-2.5 mEq/L

CHLORIDE 95-105 mEq/L

BICARBONATE 22-26 (ARTERIAL) mEq/L

PHOSPHATE 2.8-4.5 mg/dl

FLUID AND ELECTROLYTE MOVEMENT

OSMOSIS

DIFFUSION

ACTIVE TRANSPORT

FILTRATION

FLUID SOURCES

- Ingested fluids

- Water in food

- Water from metabolic oxidation

THIRST

- Regulated by Hypothalamus

- Thirst requires an alert state

- Average intake 2200-2700 mL per day

FLUID OUTPUT REGULATION

Kidneys  1200-1500 mL/24 hours  (Sensible loss)

Skin and Lungs  (Insensible loss)

          Lungs 500 mL daily

          Skin 500-600 (sensible and insensible)

GI Tract  200 mL/24 hours

OSMOSIS

(FLUID AND ELECTROLYTE MOVEMENT)

OSMOSIS - Major method of transporting body fluids; movement of water to area of higher concentration of solute

DIFFUSION

(FLUID AND ELECTROLYTE MOVEMENT)

DIFFUSION - The tendency of solutes to move freely through solvent to are of lesser concentration

FLUID AND ELECTROLYTE IMBALANCES

- Fluid volume deficit

- Fluid volume excess

- Hyponatremia and Hypernatremia

- Hypokalemia and Hyperkalemia

- Hypocalcemia and Hypercalcemia (calcium)

- Hypomagnesemia and Hypermagnesemia  (magnesium)

- Hypophosphatemia and Hyperphosphatemia  (phosphateZ)

FLUID VOLUME DEFICIT

- Isotonic most common

- GI losses, loss of plasma/whole blood, excessive prespiration, fever, decreased oral intake, confusion/depression, diuretics

FLUID VOLUME DEFICIT SIGNS

Postural BP

Tachycardia

Dry mucous membranes

Poor skin turgor

Thirst

Confusion

Oliguria (<30 mL/hr)

Flat neck veins

ACTIVE TRANSPORT

(FLUID AND ELECTROLYTE MOVEMENT)

ACTIVE TRANSPORT - mvmt of substances through a cell membrane from an area of lee\sser concentration to an area of higher concentration. 

(insulin supports glucose)

FILTRATION

(FLUID AND ELECTROLYTE MOVEMENT)

FILTRATION - The passage of fluid through a permeable membrane from high pressure to lower pressure.

ACID-BASE IMBALANCES

- Rspiratory Acidosis

- Respiratory Alkalosis

- Metabolic Acidosis

- Metabolic Alkalosis

RESPIRATORY ACIDOSIS

Retained Pa CO2/Carbonic acid from hypoventilation

RESPIRATORY ALKALOSIS

Decreased paCO2 due to hyperventilation

METABOLIC ACIDOSIS

High acid content of blood commonly due to severe diarrhea/renal disease

METABOLIC ALKALOSIS

Due to heavy loss of acid from bosy or increase in bicarbonate commonly due to excessive vomiting/prolonged gastric suctioning

PHYSICAL ASSESSMENT OF FLUID AND ELECTROLYTE BALANCE

- Fluid I&O

- Daily weights - same time, same scale, after voiding.  Single most important indicator of fluid status.  Each kg (2.2 lbs) = 1 L of fluid.

- Lab Studies

      - CBC

      - Serum Electrolytes

      - Urine pH and specific gravity

      - Arterial blood gases

REGULATION OF ACID-BASE BALANCE

- Body metabolism produces acids that are constantly being buffered

- Buffers can absorb or release H+

- Buffering systems are lungs and kidneys

- Lungs adapt rapidly

- Kidneys adapt in a few hours to several days

pH LEVEL

     6.80          7.35              7.45             7.80

_____________________________________

       Death       Acidosis         Normal           Alkalosis           Death

 VASCULAR ACCESS DEVICES

- Short or midline peripheral catheters

- Central venous access devices

           - Peripherally inserted percutaneous central venous cath

           - Tunneled central venous cath

           - Implanted ports

IV SOLUTIONS

ISOTONIC

- Isotonic - most common for extracellular volume replacement (prolonged vomiting)

- Expand body's fluid volume w/o causing fluid shift

- Examples;  D5W, .9% sodium chloride (NS), Lactated Ringer (contains Na, K+, Calcium, Chloride, Lactate)

FLUID VOLUME EXCESS

- Water and sodium retained in isotonic proportions

- Seen in heart failure, renal failure, cirrhosis

- Sx include weight gain, edema, hypertension, polyuria, neck vein distension, increased blood pressure, lung crackles, confusion

POTASSIUM IMBALANCE

- One of the most common electrolyte disturbance

- Little tolerance for fluctuation because the initial amt is so small

- Primary cause of hypokalemia is vomiting and K+ wasting diuretics

- Primary cause hyperkalemia renal failure

- Both can impair cardiac function

PROBLEM MEDICATIONS

-Diuretics-metabolic alkalosis, hyper/hypokalemia

- Steroids-metabolic alkalosis

- K+ supplements-GI disturbance

- Opiods- depress respirations

- Antibiotics-nephrotoxicity, hyperkalemia

- NSAID's nephrotoxicity, heart failure, GI distress

ADMINISTERING IV THERAPY

Vascular access devices

- short or midline peripheral catheters

- central venous access devices

        - peripherally inserted central catheters

        -  non-tunneled percutaneous central venous catheters

        - tunneled central venous catheters

        - implanted ports

IV SOLUTIONS

Isotonic - most common for ex cell volume replacement  (ie prolonged vomiting)

Expand body's fluid volume w/o causing fluid shift