IV THERAPY: Initiating IV Therapy Part 3
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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)
Sing “Happy Birthday”
Equipment
BE ORGANIZED
Patient identification & assessment
Patient education re: procedure
Site selection
PHYSICIAN’S ORDER
Date, time to start infusion.
Solution to be infused, any additives ?
Route of administration
Dosage
Rate
Duration
Signed by physician
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
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.
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
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
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)
SITE SELECTION
1.
2.
3.
4.
5.
6.
Type & Rate of solution to be infused
Duration of IV therapy
Cannula size
Vein integrity
Patient age, diagnosis
Patient preference
Hand dominance
7. Patient activity level
8. AV fistula/post-mastectomy
9. Anticoagulant use
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
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
IV SITE SELECTION
Dorsal digital veins
Metacarpal veins
Accomodates large gauge IV cannula
Accessory cephalic vein
Ideal site for IV use, primary choice
Cephalic vein
Small IV cannula, support w/ tongue blade or board
Accomodates large gauge IV cannula
Basilic vein
Appropriate choice, often overlooked
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
CATHETER SELECTION
Size of catheter (gauge)
Purpose of IV fluids, ie: blood product
Competency of veins
16-18 g.
20 g.
22 g.
24 g.
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
Avoid bright, overhead lighting
Flush air from tubing
Prefilled 10ml syringe
is best
Select the most distal
site if possible
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
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
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
VENIPUNCTURE PROCEDURE
CATHETER INSERTION
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
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
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
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
IV INSERTION VIDEOS
New England Journal of Medicine – IV insertion
video #1 (amola36)
http://www.youtube.com/watch?v=nVem1__qW14
New England Journal of Medicine – IV insertion
video #2 (amola36)
http://www.youtube.com/watch?v=Vrg69FlHi6g
IV insertion video #3 (craigmdo)
http://www.youtube.com/watch?v=jT16tL-g000
Peripheral IV insertion Demo 2 – alicec3 5:41
http://www.youtube.com/watch?v=r8ERE1SrglA
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 2011 – rotate according to clinical condition
CDC recommends site change every 72-96 hours
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
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