IV Holding Techniques-Neonates and Infants

1
IV Holding Techniques-Neonates and Infants

• Remember to gather all necessary equipment as
  well as a second person to hold
• Equipment includes 24 gauge insyte IV catheter,
  NS for flush, extension tubing, 4X4s, extension
  tubing, padded armboards, protective cups for
  older infants, tape (microbore /or paper),
  tourniquet, tegaderm (small or medium), and
  gloves, cotton (from the 4X4s)

2
Appropriate IV Sites

• Extremities (Hicks Gilles, 1999)
• Hands/arms-when choosing hand IV, take into
  account which hand is used for finger/thumb
  sucking
• Feet/legs- make sure that there is adequate
  access for heelsticks if applicable
• Scalp-for infants 18 months and younger only
  contraindicated with infants with hydrocephalus
• Important to tell to parents that scalp IVs are
  just under the skin and do not go into the brain
  or skull, that hair may be shaved also the
  advantage of scalp IVs is that they allow their
  infant to have full mobility of their hands and
  feet (Zaichkin, 2002)

3
Appropriate IV Sites

• Scalp IVs
• all attempts should be made to minimize the
  amount of hair to be shaved for IVs-look before
  shaving
• Save shaved hair for parents-show RCNIC card
• Best places-scalp line along the forehead,
  especially in the middle, on the temporal sides,
  and behind the ears try to avoid areas near the
  eyes
• can part hair with alcohol wipes/swabs, water, or
  surgilube

4
Armboards

• Can be placed before or after IV insertion,
  usually easier after insertion
• There are small and regular size padded armboards
  used for neonates and preemies
• Use as little tape as possible, in some instances
  you should use double back tape to secure
  extremity
• Tape should not cover tips of fingers or toes and
  nailbeds should remain exposed
• IMPORTANT Have an experienced assistant help you
  hold site/extremity/infant securely and keep
  infant as calm as possible

5
Other Helpful Tips

• (Hicks Gilles, 1999)
• Warm area by using heel warmer or warm wet cloth
  for 10-15 minutes OR turn on radiant warmer if
  readily available
• Calm infant by swaddling, snuggling, offering
  pacifier, playing music, placing toys in view
  Also ask parents what their infant likes
• Apply tourniquet-can use rubber band-but be aware
  of latex precautions when applicable
• Hold extremity in dependent position-extremity
  should be lower than heart to allow venous
  distention
• Rub site vigorously with alcohol, but be cautious
  with preemies and infants with impaired/compromise
  d skin integrity

6
Developmentally Supportive Care

• It is important to watch infants for maladaptive
  behaviors. You should allow a rest period
  whenever possible between caregiving activities,
  including IV starts. Use the infants clinical
  status to determine what and how much you do.
  This helps to prevent overstimulation. (NANN,
  2000)

7
Developmentally Supportive Care

• Touch and Pain (Zaichkin, 2002)
• The sense of touch is the first to develop
• The nerves carrying feeling to and from the
  extremities develop during the 5th week of
  gestation.
• Sensory endings in the skin develop during early
  gestation.
• As early as 25 weeks, infants have an acute sense
  of touch.
• Therefore, interventions that provide a positive
  sense of touch is extremely important, even in
  the most premature of infants.

8
Developmentally Supportive Care

• Touch and Pain-
• Consider the use of Sweet-Ease before beginning
  painful procedures such as IV starts and
  heelsticks
• See RCNIC protocol for use of Sweet-Ease
• Must be ordered by physician or NNP

9
Developmentally Supportive Care

• Swaddling and/or snuggling for containment
• swaddling in blankets or snuggling in a
  snuggle-up provides containment
• containment helps to (NANN, 2000)
• maintain flexed position for infant, bringing
  arms and legs midline, which is similar to the
  fetal positions this is an example of
  self-consoling behavior
• facilitate tucking, which has been shown to
  positively help a preterm infants response to
  pain
• decrease stress during routine procedures
• stabilize infants motor and physiologic
  subsystems during stressful manipulations

10
Developmentally Supportive Care

• Containment (continued) helps to
• promote self-regulatory/self-consoling behaviors
  such as finger and fist sucking, hand to mouth
  maneuvers, leg-bracing (pressing up against a
  stable object) and hand clasping (NANN, 2000)
• provide boundaries which gives infants a sense of
  security because of the womb feeling (Zaichkin,
  2002)
• Infants prefer boundaries or a nest made of
  soft surfaces that yield to their movements
  (Zaichkin, 2002)

11
Developmentally Supportive Care

• Other Interventions/Considerations
• Grasping can provide comfort for the
  infant-provide objects such as blanket, diaper,
  piece of tubing (NANN, 2000)
• Light-Dim lighting by shading face during IV
  starts-helps to reduce environmental stress and
  provide them with womb-déjà vu (dark and muted
  environment). (Zaichkin, 2002)
• Visual-Provide toys for distraction. Infants
  prefer objects high in contrast like black
  white bulls eye shape infants also like faces,
  like your face or photos (Zaichkin, 2002)

12
Developmentally Supportive Care

• Sound-(Zaichkin, 2002)
• Ears are functionally developed at 27 weeks, but
  auditory canal continues to mature after birth
  making infants susceptible to noise damage
  continuous loud noises can harm infants hearing
  and produce physical stress
• you can protect hearing during IV starts by
• playing only soft, soothing music
• conversing softly when near infant minimizing
  conversations

13
Peripherally Inserted Central Catheters (PICCs)

• Long, soft, flexible catheters inserted through a
  peripheral vein (extremities or scalp) designed
  to reach one of the larger veins near the heart
• They are placed sterilely by specially-trained
  RCNIC RNs or CVC RNs
• May be done at the bedside or under fluroscopy
• Follow central line protocol
• See Nursing Policy and Procedure III-3.03
  Central Venous Catheters for care and maintenance
  of PICCs

14
PICCs

• Generally use 1.9 French Neo-PICCs in the RCNIC

15
Central Venous Catheters (CVC)

• A special intravenous catheter placed for
  long-term use
• Allows a child with chronic conditions who have
  need of long term intravenous access to receive
  needed fluids, medications, blood products, or
  blood draws

16
Central Venous Catheters (CVC)

• Placement of Central Venous Catheters (CVC)

17
Central Venous Catheters (CVC)

• Types of CVCs
• Tunneled- Usually tunneled under the skin on the
  chest into a vein near the neck tip of the
  catheter is in a large blood vessel near the
  heart (superior vena cava)

18
Central Venous Catheters (CVC)

• Types of CVCs
• Non-Tunneled- (Cutdown)-Placed percutaneously
  in a major vein such as the subclavian or femoral
  veins usually double-lumen Cook catheter used
  in the RCNIC

19
Central Venous Catheters (CVC)

• Refer to the following policies and procedures
  for care and maintenance and care of CVCs-
• Nursing Policy and Procedure III-3.03 for care
  and maintenance of CVCs
• RCNIC Policy III-2.06-Care of venous and arterial
  cutdown in neonates
• RCNIC Policy-2.15-Drawing blood from a CVC in the
  RCNIC

20
Umbilical Arterial (UAC) and Venous (UVC)
Catheters

• Venous and arterial access that is placed in the
  umbilical artery and umbilical vein by the
  physician or practitioner
• Ideally, catheters must be placed within 24 hours
  of delivery
• In general, use a 3.5 FR or 5 FR catheter for the
  umbilical artery and a 5 FR or 8 FR catheter for
  the umbilical vein
• May place a double lumen catheter in the
  umbilical vein
• See RCNIC Policy III 2.05 and III 2.11 for care
  and maintenance of UACs and UVCs

21
Umbilical Arterial (UAC) and Venous (UVC)
Catheters

• Proper placement-
• UAC-recommended low placement-tip at L3-L4
• UVC-tip of the catheter should be visible just
  above the diaphragm on x-ray
• Ideal placement is at the junction of the
  inferior vena cava and the right atrium
• Uses-
• UAC-continuous blood pressure monitoring, blood
  sampling, volume exchanges must be transduced
• UVC-provide IV fluids, administer meds, volume
  exchanges

22
Umbilical Arterial (UAC) and Venous (UVC)
Catheters

• Available in 3.5, 5, and 8 french catheters

23
Peripheral Arterial Lines

• May be placed in the same manner as a PIV or
  placed surgically
• Provides blood sampling and continuous blood
  pressure monitoring
• May also be used in volume exchanges
• Must be transduced
• See RCNIC Policy III-2.06-Care of venous and
  arterial cutdown in neonates

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Resources

• Hicks, K., RN Gilles, A., RN (Revised, 1999).
  CHMC orientation module Phlebotomy Skills and
  IV insertion. Cincinnati, OH Childrens
  Hospital Medical Center.
• National Association for Neonatal Nurses (NANN).
  (2000). Infant and family-centered developmental
  care Guidelines for practice (Document 1201).
  Des Plaines, IL Author.
• Zaichkin, J., RNC, MN (2002). Newborn intensive
  care What every parent needs to know . Santa
  Rosa, CA NICU Link.