13.1: Principles of Intravenous Therapy

Learning Objectives

By the end of this section, you will be able to:

• Identify indications for using the intravenous route
• Recognize and understand how to comply with safety considerations when using the intravenous route
• Describe common medications given intravenously

In intravenous (IV) therapy, fluids and medications are administered directly into the vein. One of the most used types of IV is a peripheral intravenous (PIV) line in which a small plastic catheter is inserted into a peripheral vein, usually in the hand, arm, or forearm. There are several situations that indicate use of IV administration because of its fast onset of action and ability to bypass the digestive system. While IV therapies can provide great benefit, there are also important safety considerations, including potential mild to severe complications. This section discusses the basic principles of IV therapy, including indications for use, safety considerations, and medications commonly administered via the IV route.

Indications for Using the Intravenous Route

Intravenous therapy involves the administration of substances, such as fluids, electrolytes, blood products, nutrition, or medications directly into a patient’s vein. The IV route works best to administer fluid and medications quickly. Directly administering medication into the bloodstream allows for a more rapid onset of medication actions, restoration of hydration, and correction of nutritional deficits and electrolyte balances more quickly than the oral route.

Rapid Onset of Medication Action

The IV route is preferable for administering many medications when the patient’s condition necessitates rapid onset. For example, many types of pain medications can be infused directly into the bloodstream, and the patient will receive relief in minutes rather than hours for peak relief if they were administered orally. Rapid onset through IV administration is also critical to treat cardiac emergencies or severe allergic reactions to quickly restore patients to optimal body functioning. Each IV medication has its own safe rate of infusion, which is specified by the drug’s manufacturer (Infusion Nurses Society [INS], 2024; Institute for Safe Medication Practices, 2015).

Precise Control Over Dosage

The IV route of medication administration provides precise control over medication dosages. Because medications administered via the IV route bypass the gastrointestinal system, patients absorb 100 percent of the drug into their bloodstreams.

Intravenous push medications work for short-term dosing of medications. In short-term dosing, a specific medication is prescribed for a relatively brief duration. In contrast, long-term or chronic medication use typically involves taking a medication over an extended period, often for the management of a chronic condition or as part of ongoing preventive care. Medications administered via IV push are manually injected into the IV line. They are typically administered slowly, ranging from minutes to seconds, and have a fast-acting therapeutic effect. Intravenous push medications can be prescribed as needed or can be prescribed on a schedule.

A continuous infusion is constantly delivered over an extended period of time, from hours to days, while an intermittent infusion is delivered at a specific interval or scheduled time. Continuous infusions maintain drugs with a narrow therapeutic window to eliminate fluctuations between peak and trough concentrations. One of the main advantages of administering a medication by continuous IV infusion is that nurses and healthcare providers can tailor drug concentrations to meet the needs of each patient. For example, the difference between a therapeutic dose of heparin and a dose that can lead to serious bleeding is relatively small. Therefore, IV heparin is administered via continuous IV infusion to allow for close monitoring and careful dosage adjustment to ensure that the patient receives the appropriate level of anticoagulation while minimizing the risk of bleeding or clotting complications.

Restore and Maintain Fluid and Electrolyte Balance

Maintaining fluid and electrolyte balance is critical for cell functioning. Administering IV fluids quickly and efficiently restores fluid imbalances and helps maintain proper fluid levels and electrolytes. Nurses often administer IV fluids to correct deficits in fluid volume, such as dehydration. They may also be administered to move fluids in and out of intracellular and intravascular spaces. Intravenous fluids also can replace electrolytes, such as potassium, calcium, and magnesium.

Nutrition (Parenteral Nutrition)

An IV can also administer parenteral nutrition (PN). When the patient is unable to meet their dietary needs through regular digestion, whether it be malfunctioning of the gastrointestinal system or the patient’s inability to tolerate foods and fluids for a long period of time, parenteral nutrition is warranted.

There are two types of parenteral nutrition: peripheral parenteral nutrition (PPN), which is typically used for nutritional supplementation in combination with other nutritional sources; and total parenteral nutrition (TPN), which is used for total replacement of dietary needs. Administration of PPN is via a peripheral IV, and TPN is administered via a central venous access, or central line, where the IV is inserted in or near a large vein that goes into the superior vena cava. While PPN and TPN both deliver nutrients and calories, PPN is typically made up of a diluted formula with fewer calories, and TPN is a denser formula with more calories. Peripheral parenteral nutrition is only appropriate for short-term therapy, while TPN may be used for more long-term or permanent therapy.

Safety Considerations when Using Intravenous Route

When administering IV therapies, nurses should comply with safety precautions to reduce the risk of potential complications. These complications may be local or systemic and include infection, damage to the vein and surrounding tissue, air emboli, blood clots, and fluid overload. The nurse plays a key role in monitoring for signs of complications, initiating safety interventions to reduce the risk and severity of complications, and performing routine assessments of the IV. For example, replacing electrolytes such as sodium, potassium, or magnesium via the IV route is faster than the oral route; however, the nurse must be mindful of giving the correct amounts of electrolytes and maintaining therapeutic levels. The nurse will monitor the patient’s sodium and potassium levels, through blood tests, as well as assess the patient for symptoms of overdose or toxicity.

Clinical Safety and Procedures (QSEN): QSEN Competency: Monitoring an IV Site and Infusion

See the competency checklist for Monitoring an IV Site and Infusion. You can find the checklists on the Student resources tab of your book page on openstax.org.

Infection

Redness, tenderness, swelling, and purulent drainage from the IV site can indicate local site infection. If you suspect a local infection, remove the IV and notify the provider (INS, 2024). Monitor blood work and all vital signs, which may identify a systemic infection. While identifying the signs and symptoms of infection are necessary, a prudent nurse will take steps to prevent infection during the IV process. The nurse will ensure that all equipment is sterile with intact packaging and the site is cleaned with alcohol or another accepted agent per facility policy. The nurse will wear gloves and use proper technique to insert and properly secure the IV, label it appropriately, and inspect it daily for signs of infection (INS, 2024). The nurse will provide ongoing education to the patient and caregivers about IV site care and when to notify the nurse of any changes.

Damage to the Vein and Surrounding Tissue

Damage to the vein and surrounding tissue may be caused by infiltration, extravasation, or phlebitis. In the event these complications occur, stop the IV fluids immediately, and remove the IV. Notify the provider and implement appropriate nursing interventions to ease symptoms. If the patient needs ongoing vascular access, restart the IV in an alternate area (INS, 2024). Collaborate with the provider about the benefits of a slower infusion rate, different medication, or further dilution to prevent reoccurrence (INS, 2024).

An infiltration occurs when the tip of the catheter slips out of the vein allowing fluid to infuse into the surrounding tissue, instead of through the vein (Figure 13.2). Infiltration may cause pain, swelling, and skin that is cool to the touch. If infiltration occurs, the nurse should remove the IV and assess it to make sure it is intact, then follow agency protocols. This may include applying a warm or cold compress, elevating the limb, or other approved treatments per facility policy (INS, 2024).

Figure 13.2: Intravenous infiltration causes swelling around the site. (CC BY 4.0; Rice University & OpenStax)

An extravasation refers to infiltration of damaging IV medications, such as chemotherapy, into the extravascular tissue around the site of infusion. Extravasation causes tissue injury, and depending on the medication, site, and length of exposure, it can cause tissue death, which is referred to as necrosis (Figure 13.3). Common symptoms and signs of extravasation include pain, stinging or burning sensations, blisters, and edema around the IV injection site. If extravasation occurs, the nurse should remove the IV and assess it to make sure it is intact, then follow agency protocols. This may include applying a warm or cold compress, elevating the limb, or other approved treatments. Avoid using the affected limb for vascular access until extravasation has resolved (INS, 2024). If detected early, extravasation may be treated with medications that help avoid the complication of necrosis.

Figure 13.3: Extravasation can be painful and cause edema around the IV injection site. (CC BY 4.0; Rice University & OpenStax)

Real RN Stories: Extravasation Leading to Long-Term Scarring

Name: Diane, RN
Clinical setting: Neonatal intensive care unit
Years in practice: 8
Facility location: Jackson, Mississippi

It was August 2014, and I was caring for a young male, Cole, who was born eight weeks prematurely. Cole was receiving IV vancomycin for a staphylococci infection. I began the IV vancomycin infusion in the IV located in Cole’s right hand. Concerned about the IV dislodging, I wrapped the IV site in gauze to stabilize the tubing. Several hours later when I unwrapped the IV to give Cole a bath, I noticed the IV had infiltrated and caused extravasation in the tissue surrounding the IV site. I immediately removed the IV and initiated a new IV site. The extravasation of the fluids caused tissue injury that resulted in a scab formation. Nine years later, Cole still has permanent scarring to his right hand as a result of the extravasation (Figure 13.4). Had I not wrapped the IV site and assessed it more frequently, I probably would have caught the infiltration earlier and avoided the permanent tissue injury.

Figure 13.4: Extravasation can cause permanent scarring. (CC BY 4.0; Rice University & OpenStax)

Inflammation of a vein is termed phlebitis and can be caused by chemical factors, mechanical factors, or infectious factors (INS, 2024). A reaction to irritating infusions or medications can cause chemical phlebitis. Factors such as catheter insertion angle, constant flexion at the catheter site, inadequate securement, large catheter size, and insertion trauma can cause mechanical phlebitis. Infectious phlebitis is caused by bacterial contamination. Phlebitis causes redness and tenderness along the vein (Figure 13.5). Treatment includes warm compresses, elevation, nonsteroidal anti-inflammatory medications, and antibiotics (INS, 2024).

Figure 13.5: Phlebitis is characterized by redness along the vein. (credit: “1345” by Sellers/CDC, Public Domain)

Air Emboli

An air embolus occurs when air or gas makes its way into the vascular system. A venous air embolus will travel to the right ventricle and/or pulmonary system. An arterial air embolus travels until it becomes trapped somewhere in the arterial system. While most patients typically tolerate small air bubbles, over 10 mL of air may have serious side effects, including death. Symptoms of an air embolism include the following:

• sudden shortness of breath
• coughing
• breathlessness
• wheezing
• shoulder or neck pain
• lightheadedness
• increased heart rate
• hypotension
• altered mental status
• jugular vein distension
• agitation and/or feelings of impending doom

If you suspect an air embolus, occlude, or close off, the source of air entry by engaging the roller clamp on the tubing, place the patient in Trendelenburg (with the head lower than the rest of the body and the legs elevated) on the left side, apply 100 percent oxygen, obtain vital signs, and notify the provider immediately (INS, 2024). To prevent air emboli, ensure that the drip chamber (the portion of IV tubing located just below the IV bag that controls the flow rate of the fluid) is one-third to one-half full, confirm tight security in all IV connections, and properly remove all air from the IV tubing when priming the line (INS, 2024).

Catheter-Associated Thrombosis

A catheter-associated thrombus is an inflammatory response to an IV catheter that causes a blood clot to form and block one or more veins. When the blood clot involves superficial veins of the arms or legs, it is known as superficial vein thrombosis (SVT). An SVT is not usually a serious medical emergency, but it should be treated to prevent the clot from becoming bigger. If an SVT becomes bigger, it may develop into a deep vein thrombosis (DVT), defined as a blood clot that forms in a deep vein of the arm or leg.

Patients with a history of obesity, diabetes, thrombophilia, cancer, a family history of thrombosis, or receiving IV chemotherapy are at highest risk for developing a catheter-associated thrombus (INS, 2024). Blood clots are typically diagnosed by Doppler or ultrasound study and treated with anticoagulants. Patients with catheter-related blood clots should be carefully monitored for more severe symptoms, such as shortness of breath, low oxygen saturation, tachycardia, hypotension, and chest pain, which may indicate that the blood clot has broken off the catheter and traveled to the heart or lungs, causing a pulmonary embolism.

Clinical Judgment Measurement Model: Take Action: Intervening in a Suspected IV Complication

The nurse is caring for a patient receiving continuous IV fluids by gravity. The patient calls the nurse into the room complaining of shortness of breath, lightheadedness, and feelings of impending doom. Upon further assessment, the nurse notes that the patient is experiencing an increased heart rate, hypotension, altered mental status, jugular vein distension, and agitation. The nurse analyzes the cues to determine that the patient may be experiencing an IV complication. According to the symptoms present, the nurse hypothesizes that the patient may be experiencing a pulmonary embolism related to a catheter-associated blood clot or an air embolism. Upon assessing the IV tubing, the nurse notes the IV bag is empty, and the IV line is filled with air. The nurse concludes that the air in the IV tubing most likely caused the patient to experience an air embolism. The nurse immediately clamps the IV tubing to occlude the source of air entry, places the patient in Trendelenburg on the left side, applies 100 percent oxygen, obtains vital signs, and notifies the provider.

Due to the safety risks with administering IV fluids by gravity, it is preferable to administer IV fluids using an IV pump, as IV pumps contain sensors that would identify the air in the IV line before it reaches the patient. However, there may be some situations and agencies in which an IV pump may not be available. In these situations, it is imperative to closely monitor the IV fluid levels to ensure patient safety.

Fluid Overload

Excessive fluid volume (also referred to as fluid overload) occurs when there is increased fluid retained in the intravascular compartment. Patients at risk for developing excessive fluid volume are those with the following conditions:

• heart failure
• kidney failure
• cirrhosis
• pregnancy

Symptoms of fluid overload include pitting edema ascites, and dyspnea and crackles from fluid in the lungs. Edema is swelling in dependent tissues due to fluid accumulation in the interstitial spaces (Figure 13.6). Ascites is fluid retained in the abdomen.

Treatment depends on the cause of the fluid retention. Sodium and fluids are typically restricted, and diuretics are often prescribed to eliminate the excess fluid. The nurse must acknowledge the importance of monitoring intake and output levels to help avoid or monitor this situation.

Figure 13.6: Edema can be caused by fluid overload. (credit: “Edema Hands 01.jpg” by Wang Kai-feng, Pan Hong-ming, Lou Hai-zhou, Shen Li-rong, Zhu Xi-yan/Wikimedia Commons, CC BY 2.0)

Common Medications Administered Intravenously

Intravenous medications are often used when providers want greater control over bioavailability (medication speed of action) and dosing. Other medications must be administered via IV because they are poorly absorbed by the digestive tract or are destroyed by digestive enzymes. Examples of medications that may be administered by IV include antibiotics, pain medications, emergency medications, chemotherapy, and immunoglobulins (IV immunoglobulin (IVIG)).

Antibiotics

Intravenous antibiotics are generally used to treat bacterial infections in the lungs, heart, bones, soft tissue, and brain. They are also used for severe infections, like sepsis, because IV antibiotics reach the tissues faster and at higher concentrations than oral antibiotics. Intravenous antibiotics may also be warranted when oral antibiotics are less likely to reach the infection, such as infection in the spinal fluid and bone, or when the infection is resistant to oral antibiotics. Examples of antibiotics commonly administered via the IV route include ampicillin, cefazolin, cefepime, vancomycin, and piperacillin.

Pain Medications

Pain medications may be administered via the IV route when pain is severe or uncontrolled by oral medications. Intravenous pain medications may also be ordered when the patient cannot take oral medications. For example, they have an order for nothing by mouth (NPO), are not awake enough to swallow, or are at a high risk for choking. Two examples of IV pain medication classifications are nonsteroidal anti-inflammatory drugs (NSAIDs) and opioid-based narcotics. Examples of NSAID pain medications commonly administered via the IV route include ketorolac (Toradol), and ibuprofen (Caldolor). Examples of opioid-based narcotics administered via the IV route include fentanyl, hydromorphone, and morphine.

Emergency Medications

Due to the rapid onset, the IV route is often the preferred method for administering emergency medications. For example, plasminogen activator (tPA) and alteplase are administered via the IV route to treat strokes. Intravenous morphine may be administered to treat angina pain that is unresponsive to nitroglycerin. In the hospital setting, naloxone is administered via IV to reverse opioid overdoses, and flumazenil is used to treat benzodiazepine overdoses. Intravenous lorazepam or midazolam is used to treat status epilepticus. Atropine, epinephrine, and dopamine may be administered to treat bradycardia. Adenosine, diltiazem, atenolol, and amiodarone may be administered to treat tachycardia.

Chemotherapy

Intravenous chemotherapy is often required for treatment of cancer. Because chemotherapy drugs are vesicants, drugs that can cause blisters or tissue necrosis if leaked into the surrounding tissue, they are typically administered via a central venous catheter (CVC). Administering chemotherapy via a CVC reduces the risk of extravasation, reduces the number of times the patient must be stuck with a needle, and ensures reliable IV access for administering the drug.

Intravenous Immunoglobulin

Human antibodies administered to help fight certain infections are termed IV immunoglobulin (IVIG). Intravenous immunoglobulin may be required when the body does not make enough antibodies or if a patient has an autoimmune disease where the immune system attacks their own body, such as myasthenia gravis, Guillain-Barré syndrome, Kawasaki disease, and lupus. Side effects of IVIG include headache, fever, chills, flushing, flu-like aches, fatigue, nausea, vomiting, and rash. More serious side effects, while rare, include allergic reactions, anemia, and contracting disease through the human antibodies that were donated by others, such as HIV, hepatitis B, and hepatitis C.