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 Pt assessment important. Site – touched on in A & P, will discuss again – lots of things influence site selection. It is not “cut & dry” (for lab venipuncture, selection is not as detailed, but principles are the same) Show video “Problems in IV therapy” if time permits

Physician’s order Date, time to start infusion. Solution to be infused, any additives ? Route of administration Dosage Rate Duration Signed by physician Does it say IV? How much? Even a straight IV has to say .45 NS or .9 NS How fast? 100cc/hr? Over 8 hrs? Indefinitely? Until bag complete? (Not always specified – you may need to check) Signature? Review sample orders on overhead - which ones are correct?

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 Handwashing always before and after pt contact. Soap and water loosen debris, but alcohol based products are most effective and recommended for decontamination – vigorous 10-15 min scrub. Gloves for ALL body fluids, after cleaning hands. Universal precautions (“standard” is interchangeable)– these principles are maintained for ALL patients – thus “universal” Infection can be even more problematic w/ IV therapy since by its nature there is ALWAYS “exposure” since you have direct access to the vascular system. CDC “standard precautions” also include knowledge of the chain of infection………next slide….

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) Additional supplies at bedside ! Equipment – must be prepared. Once you start the procedure it is too late to try and run around to find things. Remember – IV solution: Check the order for the correct solution. Proper size Should be clear and intact. Check expiration date – should be habit. Tubing: Must be appropriate and package intact. Primary tubing for continuous IV, Secondary tubing for piggybacks, and pump tubing if needed for electronics – we will talk about this more, but for right now PRIMARY tubing will be what we are referring to. (Secondary is simply shorter and usually without injection ports) Appropriate catheter – we will discuss in detail. Tourniquet – try to use latex-free. Alcohol, betadine, or chlorhexadrine are most typical. Do NOT use alcohol AFTER betadine – it negates the effect of the betadine. The choice of antimicrobials is institution – dependent. Many studies done. For the most part, alcohol is oldest and very effective, but doesn’t last long. Betadine is not fast-acting but lasts much longer. (Companies in the process of developing combo solutions). Chlorhexedrine is also approved, and some studies show this solution to be superior to alcohol or betadine. Pump – we will talk about later, but have it if you need it. Tape Tegaderm (or other transparent dressing), so you can see site Gloves – INS recommends powder-free for IV insertion. Each piece of equipment will make sense as we go through the procedure. We will do this in detail in the lab, however I want to explain first how to choose a site and choose a needle or cannula before I explain the rest of procedure.

Site Selection 1. Type & Rate of solution to be infused 2. Duration of IV therapy 3. Cannula size 4. Vein integrity 5. Patient age, diagnosis 6. Patient preference Hand dominance 7. Patient activity level 8. AV fistula/post-mastectomy 9. Anticoagulant use INS says hand dominance is not an important factor for site selection

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 INS – vasculature should accommodate the gauge and length of the catheter required for the prescribed therapy Site selection must always include the patients condition

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 Cephalic vein Small IV cannula, support w/ tongue blade or board Metacarpal veins Ideal site for IV use, primary choice Cephalic vein Accomodates large gauge IV cannula Accessory cephalic vein 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. Blood products, trauma (green) 20 g. Most commonly used (pink) 22 g. Pediatrics, elderly, small veins (blue) 24 g. 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 Assess intravenous (IV) devices and equipment for compliance with the Needlestick Safety and Prevention Act. Note : The Needlestick Safety and Prevention Act requires the use of needleless systems for laboratory sampling, parenteral administration of medication or fluids, or any procedure carrying the risk of injuries from contaminated sharps and occupational exposure to bloodborne pathogens. (Needlestick Safety and Prevention Act–HR 5178, Section 3, 2000.) Always dispose in sharps container. Next slide….

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 Again I will review procedure step-by-step

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 Excellent illustration of technique. Now – will practice in lab. ½ class will do computer tutorial, then will switch for next class. Need to practice on own.

Catheter Insertion Needle bevel UP, 15-30 degree angle 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 Phillips book says 30 degree angle

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 Phillips book says at least 2 ml for peripheral IV

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 This is just an overview of essentials of charting – obviously anything that needs clarification or elaboration needs to also be documented.

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