Presentation on theme: "IV THERAPY: Initiating IV Therapy Part 3"— Presentation transcript:
1IV THERAPY: Initiating IV Therapy Part 3 Catherine Luksic, BSN RN
2Initiating IV Therapy Prior to procedure Check Physician’s order ! Check patient allergiesHandwashing (min seconds)Sing “Happy Birthday”EquipmentBE ORGANIZEDPatient identification & assessmentPatient education re: procedureSite selectionPt assessment important.Site – touched on in A & P, will discuss again – lots of things influence site selection. It is not “cut & dry” (for lab venipuncture, selection is not as detailed, but principles are the same)Show video “Problems in IV therapy” if time permits
3Physician’s order Date, time to start infusion. Solution to be infused, any additives ?Route of administrationDosageRateDurationSigned by physicianDoes it say IV?How much? Even a straight IV has to say .45 NS or .9 NSHow fast? 100cc/hr? Over 8 hrs?Indefinitely? Until bag complete? (Not always specified – you may need to check)Signature?Review sample orders on overhead - which ones are correct?
4Physician’s Order Example: Infuse 1000 ml. D5W at 100 ml/hr Infuse 500 ml. 0.9 NS over 4 hoursInfuse 20 meq Potassium Chloride in 100 ml. 0.9 NS over 1 hourAlways check electrolytes, BUN, creatinine before administering potassium
5Physician’s order Potential for Errors: Illegible handwriting. Verbal orders transcribed incorrectly.Use of abbreviations.Incomplete orders.Prescriber ignorance.Failure of nurses and pharmacists to challenge questionable orders.
6INFECTION CONTROL & SAFETY Universal PrecautionsHigher risk w/ IV therapydirect vascular accessrisk of needle sticksAlways follow OSHA standardsHandwashing before and after all clinical proceduresWear gloves – blood/body fluid contactNo artifical nailsNever reuse catheter or needleInjection ports must be aseptically cleansedHandwashing always before and after pt contact. Soap and water loosen debris, but alcohol based products are most effective and recommended for decontamination – vigorous min scrub. Gloves for ALL body fluids, after cleaning hands.Universal precautions (“standard” is interchangeable)– these principles are maintained for ALL patients – thus “universal”Infection can be even more problematic w/ IV therapy since by its nature there is ALWAYS “exposure” since you have direct access to the vascular system. CDC “standard precautions” also include knowledge of the chain of infection………next slide….
7INFECTION CONTROL & Safety: Needlestick Prevention NEVER recap used needle !!Count all needles used prior to and after procedureDispose of all needles & syringes in “sharps”containerpuncture resistantGloves will not protect against needle sticks
8Equipment IV solution & tubing Insertion catheter/cannula (*radiopaque)Extension set and NS flush (5-10ml)Tourniquet (latex-free ?)Antimicrobial solutionChlorhexadine, Chloraprepunless allergicElectronic pumpTapeTransparent dressingGloves (powder-free, ? latex free)Additional supplies at bedside !Equipment – must be prepared. Once you start the procedure it is too late to try and run around to find things.Remember – IV solution:Check the order for the correct solution.Proper sizeShould be clear and intact.Check expiration date – should be habit.Tubing: Must be appropriate and package intact. Primary tubing for continuous IV,Secondary tubing for piggybacks, and pump tubing if needed for electronics – we will talk about this more, but for right now PRIMARY tubing will be what we are referring to. (Secondary is simply shorter and usually without injection ports)Appropriate catheter – we will discuss in detail.Tourniquet – try to use latex-free.Alcohol, betadine, or chlorhexadrine are most typical. Do NOT use alcohol AFTER betadine – it negates the effect of the betadine. The choice of antimicrobials is institution – dependent. Many studies done. For the most part, alcohol is oldest and very effective, but doesn’t last long. Betadine is not fast-acting but lasts much longer. (Companies in the process of developing combo solutions). Chlorhexedrine is also approved, and some studies show this solution to be superior to alcohol or betadine.Pump – we will talk about later, but have it if you need it.TapeTegaderm (or other transparent dressing), so you can see siteGloves – INS recommends powder-free for IV insertion.Each piece of equipment will make sense as we go through the procedure.We will do this in detail in the lab, however I want to explain first how to choose a site and choose a needle or cannula before I explain the rest of procedure.
9Site Selection 1. Type & Rate of solution to be infused 2. Duration of IV therapy3. Cannula size4. Vein integrity5. Patient age, diagnosis6. Patient preferenceHand dominance7. Patient activity level8. AV fistula/post-mastectomy9. Anticoagulant useINS says hand dominance is not an important factor for site selection
10IV Site Selection Hand veins (metacarpal) preferred site or forearm veins**INS recommendation: vasculature shouldaccommodate gauge/length of catheterChoose straight vein w/ normal vasculatureDistal veins firstBut proximal to any previous cannulationNon-dominant armAvoid areas of flexionArmboard may be necessary to stabilizeChoose vein that allows for ADL’s & movementINS – vasculature should accommodate the gauge and length of the catheter required for the prescribed therapySite selection must always include the patients condition
11IV Site Selection Avoid: Bruised, red, swollen veins Site of previous infiltrationArea near surgical siteArea near woundLimb affected by CVA, surgery or lymphedemaLimb with AV fistula or graftThin, small, curvy veins
12IV Site Selection Dorsal digital veins Metacarpal veins Cephalic vein Small IV cannula, support w/ tongue blade or boardMetacarpal veinsIdeal site for IV use, primary choiceCephalic veinAccomodates large gauge IV cannulaAccessory cephalic veinBasilic veinAppropriate choice, often overlooked
13IV Site Selection Sites of last resort Lateral or inner aspect of wrist – are thin and associated with bruising, infiltrationAntecubital fossa – interferes with flexionVeins of legs, feet, ankles – can compromisecirculation*dorsum of foot is best choice ifnecessary
14Catheter Selection Size of catheter (gauge) Purpose of IV fluids, ie: blood productCompetency of veins16-18 g. Blood products, trauma (green)20 g Most commonly used (pink)22 g Pediatrics, elderly, small veins (blue)24 g Pediatrics, elderly (yellow)**color coded packaging
15Venipuncture Procedure: Tips Talk to your patient, explain & reassureAssemble equipment ahead of time, be organized !!Inspect fluid, appearance, expiration date and sterility of equipmentAdequate lightingAvoid bright, overhead lightingFlush air from tubingPrefilled 10ml syringe is bestSelect the most distal site if possibleAssess intravenous (IV) devices and equipment for compliance with the Needlestick Safety and Prevention Act.Note : The Needlestick Safety and Prevention Act requires the use of needleless systems for laboratory sampling, parenteral administration of medication or fluids, or any procedure carrying the risk of injuries from contaminated sharps and occupational exposure to bloodborne pathogens. (Needlestick Safety and Prevention Act–HR 5178, Section 3, 2000.)Always dispose in sharps container.Next slide….
16Venipuncture Procedure: Tips Stabilize extremityStabilize adjacent skin & veinHold skin & vein tautPlace tourniquet 4-6 inches above siteIf radial pulse not felt, tourniquet = TIGHTAsk pt. to clench/unclench fistMay lightly tap veinRemove tourniquet before removing needleSingle useRemove needle & place in sharpsCheck for adequate flowAgain I will review procedure step-by-step
17Venipuncture Procedure: Tips Trouble visualizing vein ?Lower arm below ht. level x5 minutesApply warm compress to area x5-10 minutesLight tapping of veinAsk pt. to clench/unclench fistAlso ?? Use of BP cuff inflated to 30 mm/Hg
18Age related considerations ElderlySkin: dry skin, decreased elasticity, decreased turgor, thin & transparent skinVeins: walls are thicker & tougher, decreased elasticity, incompetent valves, varicosed veins (distended superficial veins)Hearing/visual impairment: may be a factor regarding patient education/understanding
19Venipuncture Procedure Excellent illustration of technique.Now – will practice in lab.½ class will do computer tutorial, then will switch for next class.Need to practice on own.
20Catheter Insertion Needle bevel UP, 15-30 degree angle Handwashing 1st !! Maintain aseptic techniqueEquipment (prepared) & site selectionIdentify veinApply tourniquet 4-6 inches above siteApply glovesCleanse skin (center then outward 2-3 in.) w/ chlorhexadine, chloraprep, or alcohol/betadine x seconds, allow to air dryDo not use alcohol after betadine (negates the effect)Check for pt allergies firstDo not touch site after cleansingStabilize the vein w/ thumb or fingerPerform venipuncture with IV catheterNeedle bevel UP, degree angleNo more than 2 attempts in same areaPhillips book says 30 degree angle
21Catheter Insertion Look for “flash” of blood Slowly advance IV catheter ¼ - ½ inchHold stylet in place & Remove tourniquetTHEN remove styletTHEN advance catheter furtherAttach extension set, aspirate for blood return (if possible) then flushAssess for infiltrationApply transparent IV dressing to siteSecure extension tubing w/ tapeUse IV securement deviceSecure IV tubing w/ tapeLabel site w/ date-time-gauge-initialsAssess site and patient !!Reassurance & documentation
22Catheter Insertion Aspirate for blood return before administering meds Flush qshift or qd – check policy first3-10 ml salineDO not force flush if meet resistance !Does flushing cause pain ?Assess for signs of infiltrationPhillips book says at least 2 ml for peripheral IV
23IV Insertion videosNew England Journal of Medicine – IV insertion video #1 (amola36)New England Journal of Medicine – IV insertion video #2 (amola36)IV insertion video #3 (craigmdo)
25IV Site Dressings Sterile Transparent is preferable Gauze is acceptable (inspect site & change q 24 hr.)Dressing change according to hospital policyChange dressing prn if soiled or looseDo NOT tape over transparent dressingAcceptable to Chevron tape w/ winged IV catheter setIV site must be removed and rotated every 72 hours (or according to policy)INS – rotate according to clinical conditionCDC recommends site change every hours
28Nursing Documentation DATE/TIME (of insertion)LOCATIONVEIN USEDCATHETER SIZE (gauge used)INFUSION ( rate & solution; pump or grav.)ATTEMPTS MADE/LOCATIONCONDITION OF SITEPATIENT TOLERANCENURSE SIGNATUREThis is just an overview of essentials of charting – obviously anything that needs clarification or elaboration needs to also be documented.
29Discontinuation of an IV Catheter LPN can performGlovesStop IV infusion and detachLoosen tapePull catheter out while holding site with 2x2 gauze (no alcohol - prolongs bleeding)Hold pressure x1 minuteApply dressing or bandaid, check siteCheck for intact catheter after removed, discard and document