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NURS 228 Initiating Peripheral Intravenous Infusion

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than 6 inches in any direction, cool to touch, mild to. moderate pain, possible numbness ... 045% sodium chloride and is complaining of pain at the IV site. ... – PowerPoint PPT presentation

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Title: NURS 228 Initiating Peripheral Intravenous Infusion


1
NURS 228Initiating Peripheral Intravenous
Infusion
  • Janie Best, MSN, RN
  • Presbyterian School of Nursing at Queens
    University

2
Intravenous Solutions
  • 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

3
Peripheral IV Access -
  • Hand veins
  • Superficial dorsal
  • Basilic
  • Cephalic
  • Arm veins
  • Radial (wrist)
  • Cephalic
  • Basilic
  • Median cubital
  • Median

4
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.

5
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

6
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7
Equipment
  • Correct Patient
  • Correct IV solution
  • Proper catheter for venipuncture
  • IV start kit
  • Correct tubing, IV loop

8
Selecting the Site
  • Consider
  • Type of solution to be administered
  • Expected duration of IV therapy
  • Patients general condition, age, size
  • Right or left handedness
  • Availability of appropriate veins
  • Skill of person performing the venipuncture

9
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)

10
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

11
Steps (1)
  • Maintain sterility of IV system
  • Use Standard Precautions
  • Identify accessible vein
  • Use distal veins before proximal veins
  • Avoid areas
  • that are painful to palpation
  • below an infiltrated IV site
  • Veins too small for the selected IV catheter
  • That interfere with ability to perform ADLs

12
Steps (2)
  • Place tourniquet 4-6 inches above potential
    insertion site
  • Make sure you can still feel the radial pulse!
  • Clean with Betadine, chlorhexidine gluconate
    solution, or alcohol 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

13
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.

14
Venipuncture
  • Have all equipment prepared and within reach
  • Enter the skin with Bevel UP
  • Watch for blood return
  • Insert needle and cannula about ½ into the vein
  • Thread the plastic catheter into the vein
  • Attach tubing
  • Anchor the catheter and complete dressing as per
    policy

15
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

16
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

17
Delegation Considerations
  • May only delegate removal of peripheral IV to the
    NA II if skill has been validated by a RN

18
Patient Education
  • Explain the procedure PRIOR to venipuncture
  • Have patient report
  • Burning, bleeding, swelling at site
  • IV dressing becomes wet or leaks
  • Pump alarms

19
Complications
  • Infection
  • Infiltration
  • Phlebitis
  • Fluid volume excess
  • Bleeding

20
Potential Origins for Contamination
  • Hands of medical personnel
  • Clients skin microflora
  • Insertion site
  • Hematogenous spread
  • Hub colonization
  • Contaminated fluid

21
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

22
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

23
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

24
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

25
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

26
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!)

27
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

28
Extravasation Interventions
  • Stop the infusion, elevate the extremity
  • Remove the cannula
  • Call MD
  • Administer antidote (if appropriate) intradermaly
    into infiltrated tissue
  • 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.

29
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

30
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)

31
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

32
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

33
Phlebitis
  • Causes
  • movement of the cannula within the vein
  • medications that irritate the vein
  • 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

34
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

35
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 funs dry or is not purged of air
    properly (purge those air bubbles out of line
    when priming tubing prior to hooking up to
    patient!)

36
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
37
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

38
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

39
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

40
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

41
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

42
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

43
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

44
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

45
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

46
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.

47
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.
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