NURS 228 Initiating Peripheral Intravenous Infusion

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NURS 228Initiating Peripheral Intravenous
Infusion

• Janie Best, MSN, RN
• Presbyterian School of Nursing at Queens
  University

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Objectives

• Demonstrate safe and appropriate techniques for
  initiation of Intravenous Therapy
• Discuss indications and nursing interventions for
  blood and blood product transfusions

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Intravenous Solution Review

• Isotonic
• Extracellular volume replacement
• Concentration of ECF ICF
• Hypotonic
• Pulls water into the cells and rehydrates the
  cells
• Hypertonic
• Pulls water from the cells into the vascular
  space to maintain circulating blood volume

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Peripheral IV Access -

• Hand veins
• Superficial dorsal
• Basilic
• Cephalic

• Arm veins
• Radial (wrist)
• Cephalic
• Basilic
• Median cubital
• Median

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Common IV Sites

• Metacarpal, cephalic, basilic, and median veins
  and their branches
• More distal sites should be used first, with more
  proximal sites used subsequently.
• Feet / leg sites require MD order
• Avoid arm on mastectomy side

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Central Line IV Access

• Internal , External Jugular, Subclavian veins
• Type of Access
• Non tunneled
• Varies from 1-4 lumen catheters
• Peripherally inserted (PICC)
• Tunneled
• Hickman
• Groshong
• Implantable ports

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Equipment

• Correct Patient
• Correct IV solution
• Proper catheter for venipuncture
• IV start kit
• Correct tubing, IV loop

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Selecting the Site

• Consider
• Condition of the vein
• Type of fluid or medication to be infused
• Duration of therapy
• Patients age and size
• Whether patient is left or right handed
• Patients medical history and current health
  status
• Skill of the person performing the venipuncture

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Selecting the Site

• Avoid areas
• that are painful to palpation
• where the vein is hard or lumpy
• below an infiltrated IV site
• Veins too small for the selected IV catheter
• That interfere with ability to perform ADLs

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Choosing the correct size catheter

• Smaller the gauge (diameter) less trauma
• Catheters that are too big invite complications
• Gauge must match the type of fluid to be
  administered

• the larger the , the smaller the diameter
  (gauge)

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Preparing the Administration Set

• Check the date of expiration
• Check the solution for cloudiness, precipitate,
  discoloration, leakage
• Follow strict aseptic technique as you handle IV
  tubing and bag
• Be sure that you have primed the tubing
  removing ALL air prior to connecting to the
  patient

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Steps (1)

• Verify prescription for IV therapy, check
  solution label, ID patient
• Question patient about allergies to latex /
  iodine
• Hand hygiene and apply disposable gloves
• Apply tourniquet 4-6 inches about the site / ID
  suitable vein
• Position patients arm below heart level to
  encourage capillary filling

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Steps (2)

• Clean skin and allow time for air drying after
  applying antiseptics
• Do not shave the area, but may clip long hairs
  that will impede venipuncture and adherence of
  dressing
• Hold needle bevel up and at 5-25º angle
• Pierce skin and advance needle once backflow of
  blood is visible.

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Steps (3)

• Insert needle and cannula about ½ into the vein
• Thread the plastic catheter into the vein
• Attach tubing and release tourniquet
• Anchor the catheter and complete dressing as per
  policy
• Safety dispose of needle in sharps container

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Tips for Success

• Having difficulty finding a good vein?
• Apply warm moist soaks
• Apply warm towel or washcloth (DO NOT microwave)
• Let gravity help you! Have patient hang arm over
  side of bed.

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Cultural Aspects

• Appropriate sites may be difficult to see if skin
  has increased melanin
• Excess ultraviolet light exposure may cause ?
  resistance when penetrating the skin
• Loss of skin elasticity / subcutaneous tissue in
  the elderly

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Older Adults

• Have
• ? subcutaneous support tissue
• veins tend to be superficial
• Veins less stabile and tend to roll
• Fragile veins
• Use minimal or no tourniquet pressure
• Use insertion angle of 5-15 degrees
• Apply traction to the skin below the projected
  insertion site to ? stability

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Delegation Considerations

• May only delegate removal of peripheral IV to the
  NA II if skill has been validated by a RN

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Patient Education

• Explain the procedure PRIOR to venipuncture
• Have patient report
• Burning, bleeding, swelling at site
• IV dressing becomes wet or leaks
• Pump alarms

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Complications

• Infection
• Infiltration
• Phlebitis
• Fluid volume excess
• Bleeding

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Potential Origins for Contamination

• Hands of medical personnel
• Clients skin microflora
• Insertion site
• Hematogenous spread
• Hub colonization
• Contaminated fluid

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Septicemia

• Possible causes
• Contaminated IV device or fluids
• Failure to maintain aseptic technique during
  insertion / administraton
• Immunosuippression
• Device in vein longer than 72 hours

• S/S
• Fever, chills without apparent reason
• ? pulse, respiratory rate
• Nausea vomiting
• General malaise
• Backache, headache
• Often occurs shortly after infusion is begun

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Septicemia Interventions

• Notify MD immediately
• Symptomatic care
• Identify other sources of infection
• Remove IV device
• Culture the IV cannula, tubing, or solution if it
  is suspect
• Return fluid to pharmacy
• Establish a new IV site for medication or fluid
  administration

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Infiltration

• Causes
• Displaced cannula
• Enlarged puncture wound

• S/S
• Swelling, tenderness above the IV site that may
  extend along the entire limb eventual tissue
  necrosis
• Decreased skin temperature around site (cool)
• Fluid infuses into interstitial tissue
• Absence of blood black flow
• Flow rate slower than rate or flow is stopped

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Grading for Infiltration

• 0 - No clinical symptoms
• 1 - Skin blanched, edema less than 1 inch in any
  
• direction, cool to touch, with or
  without pain
• 2 - Skin blanched, edema 1 to 6 inches in any
  direction,
• cool to touch, with or without pain
• 3 - Skin blanched, translucent, gross edema
  greater
• than 6 inches in any direction, cool to
  touch, mild to
• moderate pain, possible numbness
• 4 - Skin blanched, translucent, skin tight,
  leaking, skin
• discolored, bruised, swollen, gross
  edema greater
• than 6 inches in any direction, deep
  pitting tissue
• edema, circulatory impairment, moderate
  to severe
• pain, infiltration of any amount of
  blood products,
• irritant, or vesicant

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Treatment of Infiltration

• Discontinue the infusion
• Apply warm, moist heat to ?edema
• Elevate the extremity
• Restart the infusion at another site, preferable
  the other arm

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Prevention of Infiltration

• Select site over long bone to act as a splint
• Avoid sites over joints
• Use armboard to stabilize (as a last resort!)

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Extravasation

• Cause
• Vasoconstriction of vesicant drugs infiltrating
  the subcutaneous tissues (I.e., Dopamine,
  Adriamycin)

• S/S
• swelling, tenderness above the IV site that may
  extend along entire limb, eventual necrosis if
  problem not corrected
• Fluid continues to infuse into interstitial
  tissue
• absence of back flow of blood
• flow rate slowed or stopped

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Populations at Risk for Extravasation

• Neonates or infants
• Elderly
• Cancer patients
• Comatose or anesthetized patients
• Patients who undergo CPR

• Patients with
• peripheral or cardiovascular disease, diabetes
  mellitus, Raynauds phenomenon, Disseminated
  Intravascular Coagulation (DIC)

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Populations at Risk for Extravasation, cont.

• Patients treated using high-pressure infusion
  pumps
• Any patient undergoing therapy that involves
  infusion of irritant or vesicant drugs, or those
  too young or ill to verbalized discomfort due to
  pain and pressure

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Examples of Medications with Increased Risk for
Extravasation Injury

• Aminophylline
• Amphotericin B
• Arginine
• Barbiturates
• Calcium Chloride
• Calcium Gluconate
• Diazepam
• Dobutamine
• Dopamine
• Epinephrine
• Mannitol

• Metaraminol Bitartrate Metronidazole
• Nafcillin
• Nitroprusside Sodium
• Norepinephrine
• Phenytoin
• Potassium Chloride
• Renografin-60 (contrast dye)
• Thiopental
• Vancomycin

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Extravasation Interventions

• Apply warm moist compresses for 20 minutes Q 4
  hours (see hospital policy)
• Document location, appearance, solution and
  estimated amount, nursing actions, name of doctor
  and time notified with orders given, QAR.

• Stop the infusion, elevate the extremity
• Remove the cannula
• Call MD
• Administer antidote (if appropriate) intradermaly
  into infiltrated tissue

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Clotting / Obstruction

• Causes
• Kinked IV tubing
• Very slow infusion rate
• Empty IV bag
• Failure to flush the IV line after intermittent
  administration
• Signs
• ? infusion rate
• Blood backflow into the IV tubing

• Do NOT irrigate, milk tubing, or raise the rate
  or solution container.
• Discontinue the IV and restart in a different
  location

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Phlebitis

• Causes
• movement of the cannula within the vein
• Veins irritated by medication
• S/S
• area along vein red, tender, and warm
• vein hard and cordlike when palpated
• decreased flow rate
• irritation with infusion

• Interventions
• remove IV device
• apply warm soaks
• notify MD
• restart IV infusion in a different extremity
• document your actions

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Grading for Phlebitis

• 0 - No clinical symptoms
• 1 - Erythema at access site with or without pain
• 2 - Pain at access site, erythema, edema, or
  both Pain at access site
• 3 - Erythema, edema, or both Streak formation
• Palpable venous cord (1 inch or shorter)
• 4 - Pain at access site with erythema streak
• formation, palpable venous cord (longer
  than 1
• inch), purulent drainage

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Air Embolism

• Definition Air in the circulatory system
• More common with central venous lines
• S/S
• respiratory distress
• unequal breath sounds
• weak pulse
• increased CVP
• hypotension
• loss of consciousness

• Possible Causes
• empty solution container
• disconnected IV, which allows air to be sucked in
• IV tubing that runs dry or is not purged of air
  properly (purge those air bubbles out of line
  when priming tubing prior to hooking up to
  patient!)

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Air Embolism

• Nursing Actions
• Immediately clamp the tubing
• Turn patient to left, head down (to allow air to
  enter right atrium and be dispersed via pulmonary
  artery)
• Monitor vital signs
• Administer O2
• Notify MD
• Document actions

Complications Shock Death
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Air Embolism

• Preventative measures
• Tape all connectors or use leur lock connectors
• Instruct patient to use Valsalva maneuver when
  changing tubing on a central line

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Fluid Overload

• Treatment
• Slove the infusion rate
• Monitor VS
• High Fowlers position
• Oxygen as needed
• Notify MD immediately
• Complications
• Heart failure
• Pulmonary edema

• S/S
• ? pulse
• ? B/P
• Distended neck veins
• Dyspnea
• Moist crackles
• Shallow, rapid respirations

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Fluid Overload

• Prevention
• Monitor rates carefully especially for high risk
  patients
• Elderly
• Infants / children
• Heart failure
• Renal disease
• DO NOT catch up fluids when IV gets behind

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Pulmonary Edema

• When circulatory overload is unrecognized, fluid
  backs up into the lungs
• rapid, labored respiration
• diffuse crackles
• frothy bloody sputum
• tachycardia or atrial fibrillation
• diaphoresis, cool skin, cyanosis
• thready pulse
• decreased BP

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Speed Shock

• Rapid infusion of medication of fluid into the
  circulation causes toxic concentrations to
  accumulate
• Drugs can cause a shock-like syndrome
• tachycardia with hypotension
• progressive syncope
• cardiovascular collapse/cardiac arrest
• facial flushing, HA, chest tightness, irregular
  pulse

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Slower-than-orderedInfusion Rates

• Deprives the patient of fluids and medications
• Always check infusion rates against orders at
  beginning of shift, and after secondary infusions
  (I.e., antibiotics) to insure proper rate is
  maintained

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IV Push Medications

• Check compatibility prior to mixing any
  medication administration through the same line
• Check for correct catheter placement prior to
  administration
• If PRN adapter, flush with 2ml of saline prior to
  medication administration and 2ml after
  administration

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Blood Component Therapy

• Reasons for Administration
• Collaboration Delegation

• Products
• Whole blood
• PRBCs / Washed PRBCs
• Plasma / FFP
• Platelets
• Cryoprecipitates
• Albumin

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Blood Administration Nursing Responsibilities

• Knowledge of
• correct administration techniques
• Possible complications
• Agency polices procedures
• Correct administration
• Patient / family education

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Blood Administration Nursing Responsibilities

• Assessment
• Patient history
• Reactions
• of pregnancies
• Comorbidities
• Culture, religion
• Physical assessment
• Vital signs
• Respiratory auscultation
• Cardiac edema / HF symptoms

• Patient Education
• s/s transfusion reaction
• Risk of infection

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Nursing Diagnoses

• Deficient knowledge r/t transfusion
• No prior experience
• Asks many questions
• Asks no questions
• Has misconceptions
• Risk for ineffective protection r/t
  administration of blood / blood products
• Symptoms of transfusion reactions

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Blood Administration

• Other Complications
• Circulatory overload
• Bacterial contamination
• TRALI (transfusion-related acute lung injury)

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Nursing Management for Transfusion Reactions

• Stop the transfusion
• Maintain IV with NEW tubing and 0.9 NaCl
• Assess patient carefully
• Notify MD of assessment findings
• Implement prescribed treatments
• Notify blood bank of suspected reaction
• Send blood container and tubing to Blood bank

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Pharmacologic alternatives to blood transfusions

• Growth factors
• Erythropoietin
• Granulocyte-colony stimulating factor
• Thrombopoietin

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NCLEX Questions

• The physician is going to order a hypotonic IV
  solution for a client with cellular dehydration.
  The nurse would expect which of the following
  fluids to be administered?
• 0.9 Normal saline
• 5 dextrose in Normal saline
• Lactated Ringers
• 0.45 sodium chloride

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NCLEX Questions

• While assessing a clients IV, the nurse notes
  that the area is swollen, cool, pale, and causes
  the client discomfort. The nurse suspects which
  of the following problems?
• Infiltration
• Phlebitis
• Infection
• Air embolism

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NCLEX Questions

• The client is receiving D5and .045 sodium
  chloride and is complaining of pain at the IV
  site. The nurse assesses the site and notes
  erythema and edema. Recognizing these as signs
  of phlebitis, which of the following would be the
  approprate action?
• Slow the infusion rate
• Discontinue the IV and apply a warm compress to
  the IV site
• Apply antibiotic ointment to the IV site
• Gently pull back the IV access device to
  reposition within the vein.

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NCLEX Questions

• The nurse is starting a new peripheral
  intravenous line in a patient. The patient
  reports a latex allergy. The nurse has a typical
  IV start kit for the IV start. Because of the
  latex allergy, the nurse should take which of the
  following actions?
• Avoid putting povidone-iodine on the skin.
• Suggest an alternative therapy to a peripheral
  intravenous line.
• Utilize a blood pressure cuff to distend the
  vein.
• Utilize a new tourniquet for the patient.

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References

• Craven, R.F., Hirnle, C.J. (2007). Intravenous
  Therapy. In Fundamentals of Nursing Human
  health and function, 5th ed. Lippincott
  Williams, Wilkins, Philadelphia. Pp.
  604-6639.
• Hogan, M.A., Bowles, D., White, J.E. (2003).
  Nursing Fundamentals.
• Wmeltzer, S.C., Bare, B.G., Hinkle, J.L.,
  Cheever, K.H. (2008). Fluid and electrolytes
  balance and disturbances. In Brunner and
  Suddarths Textbook of Medical-Surgical Nursing,
  11th ed. Lippincott, Williams Wilkins,
  Philadelphia. pp. 339-352.