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Insertion: Half the Battle!
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Pre-insertion checklist
Cross check your order with the IV solution Prime your tubing before getting started Check patient’s allergies IV Pole IV Supplies IV catheter of choice Double check patient’s identity- Are you sure? Ask pt for his/her name.
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Collect the supplies Items needed to start an IV Tourniquet Antiseptic
Alcohol pads Tape Dressing Label for site Barrier Gloves -- Needle/catheter
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Prime the tubing Open the package per manufacturer’s recommendations. Inspect the equipment. Slide roller clamp up close to drip chamber. Close the roller clamp. Remove protective cuff on fluid container. Remove the protective cover over the piercing pin on the tubing and the bag, maintaining sterility.
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Connect tubing to IV bag, hang set
Spike the piercing pin into the bag in an aseptic manner. Squeeze the drip chamber 1/3-1/2 full. Hang the container on an IV pole. Maintaining sterility of the end of the tubing, loosen the protective cap. Invert all Y-sites for better filling and to prevent air trapping. Open the roller clamp and allow solution to flow, removing all air bubbles from the tubing- this is called “priming” the tubing (also GI tube feeds)
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After priming the tubing, close the clamp and tighten the protective cover at the end of the tubing.
Loop the tubing over the IV pole for protection and availability for use.
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Universal Precautions
Consider exposure to bloodborne pathogens Recommends protective barriers and appropriate use- policy/nurse judgemt. Gloves Gowns Masks Goggles
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Hair Removal-FYI, rarely needed for IV mgmt.
Clipping vs. shaving INS Standards of Practice discourages The use of razors because micro-abrasions alter the integrity of the skin If necessary, hair should be removed with scissors/clippers
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Patient Positioning Ideally…... Alternative
Comfortable supine position Arm extended 45 degree angle Maintain insertion site below level of heart Alternative Sitting degree angle as tolerated Arm abducted 30 degrees
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Control the Environment
Adjust lighting Adjust height of bed Ask visitors to leave during the procedure Draw curtain if semiprivate room Iintroduce yourself “Have you had an IV before?” -explain procedure if needed -ask how much difficulty there has been in starting IV’s in the past -a preferred location
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Provide information and answer questions
Check for allergies especially iodine Explain why IV is needed How venipuncture is done Degree of discomfort IV limits movements Possible discomforts while IV is infusing
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Venous Assessment Assessment should include both extremities'
Team up for a look !!!!!! Fundamental: Why do we infuse into veins not arteries?
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Optimal Vein Conditions
Soft, straight, elastic Supported by intact, elastic skin Springy, easily palpated Easily stabilized
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Key Points to Remember Good lighting
Distal to Proximal (saves sites more proximal for future IV starts) Alternate arms whenever possible Avoid areas of flexion Site should be free of trauma, abrasions or cuts Schlerosed, thrombosed (clotted) or varicosed veins should be avoided
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Prepare your site Clip excessive hair. You can use scissors; tape will pick up excessive hair- pain Visualize/landmark (fingernail mark?) Cleanse according to your institution’s Policy and Procedure Chlorhexidine/alcohol options Once cleansed do not touch the site. If you palpate the vein, the skin must be cleansed again
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Select your cannula Smallest gauge needed
Less trauma to the vein Greater blood flow around the tip reducing the risk of phlebitis Always open per manufacturer’s instruction; not by punching the cannula through the wrapping Check for errors in packaging Check to see that the needle extends beyond catheter
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Catheters (and needles) are sized by their diameter, which is called the gauge. The smaller the diameter, the larger the gauge. Therefore, a 22-gauge catheter is smaller than a 14-gauge catheter.
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Catheter Sizes 14-16 G—Trauma, possible OR, plasma pheresis, anesthesia 18G-blood, surgery, anesthesia 20G-procedures, large volumes, transfusions, heart monitor 22G-IV fluids, medication, COMMON 24G –26G-non viscous intermittent medications, last resort, Flow must be 100cc or less if infusing on a pump
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Venipuncture Technique
After skin prepping, apply tourniquet Ascertain the integrity of the IV Catheter Position in front of the limb with your dominant hand in alignment with the vein to be punctured. Stabilize the vein by placing thumb below intended site and draw skin toward you, pulling the skin taut
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How to hold the catheter- options
Butterfly: Grasp the wings between your thumb and forefinger with the bevel facing upward. Squeeze the wings together Over the needle: Grasp the flash back chamber and the color-coded hub with the dominant hand and remove the cover, then hold the hub and flash back chamber between thumb and forefinger. BEVEL UP!
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Venipuncture Place the needle, bevel side up, parallel with and directly above the vein
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The “poke” Insert Needle At approx. 30 degree angle to the skin
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For IV placement (vs blood draw)
After skin and vein are penetrated and a flash back of blood is observed, lower the needle to a 10 –15 degree angle and slowly advance about 3-4 millimeters farther into the vein. This is required because the catheter is shorter than the needle; thus, backflow may occur before the catheter tip is fully in the vein
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Placing an IV Gradually advance only the catheter, gently
Leave the stylet (needle) in place to occlude the catheter to prevent bleeding (some leaking may occur- this is normal)
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Placing an IV RELEASE THE TOURNIQUET
Collapse vein by placing a finger ½ inch above the insertion site Place the stylet in sharps container . . . Never reinsert the stylet into the catheter. Attach tubing to hub of needle maintaining sterility Apply clear occlusive dressing or gauze dressing up to the hub of the catheter but not covering it Make sure to loop tubing and tape it well.
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Stabilizing Cannula Try not to place tape on occlusive dressings
Do not encircle extremity with tape Do not allow tape to cover cannula or insertion site
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Securing Techniques Goals: To prevent dislodging of IV catheter
Prevent phlebitis Secure to prevent movement Circulation is not inhibited
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Chevron Method
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U Method
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H Method
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What’s wrong with this picture?
Loop tubing and secure What’s wrong with this picture? IV POLICE
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Tubing Dressing Transparent: Semi-permeable membrane that allows for visual inspection of site. Change: With site change If seal is broken Dressing is wet and lifting up Sterile 2X2 used only if client is allergic to transparent dressings. Tape all four corners. Change dressing every hours. Dressing should be labeled with: Date & time Gauge of cannula Your initials & title
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Dispose of your sharps immediately !!!
A majority of needlesticks occur to other nurses who come to help ‘clean’ up.
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Documentation If it’s not noted, it was not done Gauge size
Identify the site Length of catheter Dressing type Date/time of insertion Prepping procedure Patient allergies Patient education Patient tolerance Local anesthetic Insertion difficulties Number of sticks Inserter initials
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Patient Teaching Allowed range of motion
To maintain dryness of dressing Position of involved extremity when ambulating Call for assistance if: Dressing begins to feel wet Pain develops Redness develops Swelling develops Blood backs up into tubing IV pump is beeping
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Catheter Flushing Heparin Flushing Saline Flushing Volume of flush
10u/ml for peripheral 100u/ml for central NEEDS AN MD ORDER Saline Flushing Studies indicating that for peripheral flushing it is as effective as heparin Not utilized as often in home care
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Catheter Flushing SASH Flushing
This flushing method is used to ensure that medication incompatible with heparin gets flushed through the catheter with saline then is flushed with heparin Saline Administer medication Heparin
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Catheter Flushing Positive Pressure Flushing Effects of valve products
Technique that prevents blood from backing up into the catheter by keeping pressure on the syringe plunger while pulling out of the injection cap. Don’t completely empty your syringe of flush Effects of valve products e.g. Posiflow
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Extension Set/Cap Changes
Change per facility policy Use aseptic technique Utilize luer lock connections Never use clamps, scissors or hemostats Know volume capacity of add-ons
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Extension tubing Prevents manipulation of the IV catheter
Easily grasped for injections Safeguards catheter dislodgement by advantage of looped tubing
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Site Maintenance Follow your facilities policies Fluid hang time
Usually 24 hours for TPN Could be hours for most medications Venipuncture site rotation Usually hours If poor access, notify physician and document reason Get a PRN site change order from MD
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Site Monitoring Observe every 1-2 hours on continuous flow IV
Observe every 8 hours on heparin or saline lock Document at least every shift Goals To assure proper infusion of intravenous solution Reduce risk of complication Early detection of IV related complications
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Evaluation of therapy Patient Assessment to include:
Renal and Cardiac status is evaluated before initiating IV therapy. Comparison of I&O measurements. Vital Signs Skin Turgor Daily Weights Urinary Specific Gravity Lab Values
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Site Maintenance Dressing Change Intervals Tubing Change
Transparent Dressing: change with site change or occlusive seal broken Gauze Dressing: Change every 48 hours or when soiled and PRN Tubing Change Every hours as dictated by your institution’s policy
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Documentation IV Flow Sheet Nurses Notes Medicine Record I&O Weight
Vital Signs Care Plan Alteration in fluid/electrolytes Potential for Injury in relation to IV therapy
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Heparin/Saline Locks A heparin lock may consist of a catheter with tubing ending in a resealable rubber injection port, or a needless system such as a reflux valve. Many options are on the market.
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Termination of IV site Gather supplies, wash hands and don gloves
Clamp tubing to stop IV infusion. Withdraw catheter slowly flush with the skin Cover with 2x2 dry sterile dressing. Raise the extremity above the heart and apply firm pressure for 1 minute Assess catheter – CHECK THE TIP; also look for abrasions or shearing evidence Document
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Troubleshooting Slow Drip Rates
Check for infiltration Check for kinking of the tubing Check for phlebitis Readjust clamp on tubing above/below previous area of pinching Check air vent on administration set if indicated Check catheter for patency by lowering the bag of fluid below the level of the site, you will see blood back up Cather tip may be pressed against a vein valve
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Venous spasm may occur—heat may help relax vein to relieve the spasm
Check height of the container above the patient Do not irrigate traumatized vessel Assess pump function If in doubt, pull it out.
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Admixing- or- Attached vial of powder
To a bag Stabilize injection port with one hand Insert the needle through the center of the rubber stopper with the other Inject the medication. Rotate bag to spread medication. Label bag with correct medication added label
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Admixing To a bottle Insert the needle through the rubber seal
Rotate the bottle to spread medication Label with correct medication order -Admixtures should not be performed on infusing IV solutions !!! -Prevents delivering a bolus of the drug to the patient
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Complications
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Arterial Puncture- rare for “poke”
Signs & Symptoms Color of blood Pulsatile flow of blood Retrograde flow of blood Blanches when flushed
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Arterial Puncture Never infuse into an artery!- drug goes to?
Intervention Remove needle/catheter immediately Apply direct pressure for 5-10 minutes by clock Compression dressing Causes Failure to identify the artery Deep insertion approach Excessive probing Prevention Identify artery Remain superficial Avoid fishing & probing Never infuse into an artery!- drug goes to?
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Phlebitis- inflammation of vein and surrounding areas
Signs & Symptoms Pain or tenderness along the vein Erythema Swelling or edema Palpable cord Warmth Drainage
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Phlebitis Classification Mechanical Chemical Bacterial
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Causes of Mechanical Phlebitis
Excessive manipulation of the catheter Catheter gauge too large for the vein Improper insertion technique (poked through?) Inadequate stabilization of the catheter Patient factors
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Causes of Chemical Phlebitis
Infusion of hypertonic or hypotonic solutions or medications Particulate matter Infusion rate too rapid for the vein pH of the solution too acid or alkaline
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Causes of Bacterial Phlebitis
Compromised aseptic technique when accessing the vein or the infusion system Improper skin preparation Contaminated infusate Extended catheter dwell time
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Intervention for Phlebitis
Remove short peripheral catheters Obtain cultures if infection is suspected Cleanse the site with an antimicrobial solution Apply warm, moist compresses NSAIDS, mild exercise Modify medication if chemical phlebitis is suspected- notify provider/MD
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Prevention of Phlebitis
Use only one catheter per insertion attempt Appropriate catheter size Assess appropriateness of the catheter for the specific therapy Employ proper site preparation and care Stabilize the IV catheter adequately Use strict aseptic technique for admixture, flushing and infusion management Dilute/slow down irritating medications Instruct patient or caregiver in signs and symptoms Rotate peripheral IV site at established intervals
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Clinical Criteria--Phlebitis
INS Grade Clinical Criteria--Phlebitis No Symptoms 1 Redness at access site with or without pain 2 Pain at access site with erythema and/or edema 3 Pain at access site with erythema and/or edema. Streak formation. Palpable venous cord 4 Pain at access site with erythema and/or edema. Streak formation. Palpable venous cord>1 inch in length. Purulent drainage
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Local Site Infection Signs & Symptoms Drainage from insertion site
Erythema Swelling Pain or tenderness No systemic symptoms
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Site Infection Causes Contamination of insertion site
Improper skin prep Improper site maintenance Patient condition Handwashing techniques Aseptic techniques Prevention Strict adherence to sterile & aseptic techniques Intervention Notify physician Manage according to causative agent and type of catheter May include: culture antibiotics daily dressing changes catheter removal & replacement
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Preventative Measures
Interruption of transmission requires Good handwashing techniques Strict adherence to aseptic technique Practice of Standard/Universal Precautions
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Ecchymosis/Hematoma The infiltration of blood into the tissues. A hematoma occurs if the bleeding is uncontrolled at the venipuncture site, creating a hard lump Identified as a swelling above the IV site; bruising may be immediate or slow
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Ecchymosis/Hematoma -Causes
Unskilled venipuncture Patient with tendency to bruise easily Patient on anticoagulant or long-term steroid therapy Multiple entries into the vein Inadequate pressure to the site Applying a tourniquet to the same extremity immediately after an unsuccessful IV attempt or current IV in place.
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Echcymosis/Hematoma -Interventions
Remove catheter Apply firm pressure to the IV site Elevate the extremity Do no use the affected extremity until bleeding has completely stopped
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Ecchymosis/Hematoma -Prevention
Skilled venipucture Do not reapply a tourniquet to the affected extremity until bleeding has completely stopped Apply firm pressure to prevent bleeding into subcutaneous tissue when catheter removed
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Infiltration The inadvertent administration of a non-vesicant solution or medication into surrounding tissues Edema at the insertion site Skin may appear taut or stretched Blanching or coolness of the skin Infusion may be sluggish or stopped Tenderness at the site
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Extravasation The inadvertent administration of a vesicant (highly irritating/destructive) solution or medication into surrounding tissues (phenergan, some abx, others) Severe pain or burning during infusion Blotchy redness around the insertion site Edema at the insertion site Slowing or stopping of the infusion rate
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Infiltration/Extravasation -Causes
Improper selection of the catheter or site—catheter gauge too large, or small thin-walled veins Traumatic insertion IV catheter inadequately secured IV site is over a joint Inappropriate route or rate of administration for the solution/medication
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Infiltration -Intervention
Stop the infusion and remove the catheter Elevate the extremity to improve circulation and absorb the fluid Initiate a new infusion in the opposite extremity, if indicated Document
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Extravasation -Interventions
Discontinue infusion immediately, leave the catheter in place Notify the physician Have antidote available if indicated Aspirate residual medication and blood Discontinue the catheter Elevate the extremity to improve circulation Observe the site frequently for signs of erythema, palpable cord or necrosis Photograph the site
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Infiltration-Prevention
Choose appropriate vein and catheter Avoid areas of flexion when inserting a catheter Obtain assistance when inserting an IV in a hyperactive patient Minimize trauma when initiating venous access Secure the IV catheter Protect the IV site from excessive movement or pressure by the use of arm boards or restraints per policy Assess the site frequently Educate the patient regarding the signs and symptoms of infiltration.
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Extravasation-Prevention
Same as Infiltration PLUS: Anticipate extravasation when administering a vesicant -an agent capable of causing or forming a blister or causing tissue destruction Consider the placement of a central catheter When in doubt—pull it out! Educate the patient regarding recognition of potential problems and action required
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Catheter Occlusion Resistance when instilling solution/drug
Difficulty infusing solutions Inability to flush catheter Inability to aspirate blood Rate of infusion slows or stops
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Causes of Catheter Occlusion
Blood Draw Transfusion Reflux of blood Failure to flush Incompatible medication Poor solubility Mechanical Failure—kinking, clamps, or malposition
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Occlusion--Intervention
Attempt flush with 10 mL SYRINGE only! Don’t force! Remove peripheral catheter, restart in another vein Alteplase for Central Line Catheters
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Syringe Selection & PSI
The laws of physics dictate that given equal force on two syringes, that a small-cylinder syringe (like a 2-3 ml) will exert more pressure than a larger syringe (like a 10 ml) for IV lines, and for the patient’s vein. The high pressure may “blow” the patient’s vein, as in tear it, creating extravasation/bleed. “Larger syringes create less pressure when used to withdraw and/or flush” Macklin D. “What's physics got to do with it” JVAD. Summer 1999
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Nerve Damage/Stimulation
Signs & Symptoms Numbness Tingling Weakness
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Nerve Damage/Stimulation
Causes Rare Irritation to the nerve during insertion Improper arm positioning catheter outside of vein Prevention Appropriate assessment support the arm Avoid unnecessary probing Advance slowly & gently Intervention Stop advancement Restart using slower motion If sensations continue catheter should be removed
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Catheter Embolism Signs & Symptoms
Visible shearing---only identified when catheter removed
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Catheter Embolism Intervention
To prevent migration of retained apply direct pressure Retrieve fragments if visualized Notify physician Causes Damage to catheter Reinserting stylet into catheter Aggressive stylet removal Prevention Remove from packaging per manufacturer’s recommendation Do not reinsert stylet after removal Avoid use of clamps and scissors
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Catheter-Related Bloodstream Infection
Signs & Symptoms Fever & chills Elevated temp Increased WBC Positive cultures Hypotension Vascular collapse Shock Death More prevalent in Central Line
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Catheter-Related Bloodstream Infection
Causes Contaminated equipment or solutions Improper hand washing and aseptic technique during catheter insertion and care Improper set-up and handling of infusion equipment and solution
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Sources of Bacterial Contamination
Patient’s skin Hands of medical personnel Hub contamination Insertion site contamination Another site of infection, i.e., GI or Urinary tract infection Contaminated fluids
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Catheter-Related Bloodstream Infection
Risk factors Insertion of a IV catheter into a patient who already has an infection Frequent manipulation of the intravenous system Duration of catheterization Prolonged hospitalization before central venous catheterization Catheter insertion in the internal jugular vein
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Catheter-Related Bloodstream Infection
Prevention Strict adherence to sterile & aseptic techniques Strict hand washing before initiating any infusion procedure Clip excessive hair at insertion site Cleanse the IV insertion site with an antimicrobial solution and friction Use maximum sterile barrier precautions for central line insertions Disinfect ports/hub before accessing with an antiseptic solution Change all solutions and tubing according to facility policy D/C catheter ASAP Ongoing staff training and education
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Catheter-Related Bloodstream Infection
Intervention Notify physician Evaluate symptoms for possible causes Monitor Vital Signs Obtain 2 blood cultures If catheter is discontinued, aseptically remove and send tip for culture(Catheter related infection is documented by isolation of the same organism from a catheter tip and the two blood cultures with no other apparent source for clinical S/Sx of infection
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Culturing Infected Catheters
Remove dressing securing site, thoroughly cleanse site with 70% alcohol, air dry. Remove the cannula without touching it or dragging it on the client’s skin After the cannula has been removed, clip approximately ½-1 inch of catheter with sterile scissor, drop into a sterile specimen cup
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