1. Chapter 7 Intravenous Access and Medication Administration Part 2 Intravenous Access, Blood Sampling, and Intraosseous Infusion

2. Topics Types of Intravenous Access Equipment for Intravenous Access
IV Drug Administration
Venous Blood Sampling
Intraosseous Infusion

3. Intravenous (IV) Access Indications
Fluid and blood replacement
Drug administration
Obtaining venous blood specimens for lab analysis

4. Types of IV Access
Peripheral venous access
Central venous access

5. Peripheral IV Access Sites
In adults - arms, hands, external jugular, and feet as a last resort.
In infants – you can use veins in feet and ankle, plus scalp veins. **

6. Central Venous Access Veins located deep in the body
Internal jugular, subclavian, femoral
Peripherally inserted central catheter (PICC lines)
Larger veins that will not collapse in shock

7. IV Solution Containers

8. Do not use any IV fluids after their expiration date; any fluids that appear cloudy, discolored, or laced with particulate; or any fluid whose sealed packaging has been opened or tampered with.

9. IV Administration Sets (1 of 2)
Macrodrip
10 gtts = 1 mL, for giving large amounts of fluid
Microdrip
60 gtts = 1 mL, for restricting amounts of fluid
Blood tubing
Has a filter to prevent clots from blood products from entering the body
Measured volume
Delivers specific volumes of fluids

10. IV Administration Sets (2 of 2)
I V extension tubing
- extends original tubing
Electromechanical pump tubing
- specific for each pump
Miscellaneous
- some sets have a dial that can set the flow rates (Dial-a- Flow)

11. Primary Tubing

12. Secondary Tubing

13. Macrodrip vs. Microdrip Tubing

14. Measured Volume Admin. Set aka Burette or Buretrol

15. Extension Tubing aka J-Loop

16. Pump Tubing

17. Dial-a-Flow

18. Y-Tubing for Blood Administration

19. In-Line Intravenous Fluid Heaters
IV fluids can be heated to near body temperature with heating devices. Applies to both IV fluids and blood.

20. Intravenous Cannulas Over-the-needle catheter Hollow-needle catheter
Plastic catheter inserted through a hollow needle

21. Over-the-Needle Catheter

22. Hollow-Needle Catheter (Butterfly)

23. Catheter Inserted Through the Needle

24. Peripheral IV Access

25. Place the constricting band.
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26. Cleanse the venipuncture site.
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27. Insert the intravenous cannula into the vein.
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28. Withdraw any blood samples needed.
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29. Connect the IV tubing.
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30. Turn on the IV and check the flow.
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31. Secure the site.
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32. Label the IV solution bag.
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33. Intravenous Access With a Measured Volume Administration Set

34. Prepare the tubing.

35. Open the uppermost clamp and fill the burette chamber with approximately 20 mL of fluid.

36. Close the uppermost clamp and open the flow regulator.

37. Intravenous Access with Blood Tubing

38. Insert the flanged spike into the spike port of the blood and/or normal saline solution.

39. Squeeze the drip chamber until it is one-third full and blood covers the filter.

40. Attach blood tubing to the intravenous cannula or into a previously established IV line.

41. Open the clamp(s) and/or flow regulator(s) and adjust the flow rate.

42. Factors Affecting IV Flow Rates **
Constricting band
Cannula diameter
Edema at puncture site
Cannula abutting the vein wall or valve
Administration set control valves
IV bag height
Completely filled drip chamber
Catheter patency
Venting of the fluid container
Position of extremity

43. IV Access Complications
Pain
Local infection
Pyrogenic reaction
Allergic reaction
Catheter shear
Inadvertent arterial puncture
Circulatory overload
Thrombophlebitis
Thrombus formation
Air embolism
Necrosis
Anticoagulants

44. Changing an IV Bag or Bottle
Prepare the new bag or bottle.
Occlude the flow from depleted bag or bottle.
Remove spike from depleted bag or bottle.
Insert spike into the new IV bag or bottle.
Open the clamp to appropriate flow rate.

46. Complications of Intravenous Therapy

47. Learning Outcomes:
Differentiate between local and systemic complications.
Describe the signs and symptoms of local complications.
Identify prompt treatment for local and systemic complications.
Identify International Standards of practice rating infiltration.
List three risk factors for phlebitis.
Identify organisms responsible for septicemia related to infusion therapy.
Identify prevention techniques for the systemic complications.

48. I.V. Catheter Complications
Phlebitis
Thrombophlebitis
Infection
Infiltration
Hematoma
Hypothermia
Extravasation
Venous Spasm

49. https://youtu.be/XH3IK4hV3Qg

50. I. Local complications 1. Hematoma:
Formations resulting from the infiltration of blood into the tissues at the Venipuncture site.
Causes:
Rupture the vein during an unsuccessful
Venipuncture attempt.
Discontinuing the I.V. cannula or needle without
pressure.
Applying a tourniquet too tightly above a
previously attempted venipuncture site.

51. 1. Hematoma (cont.) Signs/symptoms: Discoloration of the skin.
Site swelling and discomfort.
Inability to advance the cannula all the
way into the vein during insertion.
Resistance to positive pressure during
the lick flushing procedure.
Document:
The observable ecchymotic areas.

52. 2. Thrombosis
Catheter-related obstructions can be categorized as mechanical or non-thrombotic ( 42% of all obstructions)
or thrombotic (58% of all obstructions),
Signs/symptoms:
Fever and malaise.
Slowed or stopped infusion rate.
Inability to flush licking device.

53. 2. Thrombosis (cont.)
If you can’t flush the catheter, do not forcibly try to flush it. You can dislodge the thrombus and send it travelling through the circulatory system. Instead, d/c the catheter, start another one, preferably in the other arm and document.

54. 2. Thrombosis (cont.) Documentation:
Document the change of infusion rate.
The steps taken to solve the problem,
and the end result.
Chart new IV sites.
It’ s patency, and the size of the catheter used.

56. An inflammation of the vein.
3. Phlebitis
An inflammation of the vein.
Signs/symptoms:
Redness at site.
Site warm to touch and local swelling.
Palpable cord along the vein.
Sluggish infusion rate.
Increase in basal temperature of 1 °C or more.

57. Types of Phlebitis
Bacterial Phlebitis – is usually an indication of an infection at the insertion site.
Chemical Phlebitis – is most commonly seen with peripheral IV devices when medications or solutions irritate the endothelial lining of the small peripheral vessel wall, for example:
Erythromycin
Tetracycline
Vancomycin
Large doses of Potassium Chloride
(K+)
multivitamins

58. Types of Phlebitis
Mechanical Phlebitis – occurs when the size of the cannula is too big for the selected vein causing unnecessary friction on the internal lining of the vein, leading to inflammation.

59. Fighting Phlebitis
Phlebitis is most common after continuous infusions, developing 2 – 3 days after the vein is exposed to the drug solution.
Phlebitis is more common in distal veins than in veins close to the heart.

60. Steps to Prevent Phlebitis
Use proper venipuncture technique.
Dilute drugs correctly.
Monitor administration rates.
Observe the I.V. site frequently.
Change the infusion site regularly according to policy.

61. 3. Phlebitis (cont.) Nursing Interventions: Apply warm soaks.
Remove IV device.
Apply warm soaks.
Notify primary care provider.
Restart IV infusion in a different extremity.
Document your actions.

62. Thrombosis and inflammation.
4.Thrombophlebitis
Thrombosis and inflammation.
Signs/symptoms:
Sluggish flow rate, edema in the limbs.
Tender and cordlike vein, site warm to
touch.
Visible red line above Venipuncture site.
Diminished arterial pulses.
Mottling and Cyanosis of the extremities.

63. 5. Infiltration Accidental administration of a non vesicant solution
into surrounding tissue.
Signs/symptoms:
Coolness of skin around site, and tight skin.
Dependent edema and absence of blood backflow.
A pinkish blood return.
Infusion rate slows but the fluid continues to infuse.
Edema at the site and above.

64. 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.

65. Prevention of Infiltration
Select site over long bone to act as a splint.
Avoid sites over joints.
Use arm board to stabilize (as a last resort!).

66. 5. Infiltration (cont.) Documentation: assessment findings.
any written and verbal communications.
nursing and medical interventions.
client response patterns.

67. 6. Extravasations
The accidental administration of a vesicant solution into surrounding tissue.
Signs/symptoms:
Complaints of pain or burning; swelling proximal or distal to the IV site.
puffiness of the dependent part of the limb; skin tightness at the Venipuncture site; and coolness of the skin.
Slow or stopped infusion; damp or wet
dressing.
What is a vesicant solution?

68. Extravasations Interventions
Stop the infusion, and elevate extremity.
Remove the cannula.
Call physician.
Administer antidote (if appropriate) intradermaly into infiltrated tissue.
Apply warm moist compresses for 20 minutes every 4 hours (see hospital policy).

69. 6. Extravasations (cont.)
Documentation:
Document assessment and interventions. Include the vascular access device type, insertion site, name of medication or solution, and how it was infused.

70. 7. Local infection
Microbial contamination of the cannula or infusate
Signs/symptoms:
Redness and swelling at the site; possible
exudates of purulent material.
Increased quantity of white blood cells;
and elevated temperature.

71. 7. Local infection (cont.)
Documentation:
Assessment of site.
culture technique & sources of culture.
physician notification and any treatment initiated.

72. 8. Venous spasm
A sudden involuntary contraction of a vein or an artery resulting in temporary cessation of blood flow through a vessel.
Signs/symptoms:
sharp pain at the IV site that travels up the arm, which is caused by acute flow of fluid that irritates the vein wall; slowing of the infusion

73. 8. Venous spasms (cont.) Documentation:
client complaints, duration of complaints, treatment, and length of time to resolve the problem.

74. II. Systemic Complication
1. Septicemia: (sepsis)
A febrile disease process that results from the presence of pathogenic microorganisms or their toxic products in the circulatory system.
Signs and Symptoms:
Fluctuating fever, tremors, little cold sweat, nausea and vomiting, diarrhea, abdominal pain.
Tachycardia, increased respirations or hyperventilation, altered mental status, and hypotension

75. Septicemia Interventions
Notify physician 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.

76. 1. Septicemia (cont.) Documentation:
Document S/S assessed; physician notification, all treatments instituted.

77. 2. Fluid overload & Pulmonary edema
Caused by infusing excessive amounts of isotonic or hypertonic crystalloid solutions to rapidly, failure to monitor the IV infusion or too-rapid infusion of any fluid in a patient compromised by cardiopulmonary or renal disease.

78. 2. Fluid overload & Pulmonary edema (cont;)
S/S:
Restlessness, headache, tachycardia, weight gain over a short period of time, cough, and presence of edema.
Hypertension, wide variance between intake and output, distended neck veins.

79. 2. Fluid overload & Pulmonary edema (cont.)
Documentation:
client assessment, notification of physician, and treatments instituted by physician order.

80. 3. Air embolism
Air entering the central vein, which is quickly trapped in the blood as it flows forward. Prevention is the key.

81. 3. Air embolism(cont.) complaints of palpitations, and weakness.
Pulmonary findings: dyspnea, cyanosis, tachypnea, expiratory, wheezes, cough, and pulmonary edema.
Cardiovascular: murmur; weak, thready pulse; tachycardia; substernal chest pain; hypotension; and jugular venous distention.
Neurologic findings: change in mental status, confusion, coma, anxiousness, and seizures.

82. 3. Air embolism (cont.) Nursing Interventions:
Immediately clamp the tubing.
Turn client to left, head down (to allow air to enter right atrium and be dispersed via pulmonary artery)
Monitor vital signs.
Administer O2.
Notify physician.
Document actions.
Documentation:
Client assessment, nursing interventions, physician notification, and treatment.

83. 4. Speed shock
Occurs when a foreign substance usually a medication is rapidly introduced into the circulation
S/S: dizziness, facial flushing, headache, tightness in the chest, hypotension, irregular pulse, progression of shock.

84. 4. Speed shock (cont.)
Documentation: medication or fluid administered and the signs and symptoms the pt reported, physician notification, treatment initiated and the client response.

85. 5. Catheter embolism
A piece of the catheter breaks off and travels through the vascular system.
S/S: sharp sudden pain at the IV site, minimal blood return, rough and uneven catheter noted on removal, cyanosis, chest pain, tachycardia, hypotension.

86. Intravenous Bolus Administration

87. Prepare the equipment.

88. Prepare the medication.
Important notes:
NEVER GIVE K+ IV PUSH **
THE HIGHEST CONCENTRATION OF DEXTROSE YOU CAN GIVE THROUGH IV LINE IS 50%.**

89. Check the label.

90. Select and clean an administration port.

91. Pinch the line.

92. Administer the medication.

93. Adjust the IV flow rate.

94. Monitor the patient.

95. Intravenous Infusion Administration

96. Select the drug.

97. Draw up the drug.

98. Select IV fluid for dilution.

99. Clean the medication addition port.

100. Inject the drug into the fluid.

101. Mix the solution.

102. Insert an administration set and connect to the main IV line with needle.

103. Heparin/Saline Lock

104. Venous Access Device
Surgically implanted device that permits repeated access to the central venous circulation
Generally located on anterior chest near the third or fourth rib lateral to the sternum
Accessed with a special needle specific to the device
Requires special training

105. Electromechanical Infusion Devices
Infusion controllers
Infusion pumps

106. Infusion Pump

107. Syringe-Type Infusion Pump

108. Drawing Blood

109. Blood Tubes

111. Vacutainer and Leur Lock

112. Obtaining a blood sample with a 20 mL syringe

113. Leur Sampling Needle

114. Remove any IV that will not flow or has fulfilled its need.

115. Intraosseous Infusion
A rigid needle is inserted into the cavity of a long bone.
Used for critical situations when a peripheral IV is unable to be obtained.
Initiate after 90 seconds or three unsuccessful IV attempts.

116. Anterior tibia

117. Pediatric and adult intraosseous needle placement sites.

118. Manual intraosseous needle

119. Bone injection gun (B.I.G.)
WAISMed., Ltd.

120. FAST1 – Sternal IO
Employs an introducer to insert an infusion tube into the top bone of the sternum

121. Battery-powered IO driver and needle set
EZ-IO
Battery-powered IO driver and needle set

122. E Z IO EDUCATION

123. Intraosseous Medication Administration

124. Select the medication and prepare equipment.

125. Palpate the puncture site and prep with an antiseptic solution.

126. Make the puncture.

127. Aspirate to confirm proper placement.

128. Connect the IV fluid tubing.

129. Secure the needle appropriately.

130. Administer the medication. Monitor the patient for effects.

131. Intraosseous Access Complications
Fracture
Infiltration
Growth plate damage
Complete insertion
Pulmonary embolism
Infection
Thrombophlebitis
Air embolism
Circulatory overload
Allergic reaction

132. Contraindications to Intraosseous Placement
Fracture to tibia or femur on side of access
Osteogenesis imperfecta— congenital bone disease resulting in fragile bones
Osteoporosis
Establishment of a peripheral IV line

133. Summary Types of Intravenous Access Equipment for Intravenous Access
IV Drug Administration
Venous Blood Sampling
Intraosseous Infusion