Pediatric IV Therapy Amy E. Irwin, DNP, MS, RN Denver School of Nursing.
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Transcript of Pediatric IV Therapy Amy E. Irwin, DNP, MS, RN Denver School of Nursing.
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Pediatric IV TherapyAmy E. Irwin, DNP, MS, RN
Denver School of Nursing
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Purpose of IV Therapy
• Correct fluid and electrolyte imbalances
• Administer medications
• Administer blood products
• Administer nutrients
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Principles of IV Access
• The largest visible vein is not necessarily the preferred one
• Consider the comfort of the patient
• Consider the position and extent restraint
• Consider the vessel’s ability to maintain a needle
• Consider the solution to be infused
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Developmental Considerations• INFANT
– Handle infant gently, speak softly– Avoid arm used for thumb sucking– Cuddle immediately after insertion– Don’t feed immediately prior to insertion– Avoid presence of extra personnel to minimize
stranger anxiety
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Developmental Considerations
• TODDLER/PRESCHOOLER:– Prepare child immediately prior to procedure– Give simple explanations in concrete terms– Explain that you will help child hold still– Emphasize that the IV is not punishment
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Developmental Considerations
• SCHOOL-AGER– Prepare child ahead of time, but on the day of
insertion only– Give the child choices as appropriate– Give positive reinforcement after completion
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Developmental Considerations
• ADOLESCENT– Prepare teenager several hours to a day before
procedure– Approach discussions on a more adult level– Discuss fears related to procedure– Include teen in decisions
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Pediatric Optimal Locations
• Hands
• Forearm
• Feet
• Scalp
**Note if the child is a thumb sucker,etc
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Pediatric Catheter Gauges
• Use the largest catheter you can successfully insert
• Catheter Sizes:
Newborn: 24, 22 gauge
Infant < 1 year: 24, 22 gauge
1 – 8 years: 22, 20, 18 gauge
8 years and older: 20, 18, 16 gauge
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EMLA Cream
• Minimizes or prevents pain from needle puncture for an IV, blood sample, or implanted port access.
• Apply EMLA cream to the selected site 60 minutes before the procedure.
• Cover at least two sites in case the first attempt is not successful.
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Complications of PIVs
• Mechanical factors predispose IV infusion to shorter dwelling time
• Mechanical factors include:Insertion siteLength of catheterSize of vesselVessel fragilityActivity level of the patientForceful administration of boluses of fluidInfusion of vessicants or irritants through small
vessels
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Complications of IV Therapy
• Infiltration (extravasation)– Fluid leaks into subcutaneous tissue
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Complications of IV Therapy
• Catheter Occlusion– Blockage usually by clotted blood or precipitate
• Air Embolism– Air enters circulation & travels to right side of heart
• Phlebitis– Injury to vein without clot
– Inflammation of the blood vessel
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Complications of IV Therapy
• Thrombophlebits– Inflammation of a blood vessel with thrombus
formation
• Infection– Introduction of pathologic organisms locally
or systemic
• Metabolic derangement– Imbalance in electrolytes, minerals, glucose &
proteins
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Venous Access Devices
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Intraosseous Infusion
• Used in emergency situations when a peripheral vein cannot be accessed
• Needle is inserted into the medullary cavity of a bone
• Used to administer fluid and medications
• Safe and reliable method for rapid administration
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Intraosseous Infusion Site Tips
• Using aseptic technique, prep site with povidone-iodine solution
• Use 18 gauge in infants < 3 months of age• Use firm, gentle pressure in a twisting motion to insert
needle• Insert perpendicular to site, or at a slight angle away from
nearest joint• Stop when you feel a “pop” and attempt to aspirate and/or
flush• Secure tubing to leg to prevent pulling on insertion site• Flush meds with 5 – 10 cc NS• Requires pressure for fluids to run
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Characteristics of Pediatric Administration Sets
• Calibrated volume & control chamber with a limited capacity & an automatic shutoff mechanism– Ie. Buretrol, Metriset
• Standard of Practice– All IV meds should be placed on a syringe
pump if child is < 6 months
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Buretrol Administration Set
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Characteristics of Pediatric Administration Sets
• Drip chamber with microdropper delivering 60 gtts/min or 60cc/hr
• Tubing compatible with pump, catheter adapter for needleless systems
• Standard of practice: All IV sites should be checked and reprogrammed every hour
• Armboards are utilized to maintain integrity of IV site (may also require restraints)
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Principles of IV Fluid Therapy
• IV fluids are administered for the following reasons:– To provide water, electrolytes, nutrients– To replace water, correct electrolyte deficits
(replacement)
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Composition of Fluids
• Isotonic: electrolyte content approximately 310 meq/L– Examples: D5W, D10W, NS, LR
• Hypotonic: electrolyte content less than 250meq/L (never used in children)– Examples: No examples in pediatrics
• Hypertonic: electrolyte content exceeds 375 meq/L– Examples: 3% saline, D5.45NaCl, D5.9NaCl
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Maintenance Fluid Requirements
• Fluid calculations are based on weight in kilograms
Maintenance Fluid Intake
0 – 10 kg weight needs 4 cc/kg/hr
11 – 20 kg weight needs 2 cc/kg/hr additional
21 kg plus weights needs 1 cc/kg/hr additional
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Example
23 kg Child
Calculate:
• 10 x 4=40
• 10 x 2=20
• 3 x 1=3
Total maintenance fluid requirements=63cc/hr
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Example
22 kg Child who is “fluid-restricted” at 2/3 maintenance due to kidney failure
Calculate:
10 x 4 = 40
10 x 2 = 20
1 x 2 = 22
Total maintenance fluid = 62 cc/hr
At 2/3 maintenance = ?
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Factors Influencing Pediatric Drug Administration
• Children vs. Adults
• Physiological differences
• Immature kidney and liver function
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Factors Influencing Pediatric Drug Administration
• Slow gastric emptying time.
• Decreased gastric acid secretion in children under 3 years of age
• Lower concentration of plasma proteins
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Additional Variations to consider with Pediatric IV medications
• Patient weight in kilograms• Patient fluid status/maintenance rate• Patient diagnosis (fluid restriction?)
– Renal– Cardiac
• Additional medications to administer• Volume of IV tubing
– Need to flush med through after administration
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IV Drug Administration
• 1. Calculate Safe dose (mg/kg)
• 2. Calculate amount to administer (cc)
• 3. Calculate final concentration or dilution for IV medications
• 4. Calculate rate of infusion
• 5. Set pump accordingly
• 6. Flush med! (same rate as administered)
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Patient Example
• 12 kg child– 825 mg Ancef q8h
• Follow each step!– 1. Safe dose?– 2. Amount to administer?– 3. Final concentration?– 4. Rate of infusion?– 5. Does it make sense?
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1. Calculate Safe Dosage
• Mg/kg x patient weight
• Example: 12 kg ChildOrdered: Ancef 825 mg IV q 8 h
Recommended 200-400mg/kg/Day
Dose on hand: 200mg/cc
Pt wt. = 12 kg
200 x 12 = 2400mg/Day
400 x 12 =4800mg/Day
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Calculate Safe Dosage
• Divide by 3 (for Q 8 hours) for the safe dose:– 2400 divided by 3 = 800mg/kg/dose– 4800 divided by 3 = 1600mg/kg/dose
– Therefore the DOSE IS SAFE because it falls within the range
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2. Calculate the Amount to Administer
• Dose on hand (concentration from pharmacy) = 200mg/cc
• 200mg : 825mg =4.12cc to administer
1cc x
200x = 825
x=4.12cc
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3. Calculate Final Concentration(Dilution)
Recommended: 125 mg / 5cc infuse over 30”
125 mg : 825mg = 33.0cc dilution required
5cc x
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4. Calculate Rate of Infusion
• Volume – 4.12 cc med + 33.0cc dilution = 37.12 total– Desired minutes: 30
37.12 x 60 = 74 cc/hr 30
Set pump at 74 cc/hr
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5. Don’t Forget……
• After completing all of your calculations….
• DOES IT MAKE SENSE??
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Blood Products
• It is the RNs responsibility to know1. Why a specific product is being given2. A safe volume over a safe time has been ordered3. The common side effects of giving the product
• No solutions other than normal saline and 5% albumin should be in IV tubing used to administer blood products
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Blood Products Continued
• Once a blood product has been issued from the blood bank, the transfusion must be completed within 4 hours
• Tubing is changed after blood products are given unless one unit is followed immediately by the next, in that case multiple units can be given with the same infusion set
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Blood Products Continued
• Most infusion sets are limited to 4 units, and all infusion sets are limited to 4 hours (whichever occurs first).
• All blood components must be administered through an infusion set with an in-line filter designed to retain blood clots and particles potentially harmful to the recipient
• Platelets, fresh frozen plasma, and cryoprecipitate do not need to be cross-matched; however, a blood type is necessary to pick the appropriate products. If the patient has a blood bank history, no specimen is required.
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Assessment, Administration, and Tranfusion Reactions:
• Complete assessment prior to starting the transfusion including: Vital Signs (Temp, HR, RR, BP), Skin (color, temp, and condition), Breath sounds, Description of the IV infusion site
• Observe the patient during the first 5-10 minutes of the transfusion to watch for immediate signs of acute reaction
• Complete reassessment at 15 minutes into transfusion
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Assessment, Administration and Transfusion Reactions (Cont.)
• Then hourly VS and IV site checks, as well as 1 hour after transfusion
• Document: physical assessment and reason for transfusion, VS prior to and at 15 min/ and hourly
• If a transfusion reaction is suspected immediately STOP the transfusion and notify a physician.
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Blood Compatibilities
Blood Group Compatible RBC’s Compatible Plasma/Platelets
O O O, A, B, AB
A A, O A, AB
B B, O B, AB
AB AB, A, B, O AB
Rh Type RBC Rh Type Plasma Rh Type for Transfusion
Positive Positive or Negative Positive or Negative
Negative Negative Positive or Negative