Basic Vascular Access Ice Ppt Presentation.Ppt2

Basic IV Therapy and Central Vascular Access

Devices

Precision Placements

Presented by

ObjectivesParticipant will:

• Describe the peripheral and central venous anatomy as well as the application of infusions to the appropriate venous access sites and devices

• Differentiate between the four(4) Central Venous Access devices and understand advantages, disadvantages, potential complications, nursing care and maintenance of the specific devices

• Accurately observe, monitor, report and document the status of a peripheral and central venous site

• Be able to demonstrate the principles of asepsis and standard precautions in the management of infusion therapy

• Demonstrate peripheral IV insertion (IV catheter over the needle ) and PICC dressing change with adherence to sterile technique

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Anatomy of a Vein Tunica Intima:

The layer of smooth endothelial cells lining the length of the blood vessel

• Innermost layer

• Has one thin layer of cells (endothelial lining)

• Irritating this layer causes thrombus formation

Tunica Adventitia:

The outermost layer of vein

• Supports and surrounds vessel

• Blood supply of this layer called Vaso Vasorum

Tunica Media:

Middle layer of vein

•Composed of muscular and elastic tissue

•Contains nerve fibers

•Collapses or distends with pressure

Anatomy of a Vein vs. an Artery

VEINS:

superficial in sub-Q tissue

valves

do not pulse

dark red blood

3 layers3 layers

ARTERIES:

deeper in sub-Q tissue

no valves

pulse

bright red blood

3 layers3 layers

VEIN

ARTERY• Tunica Intima:Tunica Intima:

• Tunica Media: Tunica Media:

• Tunica AdventitiaTunica Adventitia:

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Vein Identification

BasilicCephalic

Digitals

DorsalMetacarpals

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Vein Information Chart

Vein Location

Size Catheter Considerations

Digital Veins N/A Do Not Use

Metacarpal Veins

24-20g • Not first choice in the elderly• Only infuse isotonic or near isotonic

solutions or medications

Cephalic Vein 24-20g • Large vein, easy to access• Useful for infusing isotonic, near isotonic and chemically irritating

medications

Basilic Vein 24-20g • Difficult to access and to stabilize• Large, palpable vein-moves easily

Basilic Vein

Vein Identification

Median Antebrachial

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Vein Information Chart…Continued

Vein Location

Size Catheter Considerations

Median Antebrachial

Vein

N/A • Flat, small in diameter• Decreased hemodilution

• Avoid these veins due to increase of infiltration and painful access

Median Antecubital

Vein

1. Median Basilic2. Median Cubital

3. Median Cephalic

N/A • Avoid peripheral infusion• Reserve for blood lab draws

• Reserve for future needs• PICC & Midline• Renal patients

• Emergency use only

Nerves of the Upper Extremities

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Nerves of the Hand and Wrist

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Important ConceptsOsmolarity:

• Measure of solute concentration

• Normal blood plasma Osmolarity is 290-340 mOsm/L and is

considered Isotonic

Example: D5W, LR, 0.9Nss

• Osmolarity higher than 340 mOsm/L is considered Hypertonic

Example: D5.45Nss, D5LR, 10% and > dextrose concentrations

• Osmolarity lower than 290 mOsm/L is considered Hypotonic

Example: 0.45Nss and 0.33Nss

pH:

• Hydrogen ion concentration

• Normal blood pH is 7.35-7.45

• Solutions with a pH < 6.0 are Acidic

• Solutions with a pH > 8.0 are Alkaline

Important Terms

Phlebogenic Drugs: Cause irritation to the inner lining of the vein

Examples:

Amphotericin B Phenytoin Erythromycin Pentamidine

Dobutamine Ganciclovir Potassium Chloride Phenobarbitol

Foscarnet Chemotherapeutic Agents Gentamycin Doxycycline

Penicillins (Oxacillin ,Nafcillin,Unasyn,Methicillin) Morphine

Important Terms

Vesicants:

• Drugs that have properties that when inadvertently infused into the SubQ tissue can cause severe tissue

damage

• Necrosis can lead to grafts, possibly loss of limb

Examples: Vancomycin, Dopamine, Dextrose concentrations > 10% and Chemotherapy

Infiltration:

• Inadvertent administration of non-vesicant infusion onto

the SubQ tissue

Extravasations:

• Inadvertent administration of vesicant infusion into the SubQ tissue

Intravenous FluidsHydrationDextrose Solutions:

• Provide calories

• 5% dextrose = 5g dextrose in 100ml

• Hypotonic dextrose hydrates the intracellular compartment

• Hypertonic dextrose pulls water from the intracellular compartment and decreases swelling

Sodium Chloride Solutions:

• Provide ECF replacement

• Hypotonic saline (0.45% or less) can be used to supply daily salt and

water requirements

• 0.9% Sodium Chloride is the only solution to be used with blood components

Hydrating Solutions:

• Combination of dextrose and hypotonic sodium chloride

• Hydrates patients in dehydrated state

• Promotes diuresis

Multiple Electrolyte Solutions/ Lactated Ringers:

• Solution most like the body’s electrolyte content

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Intravenous FluidsAntibiotics

• A. Aminoglycosides (Gentamycin, Amikacin and Tobramycin) OTO and NEPHRO TOXIC

• B.Cephalosporins ( Rocephin,Ancef and Kefzol ) Related to Penicillin so check allergy history.

• C. Penicillins (Nafcillin,Ampicillin,Timentin,

Oxacillin, and Unasyn)

• D. Tricyclic Glycopeptides (Vancomycin)

OTO and NEPHRO TOXIC

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Aminoglycosides and Tricyclic Glycopeptides

• Drugs that are oto and nephro toxic require blood monitoring levels. Amikacin,Gentamycin,Tobramycin and Vancomycin require monitoring. The Trough levels are drawn just prior to the start of an infusion. Peak levels are drawn 30-60 minutes after the completion of an infusion. Typically drug levels are started after the fifth dose to allow adequate time for the drug to reach consistent blood levels.

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Intravenous FluidsTPN/ PPN

• Total Parenteral Nutrition: TPN provides nutrients (carbohydrates, protein, fat, minerals, and trace elements) through the veins. Has greater than 10% Dextrose Concentration.– Indications: severe malnutrition, bowel rest,

obstruction, short bowel syndrome, malabsorbtion, hyperemesis, intractible diarrhea and motility disorders.

• Peripheral Parenteral Nutrition: PPN provides some nutrients and has lower calories and dextrose concentration than TPN. PPN must be lower than 10% Dextrose concentration. Is typically indicated for short term supplement or when central venous access is not available.

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Intravenous FluidsPain Management

Morphine

DilaudidMorphine and Dilaudid can be given IV ,SUB-Q and IM.

Pain control analgesia pumps (PCA) are often used to deliver pain management and offer the patient continuous pain management with bolus ability.

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Complications of Pain Management

Nausea

Vomiting

Increased sedation

Constipation

Respiratory depression

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Intravenous FluidsChemotheraputic Agents

Preferred way to administer Chemotherapy is through a central venous access device.

Side Effects of Chemotherapy:

• Nausea

• Vomiting

• Fatigue

• Anorexia

• Hair Loss20

Checklist for Peripheral IV Insertion

Check physician's orders

Identify patient -2 identifiers

Check for allergies

Informed consent

Patient teaching

Standard precautions

Intravenous Nurses Society Standards

• Use the smallest gauge and shortest length catheter to accommodate the prescribed therapy

• A peripheral IV (short cannula, midline catheter) is not appropriate for continuous vesicant chemotherapy, TPN, solutions or medications with a pH < 5 or >9 and/or a serum osmolarity > 500 mOsm/L

Criteria for Vein Selection

Distal Branches of Large VeinsVeins below Antecubital FossaPalpable, Soft to Firm and VisibleAdequate size for the type of infusion being administered

Considerations:Length of therapyPurpose and type of infusionPatient activityPredisposing medical conditions

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Catheter Selection

1. Over the needle

• Insyte autoguard

2. Winged catheter

• Butterfly

3. Midline

Flashback Chamber Hub

t

Vein Selection

Considerations

• What are you giving?

• Length of therapy

• Vein integrity

• Previous venipunctures

• Clinical assessment

• Patient compliance

Specifically:

• Avoid areas of flexion

• Avoid boney prominences

• Avoid nerves

• Distal to proximal

• Avoid bruised and edematous area

• Alternate arms

Vein Dilation

Technique

• Tourniquet

• BP cuff

• Gravity

• Fist clenching

• Tapping vein

• Warm compress

• Multiple tourniquets

Venipuncture Technique

• Gather Supplies• Wash Hands• Explain Procedure to your

patient• Set up clean area• Prepare for venipuncture

in a position that will be stable for both you and your patient

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Venipuncture Technique Apply Tourniquet and proceed:

• Apply gloves

• Antimicrobial scrub and place tourniquet 4-6” above puncture site

• Pull skin below puncture site to stabilize and prevent vein from rolling

• Insert needle, bevel up, at a 15- 300- angle (low and slow)

• When blood in flashback chamber occurs, lower angle of catheter and advance catheter with stylet as a unit into the vein, approximately 1/8” just enough to ensure

catheter is in the vessel

STOP!


• Advance catheter off the stylet until ENTIRE catheter is in the vessel

• Release tourniquet

• Apply manual pressure just above the site that you imagine where the catheter tip is

• Remove stylet (hit safety button)

• Connect the extension tubing with the valve cap

• Tape hub/wings of catheter

• Flush with .9NSS and check for blood return

• Apply transparent dressing

Peripheral IV Dressings

Dressing

• Gauze dressing with tape(48 hour dressing change)

• Tegaderm occlusive dressing

Dressing change with IV catheter change

(72-96 hours)

Labeling

• Venipuncture site label

• Date and time

• Type and length of catheter

• Nurse’s initials

• Label administration set

• Tubing changes

• Label solutions container

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• Attach infusion and regulate flow

• Label administration set tubing and bags

• Dispose of needles in sharps containers

• Document procedure


Documentation

• Date and time of insertion

• Manufacturer’s brand name and style of device

• Gauge and length

• Specific name and/or location of accessed vein

• # of attempts

• Infused by regulator tubing or electronic

pump

• Patient’s response

• Signature

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Peripheral IV Removal

Technique

• Use dry sterile gauze to apply pressure until bleeding stops

• Apply band-aid or gauze and tape

• Examine catheter integrity and dispose

• Document site assessment and catheter integrity

• Keep dressing clean and dry until scab forms

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Peripheral IV Demonstration

• Skills validation

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IV Rate Calculations

A.Total Volume X drops/ml

= Drops/Min.

Total Time in Minutes

B. Drip Rates of IV Tubing ( check package)

Formulas

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IV Rate Calculations

Example:

1000ml D/W to infuse over 12 hours

1000ml x 10gtts/ml

---------------------- =14DropsMin.(13.8) 720

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Midline Catheter• Peripheral IV catheter whose tip terminates in the proximal upper extremity

• No vesicants through this line

• Increased dwell time (up to 2-4 weeks)

• Open ended (Flush S-A-S-H)

• Closed ended (Flush S-A-S)

• Insertion and Removal

• Care and Maintenance: dressing,flush,site observation

S-A-S = Saline - Administration - Saline

S-A-S-H = Saline - Administration - Saline – Heparin(100units/ml)

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Central Venous Anatomy

Cephalic Vein

Basilic VeinSuperior Vena Cava

Innominate Vein

Or Brachiocephalic Vein

Subclavian Vein Jugular Vein

Axillary Vein

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Central Venous Access Devices

• Central Venous Catheter

• tip is located in the Superior Vena Cava

• Greatest hemodilution of vascular system

• SVC is the largest vein in venous anatomy

• SVC: turbulent blood flow

• Appropriate location for vesicant therapy, TPN, long-term IV therapy, solutions/medications with a pH < 5 or > 9 and or serum osmolality > 500 mOsm/L

• Tip confirmation must be verified post insertion

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Central Venous Access Tip Placement

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Peripherally Inserted Central Catheter (PICC)

• PICC

• Tip terminates in the SVC

• Dwell time is (up to) 6 months - 1 year

• Open or closed ended

• 1-2 lumens

• Insertion and removal

• Advantages

• Disadvantages

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•Complications :

1.Fibrin Sheath/Tail

2.Clotted catheter

3.PICC Migration

•Interventions:

1.Cathflow Activase Instillation (2 mg. x 2 /lumen)

2.Cathflow Activase Instillation (2 mg. x 2 /lumen)

3.PICC exchange

• Exchange

• Repairs of Groshongs are no longer done

Peripherally Inserted Central Catheter (PICC)…Continued

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• Care and maintenance

• Dressing Change – 24 hrs. post insertion. Thereafter, weekly and PRN for transparent dressings and 3x/week for gauze dressings. Strict adherence to sterile technique is required.

• Flushing – Most PICC lines are flushed with Normal Saline and Heparin Lock Flush/per facility policy and MD order. (usual amounts are 10ml Normal Saline and 5ml Heparin flush of 100 units/ml).

Note: GROSHONG PICC’s do not require Heparin Flush because they are closed ended catheters with a valve at the end.

•Cap and Extension Changes –The cap and extension tubing are

changed with each dressing change weekly and after every blood draw.

•

Peripherally Inserted Central Catheter (PICC)

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Implanted Ports- AKA portacaths, ports,mediports and passports

• Port implanted in the SQ tissue, catheter tip terminates in the SVC

• Design: 1-2 lumens, reservoir, septum, catheter

• Dwell time can be greater than 1 year



• Advantages

• Disadvantages


• Routine flushing: Monthly

• Huber needle only: Needle and dressing change weekly

• Complications/ Interventions (Pinch off syndrome, Sludge)

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What is Pinch Off Syndrome?

• Pinch Off Syndrome is the compression of a catheter as it passes between the clavicle and first rib at the costoclavicular space.

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Non-Tunneled Catheters -Triple lumen, Subclavian, CVC

• Short-term emergent central catheter

• 1-3 Lumens

• Open ended only


• Advantages

• Disadvantages


• Complications and interventions 46

Tunneled Catheters - Hickman,Groshong

• Central line catheter tunneled under SubQ tissue with tip placement in SVC

• 1-3 Lumens


• Dwell time: long-term IV therapy (> 1 year)


• Advantages

• Dacron cuff

• Disadvantages


• Complications and interventions47

Documentation

• Specific to your institution’s policy and procedure

• Flushing protocols

• Solution, amount and technique

• Dressing, tubing and cap changes

• Measurement as appropriate

• Site assessments

• Interventions taken

• Any other pertinent information

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Demonstration of Central Line Dressing Change

• Skills Validation

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Complications

Infiltration:• Inadvertent administration

of an IV fluid in

surrounding SQ tissue

around area of vein

(non-vesicant)

Interventions: • DC IV; Restart• Compress?

Phlebitis:• Injury to the endothelial

lining of the vein Bacterial Mechanical Chemical

Interventions:• DC IV; Restart• Compress?

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Phlebitis

Infusion Phlebitis - inflammation of the vein associated with infusion phlebitis as seen in this photograph.

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Complications

Cellulitis:• Infection of SQ tissue

• Characteristic of a circular

pattern, with redness,

induration and exudate

Interventions:• DC IV• Topical antibiotics (apply

with sterile dressing)• Monitor for septicemia

Sepsis:• The presence of infectious

microorganisms or other

toxins in the blood stream

Interventions:• Restart IV• Obtain cultures• Notify physician• Monitor patient daily• Antimicrobial therapy as ordered 52

Complications

Cellulitisadhering to aseptic technique is vital in the prevention of intravenous related infections. Asepsis should be maintained at insertion, during clinical use and at removal of the device.

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Sepsis

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Complications

Thrombosis:• Formation of blood clot in

the catheter lumen• Formation of a blood clot

within a blood vessel

Interventions:•Thrombolytics

PREVENTION:• Flush immediately after

infusion• Appropriate tip locations• Appropriate size catheter in

relation to vein size

Catheter Related

Embolism:• Air embolisms• Catheter embolism

Interventions: • PREVENTION• This is an EMERGENCY• Turn patient on left side and

place in Trendelenberg

position• Nasal oxygen• Prepare for resuscitation• 911

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Thrombosis

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PICC Line Embolism/Rupture

• You are the key to prevention –

ONLY syringes that are 10cc’s and larger should be used on a PICC line. Smaller syringes generate a higher pressure that can cause the catheter to rupture.

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ComplicationsCatheter Occlusions:• Occlusions may be due to

blood, fibrin, drug,

precipitate or lipids/sludge

build up

Interventions:• PREVENTION• Flush catheter immediately

after infusion • Flush between

incompatible drugs• Thrombolytics

Catheter Malposition or Migration:• Can occur during insertion

or spontaneously sometime

after insertion

Interventions:• LISTEN to your patient• Follow up x-rays when

indicated

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Complications

Extravasation:• Inadvertent administration of a vesicant solution or medication

into the surrounding tissues resulting in potential blistering,

necrosis and tissue sloughing

Interventions:• PREVENTION

• Stop infusion

• Don’t remove cannula – aspirate

• Notify physician

• Pharmacological intervention, if appropriate (controversial)

• Compress (controversial)

• Immobilization and elevation

• Follow up 59

Extravasation

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Blood Sampling Through CVADDirect or Indirect Methods can be used:

1. Turn off all IV infusions in multi-lumen device for a minimum of one full minute prior to taking sample.

2. Flush lumen that you are using for sampling with 5ml/Ns.

3. Attach vacutainer or attach sterile syringe to lumen and obtain 5-10ml of blood in a collection tube or syringe for discard.

4. If using a vacutainer use collection tubes and obtain blood for sampling. If using a syringe withdraw blood for sampling.

5. When using a syringe: Maintain sterility of sample transfer in syringe to collection tubes with ‘blood transfer device.

6. Remove vacutainer or syringe and flush lumen with 10-20ml/Ns.

7. Change valve cap ( cap must be changed with every blood draw).

8. Reconnect infusion to new cap and use SAS for close ended CVAD’s and SASH for open ended CVAD’s.

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Legal Considerations

• Get informed and written consent

•For PIVs -verbal consent

•For CVADs- written informed consent with risks and benefits outlined.

• Inform patient of all VAD options

•Know tip placement of each CVAD before using it

This also refers to patients readmitted with ports, tunneled lines, etc…

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Legally Speaking

• Know and follow all of your facility’s policies and procedures. If you are not sure where to find them ask a colleague or supervisor/ manager so that you can become familiar with them.

• Always use concise and accurate documentation.

• Don’t use CVAD without a blood return unless the reason for the absence has been determined.

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Questions and

Review for Test

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Congratulations !Thank You for Your Participation

• It has been my pleasure to have you in this class today. • The greatest gift in learning something new is putting that

knowledge into practice and then sharing what you know with someone else.

• Go and use your new found or renewed knowledge and Practice! Practice! Practice!

• You are all Winners!65

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Basic Vascular Access Ice Ppt Presentation.Ppt2