1. IV THERAPY: Initiating IV Therapy Part 3
Catherine Luksic, BSN RN

2. Initiating IV Therapy Prior to procedure Check Physician’s order !
Check patient allergies
Handwashing (min seconds)
Sing “Happy Birthday”
Equipment
BE ORGANIZED
Patient identification & assessment
Patient education re: procedure
Site selection
Pt 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

3. Physician’s order Date, time to start infusion.
Solution to be infused, any additives ?
Route of administration
Dosage
Rate
Duration
Signed by physician
Does it say IV?
How much? Even a straight IV has to say .45 NS or .9 NS
How 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?

4. Physician’s Order Example: Infuse 1000 ml. D5W at 100 ml/hr
Infuse 500 ml. 0.9 NS over 4 hours
Infuse 20 meq Potassium Chloride in 100 ml. 0.9 NS over 1 hour
Always check electrolytes, BUN, creatinine before administering potassium

5. Physician’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.

6. INFECTION CONTROL & SAFETY
Universal Precautions
Higher risk w/ IV therapy
direct vascular access
risk of needle sticks
Always follow OSHA standards
Handwashing before and after all clinical procedures
Wear gloves – blood/body fluid contact
No artifical nails
Never reuse catheter or needle
Injection ports must be aseptically cleansed
Handwashing 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….

7. INFECTION CONTROL & Safety: Needlestick Prevention
NEVER recap used needle !!
Count all needles used prior to and after procedure
Dispose of all needles & syringes in “sharps”
container
puncture resistant
Gloves will not protect against needle sticks

8. Equipment IV solution & tubing
Insertion catheter/cannula (*radiopaque)
Extension set and NS flush (5-10ml)
Tourniquet (latex-free ?)
Antimicrobial solution
Chlorhexadine, Chloraprep
unless allergic
Electronic pump
Tape
Transparent dressing
Gloves (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 size
Should 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.
Tape
Tegaderm (or other transparent dressing), so you can see site
Gloves – 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.

9. Site Selection 1. Type & Rate of solution to be infused
2. Duration of IV therapy
3. Cannula size
4. Vein integrity
5. Patient age, diagnosis
6. Patient preference
Hand dominance
7. Patient activity level
8. AV fistula/post-mastectomy
9. Anticoagulant use
INS says hand dominance is not an important factor for site selection

10. IV Site Selection Hand veins (metacarpal) preferred site or
forearm veins
**INS recommendation: vasculature should
accommodate gauge/length of catheter
Choose straight vein w/ normal vasculature
Distal veins first
But proximal to any previous cannulation
Non-dominant arm
Avoid areas of flexion
Armboard may be necessary to stabilize
Choose vein that allows for ADL’s & movement
INS – vasculature should accommodate the gauge and length of the catheter required for the prescribed therapy
Site selection must always include the patients condition

11. IV Site Selection Avoid: Bruised, red, swollen veins
Site of previous infiltration
Area near surgical site
Area near wound
Limb affected by CVA, surgery or lymphedema
Limb with AV fistula or graft
Thin, small, curvy veins

12. IV Site Selection Dorsal digital veins Metacarpal veins Cephalic vein
Small IV cannula, support w/ tongue blade or board
Metacarpal veins
Ideal site for IV use, primary choice
Cephalic vein
Accomodates large gauge IV cannula
Accessory cephalic vein
Basilic vein
Appropriate choice, often overlooked

13. IV Site Selection Sites of last resort
Lateral or inner aspect of wrist – are thin and associated with bruising, infiltration
Antecubital fossa – interferes with flexion
Veins of legs, feet, ankles – can compromise
circulation
*dorsum of foot is best choice if
necessary

14. Catheter Selection Size of catheter (gauge)
Purpose of IV fluids, ie: blood product
Competency of veins
16-18 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

15. Venipuncture Procedure: Tips
Talk to your patient, explain & reassure
Assemble equipment ahead of time, be organized !!
Inspect fluid, appearance, expiration date and sterility of equipment
Adequate lighting
Avoid bright, overhead lighting
Flush air from tubing
Prefilled 10ml syringe is best
Select the most distal site if possible
Assess 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….

16. Venipuncture Procedure: Tips
Stabilize extremity
Stabilize adjacent skin & vein
Hold skin & vein taut
Place tourniquet 4-6 inches above site
If radial pulse not felt, tourniquet = TIGHT
Ask pt. to clench/unclench fist
May lightly tap vein
Remove tourniquet before removing needle
Single use
Remove needle & place in sharps
Check for adequate flow
Again I will review procedure step-by-step

17. Venipuncture Procedure: Tips
Trouble visualizing vein ?
Lower arm below ht. level x5 minutes
Apply warm compress to area x5-10 minutes
Light tapping of vein
Ask pt. to clench/unclench fist
Also ?? Use of BP cuff inflated to 30 mm/Hg

18. Age related considerations
Elderly
Skin: dry skin, decreased elasticity, decreased turgor, thin & transparent skin
Veins: walls are thicker & tougher, decreased elasticity, incompetent valves, varicosed veins (distended superficial veins)
Hearing/visual impairment: may be a factor regarding patient education/understanding

19. Venipuncture 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.

20. Catheter Insertion Needle bevel UP, 15-30 degree angle
Handwashing 1st !! Maintain aseptic technique
Equipment (prepared) & site selection
Identify vein
Apply tourniquet 4-6 inches above site
Apply gloves
Cleanse skin (center then outward 2-3 in.) w/ chlorhexadine, chloraprep, or alcohol/betadine x seconds, allow to air dry
Do not use alcohol after betadine (negates the effect)
Check for pt allergies first
Do not touch site after cleansing
Stabilize the vein w/ thumb or finger
Perform venipuncture with IV catheter
Needle bevel UP, degree angle
No more than 2 attempts in same area
Phillips book says 30 degree angle

21. Catheter Insertion Look for “flash” of blood
Slowly advance IV catheter ¼ - ½ inch
Hold stylet in place & Remove tourniquet
THEN remove stylet
THEN advance catheter further
Attach extension set, aspirate for blood return (if possible) then flush
Assess for infiltration
Apply transparent IV dressing to site
Secure extension tubing w/ tape
Use IV securement device
Secure IV tubing w/ tape
Label site w/ date-time-gauge-initials
Assess site and patient !!
Reassurance & documentation

22. Catheter Insertion Aspirate for blood return before administering meds
Flush qshift or qd – check policy first
3-10 ml saline
DO not force flush if meet resistance !
Does flushing cause pain ?
Assess for signs of infiltration
Phillips book says at least 2 ml for peripheral IV

23. IV Insertion videos
New England Journal of Medicine – IV insertion video #1 (amola36)
New England Journal of Medicine – IV insertion video #2 (amola36)
IV insertion video #3 (craigmdo)

24. Peripheral IV insertion Demo 2 – alicec3 5:41

25. IV Site Dressings Sterile Transparent is preferable
Gauze is acceptable (inspect site & change q 24 hr.)
Dressing change according to hospital policy
Change dressing prn if soiled or loose
Do NOT tape over transparent dressing
Acceptable to Chevron tape w/ winged IV catheter set
IV site must be removed and rotated every 72 hours (or according to policy)
INS – rotate according to clinical condition
CDC recommends site change every hours

26. IV SITE DRESSINGS

27. Iv site dressings

28. Nursing Documentation
DATE/TIME (of insertion)
LOCATION
VEIN USED
CATHETER SIZE (gauge used)
INFUSION ( rate & solution; pump or grav.)
ATTEMPTS MADE/LOCATION
CONDITION OF SITE
PATIENT TOLERANCE
NURSE SIGNATURE
This is just an overview of essentials of charting – obviously anything that needs clarification or elaboration needs to also be documented.

29. Discontinuation of an IV Catheter
LPN can perform
Gloves
Stop IV infusion and detach
Loosen tape
Pull catheter out while holding site with 2x2 gauze (no alcohol - prolongs bleeding)
Hold pressure x1 minute
Apply dressing or bandaid, check site
Check for intact catheter after removed, discard and document