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Insertion: Half the Battle!. 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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pre insertion checklist
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.
collect the supplies
Collect the supplies
  • Items needed to start an IV
    • Tourniquet
    • Antiseptic
    • Alcohol pads
    • Tape
    • Dressing
    • Label for site
    • Barrier
    • Gloves

-- Needle/catheter

prime the tubing
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.

connect tubing to iv bag hang set
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)
slide6

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.

universal precautions
Universal Precautions
  • Consider exposure to bloodborne pathogens
  • Recommends protective barriers and appropriate use- policy/nurse judgemt.
    • Gloves
    • Gowns
    • Masks
    • Goggles
hair removal fyi rarely needed for iv mgmt
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

patient positioning
Patient Positioning
  • Ideally…...
    • Comfortable supine position
    • Arm extended 45 degree angle
    • Maintain insertion site below level of heart
  • Alternative
    • Sitting 45-90 degree angle as tolerated
    • Arm abducted 30 degrees
    • Maintain insertion site below level of heart
control the environment
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

provide information and answer questions
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
venous assessment
Venous Assessment
  • Assessment should include both extremities'
  • Team up for a look !!!!!!
  • Fundamental: Why do we infuse into veins not arteries?
optimal vein conditions
Optimal Vein Conditions

Soft, straight, elastic

Supported by intact, elastic skin

Springy, easily palpated

Easily stabilized

key points to remember
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

prepare your site
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

select your cannula
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
slide17

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.

catheter sizes
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
venipuncture technique
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

how to hold the catheter options
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!

venipuncture
Venipuncture

Place the needle, bevel side up, parallel with and directly above the vein

the poke
The “poke”

Insert Needle At approx. 30 degree angle to the skin

for iv placement vs blood draw
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

placing an iv
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)

placing an iv1
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.
stabilizing cannula
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

securing techniques
Securing Techniques

Goals:

  • To prevent dislodging of IV catheter
  • Prevent phlebitis
  • Secure to prevent movement
  • Circulation is not inhibited
loop tubing and secure
Loop tubing and secure

What’s wrong with this picture?

IV POLICE

tubing dressing
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 24-48 hours.
  • Dressing should be labeled with:

Date & time

Gauge of cannula

Your initials & title

dispose of your sharps immediately
Dispose of your sharps immediately !!!

A majority of needlesticks occur to other nurses who come to help ‘clean’ up.

documentation
Documentation
  • 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

If it’s not noted, it was not done

patient teaching
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

catheter flushing
Catheter Flushing
  • Heparin 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
catheter flushing1
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
      • Saline
      • Heparin
catheter flushing2
Catheter Flushing
  • Positive Pressure Flushing
    • 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
extension set cap changes
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

extension tubing
Extension tubing
  • Prevents manipulation of the IV catheter
  • Easily grasped for injections
  • Safeguards catheter dislodgement by advantage of looped tubing
site maintenance
Site Maintenance
  • Follow your facilities policies
  • Fluid hang time
    • Usually 24 hours for TPN
    • Could be 48-72 hours for most medications
  • Venipuncture site rotation
    • Usually 48-96 hours
    • If poor access, notify physician and document reason
    • Get a PRN site change order from MD
site monitoring
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
evaluation of therapy
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
site maintenance1
Site Maintenance
  • Dressing Change Intervals
    • Transparent Dressing: change with site change or occlusive seal broken
    • Gauze Dressing: Change every 48 hours or when soiled and PRN
  • Tubing Change
    • Every 24-72 hours as dictated by your institution’s policy
documentation1
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
heparin saline locks
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.

termination of iv site
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

troubleshooting slow drip rates
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
slide49

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.

admixing or attached vial of powder
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
admixing
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
arterial puncture rare for poke
Arterial Puncture- rare for “poke”
  • Signs & Symptoms
    • Color of blood
    • Pulsatile flow of blood
    • Retrograde flow of blood
    • Blanches when flushed
arterial puncture
Arterial Puncture

Never infuse into an artery!- drug goes to?

Causes

  • Failure to identify the artery
  • Deep insertion approach
  • Excessive probing

Prevention

  • Identify artery
  • Remain superficial
  • Avoid fishing & probing

Intervention

  • Remove needle/catheter immediately
  • Apply direct pressure for 5-10 minutes by clock
  • Compression dressing
phlebitis inflammation of vein and surrounding areas
Phlebitis- inflammation of vein and surrounding areas
  • Signs & Symptoms
    • Pain or tenderness along the vein
    • Erythema
    • Swelling or edema
    • Palpable cord
    • Warmth
    • Drainage
phlebitis
Phlebitis

Classification

  • Mechanical
  • Chemical
  • Bacterial
causes of mechanical phlebitis
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

causes of chemical phlebitis
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

causes of bacterial phlebitis
Causes of Bacterial Phlebitis

Compromised aseptic technique when accessing the vein or the infusion system

Improper skin preparation

Contaminated infusate

Extended catheter dwell time

intervention for phlebitis
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
prevention of phlebitis
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
local site infection
Local Site Infection
  • Signs & Symptoms
    • Drainage from insertion site
    • Erythema
    • Swelling
    • Pain or tenderness
    • No systemic symptoms
site infection
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
preventative measures
Preventative Measures
  • Interruption of transmission requires
    • Good handwashing techniques
    • Strict adherence to aseptic technique
    • Practice of Standard/Universal Precautions
ecchymosis hematoma
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

ecchymosis hematoma causes
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.
echcymosis hematoma interventions
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

ecchymosis hematoma prevention
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

infiltration
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

extravasation
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
infiltration extravasation causes
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

infiltration intervention
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

extravasation interventions
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
infiltration prevention
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.
extravasation prevention
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
catheter occlusion
Catheter Occlusion
  • Resistance when instilling solution/drug
  • Difficulty infusing solutions
  • Inability to flush catheter
  • Inability to aspirate blood
  • Rate of infusion slows or stops
causes of catheter occlusion
Causes of Catheter Occlusion
  • Blood Draw
  • Transfusion
  • Reflux of blood
  • Failure to flush
  • Incompatible medication
  • Poor solubility
  • Mechanical Failure—kinking, clamps, or malposition
occlusion intervention
Occlusion--Intervention

Attempt flush with 10 mL SYRINGE only!

Don’t force!

Remove peripheral catheter, restart in another vein

Alteplase for Central Line Catheters

syringe selection psi
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

nerve damage stimulation
Nerve Damage/Stimulation
  • Signs & Symptoms
    • Numbness
    • Tingling
    • Weakness
nerve damage stimulation1
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
catheter embolism
Catheter Embolism
  • Signs & Symptoms
    • Visible shearing---only identified when catheter removed
catheter embolism1
Catheter Embolism

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

Intervention

  • To prevent migration of retained apply direct pressure
  • Retrieve fragments if visualized
  • Notify physician
catheter related bloodstream infection
Catheter-Related Bloodstream Infection
  • Signs & Symptoms
    • Fever & chills
    • Elevated temp
    • Increased WBC
    • Positive cultures
    • Hypotension
    • Vascular collapse
    • Shock
    • Death
    • More prevalent in Central Line
catheter related bloodstream infection1
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
sources of bacterial contamination
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

catheter related bloodstream infection2
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
catheter related bloodstream infection3
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
catheter related bloodstream infection4
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
culturing infected catheters
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