Venipuncture Peripheral IV Insertion
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Venipuncture Peripheral IV Insertion

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Available on Blackboard: Professor Hidle\'s skills videos 1) Intravenous cannulization 2) Venous access. Clinical indications. Venipuncture: Blood testsMonitoring blood levelsPeripheral IV: Fluid maintenance (decreased/absent PO, NG or GT intake)Fluid boluses for dehydrationNutritional supple
Venipuncture Peripheral IV Insertion

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1. Venipuncture & Peripheral IV Insertion By Prof. Unn Hidle & Prof. Pat Dillon Updated Spring, 2010

2. Available on Blackboard: Professor Hidle?s skills videos 1) Intravenous cannulization 2) Venous access

3. Clinical indications Venipuncture: Blood tests Monitoring blood levels Peripheral IV: Fluid maintenance (decreased/absent PO, NG or GT intake) Fluid boluses for dehydration Nutritional supplementation (TPN, lipids Administration of medications/treatments Blood transfusions

4. Selecting anatomical sites: Venipuncture and PIV insertion The site chosen for venipuncture varies with the client?s age, the length of time the infusion is to run, the type of solution used, and the condition of veins. In general, for adults, veins in the hand and are commonly used, while for infants, veins in the scalp and dorsal foot veins may be used. Larger veins are preferred for infusion that need to be given rapidly and for solution that could be irritating.

5. Assessing for suitable veins Vein patency (scar tissue): Veins that have previously been used for IV insertion may have been damaged by phlebitis, infiltration or sclerosis ?Rolling veins? : Highly visible veins and ?popping up? ? tends to roll away from the needle Skin turgor (dehydration): Veins less palpable and access more difficult Edema: Veins less palpable Fistulas/shunts

6. The site selected depends on accessibility and convenience Consider the child?s developmental, cognitive, and mobility needs For veins in the extremities, it is best to start with the most distal sites. If the vein is damaged, using distal sites initially preserves access to the vein in proximal sites

7. Anatomical Sites

10. Median cubital vein ? usually saved for PICC line insertion; inconvenient in children as it limits motility Basilic vein Cephalic vein Medial antebrachial vein Dorsal hand veins Scalp veins ? used for infants Dorsal foot veins ? used for infants

13. IV Consideration in Children Most infants have 1-2 possible IV sites on each hand, arm, and foot and 4-8 sites on the scalp. Although scalp IV are easily accessible, they are used only when attempts at other sites have failed Superficial scalp veins have no valves and fluid can be infused in either direction

14. A rubber band is used from brow to occiput as a tourniquet when needed. It is often difficult to distinguish a scalp vein from an artery, even when palpating for pulsation Catheter in scalp should be inserted pointing downwards toward the heart

15. Accessing Veins Extremity veins may be difficult to locate as they are small and there is more subcutaneous fat. Warm compress, running warm water over the extremity, &/or holding the limb in a dependent position below body level will aide in visualization and palpation Use tourniquet with caution as it may cause added venous pressure in fragile veins to ?blow? when punctured, causing a hematoma

16. Preparing the child and caretakers Natural anxiety --- prepare them: HOW? Consider developmental age/stage Use play Demonstrate (i.e. doll) Let the child have some control in the situation (i.e. handle equipment, clean with alcohol wipe, assisting taping)

17. Stay away from ?safe places? ? i.e. playroom- use treatment room instead. Keep in mind that children often ?loose control? without expecting to do so Teaching child and care-takers: pre-and?post-procedure, care of IV site, signs of infection, infiltration, etc.

18. Equipment needed (will go over in demonstration) Gloves Alcohol wipes Betadine (if blood culture is needed) Tourniquet Angiocatheter or butterfly needle IV tubing and IV solution (primed) NS for injection 3cc or 5cc syringe with needle Tape &/or dressing material (Opsite, Tegaderm, gauze) Support board/arm-board if indicated Protective cover for butterfly needle

21. Procedure for IV insertion and securing the site PIV insertion Catheter hub should be firmly secured at the puncture site with transparent dressing or clear, non-allergenic tape Never encircle extremity with tape Also use extreme caution with Ace bandage, stretch bandages and gauze ? Roll; don?t stretch too tightly. I.V. cover (house) as a protective devise Immobilizers such as arm-boards, splints and elbow restraints are controversial. If restraints are used, frequently check the IV site, remove at intervals, passive/active ROM.

24. Remember, children are as scarred of IV removal as they are of insertion! Use EMLA cream pre-IV insertion - (lidocaine 2.5% and prilocaine 2.5%) is an emulsion mixture of lidocaine and prilocaine in a ratio of 1:1 ?Hurricane? spray (Benzocaine: local also in Baby Oragel for teething and Vagisil for diaper rash). Use adhesive tape remover (wash off immediately to protect the skin from irritation) Remove Tegaderm in a correct manner The ?gentler? IV

25. Benzocaine (Hurricane Spray) - ALERT Health professionals should be aware that potentially uncontrollable doses can be administered due to the design of the delivery device causing symptoms of benzocaineinduced methemoglobinemia. Methemoglobinemia is a high methemoglobin = IRON blood level This results in decreased O2 carrying capacity of RBC. Antidote = methylene blue 50 mg IV. The spray is not a metered dose product and as such each actuation does not deliver a specific dose per actuation. The instructions provided by the manufacturer for safe application appear ONLY on the canister?s cap and not on the canister?s container label. Until alternatives to this treatment regimen are implemented facilities should proactively report to FDA?s MedWatch reporting system any problems associated with Benzocaine (Hurricane Spray) use.

26. Complications Infection : Local infection (cellulitis) at the IV site insertion may present with edema, erythema spreading along vein (phlebitis), warmth (inflammation). A much more serious infection is a systemic infection in which pyrogenic substances in either the infusion solution or the IV administration set can induce a febrile reaction and septicemia. More common in immunocompromised patients.

27. Infiltration: More difficult to detect in infants and small children than in adults. A good blood return is not always an indicator of infiltration. Flush the catheter and observe the site for discoloration (blanching or redness), pain, tenderness, and edema or not any exudate or drainage and increase in skin or basal temperatures.

28. Hematoma: Results when blood leaks into tissues surrounding the IV insertion site. Leakage can result from perforation of the opposite vein wall during venipuncture, the needle slipping out of the vein, and insufficient pressure applied to the site after removing the needle or cannula. S/S include ecchymosis, immediate swelling at the site and the leakage of blood at the site. Treat with ice X 24 hours, then warm compresses to increase absorption

29. Phlebitis: Inflammation of a vein related to a chemical or mechanical irritation or both. It is characterized by reddened, warm area around the insertion site or along the vein and swelling. Increased risk with increased time IV is left in place, fluid composition, medication, size of the cannula, ineffective filtration and microorganism. Discontinue IV and restart it at another site. Apply warm, moist compress to the affected site.

30. Tissue injury / extravasation: Infiltration of a vesicant solution or medication into the surrounding tissue (VESICANTS ? chemotherapy -and other medications such as dopamine, calcium preparation). Blistering, inflammation, and necrosis of tissue can occur. Stop infusion, notify physician and administer / apply antidote prescribed. If not available, ICE!!! Sometimes IV remains in place not to worsen the extravasation.

31. Local allergy: Always ask prior to IV insertion if there are any allergies to iodine/seafood (betadine preparation), alcohol or latex

32. Clotting and obstruction / embolization: Blood clots may form in the IV line as a result of kinked IV tubing, a very slow infusion rate, an empty IV bag, or failure to flush the IV line after intermittent medication or solution administrations. The signs include decreased flow rate and blood backflow into the IV tubing. Nursing Interventions: Never force a clotted IV line, irrigate or milk it. Stop the IV line and restart in another site.

33. Air embolism: Very rare, but may occur with cannulation of central veins. Manifestation of air embolism include dyspnea and cyanosis, hypotension, weak rapid pulse, loss of consciousness and chest, shoulder, and low back pain. Nursing Interventions: includes immediately clamping the cannula, placing the patient ion the left side in the Trendenlenburg position, assessing VS and breath sounds and administering O2.

34. Venous Spasm A sudden involuntary contraction of a vein or an artery resulting in temporary cessation of blood flow through a vessel. Can be spontaneous, or resulting from high osmolarity (Dextrose > 12.5%) or high/low ph, viscous or cold fluids, rapid infusion, cannula too large, vaso-vagal response to anxiety or pain and some drugs (Diazepam, Nafcillin, Phenytoin, Potassium Cl, Propofol and Vancomycin). Signs/symptoms: sharp pain at the IV site that travels up the arm, which is caused by a piercing stream of fluid that irritates or shocks the vein wall; slowing of the infusion Nursing ? Prevention: Use a large vein and a small gauge catheter to allow for unrestricted blood flow.

35. Limitation in the use of the limb following IV insertion in that periphery. Compression of nerves and blood vessels within an enclosed space leading to impaired blood flow and muscle and nerve Causes: tight wrapping with tape or bandaging, edema/cellulitis, infiltration, and hematoma. Nerve, tendon, ligament or limb damage can lead to loss of function or amputation. Nursing Intervention/Prevention: Assess for pulses, elevate extremity immediately and report! Peripheral Nerve Palsy:

36. Points to Remember: Areas to be avoided when choosing a site: Extensive scars from burns and surgery It is difficult to puncture the scar tissue and obtain a specimen. Upper extremity on the side of a previous mastectomy Test results may be affected because of lymphedema and the area is highly susceptible to infection. Hematoma May cause erroneous test results and risk of infection. If another site is not available, collect the specimen distal to the hematoma.

37. Points to remember Intravenous therapy (IV) / blood transfusions Fluid may dilute the specimen, so collect from the opposite arm of the IV infusion if possible. Otherwise, satisfactory samples may be drawn below the IV by following these procedures: Turn off the IV for at least 2 minutes before venipucture. Apply the tourniquet below the IV site. Select a vein other than the one with the IV. Perform the venipucture. Draw 5 ml of blood and discard before drawing the specimen tubes for testing. Cannula/fistula/saline lock Hospitals have special policies regarding these devices. In general, blood should not be drawn from an arm with a fistula or cannula without consulting the attending physician. Edematous extremities Tissue fluid accumulation alters test results and risk infection.

38. How to best prevent complication of infection (cellulitis)?

39. HANDWASHING! HANDWASHING! HANDWASHING! HANDWASHING!

40. VENIPUNCTURE COLLECTION TUBES

41. Collection Tubes Color-coded stoppers indicate type of additive Additives include anticoagulants such as oxalates, citrates, ethylenediaminetetra acetic acid (EDTA), and heparin. BLOOD CULTURES are drawn in small speciment bottles before any other blood specimens . RED Tubes contain NO ADDITIVES !

42. LABORATORY TUBE COLORS RED: NO ADDITIVE. Serum is obtained in clotted blood for chemistry (electrolytes, proteins, enzymes, lipids, hormones), drug monitoring, radioimmunioassay (RIA), serology and blood bank.

43. LABORATORY TUBE COLORS GRAY: ADDITIVE is OXALATE. Plasma and blood specimens are collected for glucose testing.

44. LABORATORY TUBE COLORS BLUE: ADDITIVE is CITRATE. Plasma-blood specimens are collected for coagulation studies (prothrombin time [PT], activated partial thromboplastin time [APTT], partial trhromboplastin time [PTT]) and hemoglobin.

45. LABORATORY TUBE COLORS LAVENDER: ADDITIVE is EDTA. Plasma and blood specimens are collected for hematology (CBC), platelet count and certain chemistry.

46. LABORATORY TUBE COLORS GREEN: ADDITIVE is HEPARIN. Plasma-blood specimens are for arterial blood gases, Lupus erthematosus (LE), and sometimes electrolytes and hormones (usually red top).

47. Tubes with additives must be thoroughly mixed (Tip upside down and back). Erroneous test results may be obtained when the blood is not thoroughly mixed with the additive.

48. ORDER OF COLLECTING BLOOD Blood cultures (sterile) ? use Betadine to clean the area Chemistry (red top) = no additives which may be a source of contamination CBC (lavender) PT/PTT (blue) Others or follow specific lab instructions

49. IV FLUID RATE CALCULATION In PEDIATRICS

50. Maintenance Fluids: Hourly Rate First 10 kg: X 4 ml/h 2nd 10 kg (11-20 kg): X 2 ml/h Thereafter (21 kg and up): 1 ml/h Example: What is the maintenance IV fluid rate (1X maintenance) for a child who weighs 35kg?

51. 35 kg child: 1x maintenance IVF 10 kg X 4 ml/h = 40 ml/h 10 kg X 2 ml/h = 20 ml/h 15 kg X 1 ml/h = 15 ml/h TOTAL: 75 ml/h

52. Other examples using hourly rate (anwers at the end of slides) 1 X maintenance IVF for a child who weighs 22 kg? 1 X maintenance IVF for a child who weighs 12 kg? 1 X maintenance IVF for a child who weighs 7 kg? What about: 2 x maintenance IVF for a child who weighs 24 kg? 2 X maintenance IVF for a child who weighs 16 kg? 1/2 X maintenance IVF for a child who weighs 11 kg? 1/2 X maintenance IVF for a child who weighs 26 kg?

53. Another way?.. Per 24 hours First 10 kg: X 100 ml/24 hours 2nd 10 kg (11-20 kg): X 50 ml/24 hours Thereafter (21 kg and up): 20 ml/24 hours Then, divide the final 24 hour rate into hourly rate. Example: What is the maintenance IV fluid rate (1X maintenance) for a child who weighs 35kg?

54. 35 kg child: 1x maintenance IVF 10 kg X 100 ml/24h = 1000 ml/24h 10 kg X 50 ml/24h = 500 ml/24h 15 kg X 20 ml/24h = 300 ml/24h TOTAL: 1800 ml/24h In order to infuse this on a mechanical pump used in pediatrics, we need to calculate this hourly: 1800 ml/24h : 24h = 75 ml/h

55. Answers 1 X maintenance IVF for a child who weighs 22 kg? (10x4) + (10x2) + (2x1) = 62ml/h 1 X maintenance IVF for a child who weighs 12 kg? (10x4) + (2x2) = 44ml/h 1 X maintenance IVF for a child who weighs 7 kg? 7x4 = 28ml/h

56. Answers cont. 2 x maintenance IVF for a child who weighs 24 kg? (10x4) + (10x2) + (4x1) = 64ml/h x 2 = 128ml/h 2 X maintenance IVF for a child who weighs 16 kg? (10x4) + (6x2) = 52ml/h x 2 = 104ml/h 1/2 X maintenance IVF for a child who weighs 11 kg? (10x4) + (1x2) = 42ml/h (42/2) = 21ml/h 1/2 X maintenance IVF for a child who weighs 26 kg? (10x4) + (10x2) + (6x1) = 66ml/h (66/2) = 33ml/h

57. THE END!


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