Transcript IV THERAPY: Initiating IV Therapy Part 3

IV THERAPY:
INITIATING IV THERAPY
PART 3
Catherine Luksic, BSN RN
INITIATING IV THERAPY
Prior to procedure
 Check Physician’s order !
 Check patient allergies
 Handwashing (min. 15-20 seconds)
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Sing “Happy Birthday”
Equipment
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BE ORGANIZED
Patient identification & assessment
 Patient education re: procedure
 Site selection
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PHYSICIAN’S ORDER
Date, time to start infusion.
 Solution to be infused, any additives ?
 Route of administration
 Dosage
 Rate
 Duration
 Signed by physician
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PHYSICIAN’S ORDER
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Example:
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Infuse 1000 ml. D5W at 100 ml/hr
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Infuse 500 ml. 0.9 NS over 4 hours
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Infuse 20 meq Potassium Chloride in 100 ml. 0.9 NS
over 1 hour
 Always check electrolytes, BUN, creatinine before
administering potassium
PHYSICIAN’S ORDER
 Potential
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for Errors:
Illegible handwriting.
Verbal orders transcribed incorrectly.
Use of abbreviations.
Incomplete orders.
Prescriber ignorance.
Failure of nurses and pharmacists to challenge
questionable orders.
INFECTION CONTROL & SAFETY
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Universal Precautions
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Higher risk w/ IV therapy
direct vascular access
 risk of needle sticks
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Always follow OSHA standards
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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
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
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puncture resistant
Gloves will not protect against needle sticks
EQUIPMENT
 IV
solution & tubing
 Insertion catheter/cannula (*radiopaque)
 Extension set and NS flush (5-10ml)
 Tourniquet (latex-free ?)
 Antimicrobial solution
Chlorhexadine, Chloraprep
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unless allergic
 Electronic
pump
 Tape
 Transparent
dressing
 Gloves (powder-free, ? latex free)
SITE SELECTION
1.
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 4.
 5.
 6.
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Type & Rate of solution to be infused
Duration of IV therapy
Cannula size
Vein integrity
Patient age, diagnosis
Patient preference
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Hand dominance
7. Patient activity level
 8. AV fistula/post-mastectomy
 9. Anticoagulant use
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IV SITE SELECTION
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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
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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
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IV SITE SELECTION
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Avoid:
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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
IV SITE SELECTION
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Dorsal digital veins
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Metacarpal veins
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Accomodates large gauge IV cannula
Accessory cephalic vein
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Ideal site for IV use, primary choice
Cephalic vein
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Small IV cannula, support w/ tongue blade or board
Accomodates large gauge IV cannula
Basilic vein
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Appropriate choice, often overlooked
IV SITE SELECTION
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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
CATHETER SELECTION
Size of catheter (gauge)
 Purpose of IV fluids, ie: blood product
 Competency of veins
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16-18 g.
 20 g.
 22 g.
 24 g.
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Blood products, trauma (green)
Most commonly used (pink)
Pediatrics, elderly, small veins (blue)
Pediatrics, elderly (yellow)
**color coded packaging
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
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Avoid bright, overhead lighting
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Flush air from tubing
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Prefilled 10ml syringe
is best
Select the most distal
site if possible
VENIPUNCTURE PROCEDURE: TIPS
Stabilize extremity
 Stabilize adjacent skin &
vein
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Hold skin & vein taut
Place tourniquet 4-6 inches
above site
 If radial pulse not felt,
tourniquet = TIGHT
 Ask pt. to clench/unclench
fist
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May lightly tap vein
 Remove tourniquet
before removing needle
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Single use
Remove needle & place
in sharps
 Check for adequate flow
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VENIPUNCTURE PROCEDURE: TIPS
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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
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Also ?? Use of BP cuff inflated to 30 mm/Hg
AGE RELATED CONSIDERATIONS
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Elderly
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Skin: dry skin, decreased elasticity, decreased
turgor, thin & transparent skin
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Veins: walls are thicker & tougher, decreased
elasticity, incompetent valves, varicosed veins
(distended superficial veins)
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Hearing/visual impairment: may be a factor
regarding patient education/understanding
VENIPUNCTURE PROCEDURE
CATHETER INSERTION
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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 20-30
seconds, allow to air dry
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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, 15-30 degree angle
 No more than 2 attempts in same area
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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
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Assess for infiltration
Apply transparent IV dressing to site
Secure extension tubing w/ tape
 Use IV securement device
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Secure IV tubing w/ tape
 Label site w/ date-time-gauge-initials
 Assess site and patient !!
 Reassurance & documentation
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CATHETER INSERTION
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Aspirate for blood return before administering
meds
Flush qshift or qd – check policy first
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3-10 ml saline
DO not force flush if meet resistance !
Does flushing cause pain ?
 Assess for signs of infiltration
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IV INSERTION VIDEOS
New England Journal of Medicine – IV insertion
video #1 (amola36)
 http://www.youtube.com/watch?v=nVem1__qW14
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New England Journal of Medicine – IV insertion
video #2 (amola36)
 http://www.youtube.com/watch?v=Vrg69FlHi6g
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IV insertion video #3 (craigmdo)
 http://www.youtube.com/watch?v=jT16tL-g000
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Peripheral IV insertion Demo 2 – alicec3 5:41
 http://www.youtube.com/watch?v=r8ERE1SrglA
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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
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Acceptable to Chevron tape w/ winged IV catheter set
IV site must be removed and rotated every 72
hours (or according to policy)
INS 2011 – rotate according to clinical condition
 CDC recommends site change every 72-96 hours
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IV SITE DRESSINGS
IV SITE DRESSINGS
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
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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
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