Peripheral Intravenous Initiation Module

7/28/2019 Peripheral Intravenous Initiation Module

1/58

Self Learning Module

Peripheral IntravenousInitiation

Written by theFH Vascular Access Regional Shared Work Team Version 5 May 2012Patty Hignell RN, BSN, MSN, ENC(C)


2/58

2


3/58

TABLE OF CONTENTS

INTRODUCTION ........................................................................................................................ 5

INSTRUCTIONS......................................................................................................................... 5

SCOPE OF PRACTICE ................................................................................................................. 6

OUTCOMES ................................................................................................................................ 6

ANATOMY AND PHYSIOLOGY ................................................................................................... 7

FLUID AND ELECTROLYTE BALANCE....................................................................................... 11

BODYFLUID BALANCE..................................................................................................................... 11COMPOSITION OF BODYFLUIDS......................................................................................................... 11MOVEMENT OF BODYFLUIDS AND ELECTROLYTES ................................................................................... 12ACID-BASE BALANCE ...................................................................................................................... 13TYPES OF IVSOLUTIONS ................................................................................................................. 13

INFECTION CONTROL ............................................................................................................. 14

INFECTION CONTROL PRINCIPLES....................................................................................................... 14GENERAL MEASURES TO REDUCE IV-RELATED INFECTIONS........................................................................ 15

INFECTION

CONTROL

GUIDELINES

/P

OLICIES......................................................................................... 16APPROACH TO THE PATIENT .................................................................................................. 17

KEY POINTS TO SITE SELECTION ........................................................................................................ 17SITES TOAVOID............................................................................................................................ 17EVALUATING THE SELECTEDVEIN....................................................................................................... 18PREVENTING THE SPREAD OF INFECTION WHEN INITIATING AN IV............................................................... 18

EQUIPMENT............................................................................................................................. 18

TECHNIQUES IN VENIPUNCTURE ........................................................................................... 19

TROUBLESHOOTING IV INSERTION....................................................................................... 27

DOCUMENTATION................................................................................................................... 28

IV FLOW RATE MAINTENANCE................................................................................................ 28TROUBLESHOOTING IV INFUSION......................................................................................... 29

DISCONTINUING IV THERAPY................................................................................................ 30

DISCONTINUING APERIPHERAL IV...................................................................................................... 30

COMPLICATIONS OF IV THERAPY .......................................................................................... 31

LOCAL COMPLICATIONS.................................................................................................................... 31INFILTRATIONSCALE................................................................................................................. 31PHLEBITISSCALE ...................................................................................................................... 33SYSTEMIC COMPLICATIONS............................................................................................................... 34

ELECTRONIC INFUSION DEVICE............................................................................................. 38

BAXTERCOLLEAGUE CXEINFUSION PUMP SKILLS DEMONSTRATION SHEET.................................................... 40REVIEW QUESTIONS............................................................................................................... 41

ANSWERS TO REVIEW QUESTIONS ........................................................................................ 49

REFERENCES ........................................................................................................................... 50

APPENDIX A: COMPETENCY GUIDELINES .............................................................................. 51

APPENDIX B: CLINICAL COMPETENCY VALIDATION ............................................................. 53


4/58

4


5/58

INTRODUCTION

Welcome to the Initiation of Intravenous Therapy Self Learning Module!

Infusion therapy has evolved from an extreme measure used only as a last resort with the most criticallyill, to a highly scientific, specialized form of treatment used for greater than 90% of hospitalized clients.

Performing venipuncture is one of the more challenging clinical skills you will need to master. TheInfusion Therapy Practitioner is a Healthcare Practitioner (HCP) who, through study, supervised practiceand validation of competency, gains the acquired knowledge and skills necessary for the practice ofinfusion therapy.

Nurses provided with specialized training in peripheral vascular access, along with supportiveorganizational structures and processes, results in improved client outcomes and decreased complications(CDC, 2002; INS, 2006; Mermel et al., 2001).

Although we recognize that HCP other than Nursing may have intravenous insertion and therapy includedin their scope of practice, this Self-Learning Module has been written based primarily on the scope ofpractice of a Registered Nurse (RN).

Completing this Self Learning Module does not imply that you are competent in IV initiation and therapy.Competency assessment is multi-faceted (see pg.51). All HCPs must practice within their own level ofcompetence. When aspects of care or skill are beyond the HCPs level of competence, it is the HCPsresponsibility to seek education and/or supports needed for that care setting (CRNBC, 2005).

This Self Learning Module does not cover or imply the ability to administer medications bythe intravenous route.

INSTRUCTIONS

1. Read the information in the module and complete the self-test provided. If, while reading theinformation, you feel confident in your knowledge, proceed directly to the self-test. This workbookattempts to provide information for both the beginning and experienced Intravenous TherapyPractitioner. However, if questions arise that are not answered in the manual, please feel free to contacta Clinical Nurse Educator in your area or the General Clinical Nurse Educator for further explanation.

Standards, clinical guidelines, procedures, and protocols are referred to in the manual for your learningexperience. When you need to review these for clinical decision making, it is important for you to refer tothe Patient Care Guidelines for your facility. These can be found on the Fraser Health Intranet or fromyour Employer.

2. Once you have completed this theory, you will have the opportunity to:

Attend a learning lab Practice venipuncture (under supervision) on an anatomic training arm. Develop competency a Mentor (an RN or Intravenous Therapy Practitioner educated and

competent in the required knowledge and skills) will supervise you in the clinical setting untilproficiency is determined to be acceptable and competency has been validated (a competencyassessment tool [pg.53] will be completed by the Intravenous Therapy Practitioner and theMentor).

If you have previous IV experience, your skill competency can be validated in the clinical setting; this canbe arranged through a Clinical Nurse Educator. A Mentor will observe your venipuncture practice in theclinical setting and either validate your skill competency or discuss areas for improvement.

5


6/58

SCOPE OF PRACTICE

RNs are authorized per the Health Professions Act (HPA) to initiate and remove a peripheralIntravenous (IV) withoutan order from another health professional. The RN must havecompleted a Clinical Competency Validation in order to initiate an IV.

Other Intravenous Therapy Practitioners, including Medical Imaging Technicians, NuclearMedicine Technicians, and Licensed Practical Nurses (LPNs) may be authorized to initiate,monitor, and remove an IV, with a Physicians or Nurse Practitioners order. Clinical CompetencyValidation of these skills may be required prior to practicing these skills. Each IntravenousTherapy Practitioner needs to check with their registering and regulatory body (i.e. College) andtheir employer for their specific scope of practice standards, limits, and conditions.

All HCPs are legally responsible to be aware of, understand, and comply with theirscope of practice and understand their level of individual competence before

performing the skill of IV insertion.

An Order is required for continuing maintenance of a running IV. An Infusion Therapy Practitioners scope of practice includes:

o Specific knowledge and understanding of the vascular system and its relationship withother body systems and intravenous treatment modalities

o Skills necessary for the administration of infusion therapieso Knowledge of psychosocial aspects, including recognition of a sensitivity to the patients

wholeness, uniqueness, and significant social relationships, along with knowledge ofcommunity and economic resources

o Interdisciplinary communication, collaboration and participation in the clinical decisionmaking process.

OUTCOMES

Upon completion of this module the learner will be able to:

Locate manuals that contain standards, policies, and patient care guidelinesrelated to IV Therapy (i.e. INS Guidelines, Clinical Policy Office, Patient CareGuidelines Manual, HPA regulation, etc.)

Locate relevant learning material Describe and identify the anatomy and physiology of the venous system Describe precautions to use to prevent the spread of infection and avoid self contamination Select appropriate insertion site for prescribed therapy (and understand why site selection will

vary) Identify equipment used for venipuncture including IV cannula, start pack, intermittent injection

cap, IV extension set, and securement device

Select appropriate cannula for prescribed therapy

Identify equipment used for the delivery of intravenous therapy, including IV tubing andelectronic infusion pump or flow control device

Perform venipuncture on a training arm, secure, and dress the site Identify approaches to take to prevent, detect, and minimize complications Document appropriate information in the patients clinical record Describe the procedure for discontinuing the IV

6


7/58

ANATOMY AND PHYSIOLOGY

The systemic circulation consists of the arterial and the venous systems.

The venous system channels blood from the capillary bed back to the vena cava and the right atrium of the heart.The blood travels to the right ventricle of the heart where it is pumped to the lungs, via the pulmonary artery, foroxygenation. The lungs oxygenate the blood and it flows via the left atrium to the left ventricle, which pumps theblood to the aorta and all parts of the body.

Arteries are a high pressure system and apulse can be palpated. The muscle layer in arteries is stronger andthey will not collapse like veins. Arteries are also deeper than veins and are surrounded by nerve endings, makingarterial puncture painful.

The venous system consists of superficial and deep veins. The superficial or cutaneous veins are those used forvenipuncture. Superficial veins and deep veins unite freely in the lower extremities. For example, the smallsaphenous vein which drains the dorsum of the foot ascends the back of the leg and empties directly into the deeppopliteal vein. Because thrombosis of the superficial veins of the lower extremities can easily extend to the deepveins, it is important to avoid the use of these veins. Superficial veins are bluish in colour. The pressure withinveins is low and therefore a pulse will not be palpated in a vein. Blood in the venous system is movedback to the heart by valves and the action of muscular contraction. Damage to the valves results in stasis of bloodand varicosities. Initiation of an IV below a varicosity will result in reduced flow and decreased absorption ofadded medications, and should be avoided.

Knowledge of vein wall anatomy and physiology is necessary in understanding the potential complications of IVtherapy. The vein wall consists of three layers and each has very specific characteristics and considerationsinvolved in the introduction of IV catheters and the administration of IV fluid.

7


8/58

Tunica Intima (inner layer):This is a smooth, elastic, endothelial lining which also forms the valves (arteries have no valves). Valves mayinterfere with the withdrawal of blood, as they close the lumen of the vein when suction is applied. Slightreadjustment of the IV needle will solve the problem.Complications including phlebitis &/or thrombus may arise from damage to this layer. Injury to the lining canresult from:

MECHANICAL DAMAGE - Tearing of the lining from a traumatic insertion or excessive motion of the IVcatheter (due to frequent manipulation or inadequate securement)CHEMICAL DAMAGE - Caused by administering irritating medication/solution &/or not allowing the skinprep to completely dry prior to venipuncture (prep enters vein with IV catheter).BACTERIAL INTRODUCTION - Related to contamination of the IV site or IV catheter during or after thevenipuncture.

Tunica Media (middle layer):The middle layer of the vein wall consists of muscle and elastic tissue. This layer is thick and comprises the bulk ofthe vein. This layer is stronger in arteries than veins, to prevent collapse of the artery. Stimulation or irritation ofthe tissue may produce spasms in the vein or artery, which impedes blood flow and causes pain. The applicationof heat promotes vasodilation and reduces pain. If venospasm occurs, apply heat above the IV site to help reducespasm.

Tunica Adventicia (outer layer):

This consists of areolar connective tissue, which supports the vessel. It is thicker in arteries than in veins becauseof the greater blood pressure exerted on arteries.

Digital Veins:The dorsal digital veins flow along the lateral portions of the fingers. If large enough they may accommodate asmall gauge needle, however they are used as a last resort.

8


9/58

Metacarpal Veins:The metacarpal veins are formed by the union of the digital veins. They are usually visible, lie flat on the hand,are easy to feel, and are easily accessible. The hand provides a flat surface for stabilization and as this vein is inthe extremity it allows successive venipunctures to be performed above the site. These veins may therefore bethe first choice for venipuncture. When using, however, the distance from the insertion site to the prospectivecatheter tip must be considered to avoid tip positioning in the wrist area. It is preferred that the wrist not beimmobilized. One must consider the impact that limited ability to use the hand will present to patients requiringhands to support position changes, use crutches, walkers, and home infusion therapies.

Cephalic Vein:The cephalic vein flows upward along the radial aspect of the forearm. Its size readily accommodates a largeneedle, while its position provides easy access and natural splinting. This vein can be accessed from the wrist tothe upper arm (using the most distal region of the vein first). These veins tend to roll so anchoring the veinduring venipuncture essential.

Accessory Cephalic Vein:The accessory cephalic vein ascends the arm and joins the cephalic vein below the elbow. Its large sizeaccommodates a large needle.

Basilic Vein:The basilic vein originates in the dorsal venous network of the hand, ascending the ulnar aspect of the forearm. Itis large and usually prominent that may be visualized by flexing the elbow and bending the arm upward. The veinwill accommodate a large needle. It also tends to roll during insertion, therefore needs to be stabilized wellduring venipuncture.

Median Veins:The median antibrachial vein may be difficult to palpate and the location and size of this vein varies. It is usuallyspotted on the ulnar side of the inner forearm. It is not used as a first choice as venipuncture in the inner wrist

area may be more painful due to close proximity to the nerve.

The Median Cubital Vein:This vein lies in the antecubital fossa and is used mostly for emergency, short term access or blood withdrawal.It is used as a last resort for routine IV therapy. Accidental arterial puncture is a concern in this area.

9


10/58


11/58

FLUID AND ELECTROLYTE BALANCE

The concepts discussed in this section will alert the IV nurse to the potential dangers of electrolyte therapy andchanges in the patients condition which might alter the therapy. Knowledge of fluid and electrolytes in the bodywill contribute to safe and successful therapy.

Total body fluid is about 60% of the body weight. The body fluid content in infancy is 70-80% of the total bodyweight. Aging reduces the total body fluid to about 52% after age 60 years. The proportion in newborn infants is

approximately three-fifths intracellular and two-fifths extracellular, but changes to adult ratio by the time the childis 30 months old.

The total body fluid of the adult is divided into two main compartments, as demonstrated below. (There is alsotranscellular compartment made up of cellular metabolism and secretions such as gastrointestinal and urine.These secretions may be analyzed to help trace electrolyte loss).

Body Fluid Balance

When the volume or composition of body fluid is in the compartments deviates even a small amount, the cells andvital organs of the body suffer.

The intravascular compartment is the most accessible. Fluid is filtered from it to the kidney, lungs, skin; fluid canenter it from the GI tract and directly from IV fluids.

The interstitial space is next in accessibility, acting as a sort of storage area. The body can store extra fluid here(over time) or fluid can be borrowed from this space.

The intracellular space is the least accessible space and is protected by the cell membranes. Gains or losses ofhypertonic or hypotonic solutions (to be discussed later) will affect this compartment, causing the cell to gain orlose fluid. Cells function best in a constant environment.

Composition of Body Fluids

Body fluid contains two types of solutes (dissolved particles): non-electrolytessuch as glucose, creatinine andurea, and electrolytes(see Table 1).

Table 1

ELECTROLYTE LOCATION FUNCTION/SIGNS OF IMBALANCE

Potassium (K+) Intracellular essential for normal function of muscle tissue,especially heart muscle tissue

a low K+ will cause generalized decrease in muscularactivity, apathy, postural hypotension

excess K+ causes heart irregularities, ECG changesand tingling or numbness in extremities

11


12/58

12

ELECTROLYTE LOCATION FUNCTION/SIGNS OF IMBALANCE

Magnesium (Mg++) Intracellular enzyme action important for the metabolism ofproteins and carbohydrates

necessary to maintain osmotic pressure andneuromuscular stability (like calcium)

Sodium (Na+) Extracellular essential for regulating water distribution in the body(water follows sodium)

deficiency will cause weakness, dehydration andweight loss

excess sodium can cause oliguria, dry mucousmembranes and convulsions

Chloride (Cl-) Extracellular tends to follow sodium deficit leads to potassium defect and vice versa

Bicarbonate (HCO3-) Extracellular is the most important buffer in the body and helps tomaintain acid base balance

excess bicarbonate causes alkalosis deficiencies result in acidosis Normal range 7.35 - 7.45

Calcium (Ca+) Extracellular essential for blood clotting and required for muscularcontraction (e.g. heart muscle) and important forbone development

deficit causes muscular irritability, cramps andconvulsions

Movement of Body Fluids and Electrolytes

Body fluid compartments are separated by a semi-permeable membrane that allows both body fluids and solutesto move back and forth. Movement of water and electrolytes between compartments occurs in four ways:

Diffusion is the random movement of molecules and ions from an area of higher concentration to an area oflower concentration.

Osmosis is the movement of water across a semi-permeable membrane in response to osmotic pressure.Osmotic pressure is regulated by electrolytes and non-electrolyte particles in the fluid. If the extracellularfluid contained a large number of particles and the intracellular fluid contained a smaller number of particles,the water would pass from the cell into the extracellular space, until the particle ratio was equal. In this casethe cell might be deprived of needed water.

Active transport is a mechanism used to move molecules across a semi-permeable membrane against aconcentration gradient. This process requires cellular energy. An example is the sodium pump, which usesenergy to keep the sodium in the extracellular space and the potassium in the intracellular space. Otherwise

they would equalize over time.

Filtration is the movement of solute and water through semi-permeable membranes from an area of higherpressure to an area of lower pressure. This pressure called hydrostatic pressure is exerted in the capillariesby the pumping action of the heart. The direction of this pressure is to push fluid out of the capillary and intothe interstitial space. Colloid osmotic pressure is the pulling pressure created by proteins within the blood,which acts to draw fluid into the capillary.


13/58

The balance of these two pressures keeps the fluids within the capillaries.

Acid-Base Balance

The acidity or alkalinity of body fluid depends upon the hydrogen ion concentration expressed as the pH. Theextracellular fluid pH is 7.35 - 7.45, which is the optimum for cells to function.

Acidosis is a decrease in pH Alkalosis is an increase in pHBoth extracellular and intracellular fluids contain systems to buffer or maintain the proper acid-base balance. The

carbonic acid-sodium bicarbonate system is the most important buffer system in the extracellularcompartment. Other organs in the body also help to maintain fluid, electrolytes and acid-base balance. Healthykidneys, skin and lungs are the main regulating organs, by selectively retaining or secreting electrolytes and fluidaccording to the bodys needs.

Because cells of the vital organs require precise and constant source of fluids and electrolytes and correct pH, IVtherapy is important to replace losses caused by GI suction, burns, NPO, diuresis or diaphoresis.

Types of IV Solutions

Hypotonic has a lower osmotic pressure than blood. These solutions will cause intravascular fluid to shift out of

the blood vessels and into the cells and interstitial spaces, where osmolarity (number of particles) is greater. Ahypotonic solution hydrates the cells while depleting the circulatory system [e.g. 0.45% normal saline]. D5W(isotonic in the IV bag but when the dextrose is used by the body the remaining fluid is hypotonic).

Hypertonic has a higher osmotic pressure than the blood and draws water into it. It will draw water out of thecells and the interstitial space and into the vascular space [e.g. D5 normal saline, D10W, D50W]. (Hypertonicsolutions are very irritating to the tissue if they infiltrate). Sodium Chloride 3% and 5% are hypertonic solutionswhich must be administered with caution, they may cause dangerous shifts in the intracellular sodium and water.They should be stored apart from other IV solutions to avoid error.

Isotonic has the same osmotic pressure as the blood. Fluid will move equally between the vascular space andthe cells [e.g. 0.9% NaCl and Ringer's Lactate].

Crystalloid is a solution carrying electrolytes or non-electrolytes [e.g. Ringers Lactate, D5W, and Normal Saline].

Colloid is a solution which carries blood or blood products [e.g. Packed cells, albumin, and fresh frozen plasma](refer to Blood and Blood Product Administration Patient Care Guideline for further information). Colloids are ableto carry O2 to the cells.

13


14/58

INFECTION CONTROL

Infection Control Principles

Criteria for defining a nosocomial bacteria, cannula related infection are:

isolation of the same species in significant numbers on culture of the cannula and from blood cultures obtainedby separate venipuncture and a negative culture of the IV solution

microbiological data finding no other apparent source of septicemia clinical signs consistent with blood stream infectionBacteria causing IV-related infection come from three main sources: air, skin and blood. Less frequent sources arethe cannula and the IV solution.

Airborne bacteria increase in number when the activity in the area increases. They interfere with aseptictechnique and may also find their way into unprotected IV solutions, which hang during intermittent infusion.

The skin is the mainsource of bacteria responsible for IV infections. Resident bacteria adhering to the skininclude:Staphylococcus albus

Staphylococcus epidermidus

In hospitalized patients the following may also be present:Staphylococcus aureusKlebsiellaEnterobacterSerratia(most hospital-acquired infections are now of the gram negative type)

Blood may also harbour microorganisms such as: Hepatitis B and HIV; dangerous to the health care worker. Adhering to the Standard Precautions (Universal

Precautions), including the use of recommended gloves for blood and body fluids, is essential. Needles orstylets should not be recapped, but should be disposed of in rigid, tamper-proof containers

Other bacteria from a distant site of infection may seed the cannulated area. Assessment is necessary todetermine early signs of a low grade infection

Cannula contamination can occur: (see Figure 1)

From skin during insertion. Carefully follow site preparation At the hub by health care worker, breaking system during tubing changes. Maintain strict aseptic technique

during tubing change

At the tip if a thrombus occurs and is seeded by a distant local infection During manufacturing

14


15/58

(Figure 1, Weinstein 2001)

Solution contamination can occur:

During admixture of drugs; use of a filtered needle is recommended When accessing injection ports; should be cleansed for 30 sec with 70% alcohol and allowed to dry completelyas per Patient Care Guidelines.

By improper protection of tubing of intermittent infusions; use single-use intermittent IV tubing By allowing IV bag to hang for prolonged periods (> 24 hrs) On the shelf or during handling if small punctures occur to the bag. If using expired solutions More frequently in nutrient-rich solutions such as TPN and blood. Use laminar hood to prepare TPN solutions

and follow protocol re: tubing changes. Follow Patient Care Guidelines for Parenteral Nutrition and/or Bloodand Blood Product Administration.

General Measures to Reduce IV-Related Infections

Use of strict aseptic technique Tourniquets and all insertion equipment are to be single patient use (i.e. IV Start Pack) Careful skin preparation Careful site management Examine equipment for integrity and expiry date Use of filter needle for IV medications Correct storage and handling of blood products Single use intermittent infusion IV tubing Schedule for change of IV tubing and solutions

(Every 96 hrs for tubing and every 24 hrs for open solution containers)

Ongoing assessment to find signs of infection early (Q1H)

15


16/58

Infection Control Guidelines/ Policies

All staff will follow the latest Infection Control Guidelines for Principles of Infection Prevention and control,Routine Practices (including hand hygiene, application of personal protective equipment, and sharps handlingand disposal) and Additional Precautions, and blood and body fluid spills clean-up.

All IV insertion sites will be cleansed with a vigorous fraction scrub using 2% Chlorhexidine with 70% alcoholsolution, prior to insertion. The site must dry completely prior to the catheter insertion.

All IV injection caps will be cleansed with 70% alcohol for 30 seconds and allowed to dry completely beforeaccessing.

All IV sites will be covered with a transparent dressing. A securement device must be used to stabilize the IV catheter. Some transparent IV dressings (Tegaderm IV

Advanced) are also rated as a securement device. A stand-alone securement device (i.e. Statlock) placedunder a sterile dressing must be changed at least every 7 days.

The use of IV baskets/trays is strongly discouraged as the potential for cross-contamination betweenpatients is greatly increased. Single patient use IV start packs should be used whenever possible. A minimumof IV supplies should be taken to the patients bedside. Unused supplies that have been in contact with thepatient or their bedding can be wiped down with a disinfectant wipe provided there is no blood or body fluidcontamination. If they are contaminated they should be discarded before leaving the patient bedside/room.

16


17/58

APPROACH TO THE PATIENT

The approach of the nurse is important in the patients ability to accept the therapy. Safety both physical andpsychological is important to the patient. Although routine to the nurse, many procedures in hospital arefrightening to the patient. Exaggerated fear triggers the stress response with a cascade of undesirablephysiological events, including fluid retention and increased work of the heart. Avoid using words that might addto the patients apprehension, such as needle or stick. You might say Im going to put this soft plasticcatheter in your arm to deliver your medication (Haddaway, 2005).

Check patients chart for IV order and pertinent history and allergies (e.g. to tape or cleansing solution) Identify the patient by identiband and by asking his/her name and birthdate (dual identifiers) Address the patient by name The patients level of comfort should be assessed and pain controlled if possible, and positioning should be

adjusted as needed for access to the desired insertion site.

By calm explanation of the therapy and its expected benefits, the patients misinterpretations and fears maybe alleviated

Involve the patient in site selection (if possible) Draw bedside curtain and ensure privacy (as needed)

Key points to Site Selection

Many factors should be considered when choosing a vein for venipuncture:

- Patients age, body size, condition and level of physical activity- Patients condition and medical history- Vein condition, size and location- Type and duration of prescribed therapy. If prolonged therapy is anticipated, preservation of veins is essential.Select most distal and appropriate vein first. If medication/solution has high potential for vein irritation, select thelargest and most appropriate vessel to accommodate the infusion. Perform venipuncture proximal to a previouslycannulated site, injured vein, bruised area or site of a recent complication (infiltration, phlebitis, infection) orwhere impaired circulation is suspected.- Patient activity- Your skill at venipuncture

- Surgery to be done, position of limb during surgery, or if orthopedic surgery, avoid hands(needed for crutch walking)- Antecubital fossa contains arteries close to veins, avoid arterial puncture. This site also may limit the patientsrange of motion, increase the risk of phlebitis and infiltration and interfere with blood sampling.- The hand veins and dorsal metacarpal veins on elderly patients are often fragile- Veins on the lower extremities are more susceptible to complications

Sites to Avoid

Veins in the palm side of the wrist and the cephalic vein at the wrist level close proximity to nerves (painful,risk of nerve damage) and natural movement restricted

An arm with an arteriovenous shunt or fistula. See details in BC Renal Agency Chronic Kidney Disease: VeinPreservation Vascular Access Guidelineat www.bcrenalagency.ca.

Operative arm on patients post-mastectomy and/or auxiliary node dissection (if use of arm is needed in selectsituations, consult with physician). If physician consult is indicated, assess limb for lymphedema and ascertainlength of time post surgery (as this information will need to be relayed to the physician)

Arm with edema, impaired circulation (patient with CVA), blood clot or infection Orthopedic surgical patients avoid the hands if patient will use crutches post operatively

17


18/58

Veins of the legs, feet and ankles should not be used in adults (superficial veins of the legs and feet havemany connections with the deep veins. Catheter complications can lead to thrombophlebitis, deep veinthrombosis, and embolism). In an emergency situation, if necessary to use lower extremity, the dorsum of thefoot and the saphenous vein of the ankle can be used until central venous access is obtained. Removecatheters in lower extremity as soon as possible.

Veins below a previous IV infiltration or phlebitic area. Veins that feel hard or cord-like the vein is most likely sclerosed. Veins filled with large valves. They appear as visible bumps on the vein.

Evaluating the Selected Vein

Carefully examine both extremities using observation and palpation before selecting the most appropriate vein.By using the same fingers (not thumbs) consistently, palpation skills will become more sensitive. To palpate avein, place one or two fingertips (not thumbs) over it and press lightly. Release pressure to assess the veinselasticity and rebound filling. To acquire a highly developed sense of touch, palpate before every cannulation even if the vein looks easy to cannulate (Headway, 2005).

Preventing the Spread of Infection when Initiating an IV

Single use disposable tourniquets Use of IV start pack kits (with single use tourniquets and single use tape)

Rolls of tape moved between patient rooms, other procedures or pockets should not beused (Haddaway, 2005)

Hand washing prior to initiation of IV and after removing gloves Use of alcohol hand gel before and after patient contact Wearing non-sterile gloves to act as a barrier and reduce the risk of direct contact with blood or blood

stained equipment

Use of safety engineered IV catheters

EQUIPMENT

The Cannula

The selected cannulation device should be the smallest gauge and shortest length to accommodate the prescribedtherapy. This allows better blood flow around the catheter, reducing the risk of phlebitis and promoting properhemodilution of the fluid (Headway, 2005)

Over-the-needle catheters are available in a range of sizes:

Catheter Gauge Size Use this size gauge for:

16 18 Trauma patients/Rapid InfusionsHigh Viscosity Fluids

20 Pre-Operative PatientsBlood Transfusions

22 General InfusionsBlood TransfusionsChildren and Elderly

(Not suitable for rapid infusions)

24 Fragile-Veined PatientsChildren

18


19/58

The IV Solution

The Physicians Order should be checked for type, amount and rate of solution The colour, clarity and expiry date of the solution The integrity of the container and the administration set should be inspected The IV administration set should be primed The fluid should be suspended approximately 3 feet above the site on an IV pole.

Electronic Infusion Device

To prevent or closely control fluid volumes an electronic or flow control infusion device may be used (see pg.38 for Baxter Colleague Pump).

Examples may include an IV pump, CADD pump, or syringe pump

TECHNIQUES IN VENIPUNCTURE

GATHER EQUIPMENT

Non-sterile Gloves IV Catheter Start Pack Kit/ Insertion supplies:

- Chlorhexidine 2% with Alcohol 70% swab

- Single use tourniquet- Transparent dressing- Tape- Sterile 2x2 gauze

IV Catheter Extension set with intermittent injection cap Pre-filled 5 mL NS syringe Securement device (optional) IV solution (prepared with appropriate primed tubing suspended on a pole) Electronic Infusion Device or Flow Rate Control Device (optional)

19


20/58

VENOUS DISTENTION

Perform hand hygiene and put on non-sterile gloves. Apply a single-use disposable tourniquet tightly enough todistend the vein, while still allowing an arterial pulse. Latex-free tourniquets are preferred as they can be a sourceof exposure to those with a latex allergy. The tourniquet is applied to the mid-forearm for use of hand veins, andto the upper arm for veins in the forearm. Apply the tourniquet flat, to avoid pulling hair or pinching skin.Venous distension may take longer in elderly or dehydrated patients.

If the vein fills poorly, try the following:

Position the arm below heart level or hang arm down (before securing tourniquet) to encourage capillaryfilling

Have the patient open and close their fist several times (the fist should be relaxed during venipuncture) Light tap of your finger over the vein (hitting it too hard will cause vasoconstriction) If necessary, cover the entire arm with warm moist compresses for 10 15 minutes to triggervasodilation

SITE PREPARATION

Shaving is not recommended because there is a potential for causing micro-abrasions which increase potentialintroduction of microorganisms into the vascular system. If excess hair must be removed, clipping withscissors is recommended.

20


21/58

Using friction, apply the facility approved antimicrobial solution in a back and forth using friction, 2 to 3 inchesin diameter (CDC, 2002). The solution should be allowed to completely air dry prior to venipuncture. This maytake up to 3 minutes.

FAILURE TO ALLOW THE SKIN TO DRY COMPLETELY BEFORE APPLYING

THE TRANSPARENT DRESSING MAY CAUSE A CHEMICAL BURN ON THE

PATIENTS SKIN DUE TO THE CHLORHEXIDINE.

21


22/58

STABILIZING THE VEIN

Stabilizing or anchoring the vein prevents movement of the vein during insertion and minimizes the painassociated with venipuncture. Superficial veins have a tendency to roll because they lie in loose, superficialconnective tissue. To prevent rolling, maintain vein in a taut, distended, stable position.

Hand Vein - Grasp the patients hand with your non-dominant hand. Place your fingers under his palm andfingers, with your thumb on top of his fingers below the knuckles. Pull his hand downward to flex his wrist,creating an arch (Headway, 2005). Use your thumb to stretch the skin down over the knuckles to stabilize thevein.Forearm Vein - Encircle the patients arm with your non-dominant hand and use your thumb to pull downward onthe skin below the venipuncture site. If the skin is particularly loose, the vein may need to be held taut downwardbelow the vein and to the side of the intended site.

Maintain a firm grip of the vein throughout venipuncture.

METHODS OF VENIPUNCTURE

Direct Method - performed by holding the skin taut and entering the skin directly over the vein at a 5 15degree angle. This technique is useful for large veins. If inserted too far it may penetrate the back wall of thevein.

Indirect Method - the skin is entered beside the vein, and the catheter is redirected to enter the side of the vein.This motion reduces the risk of piercing the back wall.

22


23/58

INSERTING THE CANNULA

Before performing venipuncture, remove the cover from the IV catheter and examine the tip for smoothness. Ifany barbs are evident, discard the catheter. Rotate the catheter 360 degrees to release the catheter from thestylet as they are heat sealed during the manufacturing process. Once you have anchored the vein, press thevein lightly to check for rebound elasticity and to get a sense of its depth and resilience. Palpate the portionwhere the cannula tip will rest, not the point where you intend to insert the cannula. Note: If you touch theinsertion site, you will need to re-clean the site and let it dry completely before proceeding.

While holding the skin taut (and keeping the vein immobilized) with your non-dominant hand, grasp thecannula (bevel facing up to reduce the risk of piercing the veins back wall). Your fingers should be placed sothat you can see blood backflow in the flash chamber or extension tubing. Some catheters are designed toprovide early flashback of blood between the needle and the catheter

Images courtesy of BD

Encourage the patient to relax (breathe slowly in and out as you insert the cannula). Talk to the patientthrough the procedure to educate them and decrease their anxiety.

Insert catheter at a 5 to 15 degree angle (depending on depth of the vein), about 1 cm below the point wherethe vein is visible

Dont always expect to feel a popping or giving-way sensation (not usual on thin walled, low volumevessels). Look for blood backflow to tell you that you have entered the vein lumen

When you see continuous backflow (and you are confident the stylet tip is in the vein), lower your angle(almost to skin level) and advance slightly (approximately 1/8 inch) to ensure the cannula tip is also in thelumen of the vein. Continue to hold the stylet hub with your dominant hand

23


24/58

While immobilizing the vein, advance the catheter into the vein lumen. There are three methods of advancingthe catheter:

ONE-HAND TECHNIQUE - While non-dominant hand maintains skin traction, advance the catheter using thepush-off tab with one hand

Image courtesy of BD

TWO-HANDED TECHNIQUE - Release skin traction held by your non-dominant hand. Move dominant hand tothe plastic catheter hub and hold the stylet hub with your non-dominant hand. Separate the plastic catheter fromthe stylet by pushing the catheter into the vein slightly. Continue to hold the plastic catheter with your dominanthand. Reestablish skin traction with your non-dominant hand

Advance the plastic catheter with your dominant hand until it is inserted completely. Avoid moving the styletback into the catheter lumen (this can shear the catheter)


24


25/58

FLOATING THE CANNULA INTO THE VEIN Connect the primed administration set to the catheter hub(when the catheter is only partly inserted into the vein). Flush catheter with IV solution while advancing thecatheter.

Once the cannula is totally advanced into the vein, apply digital pressure beyond the cannula tip and releasethe tourniquet.


If using a cathalon with Blood Control technology, the tourniquet may be released and the safety mechanismactivated without applying digital pressure, due to the valve in the cathalon hub.

25


26/58

Images courtesy of 3M

Secure and stabilize the catheter using a transparent semi-permeable membrane (TSM) dressing. If the TSMdressing does not have securement properties, apply a manufactured securement device before applying the

TSM dressing.

Avoid taping over connections and circumferential taping

Image courtesy of 3M

Stabilize the hub and activate the safety mechanism. Dispose of theshielded needle in a sharps container.

Connect the pre-primed extension set with intermittent injection capwith/without continuous IV tubing.

Flush extension tubing with intermittent injection cap use positivepressure technique:

o Insert pre-filled 3-5 mL NS syringe intointermittent injection cap and inject 2-3mL of NS

or until 1-2 mL remains in syringe. While theplunger of the syringe is moving forward, clampthe extension tubing with the slide clamp.

If the IV is continuous, loop the administration set tight (withoutkinking tubing) and secure with tape. Set appropriate IV rate.


26


27/58

TROUBLESHOOTING IV INSERTION

If the initial insertion attempt is unsuccessful, consider the following options:

COMMON PROBLEMS WITH IV INSERTION

PROBLEM POSSIBLE CAUSE CORRECTIVE ACTION

Approaching a palpable vein thatis only visible for a short

segment

Patient anatomy - Insert the cannula 1 2 cmdistal to the visible segment and

tunnel the cannula through thetissue to enter the vein

Missed Vein Vein rolled or moved withinadequate anchoring allowingstylet to push the vein aside

- Anchor vein, maintain tractionand reposition catheter slightly- DO NOT excessively probe thearea and NEVER RESINSERTSTYLET BACK INTO CATHETER(can shear off a piece of theplastic).

Hematoma develops withinsertion

- Failure to lower the angleafter entering the vein

(trauma to the posterior veinwall)

- Angle too great

- Used too much force duringinsertion

- Failure to release thetourniquet promptly when thevein is sufficiently cannulated(increased intravascularpressure)

- Wrong angle

- Lower angle after enteringskin

- Decrease angle with insertion

- Use a smoother approach (toavoid piercing posterior wall)

- Release tourniquet oncecatheter has been threaded

- Ensure angle is reduced oncestylet is in the vein and advanceslightly to ensure catheter is inthe vein

Cannot advance the catheter offthe stylet

-Stopping too soon afterinsertion (so only the stylet, notthe plastic catheter, enters thelumen (blood return disappearswhen you remove the styletbecause the catheter is not in thelumen).

- Heat seal on catheter notreleased prior to use

- Pull catheter back slightly

- Rotate catheter 360 degrees onneedle and re-seat beforeinsertion

If still unsuccessful, remove the catheter, apply pressure to the site, and try again with a new catheter and anew site (preferably on the opposite arm). If you are unsuccessful after two attempts, have another RN orIntravenous Therapy Practitioner attempt insertion.

27


28/58

DOCUMENTATION

Always document in black ink.Record the following information on the following places (unless using procedure specific form):

Multidisciplinary Progress Notes: Date and time of insertion start, re-site or removal If not original site (re-site) - describe condition of the previous IV site (phlebitis, infiltration,

infection, etc.) Length and gauge of catheter inserted Location of site # of attempts, type of dressing applied and patients response to the procedure

IV Flow Sheet/ Fluid Balance Record:

NS flush Amount and type of IV solution infusing

Kardex:

Date IV extension tubing with intermittent IV cap is due (every 96 hrs) Date next tubing change is due (every 96 hrs)

IV FLOW RATE MAINTENANCE

Maintaining the IV involves planning and delivering nursing care to prevent problems, plus frequent assessment ofthe patient to identify problems or to treat them early.

1. Calculating Flow Rate:

Formula for calculating the flow rate using Macrodrip Tubinggtt/min = gtt/mL of adm set X total hourly volume (mL)

________________________________________________ (divided by)60 min.

Calculating flow rate using Microdrip TubingFor microdrip tubing the number of gtts per minute equals the number of mL/hr

2. To Monitor flow rate:

Connect administration set to a volumetric infusion pump or other flow-control device. If a pump is notavailable, prepare a time tape with the volume of fluid to be infused over one hour. Attach the tape next to thesolution container.

If the IV is not running properly, you need to check the entire system to determine the cause. Sometimesthe problem can be corrected easily; other times you will need to discontinue the IV and manage complications(pg. 29).

When evaluating patency, start at the venipuncture site and work up towards the IV bag. The chart onthe following page outlines common problems that affect flow rate and corrective actions that can be taken.

28


29/58

TROUBLESHOOTING IV INFUSION

CAUSES PREVENTION CORRECTIVE ACTION

Kinked tubing - Tape tubing without kinks - Check IV tubing for kinks and re-tape ifnecessary

IV catheter kinked - Securely tape after insertion - Remove dressing and re-tape ifnecessary- Remove catheter if permanently kinked

Incorrect administration set - Vented administration set used for glassbottles

- Replace tubing with vented set

Air trapped in tubing or injectionsites

- Remove air from administration set whenpriming line

- Tap the tubing until the bubbles rise intothe drip chamber, disconnect tubing andflush out, or withdraw from accessory portusing a syringe

Improper height of container - Suspend container 1 meter above IV site - Increase height of container- Instruct patient to keep 1 meterbetween container and IV site whenambulating

Drip chamber less than full - Fill drip chamber full when primingadministration set

- Fill drip chamber appropriately,removing air in line if necessary

IV positional (catheter tip lyingagainst vein wall)

- Avoid areas of flexion when inserting IV - Remove tape, pull catheter back slightly&/or adjust the angle of the catheter byplacing a 2 x 2 under the catheter hub.- Watch for the IV to run @ acceptablerate) and re-tape.Note:Never reinsert a catheter thathas been pulled back, as it is nowcontaminated

IV blocked (clotted) due to: No remaining solution container Blood backed up during

ambulation

Blocked in-line filter or air lock infilter

Phlebitis

Administration of medicationwith very high or low pH orprecipitates

- Maintain continuous solution in container

- Instruct patient to maintain1 meter between container and IV sitewhen ambulating

- Prime IV filter and change blood filter asper Patient Care Guideline

- REFER to pg. 33 - Complications of IVtherapy, Thrombophlebitis

- REFER to Parenteral Drug TherapyManual (PDTM) and only infuse compatibleand appropriate solutions and medicationsthrough a Peripheral IV

- Remove IV catheter and replace

- Increase height of pole duringambulation if necessary

- Inspect and replace filters as needed

- REFER to PDTM. Consider obtainingphysician referral for insertion of a centralvenous catheter (CVC) if appropriate.

If the problem of altered flow rate has not been resolved using these actions, IV cannula removal may benecessary. Consider consulting a more experienced IV nurse prior to discontinuing IV.

29


30/58

DISCONTINUING IV THERAPY

An order from a regulated member of a health professions authorized by the employing agencyis required todiscontinue IV therapy (e.g. continuing order of IV fluids or parenteral medication). However, upon discharge ofthe patient from the healthcare facility, and when they will not be returning for outpatient IV therapy, the IV maybe discontinued without an order.

IV catheters do not need to be re-sited at a pre-determined interval. They should be discontinued and re-sitedupon suspected contamination or complications (e.g. interstitial, phlebitis, etc - see table pg. 31)as follows:

Discontinuing a Peripheral IV

1. Verify physicians or authorized prescribers written order

2. Verify patients identification, using at least 2 independent identifiers, not including the patients roomnumber

3. Explain procedure to patient

4. Position patient as condition allows. Recumbent or Semi-Fowlers position is preferred.

5. Perform hand hygiene and don gloves

6. Select and assemble equipment

7. Discontinue administration of all infusates in the IV line to be discontinued.

8. Gently remove all adhesive materials, including dressing. Lifts tapes toward the catheter-skin junction bystabilizing skin surrounding venipuncture site.

9. Assess site for any complication, such as infiltration or phlebitis. Send swab for Culture if infectionsuspected.

10. Place sterile gauze above site and withdraw catheter, using a slow, steady motion. Keep the hub parallel to

the skin.11. Apply pressure with sterile gauze to the insertion site for 1-2 minutes or until hemostasis is achieved.

12. Assess integrity of the catheter that was removed. Compare catheter to original insertion length to ensureentire catheter is removed. If catheter is not removed intact, notify physician immediately.

13. Once hemostasis is achieved, apply a sterile dressing to exit wound as needed.

14. Discard expended equipment in appropriate receptaclesNote: Do not discard catheter if it was not intact on removal.

15. Remove gloves, disposes in appropriate receptacle, and perform hand hygiene.

16. Instructs patient as to:a. Recommended activity levelb. Removal of dressingc. Recognition and reporting of post-catheter removal complication(s)

17. Documents removal procedure in patients permanent health record including:a. Site assessment pre- and post-catheter removalb. Time IV was discontinuedc. Catheter condition and lengthc. Achievement of hemostasis and dressing materialsd. Ancillary procedures such as culture of exit wound and cathetere. Patient response and educationf. Name and title of clinician

30


31/58

COMPLICATIONS OF IV THERAPY

Complications of IV therapy may be classified as:

Local complications, which occur more frequently but are less serious andSystemic complications, which although rare, may be life threatening and require immediate treatment.

Local complicationsoccur as a result of trauma to the vein and include:

Complication Cause Signs Interventions Prevention

Catheter/cannuladisplacement

Swelling at site or entirelimb

Sluggish flow rate Skin blanched &/or cool

around site

Discomfort at site Absence of flashback(Flashback is not always asign of a patent infusion.Flashback may occur if the

needle has punctured theposterior of the wall, leavingthe greater portion of thebevel within the vein butalso allowing fluid to seepinto the tissue.)

Infiltration:

Discharge orescape of non-vesicantsolution ormedication intothesurroundingtissue as a

result ofcannuladislodgment,which causes:

- Delay of fluid anddrug absorption.- Limits veinsavailable- Predisposes thepatient to infection

Discontinueinfusion

Apply warmcompresses to siteto alleviatediscomfort and helpabsorb infiltration

Elevate affectedextremity

If there isdischarge from thesite, apply a steriledressing andchange prn

Rate the affectedarea using theinfiltration scale(below)

Continue to assesssite

Document in healthcare record

Notify physicianof Grade 3 or 4infiltrations.

Followprotocol formonitoringIV

Avoid jointswhenselecting asite

Secure IVsite to

minimizecathetermovement

ClinicalSymptoms

INFILTRATION SCALE

GRADE 0 1 2 3 4

Edema No 0 1in 1 6in 6in + 6in +

Cool to Touch No Yes Yes Yes Yes

Disrupted Sensation

(e.g. Pain)

No Possible Possible Mid-Moderate Moderate-Severe

Discoloration No Possible Possible Possible Yes

Extravasation No No No No Yes

31


32/58


Extravasation:Unintendeddischarge orleakage of avesicant solution or

medication intosurrounding tissuesas a result ofcannuladislodgement orinfiltration

Catheter/ cannuladislodgement

Swelling,blanching, blebformation

Stretched firm&/or cool skin

Can progress toform blisterswithsubsequentsloughing oftissues(necrosis)

Determine type,concentration andvolume of vesicantinfused

Notify physician

Rate the affectedarea using theInfiltration Scale(extravasation isalways rated as

Grade 4)Follow instructions in

PDTM for treatmentof extravasation froma medication (seePotential Hazards ofAdministration)

Follow protocolfor monitoring IV

Avoid jointswhen selecting asite

Secure IV tominimizecathetermovement

Hematoma:A collection of blood intothe tissue.

Laceration ofthe vein wall bythe IV catheteror by anunsuccessfulattempt atvenipuncture

Inadequatepressureapplied when

catheterdiscontinued

Swelling at thesite

Discomfort atsite

Raised area ofecchymosis

Occasionallybleeding at thesite

Discontinue IV andre-site IV in oppositelimb if possible

Elevate the affectedlimb and apply directpressure to the sitewith sterile gauze

Apply cold compress

Apply firmpressure toinsertion sitewith sterile gauzeafterunsuccessfulattempt start

Do not reapplytourniquet to thesame limb after

an unsuccessfulstart

Be aware ofpatients takinganti-coagulants

Slow or stoppedIV

Redness ortenderness atsite

Swelling due totissue injury

Discontinue IVApply warm

compress

Thrombosis:Formation of fibrin alongthe wall of the vein

Vein wall injury(a result ofdrugs ortechnique)

Blood stasisCatheter too

large for veinlumen

Avoid veins overjoint flexion

Anchor cannulawell to preventmotion anddecrease risk of

introducingmicroorganismsinto puncture site

Adequately diluteand mixmedicationsthoroughly

Use cannula sizesmaller than vein

32


33/58

Complication Cause Signs Interventions PreventionThrombophlebitis

Inflammation of the veinwith clot formation anddanger of embolism

Injury to thevein eitherduringvenipuncture orlater from

cathetermovement.Irritation of vein

from:

Catheter left inplace too long

Irritatingadditives

Use of a veinthat is too smallto handle theamount or typeof solution or

size of catheterSluggish flow

rate whichallows a clot toform at the endof the catheter

Poor aseptictechnique

Sluggish flowrate

Edema of limbWarm,

reddened site

Hard, cord-likevein

Pain andtendernessalong thecourse of thevein pathway.

Red line orstreak may beevident aboveIV site

Elevatedtemperature

Remove IV catheterand re-site ifnecessary onopposite arm

Apply intermittentwarm, moist heat tophlebitis site for 20minute periods 3 4times per day

If purulent drainageis present, collect aculture specimen ofdrainage prior tocleaning site andsend for analysis(see Infection Controlpg.15)

Measure degree ofphlebitis using thephlebitis scale

Notify physician ifpatient febrile orphlebitissevere(3+)


Avoid use ofveins over jointflexion

Anchor cannulawell to prevent

motion anddecrease risk ofintroducingmicroorganismsinto puncturesite

Adequatelydilute and mixmedicationsthoroughly

Use cannula sizesmaller thanvein

Clinical Symptoms PHLEBITIS SCALEGRADE 0 1+ 2+ 3+

Edema No Possible Possible Yes

Erythema (with or withoutpain)

No Yes Yes Yes

Streak Formation No No Yes Yes

Palpable Cord No No No Yes

33


34/58

Systemic Complications


Infection atVenipuncture SiteLocalized infection atvenipuncture site

Improper aseptictechnique

Contamination ofthe IV site or

equipment

Swelling anddiscomfort at site

Purulent dischargeat site

Elevatedtemperature

Discontinue IVSend catheter to

lab (see InfectionControl pg.15)

Culture sitedrainage

Clean site andapply steriledressing

Notify physician

Strict aseptictechnique whenstarting IV

IV site securedwith steriledressing

Change IV sitedressing ifnecessary

Utilize single-useintermittentmedication tubing

Septicemia:

Systemic infection

associated with thepresence ofpathogenicmicroorganisms ortheir toxins in thebloodstream.Predisposing factorsinclude: age less than1 year or greater than60 years, decreasedimmune state, andpresence of distantinfection.

Improper aseptictechnique

Contamination ofIV site,equipment, orsolution

Sudden onset offever and chills

General malaiseFlushed skinIncrease in pulse

rate

Headache,backache

Nausea, vomitingHypotension,

vascular collapse

Monitor vital signsNotify physicianDiscontinue IV -

send catheter andIV solution &equipment to labfor C&S (seeInfection Controlpg.15)

Re-site IV with newtubing and solutioncontainers usingaseptic technique

Use aseptictechnique whencaring for IV

Thoroughlyinspectmedication andsolutioncontainers priorto use

Inspect accesssite andequipmentregularly

Changeadministration setand solutionaccording toPatient CareGuideline

Utilize single-useintermittentmedication tubing

34


35/58


PulmonaryEmbolism:

Occurs when asubstance (usually a

blood clot) becomesfree and circulates tothe pulmonary arterycausing occlusion.Even small recurrentemboli may causepulmonaryhypertension and rightheart failure.

Irrigation of aclogged IV

Use of veins inlower limbs(increased risk)

Debris in IVsolution (somemay requirefilter -refer toPDTM)

Debris causedby incompletelydissolved,reconstituteddrugs

Unfiltered bloodor plasma

ApprehensionPleuritic discomfortDyspnea,

tachypnea

Cyanosis

Cough,unexplained

hemoptysisDiaphoresisTachycardiaLow-grade feverChest pain

radiating

to neck andshoulders

Place patient onstrict bed rest insemi-Fowlersposition

Notify physicianimmediatelyMonitor vital signs

Administer OxygenAssess IV and re-

site if needed (foremergency drugs)

Document in healthrecord

NEVER irrigate thecatheter if the IV isnot flowing

Use in-line filterswhere applicable

(see PDTM)Avoid siting IVs inthe lowerextremities in adultpatients whenpossible

Thoroughly inspectmedication andsolution containersfor particulatematter prior to use

Air Embolism:

Caused by the entry ofa bolus of air into thevascular system

Air is propelledinto the heart,causing anintracardiac airblock thatprevents bloodflow from theright side of theheart into thepulmonaryartery

Complicationshave beenreported with as

little as 20 mL ofair(the length of

an unprimed IVinfusion tubing)

that was injectedintravenously

(Natal, 2009).

Shortness ofbreath

Chest painShoulder or low

back pain(dependant onlocation of theembolus)

CyanosisHypotensionWeak, rapid pulseSyncope or loss of

consciousness

Shock or cardiacarrest

Immediately placepatient on left sidewith head lowerthan heart (allowsair to remain in theright atrium whereit absorbs ratherthan entering thepulmonary artery

Administer high-flow oxygen

If embolus a resultof open or leakinginfusion line, clampline near accesssite and changesolution containerand administrationset

Notify physicianimmediately

Use administrationsets with air filterswhen appropriate

Clamp tubingsduringadministration setchanges

Use luer-lockconnections on allinfusion equipment

Primeadministration setsand add-on devicescorrectly

35


36/58


CatheterEmbolism:

A piece of catheter isbroken in the vein and

enters the circulatorysystem

Over the needlecatheter stylet ispartiallywithdrawn thenreinserted into

the catheterCatheterruptures orbreaks afterplacement

Heal seal is notreleased properlybefore catheterinsertion

CyanosisHypotensionTachycardiaSyncope or loss of

consciousness

Secure tourniquetabove venipuncturesite (do not impedearterial flow)

Notify physicianimmediatelyMonitor vital signs


Submit report viaPatient SafetyLearning System(PSLS)

Carefully inspectcannula for defectsprior to use

NEVER withdraw oreinsert stylet into

catheter once it ispartially or fullythreaded

NEVER move styletback and forth incatheter to loosen ROTATE it in acircular motion360 prior to use

PulmonaryEdema:

An increase in venouspressure withincreased pressure inthe right ventricle,pulmonary artery andsubsequent fluid in thealveoli.

Rapid orexcessive fluid

administration,especially inpatients withimpaired renal orcardiac function,or elderly or veryyoung patients

EARLY Signs:RestlessnessSlow increase in

pulse rate

HeadacheShortness of

breath

Non-productivecough

Skin flushing

LATE Signs:HypertensionSevere dyspnea

with coarsecrackles

Engorged neckveins (JVD)

Pitting edemaPink, frothy

sputum

Puffy eyelidsShock, respiratory

or cardiac arrest

Place patient inhigh fowlers

positionSlow the IV to keep

vein open

Notify the physicianAdministermedications asrequested byphysicianMonitor vital signsAdminister high-

flow Oxygen


Submit report viaPatient SafetyLearning System(PSLS) when dueto accidental fluidoverload

Maintain prescribedflow rate with

regular patientassessment

Use volumetricinfusion pump forpatients wheneverpossible to avoidaccidental fluidoverload

36


37/58

Speed Shock:

A sudden adversephysiologic reaction toIV medications ordrugs that areadministered tooquickly.

Rapid infusion ofdrugs or solutioncausing toxicproportions toreach the heartand brain.

EARLY Signs:DizzinessFacial flushingHeadacheIrregular Heart

Rate

Chest pain/tightness

Sudden onset ofsymptomsassociated withparticularmedication beingadministered

DEVELOPMENTof Speed Shock:

SyncopeShockCardiac arrest

If Speed Shock issuspected:

Stop the infusionMaintain IV access

for emergencytreatment

Notify physicianimmediately orCode team ifapplicable

Monitor vital signs

Monitor gravity-flow administrationsets closely toensure correctprescribed flowrate

Use volumetricinfusion pump formedications asdirected in thePDTM

Followrecommendedinfusion rate formedication as perPDTM

37


38/58

ELECTRONIC INFUSION DEVICE

BAXTER COLLEAGUE Electronic Infusion Pump (single and triple-channel)

38


39/58

39


40/58

Baxter Colleague CXE Infusion Pump Skills Demonstration Sheet.Directions: Upon return demonstration, the participantwill check the box next to each step underdemonstration criteria, date and initial.

Blue print new CXE features. Black print review of pump

Name: ___________________________________ Dept: ________________________ParticipantsInitials/date DEMONSTRATION CRITERIA

Pump Overview: Main Display. Four keys identified as Soft Keys. MAIN DISPLAY, VOLUME HISTORY, ALARM SILENCE,andBACK LIGHTkeys. RATE, VOL, START, andON/OFF CHARGEkeys. Decimal Point and CLRkey. Pump modules, CHANNEL SELECTkeys, OPENkeys, and STOPkeys. Back of the pump: VOLUMEand CONTRASTcontrol knobs. RS 232 port, mounting clamp knob, and PANEL LOCKbutton.Turning on the Pump/Turning off the pump: Turn Pump on: ON/OFF CHARGEkey. Verify battery charge level and PumpPersonalitystatus. Clear Patient history. Change PumpPersonality. Turn Pump off: ON/OFF CHARGE key, Pop up window, Press ON/OFF CHARGE KEY a second time.Loading the Administration Set into the Pump:

Prepare container, prime Administration Set, close regulating roller clamp. Load Administration Set. Open regulating roller clamp. Verify no drops are falling into drip chamber.Unloading of Administration Set: Close regulating roller clamp. Remove administration set completely. Verify no drops are falling into drip chamber.Programming a Primary Infusion: Select desired pump channel for infusion on triple pump Program a Rate Volume infusion (mL/hr). Change Rate. Change Volume to be Infused. Program primary/Volume Timeinfusion. Program Colleague Guardianinfusion. Enter dose beyond pre-defined dose limits. Accept dose. Enter dose beyond pre-defined limits. Cancel dose. Change drug amount, diluent volume, or concentration field. Enter concentration beyond pre-defined limits. Cancel concentration change. Exit Colleague Guardianfeature and re-program in the same dose mode. Exit Colleague Guardianfeature and change dose mode to primary rate-volume. Program a Dose Modeinfusion. Discontinue a Dose Modeinfusion and change dose mode to primary rate-volume.Programming a Piggyback Infusion: Prepare container, prime administration set, close ON/Off clamp, lower primary container, and fully extend hanger. Program piggyback infusion. Enable Piggyback Callback Feature (if configured). Open On/Off clamp on secondary set. Verify drops are falling into the Piggyback drip chamber.Alarms and Alerts: Locate and identify status indicator lights. Identify audible tones and message displays associated with alert and alarms. Identify and correct KVOalert,AIRDETECTED alarm, UPSTREAM OCCLUSIONand DOWNSTREAM OCCLUSIONalarms. Understand BATTERY LOWalert,BATTERY DEPLETEDalarm, and battery life precautions. Understand FAILUREalarms and instructions for removing pump from service.Other Functions:

Place a pump channel in Standby (in Guardian displays drug) and remove a pump channel from Standby.Options Menu: Check Battery Charge Level. Battery Charge Level warnings and precautions. View Flow Check. View Personality settings. Modify Downstream Occlusion Values.Manual Tube Release: Never use for routine loading or unloading of administration set. Close regulating roller clamp on administration set. Use Manual Tube Releaseto remove administration set. Reset mechanism.

Note: The configuration of the Colleague Electronic Infusion pump will vary based on the programming options selected bthe facility. Therefore some functions may not be configured.Baxter, Colleague, Colleague Guardian and Personality are trademarks of Baxter International Inc.

40


41/58

REVIEW QUESTIONS

1. A Competency Assessed IV Nurse will:a) have successfully completed a theoretical and practical experienceb) have had at least two years of experience in IV therapyc) be automatically certified if certified at another health agencyd) will receive more money because of this skill

2. IV related standards, procedures and protocols may be found in which of the following manuals?a) INS Infusion Standards of Practiceb) Patient Care Guidelines Manualc) Perry and Potters Clinical Nursing Skills & Techniquesd) Parenteral Drug Therapy Manual and Infection Control Manual

i) a, b, cii) a, b, diii) a, c, div) a, b, c, d

3. Which of the following statements are true of the arterial circulatory system?a) Arteries carry blood to the tissuesb) Blood is under high pressure in the arterial systemc) Arteries have valves to help blood flowd) Arteries have a palpable pulse

i) a, b, cii) a, b, diii) a, c, div) a, b, c, d

4. Which of the following statements are true of the venous circulatory system?

a) The venous system is a low pressure systemb) Veins have a weak pulsec) Superficial and deep veins unite in the lower extremitiesd) Damage to valves may result in varicosities

i) a, b, cii) a, b, diii) a, c, div) b, c, d

41


42/58

5. Arteries and veins have:

a) one layerb) two layersc) three layersd) four layers

6. Name the veins and arteries on the following diagram:

7. The IV catheter most frequently used today is:a) through the needleb) cutdownc) over the needled) internal jugular

8. The gauge of needle/cannula most commonly used for routine IV therapy is:

a) #18b) #20c) #21d) #22

9. Prime factors to be considered when choosing a vein for infusion include:a) locationb) conditionc) purposed) duration

i) a, b, cii) a, b, d

iii) a, c, div) a, b, c, d

42


43/58

10. Which of the following statements are true about a saline lock?

a) The saline lock requires a short extension tubingb) The site should be assessed and changed as requiredc) The lock is flushed every 12 hours (and/or after medication) with 1-2 mL of normal salined) After removal check site for bleeding, edema, signs of infection

i) a, b, cii) a, b, diii) b, c, div) a, b, c, d

11. Which of the following are nursing actions to be done before starting the IV?a) Check patients chart for allergies and doctors orderb) Identify the patient by identiband and by asking namec) Involve the patient in site selectiond) Ensure privacy

i) a, b

ii) a, b, diii) b, c, div) a, b, c, d

12. Venous distention may be achieved by which of the following?a) Tourniquet to mid-forearm for use of the hand veinsb) Tourniquet tight enough to occlude an arterial pulsec) Position the arm below heart leveld) Application of warm packs 10-15 minutes prior to IV start

i) a, b, cii) a, b, diii) a, c, d

iv) b, c, d

13. Stabilizing the vein minimizes the pain associated with venipuncture:i) trueii) false

43


44/58

14. Factors affecting flow rate of the IV are:a) Phlebitisb) Height of the containerc) Positional IVd) Air trapped in tubing


15. Signs of infiltration include:a) Sluggish flow rateb) Warm, reddened skin at sitec) Swelling of limbd) Slow backflow


iii) a, c, div) b, c, d

16. Thrombophlebitis is caused by injury or irritation from which of the following?a) Long term therapyb) Acidic or alkaline substancesc) Trauma during insertiond) Poor aseptic technique


17. Signs of septicemia include:a) Headache, backacheb) Sudden change in pulse ratec) Hypotensiond) Sudden onset of chills


44


45/58

18. To prevent septicemia which of the following are recommended?a) Examine solutions carefullyb) Observe maximum solution hang time of 24 hoursc) Mix solutions at the bedsided) Mix solutions in the laminar flow hood


19. Symptoms of pulmonary embolus include which of the following?a) Dyspneab) Chest painc) Diaphoresisd) Weak rapid pulse


iii) b, c, div) a, b, c, d

20. If an air embolus is suspected, the appropriate intervention is to:a) Turn patient on left side head downb) Turn patient on right side head downc) Turn patient on left side head raisedd) Turn patient on right side head raised

21. Early signs of pulmonary edema include:a) Restlessnessb) Headachec) Shortness of breath

d) Fever


22. Factors predisposing the patient to septicemia including all the following except:a) Age less than one year or more than 60 yearsb) State of immune systemc) Increased red blood cell countd) Presence of distant infection

45


46/58

23. The most common source of bacteria responsible for IV infection comes from:a) Airborne sourcesb) The patients skinc) The cannulad) Healthcare workers hands

24. Which of the following measures help to reduce IV related infections?a) Handwashing prior to venipunctureb) Use of a laminar hood for IV admixturesc) Protection of intermittent infusion IV tubingd) Sterile dressing using aseptic technique


25. What percentage of the adults weight is body fluid?a) 5%

b) 15%c) 40%d) 60%

26. What percentage of the adults weight is contained in intracellular fluid?a) 5%b) 15%c) 20%d) 40%

27. What percentage of the infants weight is body fluid?a) 15%b) 40%

c) 60%d) 70%

28. Body water and electrolytes move in which of the following ways?a) Colloidalb) Diffusionc) Active transportd) Osmosis


46


47/58

29. Which electrolyte is responsible for regulating water distribution in the body?a) Potassiumb) Calciumc) Sodiumd) Chloride

30. Which electrolyte is essential for the normal function of the heart muscle?a) Potassiumb) Zincc) Sodiumd) Chloride

31. Which statements are true about acid-base balance?a) Kidneys, lungs and skin are the main regulating organsb) The normal pH is 7.35-7.45c) Acidosis is a decrease in pHd) Alkalosis is an increase in pH

i) a, b, c


32. Hypotonic is a term which means that a solution has:a) A higher osmotic pressure than the bloodb) A lower osmotic pressure than the bloodc) The same osmotic pressure as bloodd) Ability to carry O2 to the cells

33. Which of the following statements are true of a hypertonic solution?a) Draws water out of the cells and interstitial space and into the intravascular spaceb) Has a higher osmotic pressure than the blood

c) Has a lower osmotic pressure than the bloodd) Dextrose 10% and 50% in water are examples of a hypertonic solution

i) a, b, cii) a, b, diii) b, c, d

34. 3% and 5% saline have been called dangerous solutions because:a) They move water out of the cell and interstitial space and into the intravascular spaceb) They cause imbalance in the intracellular water and sodiumc) They are isotonicd) They contain a lot of potassium

47


48/58

35. Which of the following statements are true about the Electronic Infusion Pump (Baxter Colleague singor triple-channel))?

a) Only appropriate Baxter IV tubing should be used with the pumpb) Once the tubing is in the channel, the pump detects the tubing and the loading mechanism w

automatically close loading the tubing into the drive mechanismc) The pump does not have a safety clamp which is activated by opening the doord) The Manual Tube Release is for emergency use. It should NOT be used when the pump chann

is operating normally.


36. Which of the following statements are true about Quality Assurance?a) Quality Improvement is the new term used to describe QA activitiesb) Quality Improvement focuses on the processes of the systemc) Quality Improvement uses teams of experts and tools to collect datad) Any activity which results in better delivery of health care is QI


37. Which of the following should be charted on the patients health record?a) Length and gauge of the infusion deviceb) Site of venipuncturec) Date and time of insertiond) Patients response to the procedure

i) a, b, c


48


49/58

ANSWERS TO REVIEW QUESTIONS

1. a 21. i

2. iv 22. c

3. ii 23. b

4. iii 24. ii

5. c 25. d

6. see pg. 10 26. d

7. c 27. d

8. b 28. iii

9. iv 29. c

10. iv 30. a

11. iv 31. iv

12. iii 32. b

13. i 33. ii

14. iv 34. b

15. iii 35. ii

16. iv 36. iv

17. iv 37. iv

18. ii

19. iv

20. a

49


50/58

REFERENCES

Accreditation Canada (2011) Required Organizational Practices. Retrieved from www.accreditation.ca Feb 2, 2012.

Alexander, J., Corrigan, A., Gorski, L., Hankins, J., & Perucca, R. (2010) Infusion Nurses Society: Infusion NursingAn Evidence-Based Approach. St. Louis, Missouri: Saunders Elsevier.

BC Renal Agency (2011) Chronic Kidney Disease: Vein Preservation Vascular Access Guideline. Retrieved fromhttp://www.bcrenalagency.ca/professionals/VascularAccess/ProvGuide.htm February 2, 2012.

Canadian Nurses Association. (2008). Code of Ethics for Registered Nurses. Ottawa: ON: Author. Available from:http://www.cna-aiic.ca/CNA/documents/pdf/publications/Code_of_Ethics_2008_e.pdf

Center for Disease Control and Prevention (2011) Guidelines for the prevention of intravascular catheter-relatedinfections. Author.

Cohen, M. & Smetzer, J. (2008) Errors With Injectable Medications: Unlabeled Syringes are Surprisingly Common.Hospital Pharmacy. 43(2). Pg. 81-84.

College of Registered Nurses of British Columbia (2010) Scope of practice for Registered Nurses: Standards, limitsand conditions. Pub. No. 433. Vancouver, BC: Author.

College of Registered Nurses of British Columbia (2009) Scope standard reflective tool: Carrying out activities without an order. No. 08W3.Vancouver, BC: Author.

ECRI Institute (2008) Needleless connectors: Evaluation. Health Devices. 37(9).

Hadaway, L. & Richardson, D. Needless connectors: A primer on terminology. Journal of Infusion Nursing. 33(1).

Fraser Health Authority (2011) Parenteral Drug Administration Guidelines. Pg.7.

Fraser Health (2008) Peripheral Vascular Access Initiation Learning Module. British Columbia: Author.

Fraser Health Peripheral IV Access Shared Work Team (2009) Clinical Protocol: Peripheral Vascular Access Registered Nurse Initiated. BritishColumbia: Author.

Fraser Health Authority (2010) Scope of Practice. Author.

Fraser Health Authority (2009) Test: Blood Culture. MIC 02160, Microbiology. Laboratory Medicine and PathologySample Collection and Dispatch Instructions.

Fraser Health Authority (2006) Test: Catheter tip (Intravascular/IV) Culture. MIC 0250, Microbiology. LaboratoryMedicine and Pathology Sample Collection and Dispatch Instructions.

Government of British Columbia. (2009) Regulation of the Minister of Health Services: Health Professions Act[Nurses (Registered) and Nurse Practitioners Regulation, B.C. [Reg. 284/2008 amendments.]Victoria: BC.

Hadaway, L. (2012) Misuse of prefilled flush syringes: Implications for medication errors and contamination.Infection Control Resource. 4(4).

Hadaway, L. (2005) On the Road to Successful IV Starts. Nursing. 35, p.1-14.

Infusion Nurses Society (2011) Infusion nursing standards of practice. Journal of Infusion Nursing. 34(1S).

Infusion Nurses Society (2011) Policies and Procedures for Infusion Nursing(4th

ed.). Author.

Natal, B. (2009) Venous Air Embolism. eMedicine. Retrieved September 1, 2010 from http://emedicine.medscape.com/article/761367-overview

Raad, I., Hanna, H., & Darouiche (2001) Diagnosis of catheter-related bloodstream infections: Is it necessary toculture the subcutaneous catheter segment? European Journal of Clinical Microbiology and Infectious Disease. 20(566-568).

Weinstein, Sharon M. (2007). Plumer's Principles & Practice of Intravenous Therapy(8th ed.). Philadelphia, MD:Lippincott Williams & Wilkins.

50
http://www.accreditation.ca/http://www.bcrenalagency.ca/professionals/VascularAccess/ProvGuide.htmhttp://www.cna-aiic.ca/CNA/documents/pdf/publications/Code_of_Ethics_2008_e.pdfhttp://www.cna-aiic.ca/CNA/documents/pdf/publications/Code_of_Ethics_2008_e.pdfhttp://emedicine.medscape.com/article/761367-overviewhttp://emedicine.medscape.com/article/761367-overviewhttp://www.cna-aiic.ca/CNA/documents/pdf/publications/Code_of_Ethics_2008_e.pdfhttp://www.bcrenalagency.ca/professionals/VascularAccess/ProvGuide.htmhttp://www.accreditation.ca/


51/58

APPENDIX A: COMPETENCY GUIDELINES

HOSPITAL WITH IV TEAM HOSPITAL WITHOUT IV TEAM

IV TEAM WARD RN WARD RNINTRAVENOUS THERAP

PRACTITIONER

(see definition pg 5)Initial Training:IV Insertion Skills SessionSelf Learning Module(process outlined on pg 4)

Emphasis on IV initiationand becoming clinicalexperts

Initial Training:IV Insertion Skills SessionSelf Learning Module(process outlined on pg

4)

Emphasis on maintenanceExamples:- dressing change

information- use of securement

device

- pump review

Initial Training:IV Insertion Skills SessionSelf Learning Module(process outlined on pg

4)

Emphasis on initiation,maintenance, andbecoming clinical experts

Initial Training:IV Insertion Skills SessionSelf Learning Module(process outlined on pg 4)

Emphasis on initiation andmaintenance

Training done by:IV TEAM

Demonstration ofcompetency to:IV TEAM

Training done by:Clinical Nurse Educator

Training done by:Clinical Nur