Title: NURS 228 Initiating Peripheral Intravenous Infusion
1NURS 228Initiating Peripheral Intravenous
Infusion
- Janie Best, MSN, RN
- Presbyterian School of Nursing at Queens
University
2Intravenous 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
3Peripheral IV Access -
- Hand veins
- Superficial dorsal
- Basilic
- Cephalic
- Arm veins
- Radial (wrist)
- Cephalic
- Basilic
- Median cubital
- Median
4Common IV Sites
- metacarpal, cephalic, basilic, and median veins
and their branches - More distal sites should be used first, with more
proximal sites used subsequently.
5Central 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(No Transcript)
7 Equipment
- Correct Patient
- Correct IV solution
- Proper catheter for venipuncture
- IV start kit
- Correct tubing, IV loop
8Selecting 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
9Choosing 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)
10Preparing 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
11Steps (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
12Steps (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
13Tips 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.
14Venipuncture
- 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
15Cultural 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
16Older 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
17Delegation Considerations
- May only delegate removal of peripheral IV to the
NA II if skill has been validated by a RN
18Patient Education
- Explain the procedure PRIOR to venipuncture
- Have patient report
- Burning, bleeding, swelling at site
- IV dressing becomes wet or leaks
- Pump alarms
19Complications
- Infection
- Infiltration
- Phlebitis
- Fluid volume excess
- Bleeding
20Potential Origins for Contamination
- Hands of medical personnel
- Clients skin microflora
- Insertion site
- Hematogenous spread
- Hub colonization
- Contaminated fluid
21Septicemia
- 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
22Septicemia 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
23Infiltration
- 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
24Grading 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
25Treatment of Infiltration
- Discontinue the infusion
- Apply warm, moist heat to ?edema
- Elevate the extremity
- Restart the infusion at another site, preferable
the other arm
26Prevention of Infiltration
- Select site over long bone to act as a splint
- Avoid sites over joints
- Use armboard to stabilize (as a last resort!)
27Extravasation
- 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
28Extravasation 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.
29Examples 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
30Populations 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)
31Populations 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
32Clotting / 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
34Grading 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
35Air 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!)
36Air 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
37Air Embolism
- Preventative measures
- Tape all connectors or use leur lock connectors
- Instruct patient to use Valsalva maneuver when
changing tubing on a central line
38Fluid 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
39Fluid 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
40Pulmonary 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
41Speed 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
42Slower-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
43IV 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
44NCLEX 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
45NCLEX 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
46NCLEX 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.
47References
- 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.