Basic Intravenous Therapy

Basic Intravenous
Therapy
90-95% of patients in the
hospital receive some type
of intravenous therapy.
This presentation will enhance your
knowledge of how to care for them.
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Vein Anatomy and Physiology
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Veins are unlike arteries in
that they are 1)superficial,
2) display dark red blood at
skin surface and 3) have no
pulsation
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Vein Anatomy
-
Tunica Adventitia
- Tunica Media
- Tunica Intima
- Valves
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Tunica Adventitia
the outer layer of the vessel
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Connective tissue
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Contains the
arteries and veins
supplying blood to
vessel wall
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Tunica Media
the middle layer of the vessel
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Contains nerve
endings and muscle
fibers
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The vasoconstrictive
response occurs at
this layer
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Tunica Intima
the inner layer of the vessel
One
No
layer of endothelials
nerve endings
Surface
for platelet aggregation
w/trauma and recognition of
foreign object at this level
PHLEBITIS
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begins here
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Valves
present in MOST veins
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Prevent backflow and
pooling
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More in lower extremities
and longer vessels
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Vein dilates at valve
attachment
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Veins of the Upper Extremities
Digital Vessels
-Along lateral aspects fingers, infiltrate
easily, painful, difficult to immobilize and
should be your LAST RESORT
Metacarpal Vessels
-Located between joints and
metacarpal bones (act as natural splint)
Digital
-Formed by union of digital veins
-Geriatric patients often lack enough
connective / adipose tissue and skin
turgor to use this area successfully
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Veins of the Upper Extremities
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Cephalic (Intern’s Vein)
-Starts at radial aspect of wrist
-Access anywhere along entire length
(BEWARE of radial artery/nerve)
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Medial Cephalic (“On ramp” to
Cephalic Vein)
-Joins the Cephalic below the elbow
bend
-Accepts larger gauge catheters, but
may be a difficult angle to hit and
maintain
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Veins of the Upper Extremities
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Basilic
- Originates from the ulner side of
the metacarpal veins and runs
along the medial aspect of the arm.
It is often overlooked becauses of
its location on the “back” of the
arm, but flexing the elbow/bending
the arm brings this vein into view
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Medial Basilic
- Empties into the Basilic vein
running parallel to tendons, so it is
not always well defined. Accepts
larger gauge catheters.
- BEWARE of Brachial Artery/Nerve
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Purposes of IV Therapy
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To provide parenteral nutrition
To provide avenue for dialysis/apheresis
To transfuse blood products
To provide avenue for hemodynamic monitoring
To provide avenue for diagnostic testing
To administer fluids and medications with the ability to rapidly/accurately
change blood concentration levels by either continuous, intermittent or IV
push method.
Types of Peripheral Venous Access Devices
•Butterfly
(winged) or Scalp vein needles (SVN) – not recommended for non compliant
patient as it can easily penetrate the vein wall causing extravasation.
We use these
frequently for phlebotomy
•Safety
Over the needle catheters (ONC)
- PROTECTIV ®
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-ACUVANCE ®
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Starting a Peripheral IV
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Finding a vein can be challenging
- Go by “feel”, not by sight. Good veins are bouncy to the touch, but are
not always visible.
- Use warm compresses and allow the arm to hang dependently to fill
veins.
- A BP cuff inflated to 10mmHg below the known systolic pressure creates
the perfect tourniquet. Arterial flow continues with maximum venous
constriction.
- If the patient is NOT allergic to latex, using a latex tourniquet may
provide better venous congestion
- Avoid areas of joint flexion
- Start distally and use the shortest length/smallest gauge access device
that will properly administer the prescribed therapy
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(BE AWARE: Blood flow in the lower forearm and hand is 95ml/min)
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IV Start Pain Management
One of the most frequent contributors to patient dissatisfaction is
painful phlebotomy and IV starts
•
Use 25-27g insulin syringe to create a wheal similar to a TB skin test on top
of or just to side of vein with 0.1 -0.2 ml normal saline or 1% xylocaine
without epinephrine
•
Topical anesthesia cream (ie EMLA) may be applied to children>37 weeks
gestation 1 hr. prior to stick. It might be a good idea to anesthetize a couple
of sites
•
Have the patient close their fist (NO PUMPING) prior to stick
•
Make sure the skin surface cleansing agent (alcohol/chlorhexidine) is dry
prior to stick. Drawing this into the vein may stimulate the vasoconstrictive
action of the tunica media layer
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Flushing Peripheral IV’s
Use prefilled saline and heparin flush syringes located in PYXIS
Heparin flush concentrations available:
-100u/ml (5ml in a 10ml syringe)
-10u/ml
(2ml in a 3ml syringe)
Flushing intervals and amounts
- Peds: q 6hrs.
<22ga 1ml 0.9%NS followed by 1ml heparinized
(10units/ml) saline
- Adults: q 8hrs
w/1ml. 0.9%NS [3ml heparinized saline for OB]
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Dressing/Bag Changes
Physician orders are
required if a peripheral
catheter is left in the same
site for more than 3 days.
It is best to have the
pharmacy add medications
to the infusion bags under
laminare flow to reduce
contamination
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Central Venous Catheters
Percutaneous
Tunneled
PICC’s
Implanted Ports
Dialysis
Insertion
MD @ bedside w/xray confirmation
MD in OR under
fluoroscopy
MD/trained RN @bedside
w/x-ray confirmation
MD in OR under fluoroscopy
MD in OR under
fluoroscopy
Location
Visible externally.
Enters subclavian,
ext. juglar,or int.
juglar vein near
clavicular area
Visible ext. usually
midway bet. clavicle
and nipple. Tunneled
under skin &
threaded through
subclavian or IJ
Visible externally around
antecubital fossa, upper
arm or neck
Completely internal. Titanium or plastc
port is implanted in a surgically created
pocket and catheter is threaded into
subclavian or int. juglar vein. Access is
through skin into self sealing port using
special non coring needle
Visible externally.
Arm or leg
placement
Polyurethane
$200-$400
Silicone
$3500-$5000
Silicone / polyurethane
$350-$500
Silicone catheter. Port is titanium or
plastic w/self sealing diaphragm
$3500-$5000
Various materials
Lumen
2-3
2-3
1-2
1-2
2-3
Sutured
Yes/entire life
Yes, until internal
Dacron cuff healed
No
Yes
Yes
Duration
Short term 4-10
days
Long term
Long term
Long term
Mid term
Flushes
5-10ml NaCl after
use and daily
5-10ml NaCl after
use and daily
5-10ml NaCl after use and
daily
10ml NaCl followed by 4.5ml
heparinized saline (adults-100units/ml;
peds-10units/ml) after ea. use or
monthly if not accessed
Done ONLY by IV
team or dialysis
nurses
Brands/
Names
Arrow Howe, Triple
Lumen, Subclavian,
IJ
Hickman, Broviac
PICC, PIC, EDPC, Arrow
Howe, Gesco, PASV
Bard, Accces Port-A-Cath
Bard, Tesio,
Vescath, Quinton
MD or speically
trained RN @
bedside
MD in OR
Specially trained RN @
bedside
MD in OR
MD in OR
Material/Cost
Discontinue
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Central Venous Catheter Sites
Percutaneous(Subclavian)
PICC (Peripherally inserted
Central Catheter)
Implanted Port
(single or double
lumen)
Tunnelled (Hickman)
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Percutaneous (IJ-Int. Jugular)
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CVC Care/Maintenance
Percutaneous
Tunneled
 Flush after each access or daily for
catheters>21ga, q 6 hrs <21 ga
-adults: 10ml saline
- peds/neonates: 5ml saline
(preservative free for infants <1yr)
PICC
 Transparent dressing change q 7 days & prn
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CVC Care/Maintenance
 Flush after each use and weekly while accessed;
monthly when not acessed
- 10ml saline (preservative free for pts. <1yr)
Implanted Port
- followed by 4.5ml-5ml heparinized saline
100units/ml for adults
10units/ml for peds
 Transparent dressing/ access needle change q 7days
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Monitor and
document site
condition:
Site Care
• Hourly for peds
•Q 2 hr for adult
* Indicates
complication:
•Infiltration
•Phlebitis
•Thrombosis
•Cellulitis
•Septicemia
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Infiltration/Extravasation
The most common cause is damage to the
wall during insertion or angle of placement.
STOP INFUSION and treat
as indicated by Pharmacy,
Medication package insert
or drug reference book.
Notify MD and document
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Phlebitis/Thrombophlebitis
 Chemical
- Infusate chemically erodes
internal layers. Warm compresses may
help while the infusate is
stopped/changed. Anti-inflammatory
and analgesic medications are often
used no matter what the cause
 Mechanical
 Bacterial
- Caused by irritation to
internal lumen of vein during insertion
of vascular access device and usually
appears shortly after insertion. The
device may need to be removed and
warm compresses applied
- Caused by introduction of
bacteria into the vein. Remove the
device immediately and treat
w/antibiotics. The arm will be
painful, red and warm; edema may
accompany
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Cellulitis
 Inflammation of loose connective
tissue around insertion site.
- Caused by poor insertion technique
- Red swollen area spreads from
insertion site outwardly in a diffuse circular
pattern
- Treated w/antibiotics
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Septicemia/Pulmonary Edema/
Embolism
 Septicemia
- Severe infection that occurs to a system or entire body
- Most often caused by poor insertion technique or poor site care
- Discontinue device immediately, culture and treat appropriately
 Pulmonary edema- caused by rapid infusion
 Pulmonary embolism - Caused by any free floating substances that
require thrombolytic therapy for several months. Increased risk w/lower ext.
 Air embolism- caused by air injected into IV system. Keep insertion site
below level of heart
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Troubleshooting
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Vascular access device will not flush/can’t draw blood
- Evaluate for kink in tubing or catheter tip against vein wall.
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Vascular access device (VAD) leaking when flushed
- Verify that hub access cap is connected correctly
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Patient complains of pain while VAD being flushed
- Assess for infiltration
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VAD broken
- PICC’s may be repaired. All other devices must be replaced
Call IV therapy team member for any concerns or
questions.
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Policy notes
KVO rate:
RN’s and LPN’s can start
peripheral IV’s after initial
training and observation by
preceptor
Adults - 10 ml/hr
Pediatrics - 2-3 ml/hr
Neonates - 0.5-1 ml/hr
Only until rate
order received
Verification required for:
•Insulin
•Heparin
•Potassium
LPN’s CANNOT infuse blood
products or high risk IV
medications.
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•Digoxin
•Chemotherapy
LPN’s cannot push IV
medications
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IV Medication Administration
 Many medications require patient
monitoring that cannot be done on
units where the nurse/patient
ratios are greater than 1:2
 A patient can be moved to a unit
where the ratio is appropriate for
invasive/frequent monitoring or
another nurse can be brought to
care for the patient during the med
administration
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All Medications Cannot Be
Administered on All Units
General Care Units: Can give meds
requiring only basic physical
assessment data
Stepdown Units: Can give meds
that require more invasive or
frequent monitoring than is available
on general care units
Intensive Care Units: Can give
meds that require more invasive or
frequent monitoring than is available
on the Stepdown units.
VANDERBILT URL LINK FOR IV
MEDICATIONS:
www.mc.vanderbilt.edu/pharmacy/ivroom/IV
MedAdm061003.pdf
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IV Medication Administration
Sample page
from the
Pharmacy med
administration
web site
See “APPROVED
FOR” section.
You will find if
the medication
can be
administered on
your unit.
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www.ins1.org
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Infusion Nurses Society (INS)
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Professional Organization that sets the standards of care
for clinicians practicing in the field of infusion therapy.
Standards set by INS are reflected in our policies and
procedures related to infusion therapy for health care
providers.
In a court of law, the standards set by the INS are used
to assess the infusion clinician’s performance.
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