IV Tips

by Andria RN · 7 comments

in ICU

Hello NNB readers!  I recently wrote a blog post for my CRNA blog that gives IV tips.  It was suggested by a reader that I also include that post on this site as ICU RN’s struggle with IV’s as well.  So the following post has been borrowed from my CRNA blog site.  I hope you enjoy!

FAQ: Do I need to be good at IV’s before I get into CRNA school?  Answer: No, but it does help.

After 2.5 years in the ICU, a lay person may incorrectly assume I was an IV master.  But as ICU RN’s know- we rarely get the chance to place IV’s in the unit.  The patient either comes from the ER with great IV access or has a Midline, PICC or central line that has been placed by someone else.

In the ICU, IV placement is made even more challenging when patients are chronically ill and have a history of multiple IV placements.  Other difficult sticks include dialysis patients, obese patients, and hypotensive patients.  Doesn’t this sound like most of our population?  My point is- even if you did get a shot at trying to place an IV- you probably didn’t have a healthy young person with veins jumping out of their arms.

So don’t beat yourself up if you aren’t very good at IV’s.  The vast majority of new CRNA students are just as bad.  I had a preceptor recently tell me that when the new students come in, they assume we need a lot of practice with IV’s but they are occasionally surprised by a student that rocks…so if you’re awesome with IV’s, you’ll have a leg up on the rest of us until it comes to the other 99% of new skills we learn as student CRNA’s.

As a student nurse anesthetist, you get exposure to IV placement in various ways that are dependent on your clinical site and/or preceptor.  At some sites, you will get an opportunity to place an IV in your first patient of the day.  This is because as students, you get to the OR very early.  Very early.  Meaning you have plenty of time to set up your room, meet your patient, and place an IV.  Some sites do not allow students to place IV’s in awake patients.  My most recent clinical site actually assigned students a “Preop Day” to shadow the preop RN’s and place multiple IV’s.  Some of the procedures require the patient to have TWO IV’s.  It’s pretty standard for the patient to receive one IV in preop and the second in the OR after they have been sedated.  Usually, the student is allowed to place the second IV in the sedated patient.  Anesthesia causes vasodilation, which greatly helps out the student.

Here is the advice I have (so far).  Hopefully it helps someone.

Preparation

  • Gather supplies.  Think about what you need in the order you’ll need it.
    • Tourniquet
    • Some type of prep (chloraprep or alcohol) to clean the area
    • Lidocaine and 22g needle (if your site uses local anesthesia)

 

  • IV catheters (preferably a 20g or larger.  A 22g may suffice for some minor procedures).  *If in doubt, ask your preceptor.
  • 4×4’s or 2×2’s
  • Sterile dressing and tape
  • Marker or pen to date/time the IV
  • NS or LR and IV tubing.
    • Prime your IV tubing and hang it over the patient’s bed/stretcher.
    • Make sure the end is within reach and that the cap over the connector is loose enough to where you can remove it with one hand (because after you access a vein, one hand has to hold the unsecured catheter while the other hand connects the IV tubing).
    • Tip: instead of using the roller clamp to clamp the tubing, turn the most distal stopcock to the off position to stop the fluid flow.  This allows you to easily unclamp the fluid to check placement after you’ve accessed a vein without having to try to reach up over the patient and unclamp the roller.)

General Tips

  • Confidence
    • Ever heard of the phrase, “fake it ‘til you make it?”  Even if you are nervous or unsure of your skill, hide it from your patient.  Exude confidence!  Let the patient know that you are an experienced RN- this is not your first rodeo!  Avoid phrases like, “I’m going to TRY to get your IV” or “I’m not very good at IV’s.”
    • Maximize the Chances of Success
      • Raise the bed as high as you need it so you’re not bending over.
      • Stand on the same side of the bed as the patient’s arm you are targeting, even if this means moving the stretcher or temporarily displacing a visitor from their chair by the bed.
      • Remove BP cuff on that side and cut off armbands if they are in your way.  *Replace arm bands ASAP after IV has been placed
      • Set up all supplies within arms reach.  After you access a vein, you need to be able to do everything with one hand.  I like to remove the back from the tegaderm and leave it sitting sticky side up.

Finding a Vein

  • The tourniquet needs to be VERY tight.  I like to place the tourniquet over the patient’s gown sleeve to avoid pinching their skin.  Another option is to place a washcloth or 4×4’s under the tourniquet  Don’t forget to warn the patient that it’s going to be very tight.
  • Extend patient’s arm down toward the ground (use gravity to your advantage!)
  • Have patient pump fist.  I usually tell them to make 3 big fists and then relax their hand.
  • Look for veins that are most distal (hand, wrist, lower forearm).  You can always attempt a vein higher but once you’ve punctured a vein, you are at risk for infiltration if you try to place something distal to that hole you made.  *This seems obvious, but I’ve gotten a patient back to the OR that had an unsuccessful student attempt in the antecubital which was inadvertently followed by a second IV placed lower in the same vein by a CRNA.  Needless to say, my fluids and medication traveled up the arm and infiltrated at the student site.
  • Gently tap or flick the veins.  I always saw people doing this and didn’t understand it but it really does help the veins pop out.
    • Know that some veins are visible and some are palpable.  The ability to feel veins comes with practice.  Start feeling your own veins and your friends’ veins to more quickly develop this skill.
    • If you don’t see anything, release tourniquet, grab two warm blankets and wrap each arm.  Come back in 3-5 minutes to look again.  The warmth sometimes dilates the vein enough to where you can find it.
    • Feel the vein.
      • Some practitioners tear off the pointer finger of their glove or only wear one glove when trying to locate a vein.  It is easier to feel a vein with your finger than through a glove.  I usually find the vein first with my fingers and then put gloves on.
      • Once you find a vein, ask yourself these questions:
        • 1. Is the vein straight?  It’s very difficult if not impossible to thread a wiggly vein.
        • 2. Is the visible or palpable vein long enough to fit the IV catheter (compare the length of the catheter to the vein).
        • 3. Do you see any valves that may get in your way of threading the catheter?  *In some patients, you can see the valves, in others- you might not be able to see them, but if you can’t thread the catheter over the needle, you may be hitting one.
        • 4. Is the vein large enough for the size of catheter?  Don’t try to put an 18g in a small vein, it’s just not going to happen.
        • Tip: if the vein is extremely superficial, you can place a slight bend in the needle to make threading off the catheter easier.

Placement

  • When you find a vein target, use your chloraprep or alcohol to cleanse the area.
  • Tip: I like to place a sheet, blanket, towels or 4×4’s under the patient’s arm in case any blood drips out.
  • Traction!
    • This is a very important concept that I never fully grasped before.  With your non-dominant hand, pull the distal end of the vein down pretty securely.  Warn the patient that you are going to pull gently on their arm.  If you don’t do this, some veins will wiggle right out of the needle’s path.
    • With your dominant hand, use a fluid motion to puncture the skin and slowly advance the needle into the vein.
    • When you see a flash of blood in the catheter, advance the needle just a hair, being careful not to transverse the vein!  This ensures that the catheter is inside the vein and it will be easier to thread.
    • With your pointer finger or your non-dominant hand, hold the needle very secure and attempt to slide the catheter off the needle and into the vein.
      • In the past, my most common mistake was that I inadvertently backed the needle out of the vein because I didn’t hold it well enough.
      • Tip: Lift the entire needle and catheter up (parallel to the arm) while trying to thread.  This helps when bumping into the posterior vein is what is keeping you from being able to thread.
      • When the catheter is threaded, remove the needle (most have a safety device that sucks the needle into the hub and prevents needle sticks.
        • The needle is physically blocking the blood from exiting out of the catheter so keep this in mind.  When the needle comes out, simultaneous remove the tourniquet and hold pressure to the vein ABOVE the end of the catheter to stop the bleeding until you can get the IV tubing connected.
        • Attach IV tubing and unclamp.  Make sure your fluid is wide open and flowing at a fast rate.  You may need to carefully reposition the IV to get this flow.
        • Secure the IV.
          • Make sure you keep the fluid wide open and ensure the IV continues to flow well while you tape down the catheter hub.
          • Date and time your IV.

           

Troubleshooting

  • Do you get blood return but can’t thread the catheter into the vein?  You can try attaching the IV tubing and “flushing the catheter in” which involves opening up the fluid and gently pressing the catheter into the vein.  This works some of the time.
  • If you missed an IV and couldn’t get blood return, take out the needle and leave the catheter in.  *If you remove the catheter, you have to hold pressure at the insertion site to stop the bleeding and it will bleed again if you place the tourniquet on the same side.

As a student, it is the general/unofficial rule that you get one attempt in an awake patient.  So as not to torture the patient, the second attempt should be made by the preop RN, CRNA, or MDA.   If I miss the IV, I like to joke with the patient and tell them that I’m better at anesthesia than I am at IV’s.

If anyone else has any tips for newbies, we’d love to hear them.  Fill out a comment below or e-mail me at host “at” newnurseblog.com

 

 

 

  • aaliajennison

    Hey, thanks for sharing your experience with us and these “IV tips” really help me a lot. and I came to your blog through another post “Top 36 Nursing Blogs To Help With Your Nursing Career”. Therefore I’m very happy and will always visiting your site.

  • javad23

    Total parenteral nutrition (TPN)

    A look at TPN

    TPN is a highly concentrated, hypertonic nutrient solution administered by way of an infusion pump through a large central vein. For patients with high caloric and nutritional needs due to illness or injury, TPN provides crucial calories, restores nitrogen balance, and replaces essential fluids, vitamins, electrolytes, minerals, and trace elements.

    TPN also promotes tissue and wound healing and normal metabolic function; gives the bowel a chance to heal; reduces activity in the gallbladder, pancreas, and small intestine; and is used to improve a patient’s response to surgery.

    Who needs TPN ?

    Patients who can’t meet their nutritional needs by oral or enteral feedings may require I.V. nutritional supplementation or TPN. Generally, this treatment is prescribed for any patient who can’t absorb nutrients from the GI tract for more than 10 days. More specific indications include:

    • debilitating illnesses lasting longer than 2 weeks

    • loss of 10% or more of pre-illness weight

    Understanding common TPN additives

    Common components of total parenteral nutrition (TPN) solutions such as glucose, amino acids, and other additives are used for specific purposes. For instance, glucose provides calories for metabolism. Here’s a list of other common additives and the purposes each serves.

    •Electrolytes

    • Calcium promotes development and maintenance of bones and teeth and aids in blood clotting.

    • Chloride regulates acid-base balance and maintains osmotic pressure.

    • Magnesium helps the body absorb carbohydrates and protein.

    • Phosphorus is essential for cell energy and calcium balance.

    • Potassium is needed for cellular activity and cardiac function.

    • Sodium helps control water distribution and maintains normal fluid balance.

    •Vitamins

    • Folic acid is needed for deoxyribonucleic acid (DNA) formation and promotes growth and development.

    • Vitamin B complex helps the final absorption of carbohydrates and protein.

    • Vitamin C helps in wound healing.

    • Vitamin D is essential for bone metabolism and maintenance of serum calcium levels.

    • Vitamin K helps prevent bleeding disorders.

    •Other additives

    • Micronutrients (such as zinc, copper, chromium, selenium, and manganese) help in wound healing and red blood cell synthesis.

    • Amino acids provide the proteins necessary for tissue repair and immune functions.

    • Lipids support hormone and prostaglandin synthesis and prevent essential fatty acid deficiency.

    • serum albumin level below 3.5 g/dl

    • excessive nitrogen loss from a wound infection, a fistula, or an abscess

    • renal or hepatic failure

    • nonfunction of the GI tract lasting for 5 to 7 days. (See Key facts about PPN.)

    TPN triggers

    Common illnesses or treatments that can trigger the need for TPN include inflammatory bowel disease, ulcerative colitis, bowel obstruction or resection, radiation enteritis, severe diarrhea or vomiting, acquired immunodeficiency syndrome (AIDS), chemotherapy, and severe pancreatitis, all of which hinder a patient’s ability to absorb nutrients. Also, patients may benefit from TPN if they’ve undergone major surgery or if they have a high metabolic rate resulting from sepsis, trauma, or burns of more than 40% of total body surface area. Infants with congenital or acquired disorders may need TPN to promote proper growth and development.

    TPN has limited value for well-nourished patients with GI tracts that are healthy or are likely to resume normal function within 10 days. The treatment also may be inappropriate for a patient with a poor prognosis or when the risks of TPN outweigh its benefits.

    Key facts about PPN

    Peripheral parenteral nutrition (PPN) is prescribed for patients who have a malfunctioning GI tract and need short-term nutrition lasting less than 2 weeks. It may be used to provide partial or total nutitional support. PPN is infused peripherally in various combinations of lipid (fat) emulsions and amino acid-dextrose solutions. To ensure adequate nutrition, PPN solutions in final concentratons of ≤ 10% dextrose and ≤ 5% protein shouldn’t be administered for longer than 10 days unless they’re supplemented with oral or enteral feedings.

    Today’s TPN trends

    The trend of today’s nutritional supplementation is to tailor TPN formulas to the patient’s specific needs. As a result, standard TPN mixtures are becoming less popular. Nutritional support teams consisting of nurses, doctors, pharmacists, and dietitians assess, prescribe for, and monitor patients receiving TPN. The solutions may consist of:

    • protein (essential and nonessential amino acids), with varying types available for patients with renal or liver failure

    • dextrose (10% to 35% concentration)

    • fat emulsions (20% to 30% solution)

    • electrolytes

    • vitamins

    • trace element mixtures.

    Lipid emulsions

    Lipid emulsions are thick emulsions that supply patients with both essential fatty acids and calories. These emulsions assist in wound healing, red blood cell (RBC) production, and prostaglandin synthesis. They may be piggybacked with TPN, given alone through a separate peripheral or central venous line, or mixed with amino acids and dextrose in one container (total nutrient admixtures) and infused over 24 hours.

    The limits on lipids

    Lipid emulsions should be given cautiously to patients with hepatic or pulmonary disease, acute pancreatitis, anemia, or a coagulation disorder and to patients at risk for developing a fat embolism. These emulsions shouldn’t be given to patients who have conditions that disrupt normal fat metabolism, such as pathologic hyperlipidemia, or lipid nephrosis.

    Also, make sure you report any adverse reactions to the practitioner so the TPN regimen can be changed as needed.

    Warning!

    Adverse reactions to lipid emulsions

    Lipid emulsions can cause immediate adverse reactions as well as delayed complications.

    Immediate or early adverse reactions to lipid emulsions
    •Back and chest pain
    •Cyanosis
    •Diaphoresis or flushing
    •Dyspnea
    •Headache
    •Hypercoagulability
    •Irritation at the site
    •Lethargy or syncope
    •Nausea or vomiting
    •Slight pressure over the eyes
    •Thrombocytopenia

    Delayed complications associated with prolonged administration
    •Blood dyscrasias
    •Fatty liver syndrome
    •Hepatomegaly
    •Jaundice
    •Splenomegaly

    How to infuse TPN

    TPN must be infused through a central vein. As a hypertonic solution, it may be up to six times the concentration of blood and, therefore, too irritating for a peripheral vein.

    TPN may be infused around the clock or for part of the day for instance, as the patient sleeps at night. A sterile catheter made of polyurethane or silicone is inserted into the subclavian or jugular vein. A polyurethane catheter is rigid during insertion but softens at body temperatue. It’s biocompatible, so tissues don’t react to the material and it’s less thrombogenic than earlier types of manufactured catheters. A Silastic catheter may be a better alternative for therapy lasting months or years because it’s more flexible and durable and it’s compatible with many medications and solutions.

    Looking to the peripheral

    A peripherally inserted central catheter, a variation of central venous therapy, can be used for therapy lasting 3 months or more. The catheter is inserted through the basilic or cephalic vein and threaded so that the tip lies in the superior vena cava.

    The patient generally experiences less discomfort with a peripheral catheter, especially if he can move around easily. Movement stimulates blood flow and decreases the risk of phlebitis. Peripherally inserted central catheters are often used for intermediate-term therapy, both at home and in the health care facility.

    What to look for

    Signs and symptoms of electrolyte imbalances caused by TPN administration include abdominal cramps, lethargy, confusion, malaise, muscle weakness, tetany, convulsions, and cardiac arrhythmias. Acid-base imbalances can also occur as a result of the patient’s condition or the TPN content. Look for these other complications:

    • heart failure or pulmonary edema from fluid and electrolyte administration, conditions that can lead to tachycardia, lethargy, confusion, weakness, and labored breathing

    • hyperglycemia from dextrose infusing too quickly, a condition that may require an adjustment in the patient’s insulin dosage

    • adverse reactions to medications added to TPN for example, added insulin can cause hypoglycemia, which can result in confusion, restlessness, lethargy, pallor, and tachycardia

    • catheter-related infections and catheter occlusion.

    How you intervene

    Constant assessment and rapid intervention are critical for patients receiving TPN. When caring for a patient receiving TPN, you’ll want to take these actions:

    • Carefully monitor patients receiving TPN to detect early signs of complications, such as infection, metabolic problems, heart failure, pulmonary edema, or allergic reactions. Adjust the TPN regimen as needed.

    • Assess the patient’s nutritional status, and weigh the patient at the same time each morning in similar clothing, after he voids, and on the same scale. Weight indicates nutritional progress and also determines fluid overload. Patients ideally should gain 1 to 2 lb (0.5 to 1 kg)/week. Weight gain greater than 1 lb (0.5 kg)/day indicates fluid retention.

    • Assess the patient for peripheral and pulmonary edema. Edema is a sign of fluid overload.

    Teaching points

    Teaching about TPN

    When teaching a patient about total parenteral nutrition (TPN), be sure to cover the following topics and then evaluate your patient’s learning:

    • basics of TPN and its specific use

    • adverse reactions or catheter complications and when to report them

    • basic care of a TPN line

    • maintenance of equipment

    • weight, calorie count, intake and output, and glucose level monitoring.

    The sugar situation

    • Monitor serum glucose levels every 6 hours initially, then once a day. Watch for thirst and polyuria, which are indications that the patient may have hyperglycemia. Periodically confirm glucometer readings with laboratory test results. Serum glucose levels should be less than 200 mg/dl. This indicates the patient’s tolerance of the glucose solution.

    • Monitor for signs and symptoms of glucose metabolism disturbance, fluid and electrolyte imbalances, and nutritional problems. Some patients may require insulin added directly to the TPN for the duration of treatment.

    • Monitor electrolyte levels daily at first, and then twice a week. Keep in mind that when a patient is severely malnourished, starting TPN may spark refeeding syndrome, which includes a rapid drop in potassium, magnesium, and phosphorus levels. To avoid compromising cardiac function, initiate feeding slowly and monitor the patient’s electrolyte levels closely until they stabilize.

    • Monitor protein levels twice a week. Albumin levels may drop initially as treatment restores hydration.

    • Check renal function by monitoring blood urea nitrogen (BUN) and creatinine levels; increases may indicate excess amino acid intake.

    • Assess nitrogen balance with 24-hour urine collection.

    • Assess liver function with liver function tests, bilirubin, triglyceride, and cholesterol levels. Abnormal values may indicate intolerance.

    • Review the patient’s serum chemistry and nutritional studies, and alert the practitioner of abnormal results, which may indicate that the TPN fluid concentration or ingredients may need to be adjusted to meet the patient’s specific needs.

    • Avoid an adverse reaction by starting TPN slowly usually 60 to 80 ml/hour for the first 24 hours and increasing gradually. Continually monitor the patient’s cardiac and respiratory status.

    • Use an infusion pump for rate control.

    Memory jogger

    To remember how to avoid the complication of refeeding syndrome when giving total parenteral nutrition to a severely malnourished patient, think “Start low and go slow.”

    TPN technique

    • Use a 1.2-micron filter when administering TPN containing an I.V. fat emulsion (IVFE). Use a 0.2-micron filter when administering a TPN solution that doesn’t contain an IVFE.

    • Remove the TPN solution from the refrigerator 1 hour before administering it so that it can warm to room temperature.

    • Examine the TPN solution before administration. It should be clear or pale yellow if multivitamins are added to the solution. If you see particulate matter, cloudiness, or an oily layer in the bag when preparing to hang a TPN solution, return the bag to the pharmacy.

    • Flush central lines according to protocol.

    • If using a single-lumen central venous line, don’t use the line for blood or blood products or to give a bolus injection, administer simultaneous I.V. solutions, measure the central venous pressure, or draw blood for laboratory tests.

    • Never add medications to a TPN solution container once it’s actively infusing.

    • Don’t use add-on devices such as a three-way stopcock unless absolutely necessary; they increase the risk of infection.

    • Infuse or discard any TPN solution within 24 hours once the administration set is attached.

    • Perform site care and dressing changes at least three times a week (once a week for transparent semipermeable dressings), or whenever the dressing becomes wet, soiled, or nonocclusive. Use strict aseptic technique.

    • Monitor the patient for signs of inflammation and infection, and document any you find. TPN provides the perfect medium for microbial growth (both local and systemic).

    • Change the I.V. administration set according to facility policy, and always use aseptic technique. Changes of I.V. administration sets are usually done every 24 to 72 hours, depending on the type of solution.

    Timing out the TPN

    • Record vital signs at least every 4 hours. Temperature elevation is one of the earliest signs of catheter-related sepsis.

    • Provide emotional support, especially if eating is restricted because of the patient’s condition.

    • Provide frequent mouth care.

    • While weaning the patient from TPN, document his dietary intake and total calorie and protein intake. Use percentages when recording food intake. For instance, chart that, “The patient ate 50% of a baked potato,” rather than “The patient had a good appetite.”

    • When discontinuing TPN, decrease the infusion slowly, depending on current glucose intake. Slowly decreasing the infusion minimizes the risk of hyperinsulinemia and resulting hypoglycemia. Weaning usually takes place over 24 to 48 hours but can be completed in 4 to 6 hours if the patient receives sufficient oral or I.V. carbohydrates.

    • Promptly report any adverse reactions to the practitioner.

    • Prepare your patient for home care.

    • Accurately document all aspects of care, according to facility policy.

    Chart smart

    Documenting TPN

    If your patient is receiving total parenteral nutrition, make sure you document the following information:

    • adverse reactions or catheter complications

    • signs of inflammation or infection at the I.V. site

    • nursing interventions (including infusion rate) and the patient’s response

    • time and date of administration set changes

    • specific dietary intake

    • patient teaching.

    That’s a wrap!

    Total parenteral nutrition review

    Total parenteral nutrition

    • Highly concentrated, hypertonic nutrient solution used for patients with high caloric and nutritional needs due to illness or injury

    • Provides crucial calories, restores nitrogen balance, and replaces essential fluids, vitamins, electrolytes, minerals, and trace elements

    • Promotes tissue and wound healing and normal metabolic function; gives the bowel a chance to heal; reduces activity in the gallbladder, pancreas, and small intestine; and improves a patient’s response to surgery

    • Used in patients who can’t meet their nutritional needs by oral or enteral feedings, including those with inflammatory bowel disease, ulcerative colitis, bowel obstruction or resection, radiation enteritis, severe diarrhea or vomiting, AIDS, chemotherapy, and severe pancreatitis

    • Typically has limited value in well-nourished patients with GI tracts that are healthy or are likely to resume normal function within 10 days

    • Must be infused through a central vein

    Common TPN additives

    Electrolytes

    • Calcium: promotes development and maintenance of bones and teeth and aids in blood clotting

    • Chloride: regulates acid-base balance and maintains osmotic pressure

    • Magnesium: helps the body absorb carbohydrates and protein

    • Phosphorus: essential for cell energy and calcium balance

    • Sodium: helps control water distribution and maintains normal fluid balance

    Vitamins

    • Folic acid: helps with DNA formation and promotes growth and development

    • Vitamin B complex: helps the final absorption of carbohydrates and protein

    • Vitamin C: helps in wound healing

    • Vitamin D: essential for bone metabolism and maintenance of serum calcium levels

    • Vitamin K: helps prevent bleeding disorders

    Other additives

    • Micronutrients (zinc, copper, chromium, selenium, manganese): help in wound healing and red blood cell synthesis

    • Amino acids: provide the proteins necessary for tissue repair and immune functions

    • Lipids: support hormone and prostaglandin synthesis; prevent essential fatty acid deficiency

    Lipid emulsions

    • Thick preparations that supply patients with essential fatty acids and calories

    • Assist in wound healing, RBC production, and prostaglandin synthesis

    • May be piggybacked with TPN

    • Should be used cautiously in patients with hepatic or pulmonary disease, acute pancreatitis, anemia, or a coagulation disorder and in patients at risk for developing a fat embolism

    • Should be avoided in patients with pathologic hyperlipidemia or lipid nephrosis

    TPN complications

    • Electrolyte imbalances

    • Acid-base imbalances

    • Heart failure or pulmonary edema

    • Hyperglycemia

    • Rebound hypoglycemia

    • Refeeding syndrome (in severely malnourished patients), which includes a rapid drop in potassium, magnesium, and phosphorus levels

    Monitoring

    • Assess nutritional status and daily weight.

    • Assess for edema, a sign of fluid overload.

    • Monitor serum glucose level every 6 hours initially, then once daily.

    • Monitor electrolyte levels daily at first, then twice weekly.

    • Monitor protein levels twice weekly.

    • Monitor BUN and creatinine levels, liver function tests, and nitrogen balance.

  • Kimberly Anne Camacho

    Great blog! Really informative. I really like the experience based tips.

  • http://www.nursingshortage.net/ Nursing Shortage

    I have spent some time in the hospital, so I know first hand about proper IV care and placement.This is is a very thorough IV article, very informative. And yes Kimberly, experienced based tips are the best!

  • Andrea{TheUglyTruthMom}

    Love this. This is how I was taught, accept the person I was taught by always floated her catheters in. Great, clear discription.

  • Rose Paul

    May I say that the more medical personnel should be trained in IV therapy and they should make your guidelines REQUIRED reading.

    I am a cancer survivor that had 5 months of in-hospital treatment to save me from a cancer that was so aggressive that 12 weeks of giving birth to my son the cancer had spread from my uterus to both lungs and had started on my liver. Next step was brain then I was a goner.

    An intern did an IV on my inner left wrist with a butterfly and then proceeded to push a syringe filled with adriamycin and cytoxan into the vein.

    I told him it hurt and he checked for blood return and you could see a tiny bit of blood, but it wasn’t moving, he assured me he was in the vein. He pushed all 100 ml into my wrist and by the end of it he was really having to push hard on the plunger and I was in agony. He hurriedly left. An hour later my wrist had a large goose egg on it and no one knew what to do. They called my oncologist and he advised trying ice or heat, etc (I swear to you if I had a penknife or any kind of blade near me I would have cut a slit in it to let it drain out!)

    A day or two later we saw the damage it did. The sinew, ligaments and muscle in that part of the arm got fused (according to the orthopedic surgeon who was called in).

    To this day I have less than 30% rotation in the wrist, a lovely 1/4″ circle indent where the the needle was, visible scarring from the palm of my hand extending 5″ up the arm and more scarring that you cannot see but can feel going up another 4″.

    32 years ago on October 16th, 1982, I was told I had 3 months to live. On May 5th, 2015 I will celebrate my 31st year being cancer free. I had to make some sacrifices for it, my marriage, a uterus, a morphine pump implant to help with the pain from a third of my spinal cord that is degenerating due to the radiation therapy and my wrist, but it was all worth it to see my son graduate, get married and present me with 2 lovely grandchildren. For the last 10 years, I have volunteered as a Patient Advocate for the American Cancer Society.

    All because of a intern who did not know what a blood return should look like. That is why I believe your guidelines should be required reading.

  • WorldNursingJobs

    Really great and useful tips especially beginner nurses! Thanks for sharing!

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