1. What do we already know? Standard Precautions – All specimens should be treated as if they are hazardous and infectious. p. 326 Phillips Asepsis Anatomy of a vein Circulation physiology SNS fright or flight Therapeutic communication 1

2. Use of a Tourniquet: Tension Purpose: impede venous flow to heart Wider : less likely to impede arterial flow Use tighter tension: – Hypotensive (hypovolemia) – Obese Lighter tension: – Elderly – Veins easily seen & palpated Use of BP cuff: just below diastolic 2

3. Use of a Tourniquet: Duration No more than 1 minute at a time – IV start: Shunting of blood to collateral circulation – Phlebotomy: hemoconcentration; falsely high values for protein-based analysis. Release & reapply after 2 min. 3

4. Use of a Tourniquet: Position Phlebotomy: 3-4 inches above collection site IV: 5-6 inches above insertion site 4

5. Evaluating Veins Round, firm elastic, engorged NOT: hard, bumpy or flat Valves Dont keep tourniquet on too long Alternate: BP cuff to 30-40 mm Hg Anxiety, cold, hypotensive: veins will disappear. 5

6. Avoid… Fistula &/or vascular graft Mastectomy side Hematoma Drawing above an IV site (phlebotomy) Healed burn areas Skin inflammation, disease, bruising, or breakdown Sclerosed or thrombosed veins 6

7. Order of draws To prevent specimen contamination with tube additives Blood culture tubes (yellow top) Plain tubes: non-additives (red) Coagulation tubes Additive tubes 7

8. Filling Multiple Tubes Fill tube until vacuum is exhausted Carefully remove tube and fill additional tubes in proper order Invert tubes as they are filled As final tube is filling………. 8

9. The Butterfly Needle 9

10. Special Situations Patient has IV Timing of peak and trough levels – peak 1.5-2 hrs. after dose completed – trough just before dose Blood alcohol levels - legal issues and chain of custody 10

11. Specimen Integrity and Pre-Analytic Errors Patient Identification Hemolysis Hemoconcentration Correct Tube, Correct Order of draw Mixing Labeling Specimen contamina tion 11

12. Complications Allergies to antiseptic Pain Anxiety/fainting Hematoma Infection of site Vein or nerve damage Arterial puncture 12

13. General considerations Start low – Nondominant arm if possible Palm side of wrist only if necessary Legs, feet, ankles – only w/MD order Dorsum of hand: avoid abx, KCL, vesicant agents Antecubital – nice large vein – avoid for routine use Forearm – good sites for IV 13

14. Selecting a Vein Patients medical history Age, size, general condition Condition of veins Type of solution Condition of vein Duration of therapy Cannula size Patient activity Patients receiving anticoagulation therapy 14

15. When starting an IV, Avoid Veins… Below a previous I.V. infiltration Below a phlebotic area Previously areas listed earlier – Fistula &/or vascular graft – Mastectomy side – Hematoma – Healed burn areas – Skin inflammation, disease, bruising, or breakdown – Sclerosed or thrombosed veins 15

16. Site preparation Do not shave; clipping OK Solutions – Chlorhexidine gluconate (recommended) – Iodophor (povidone-iodine) – 70% isopropyl alcohol 15 – 20 seconds If allergic to prep solution use 70% alcohol for 30 seconds 16

17. Taping INS: sterile tape under transparent dressing. No tape directly on transparent dressing Gauze under hub to stabilize prn 17

18. Educate patient Limitations on movement or mobility Explain all alarms if EID used Instruct to call for assistance Report redness, tenderness, or swelling Inform that site will be checked by nurse frequently 18

19. Complications - systemic Septicemia Fluid overload & pulmonary edema Air embolism Catheter embolism 19

20. Systemic Complication: Septicemia Cause Febrile disease: microorganisms and their toxic products introduced into the circulatory system Health care- associated intravascular device-related bloodstream infection is associated with 12% – 28% mortality rate Signs and symptoms Fluctuating fever, tremors, chattering teeth Profuse, cold sweat Nausea and vomiting Diarrhea Abdominal pain Tachycardia Increased respirations Evidence of decreased perfusion Elevated WBC 20

21. Systemic Complication: Septicemia Prevention Good hand hygiene Carefully inspecting IV solutions Use of only freshly opened solutions Use of 2% chlorhexidine with alcohol Implement central line bundles Use of Luer-Lok connections Cover infusion sites with sterile dressing Limit use of add-on devices Change peripheral cannula after 72 –96 hours Staff education Remove peripheral cannula at first sign of inflammation 21