IV Insertion PDF

IV Insertion Integrated Nursing Practice 4 Nikki Laidlaw, MSN, BScN LPN Scope of Practice LPNs may, with additional educational preparation, administer medication via the IV route to patients with stable and predictable states of health and change IV bags infusing via peripheral access (not centra...

IV Insertion Integrated Nursing Practice 4 Nikki Laidlaw, MSN, BScN LPN Scope of Practice LPNs may, with additional educational preparation, administer medication via the IV route to patients with stable and predictable states of health and change IV bags infusing via peripheral access (not central or midline). This does not include: a) Administration of medication via the IV Direct route (push) b) Starting transfusions of blood or blood products c) Starting or monitoring parenteral nutrition d) Administration of radiopaque dyes via parenteral instillation e) Accessing central venous catheters (CVCs) https://www.bccnm.ca/Documents/standards_practice/lpn/LPN_ScopeOfPractice.pdf Infusion Therapy Practitioner’s Scope of Practice Specific knowledge and understanding of the vascular system Its relationship with other body systems and intravenous treatment modalities Skills necessary for the administration of infusion therapies Knowledge of psychosocial aspects Recognition of a sensitivity to the patient’s wholeness, uniqueness, and significant social relationships Knowledge of community and economic resources Interdisciplinary communication, collaboration and participation in the clinical decision making process What We’ll Accomplish! Describe and identify the anatomy and physiology of the venous system Describe precautions to use to prevent the spread of infection and avoid selfcontamination Select appropriate insertion site for prescribed therapy (and understand why site selection will vary) Identify equipment used for venipuncture including IV cannula, IV Start Pack, needleless connector (IV cap), IV extension set, and securement dressing/device Select appropriate cannula for prescribed therapy Perform venipuncture, secure, and dress the site Identify approaches to take to prevent, detect, and minimize complications Document appropriate information in the patient’s permanent health record Describe the procedure for discontinuing the IV Anatomy & Physiology Arteries are a high pressure system and when they are close to the surface of the skin a pulse can be palpated (e.g. radial or brachial pulse) The Venous System consists of superficial and deep veins Human Heart Diagram - Human Body Pictures - Science for Kids (sciencekids.co.nz) https://dr282zn36sxxg.cloudfront.net/datastreams/fd%3A209cc2a3cd63b7236cb8008d7ca5753655f0f0470bef774967bf7ee6%2BIMAGE_TINY%2BIMAGE_TINY.1 Vein Anatomy The vein wall consists of three layers Each has very specific characteristics and considerations involved in the introduction of IV catheters and the administration of IV fluid https://www.anatomynote.com/wp-content/uploads/2019/07/9669/Artery-vein-and-capillary-anatomical-structure-in-detail.jpg https://somepomed.org/articulos/contents/images/f6/31/6652.myextj?title=Superficial+veins+of+hand+and+forearm Digital Veins The dorsal digital veins flow along the lateral portions of the fingers If large enough they may accommodate a small gauge needle, however they are used as a last resort https://image.slidesharecdn.com/peripheralvenouscannulation170527202835/95/peripheral-venous-cannulation-14-638.jpg?cb=1495917257 Metacarpal Veins (Back of the Hand) They are usually visible, lie flat on the hand, are easy to feel, and are easily accessible Allows successive venipunctures to be performed above the site May be the first choice for venipuncture Can often accommodate 20 to 24 gauge catheters Avoid inserting where the tip of the catheter will end up in the wrist area Difficult for patients to use their hands to support position changes, use crutches, walkers, and home infusion therapies Not good for infusing vesicants or irritants https://image.slidesharecdn.com/peripheralvenouscannulation170527202835/95/peripheral-venous-cannulation-14-638.jpg?cb=1495917257 Cephalic Vein Flows upward along the radial aspect of the forearm Accommodates a large needle (often up to 16 gauge) Its position provides easy access and natural splinting Can be accessed from the wrist to the upper arm Use the most distal region of the vein first These veins tend to “roll” so “anchoring” the vein during venipuncture essential The large size is an excellent choice for infusing irritants Because the radial nerve is close to this vein, perform venipuncture 10 to 13 cm above the wrist. https://www.uptodate.com/contents/images/SURG/55596/Upper_extremity_veins_edt.jpg Accessory Cephalic Vein Ascends the arm and joins the cephalic vein below the elbow Its large size accommodates a large needle (usually up to an 18 gauge) Be cautious not to place the IV catheter tip in the bend of the arm. https://www.uptodate.com/contents/images/SURG/55596/Upper_extremity_veins_edt.jpg Basilic Vein Originates in the dorsal venous network of the hand and ascends the ulnar aspect of the forearm Large and usually prominent Can be seen by flexing the elbow and bending the arm upward Will accommodate a large needle (usually up to a 16 gauge) Often ignored as it tends to “roll” during insertion, therefore needs to be stabilized well during venipuncture Try placing the patient’s arm across their chest and standing on the opposite side of the bed when performing venipuncture at this site https://www.uptodate.com/contents/images/SURG/55596/Upper_extremity_veins_edt.jpg Median Veins (Antibrachial) May be difficult to palpate and the location and size of this vein varies Usually spotted on the ulnar side of the inner forearm Easily accommodates 20 to 24 gauge IV catheters Be sure to stay well clear of the inner wrist area as it may be more painful and there is a risk of nerve damage https://www.uptodate.com/contents/images/SURG/55596/Upper_extremity_veins_edt.jpg Median Cubital Vein Lies in the antecubital fossa Used mostly for emergency, short term access or blood withdrawal It should be used only as a last resort for routine IV therapy due to the high rate of complications Infiltration Nerve injuries Phlebitis Accidental arterial puncture is a concern in this area A catheter in this site also limits mobility. https://www.uptodate.com/contents/images/SURG/55596/Upper_extremity_veins_edt.jpg Examine the Veins Look at the veins and palpate to select the most appropriate vein The vein should be quite straight, no bifurcations Use the same fingers (not thumbs) consistently to develop your sensitivity To palpate a vein, place one or two fingertips (not thumbs) over it and press lightly Release pressure to assess the vein’s elasticity and rebound filling Make a habit of palpating before every cannulation – even if the vein looks easy to cannulate https://www.nursingcenter.com/getattachment/ceab9f7f-f2c7-48ce-9f9a-1f6ee1b5c239/palpating-vein.png.aspx Selecting the IV Insertion Site Key points to consider: Patient’s age, body size, condition and level of physical activity Patient’s 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 If medication/solution has high potential for vein irritation, select the largest and most appropriate vessel to accommodate the infusion https://t3.ftcdn.net/jpg/00/41/92/08/360_F_41920816_xoxL5fkgJ9xowZzhoj80PuTfBO4BknhX.jpg Selecting the IV Insertion Site More key points to consider: Select most distal and appropriate vein first Perform venipuncture proximal to a previously cannulated site, injured vein, bruised area or site of a recent complication (infiltration, phlebitis, infection) or where 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) Video: Vein Selection IV Insertion Sites to Avoid Areas of flexion Areas of pain on palpation Compromised veins Areas near valves Areas where there are planned surgical procedures The extremity on the side of breast surgery with axillary node dissection After radiation therapy to that side The presence of lymphedema The affected side after a stroke https://preview.redd.it/tvmg2r2vdtq61.png?width=474&format=png&auto=webp&s=738a87adc7707c6485c861f56153dcbced520100 Venous Distention Troubleshooting Position the arm below heart level or hang arm down (before securing tourniquet) to encourage capillary filling Have the patient open and close their hand several times BUT the hand should be relaxed during venipuncture Light tap of your finger over the vein Do not slap; hitting it too hard will cause vasoconstriction If necessary, cover the entire arm (or both arms) with warm compresses for 10 – 15 minutes to trigger vasodilation Difficult Venous Access Patients with: A history of I.V. drug use Multiple chronic illnesses Also patients with: Edema Hypovolemia Vascular pathology https://cached.imagescaler.hbpl.co.uk/resize/scaleWidth/800/cached.offline hbpl.hbpl.co.uk/news/PGH/01FAA74D-0AAA-7771-1A5EEF4A84692267.jpg https://varicoseveins.org/wp-content/uploads/2014/04/shutterstock_215081503.jpg https://www.neurorehabdirectory.com/wp-content/uploads/2017/03/Unknown.jpeg Delayed Venous Access Implications Two out of every five patients require multiple attempts to achieve I.V. access, sometimes taking 30 minutes or more to complete. The result can be: Patient pain and discomfort Lack of blood specimens Delayed diagnosis and treatment Decreased nurse productivity Increased supply costs Increased likelihood of using a more expensive high-risk procedure, such as central venous catheter (CVC) insertion http://3.bp.blogspot.com/-impQFLDOaKM/Ta_WJVivqqI/AAAAAAAAAbo/1EM5ufWXfLI/w1200-h630-p-k-no-nu/difficult+IV.jpg Vein-Finding Tools Infrared Vein Finder Shines an infrared light on the patients’ skin The hemoglobin (oxygen-carrying protein) within the patient’s blood absorbs the light, creating a red pattern that can be seen on the surface of the skin The oxygen-depleted veins appear darker in the pattern, indicating the presence of a vein https://nourishedmedspa.com/wp-content/uploads/2019/11/PRP-Hair-Restoration-Accuvein-5.png Vein-Finding Tools Ultrasound Vein Finder Uses ultrasound waves to visualize the veins https://onlinelibrary.wiley.com/cms/asset/eccdb1cf-9ee2-426c-af28-6c7e3124f4fd/jum201635112343-fig-0002-m.jpg Before IV Insertion Check patient’s chart for IV order and pertinent history and allergies (e.g. to tape or cleansing solution) Identify the patient by arm band and by asking his/her name and birthdate (at least 2 identifiers) Address the patient by name The patient’s 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 it’s expected benefits, the patient’s misinterpretations and fears may be alleviated Involve the patient in site selection (if possible) Draw bedside curtain and ensure privacy (as needed) https://www.myamericannurse.com/wp-content/uploads/2010/03/medical-band-application.jpg Other Important IV Insertion Points PVADs should not be routinely resited Resite a PVAD if signs of infiltration, phlebitis, leaking or sepsis are noted Each nurse is limited to 2 insertion attempts If not successful, ask another nurse to insert the IV IV 2 nurses are unsuccessful, consult the physician for possible PICC insertion Antecubital fossa veins should only be used if unable to access other hand/arm veins Avoid the wrist! Insert at least 5 cm (2 inches) above the wrist IV insertion in the lower limb does not require a physician’s order but should not be routinely performed https://images.squarespace-cdn.com/content/v1/56991e0b05f8e2e932ce642d/1551118833883-QPMQ4FBRB538DKXHJO13/image-asset.jpeg?format=1500w Equipment List Non-sterile Gloves IV Catheter Start Pack Kit/ Insertion supplies: Chlorhexidine 2% with Alcohol 70% swab Single use tourniquet Transparent securement dressing Tape Sterile 2x2 gauze IV Catheter Extension set with needleless connector Pre-filled 5 mL NS syringe IV solution as required (prepared with appropriate primed tubing suspended on a pole) Electronic Infusion Device or Flow Rate Control Device as required http://cdn.shopify.com/s/files/1/0045/4216/9201/products/IV_Infusion_Kit_1200x1200.jpg?v=1571730954 Selecting the IV Catheter The cannulation device should be the smallest gauge and shortest length to accommodate the prescribed therapy This allows better blood flow around the catheter, reducing the risk of phlebitis and promoting proper hemodilution of the fluid https://cpimg.tistatic.com/04628953/b/4/IV-Cannula.jpg?tr=n-w341 Catheter Gauge Use • 16-18 Trauma patients/Rapid Infusions High Viscosity Fluids • 20 Pre-Operative Patients Blood Transfusions • 22 General Infusions Blood Transfusions Children and Elderly (Not suitable for rapid infusions) • 24 Fragile-Veined Patients Children Different Types of IV Catheters Several different sizes Wings or no wings Injection ports or no injection ports Safety retraction https://cdn11.bigcommerce.com/s-xe1mvjh/images/stencil/1280x1280/products/1534/733/catheter__89388.1418841075.JPG?c=2 The IV Solution The Physician’s Order should be checked for type, amount and rate of solution Check the colour, clarity and expiry date of the solution The integrity of the administration set should be inspected The IV administration set should be primed The fluid should be suspended approximately 3 feet above the pump on an IV pole http://www.ped2-karazin.com.ua/wp-content/uploads/2018/08/dsd_iv1.jpg Pump or No Pump? Used to closely control fluid volume infusion IV Infusion pumps shall be used for administration of all IV fluids and medications, including blood and blood products Use of gravity flow-based IV fluid administration is limited to circumstances where an IV Pump cannot be used or with specified uses in specific care areas IV rates greater than 999 ml/hr CT dye infusion Limited supply Must critically evaluate who needs a pump and who doesn’t https://www.4mdmedical.com/media/catalog/product/cache/1/image/9df78eab3352 5d08d6e5fb8d27136e95/s/i/sigma-spectrum-infusion-pump-refurbished-900.jpg Site Preparation Shaving is not recommended Micro-abrasions can increase potential introduction of microorganisms into the vascular system If excess hair must be removed, clipping with scissors is recommended Using friction, apply antimicrobial solution in a back and forth motion using friction, 2 to 3 inches in diameter The solution should be allowed to completely air dry prior to venipuncture This may take up to 3 minutes https://geekymedics.com/wp-content/uploads/2017/01/CleanSite.jpg Venous Distention With Tourniquet Perform hand hygiene and put on non-sterile gloves Apply a single-use disposable tourniquet tightly enough to distend the vein, while still allowing an arterial pulse Latex-free tourniquets are preferred as they can be a source of exposure to those with a latex allergy The tourniquet is applied to the mid-forearm for use of hand veins, and to 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 https://theprocedureguide.com/wp-content/uploads/2021/03/Peripheral-IV-tourniquet-applied-and-technique-989x1024.jpg Stabilize the Vein Stabilize or “anchor” the vein Prevents movement of the vein during insertion and minimizes the pain associated with venipuncture Superficial veins have a tendency to roll because they lie in loose, superficial connective tissue To prevent rolling, maintain vein in a taut, distended, stable position https://somepomed.org/articulos/contents/images/f10/6/10345.myextj?title=Peripheral+IV+placement+4 Hand Vein Grasp the patient’s hand with your non-dominant hand Place your fingers under his palm and fingers, with your thumb on top of the fingers below the knuckles Pull the hand downward to flex his wrist, creating an arch Use your thumb to stretch the skin down over the knuckles to stabilize the vein https://i.ytimg.com/vi/6zcsYUqaWCE/hqdefault.jpg Arm Vein Encircle the patient’s arm with your non-dominant hand Use your thumb to pull downward on the skin below the venipuncture site For particularly loose skin Hold the vein taut by pulling downward below the vein and to the side of the intended site http://what-when-how.com/wp-content/uploads/2012/04/tmp2A143_thumb_thumb1.jpg Methods of Venipuncture Direct Method Hold the skin taut and enter the skin directly over the vein at a 5 – 15 degree angle Useful for large veins If inserted too far it may penetrate the back wall of the vein Indirect Method The skin is entered beside the vein The catheter is redirected to enter the side of the vein This motion reduces the risk of piercing the back wall https://learn.accuvein.com/wp-content/uploads/2013/04/Hand-Catheterization-Banner-640x320.jpg Inserting the IV Cannula Remove the cover from the IV catheter and examine the tip for smoothness If any barbs are evident, discard the catheter Rotate the catheter 360 degrees to release the catheter from the stylet as they are heat sealed during the manufacturing process https://d35cnulyv0pa6p.cloudfront.net/products/images/2017/23797/ps20687_1_copy.png?owmEUKVvxL_wI1dyXz7m4ZjKfGfViZ_O= Inserting the IV Cannula Hold the skin taut to keep the vein immobilized with your non-dominant hand Grasp the cannula Bevel facing up to reduce the risk of piercing the vein’s back wall Hold the catheter so that you can see blood backflow in the flash chamber or extension tubing http://what-when-how.com/wp-content/uploads/2012/04/tmp1427_thumb2_thumb2.jpg Inserting the IV Catheter Encourage the patient to relax (breathe slowly in and out as you insert the cannula) Talk to the patient through 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 where the vein is visible Don’t always expect to feel a “popping” or “giving-way” sensation (not usual on thin walled, low volume vessels) Look for blood backflow to tell you that you have entered the vein lumen Slow down and take a breath! After the Flashback When you see continuous backflow and you are confident the stylet tip is in the vein Lower your angle (almost to skin level) Advance slightly (approximately 1/8 inch) to ensure the cannula tip is also in the lumen of the vein Advancing the Catheter ONE-HAND TECHNIQUE While non-dominant hand maintains skin traction, advance the catheter using the push-off tab with one hand https://images.squarespace-cdn.com/content/v1/5ca7ccd232c85e0001f13bc0/1624466758988CMNMIOUPIPYGQH4T6T18/Geriatric+Hand+Stick_1.3.1.jpg?format=1000w Advancing the Catheter TWO-HANDED TECHNIQUE Release skin traction held by your non-dominant hand Move dominant hand to the plastic catheter hub and hold the stylet hub with your non-dominant hand Separate the plastic catheter from the stylet by pushing the catheter into the vein slightly Continue to hold the plastic catheter with your dominant hand Reestablish skin traction with your non-dominant hand Advance the plastic catheter with your dominant hand until it is inserted completely https://uploadsssl.webflow.com/6011a994ad210082aa98b668/605e1b957457c800f ed47dc7_advance-the-rest-of-the-cannula-into-the-vein.jpeg Advancing the Catheter “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 the catheter Once the cannula is totally advanced into the vein, apply digital pressure beyond the cannula tip and release the tourniquet https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcTNNPYvRnTWZ1ESm8G2KUKcvvkjeobYt0-FIg&usqp=CAU After Advancing the Catheter Apply digital pressure to the vein beyond the cannula tip Release the tourniquet Stabilize the hub and activate the safety mechanism Dispose of the shielded needle in a sharps container https://uploads-ssl.webflow.com/6011a994ad210082aa98b668/605e1b95a6fbf72bfd232816_applypressure-to-the-vein-at-the-tip-of-the-cannula-and-remove-the-needle.jpeg Connect IV Extension Set Connect the pre-primed extension set with needleless connector with/without continuous IV tubing Flush extension tubing with needleless connector with 2-3mL of NS using a pre-filled 3-5 mL NS syringe Clamp extension set for safety in case of accidental removal of needleless connector The frequency the PIV is flushed is every 12 – 24 hrs, depending on setting (e.g. acute vs community) https://www.medline.com/jump/product/x/Z05-PF29056 Apply IV Site Dressing Ensure that IV line is firmly anchored to arm with tape https://i.ebayimg.com/images/g/k8MAAOSwqu9VSOx6/s-l300.jpg Video: IV Insertion Video: More IV Insertion IV Insertion Troubleshooting Missed Vein Anchor vein, maintain traction and reposition catheter slightly DO NOT excessively probe the area NEVER RESINSERT STYLET BACK INTO CATHETER (can shear off a piece of the plastic) IV Insertion Troubleshooting Hematoma develops with insertion (“blowing” the vein) Reasons: Failure to lower the angle after entering the vein (trauma to the posterior vein wall) Angle too great - Used too much force during insertion Failure to release the tourniquet promptly when the vein is sufficiently cannulated (increased intravascular pressure) Just very fragile veins What to do: Lower angle after entering skin Decrease angle with insertion Use a smoother approach (to avoid piercing posterior wall) Release tourniquet once catheter has been “threaded” Ensure angle is reduced once stylet is in the vein and advance slightly to ensure catheter is in the vein For very fragile veins (elderly), tourniquet should be applied loosely or not at all IV Insertion Troubleshooting Cannot advance the catheter off the stylet Reasons: Stopping too soon after insertion so only the stylet, not the plastic catheter, enters the lumen Blood return disappears when you remove the stylet because the catheter is not in the lumen Heat seal on catheter not released prior to use What to do: Pull catheter back slightly - Rotate catheter 360 degrees on needle and re-seat before insertion Document the IV Insertion What should you document? IV catheter type and size IV insertion site IV flush or IV fluid infusing & rate Number of IV insertion attempts Discontinuing an IV Ensure physician orders, or valid reason for discontinuing Infiltration (interstitial) Redness Leaking Gather equipment 2x2 gauze Tape Discontinuing an IV Handwash and apply clean gloves Carefully remove adhesive strips and dressing Apply 2x2 gauze to IV insertion site Gently pull IV catheter from vein Apply pressure with gauze for 1-2 minutes or until bleeding has stopped Assess integrity of the IV catheter that was removed Apply sterile gauze with tape to IV exit wound Dispose of IV catheter and dressing in garbage Video: Removing an IV Catheter Document “IV to Rt hand removed, catheter intact” https://cloudfront.jove.com/files/media/science-education/science-education-thumbs/10278.jpg Sources Fraser Health Authority: Peripheral Intravenous Initiation Self-Learning Module, https://www.fraserhealth.ca/-/media/Project/FraserHealth/FraserHealth/HealthProfessionals/Professionals-Resources/Acute-Care-Orientation/IV-Initiation-SelfLearning-Module-v8-June2018.pdf?la=en&hash=320E955A6C95F3DB852E19EDA581864941EF06A1 My American Nurse: Ultrasound Guided IV Insertion, https://www.myamericannurse.com/ultrasound-guided-i-v-catheter-insertion/