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.
This simply means that something is occluding,
the tubing, or the infusion from going in.
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
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.
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
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.
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.
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.
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.
And you can’t give any medications in the same
line that you’re giving a TPN.
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.
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.
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.
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,
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.
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.
You’ll have to get your institution’s policy to
see which one you need to do.
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.
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.
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.