In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of parenteral and intravenous therapies in order to:

  • Identify appropriate veins that should be accessed for various therapies
  • Educate client on the need for intermittent parenteral fluid therapy
  • Apply knowledge and concepts of mathematics/nursing procedures/psychomotor skills when caring for a client receiving intravenous and parenteral therapy
  • Prepare the client for intravenous catheter insertion
  • Monitor the use of an infusion pump (e.g., IV, patient-controlled analgesia (PCA) device)
  • Monitor intravenous infusion and maintain site (e.g., central, PICC, epidural and venous access devices)
  • Evaluate the client's response to intermittent parenteral fluid therapy

Identifying Appropriate Veins that Should be Accessed for Various Therapies

The identification and selection of appropriate vein for various intravenous therapies are done by the nurse after considering a number of factors. Whenever possible, the best veins for the nurse to assess and then use are the distal veins on the nondominant hand so that the client is able to fully use their dominant hand. Additionally, whenever possible, the upper extremities, rather than the legs, are used to prevent lower extremity phlebitis and emboli. The veins in the hand are not the veins of choice.

The side of a client's mastectomy, paralysis and a dialysis access side are not used. Additionally, areas distal to a previous phlebitis or infiltration site should also not be used.

The appropriateness of the vein selected should also be based on the therapy that is anticipated for the client. Some clients may require small intravenous catheters and others, such as those clients who may or will be getting a blood transfusion, will require a larger intravenous catheter and the selection of a larger vein. For example, an 18 gauge intravenous catheter is needed for the administration of a blood transfusion; an even larger 16 gauge intravenous catheter is used for the many and often unanticipated needs when a major trauma client enters the emergency department; and a smaller 22 or 24 gauge intravenous catheter is used when a client only needs intravenous fluids and medication with their peripheral venous catheter.

Educating the Client on the Need for Intermittent Parenteral Fluid Therapy

As with all treatments and interventions, nurses must educate the client about the need for their intermittent parenteral fluid therapy. They should also be educated about when to call for the nurse, such as when they are experiencing pain or swelling at the insertion site or the flow stops or the alarm rings.

Applying a Knowledge and Concepts of Mathematics, Nursing Procedures and Psychomotor Skills

Nurses apply their critical thinking and professional judgment skills as well as their knowledge of mathematics, nursing procedures and psychomotor skills when they monitor and care for a client who is receiving intravenous and parenteral therapy.

The Concepts of Mathematics

The rule for intravenous flow rates is:

gtts/min = Number of mLs to be delivered x Drip or drop factor for the IV tubing

The number of minutes

For example, if the doctor's order: 0.9% NaCl solution at 100 mL per hour, how many gtts per minute should be administered if the tube delivers 20 gtt/mL?

X gtts per min = (100 x 20)/60 = 2000/60 = 33.3 gtts which rounded off to the closest drop is 33 gtts per minute

Rounded off to: 33 gtt/min

Nursing Procedures

The intravenous line and the insertion site are monitored and maintained by the nurse. The intravenous line is monitored to insure that the line is patent and that the rate of flow is as ordered.

The intravenous site is routinely assessed and inspected for any signs of infiltration and infection. The dressing is changed and dated according to the particular healthcare facility's policy and procedure which is typically every 24 hours.

All of these nursing procedures can only be done by licensed nurses, and not unlicensed assistive staff.

Psychomotor Skills

The psychomotor skills associated with venipuncture and starting an intravenous line was fully discussed step by step in the section entitled "Educating the Client on the Reason For and Care of a Venous Access Device".

Preparing the Client for an Intravenous Catheter Insertion

Preparing the client for an intravenous catheter insertion should minimally include patient education and information about:

  • The purpose of the intravenous catheter
  • The procedure for inserting the intravenous catheter
  • How the intravenous catheter will be cared for and maintained
  • When to notify the nurse of any possible complications or malfunctioning of the intravenous therapy

Monitoring the Use of An Infusion Pump

Infusion pumps are not a substitute for the monitoring and maintenance of intravenous infusion pumps. Infusion pumps can, and do, malfunction and break down so it is imperative that the nurse monitor them for accuracy and proper functioning.

There are a couple of simple ways to monitor these pumps. One way is to mathematically calculate the number of drops of minute that should be infusing and then checking the rate of the infusion pump by visually counting the number of drops that are actually being delivered. Another method, in addition to the check just discussed, is to return to the client's bedside and determine how many mLs or cc s should have been administered during the period of time that the nurse was not at the bedside. For example, if the client is supposed to receive 125 cc of fluid per hour and when you monitored the client 2 1/2 hours ago there were 650 cc remaining in the IV bag of fluid, and, now, there are 550 cc remaining in the IV bag, you should know immediately that there should only be 312 cc remaining, therefore the intravenous flow is not infusing as ordered. When more or less intravenous fluid is being delivered by the infusion pump, the nurse must correct and rectify the situation and return the pump and take it out of service when necessary.

Patient controlled analgesia pumps are also monitored for their functioning and accuracy.

Monitoring the Intravenous Infusion and Maintaining the Site

All intravenous lines, including central lines, PICC lines, and venous access devices are invasive lines that can lead to catheter associated health care related infections unless they are cared for in the proper manner. As with all aspects of intravenous therapy, only the nurse is permitted to monitor, maintain and care for these lines and sites. This care cannot, under any circumstances, be delegated to an unlicensed assistive staff member like a nursing assistant or a patient care technician.

The care and the maintenance of these sites is stated in the facility's policies and procedures and this care typically includes the use of sterile technique and the following.

Peripheral Intravenous Lines

The intravenous line and the insertion site are monitored and maintained by the nurse. The intravenous line is monitored to insure that the line is patent and that the rate of flow is as ordered.

The intravenous site is routinely assessed and inspected for any signs of infiltration and infection. The dressing is changed and dated according to the particular healthcare facility's policy and procedure which is typically every 24 hours.

Central Venous Access Devices

In addition to sterile technique, central venous access devices are managed and maintained with additional measures including the donning of sterile gloves and a personal protective face mask for both the client and the nurse. Chlorhexidine is used to cleanse the insertion site, a sterile dressing sometimes impregnated with chlorhexidine covers the site and is often changed every 48 hours except if it is an occlusive transparent dressing, the caps are changed and the line is flushed after every access. Occlusive transparent dressings can remain in place for up to 72 hours. Blood pressure readings and invasive procedures such as laboratory specimens are not done on the side of the central venous access device.

Evaluating the Client's Responses to Intermittent Parenteral Fluid Therapy

Intermittent parenteral fluid therapy can be used to administer intravenous medications and also for intravenous fluid replacements. Intravenous medication administration rapidly enters the client's circulatory system and, for this reason, adverse effects including allergic responses can also occur rapidly and place the client at risk for even life endangering complications such as anaphylaxis. The nurse, must, therefore evaluate and monitor the client's responses to these intermittent medication administrations. Clients receiving intermittent fluid replacements should be monitored in terms of their responses to it as well. The client's laboratory data, their fluid intake and output, and any signs and symptoms of fluid overload must be closely monitored when the client is receiving intermittent fluid replacement therapy.

All clients receiving intravenous therapy, both intermittent and continuous, must also be evaluated and monitored in terms of the presence of any complications associated with intravenous lines. These complications include:

  • Infection
  • Infiltration
  • Extravasation with vesicant medications
  • Hematoma
  • Phlebitis
  • Embolus formation
  • Fluid overload

Infection

The signs and symptoms of intravenous therapy infection include the classic signs of infection such as swelling, soreness, redness at the site, pain, and fever. This complication can be prevented by only using intravenous therapy when necessary, by discontinuing the intravenous therapy and catheters as soon as possible and by maintaining strict sterile asepsis when care for and dressing the site of the intravenous therapy. In addition to documenting this complication and notifying the doctor, the nurse should also discontinue the intravenous flow and catheter, elevate the client's affected limb, apply warm compresses, and administer any ordered antipyretic and/or antibiotic medications.

Infiltration

Infiltration occurs when intravenous fluid is infused into the subcutaneous tissues instead of the vein. When the client is adversely affected with an infiltration, the nurse should be able to identify its signs and symptoms which can include site pain, swelling in the area of the catheter insertion site, coolness of the skin near the site, slowing down of the intravenous fluid rate, and paleness of the skin around the insertion site. Nurse should, again, stop the infusion, remove the intravenous catheter, elevate the affected limb and apply warm compresses to the area.

Extravasation

Extravasation is a serious form of infiltration that occurs when a caustic medication, like some chemotherapeutic medications, infiltrates into the tissue. In severe cases, extravasation can lead to necrosis and the loss of an affected limb. The signs and symptoms in the early stage of extravasation are the lack of blood return, a lowered rate of infusion, burning, tingling, severe pain in the limb, erythema, swelling, redness, and blistering; and the signs and symptoms during the later stages of extravasation include the worst possible unrelenting pain, ulceration, blistering, and severe necrosis secondary to extravasation.

The interventions for extravasation include the immediate cessation of the infusion, the placement of a syringe after the removal of the intravenous line near the site, aspirating as much blood and infused fluid as possible, elevating the limb, applying warm compresses initially to rid the area of any remaining drug that is in the tissues which is then followed by cool compresses to reduce any swelling, and the administration of an ordered substance specific medication such as dexrazoxane.

Hematoma

Hematomas secondary to intravenous therapy and other injuries present with ecchymosis. The treatment of an intravenous therapy related hematoma includes the cessation of the intravenous therapy, the removal of the intravenous catheter, the application of pressure and a pressure dressing over the site, the elevation of the limb and the application of warm compresses. This complication does not typically lead to a serious condition other than minor bruising.

Phlebitis

The signs and symptoms of intravenous therapy related phlebitis include redness, swelling, pain, fever, the slowering of the intravenous flow, and the possible appearance of a palpable red streak at the intravenous insertion site and beyond. Phlebitis is treated with the cessation of the intravenous therapy, the elevation of the limb, the application of warm compresses and the possible administration of analgesics for the pain and/or antipyretics for the client's fever.

Embolus Formation

The signs and symptoms of an embolus can include shortness of breath and chest pain. In addition to notifying the doctor, the nurse should monitor the client for life threatening complications, and place a tourniquet above the site to prevent further migration of broken catheter pieces.

Fluid Overload

Fluid overload can occur when the flow rate of the intravenous fluids exceed the client's capacity to cope with this volume. The signs and symptoms of fluid overload include hypertension, adventitious breath sounds such as rales and crackles, tachycardia, shortness of breath, distended neck veins and edema. Fluid overload is a high risk for elderly clients and those affected with heart failure. The nurse monitoring the client who suspects fluid overload will notify the doctor and decrease the rate of the intravenous fluids to prevent further overload.

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SEE - Pharmacological & Parenteral Therapies Practice Test Questions