Infusion Nurses Society
Specializes in IV related stuff
Indications for starting an IV
- Fluid and electrolyte maintenance and balance: replace what has been lost or is natively difficient.
- Medication/blood administration
- Nutritional support for NPO (nothing by mouth) status, ie banana bag or tpn. Large, yellow IV. Will be a nutritional suppliment.
- Administer diagnostic reagents
- Fluid volume defecit
- Fluid volume excess
Know the layers of arteries and veins.
Vein selection assessment
- Use most distal selection first
- If site is compromised, can select another site more proximal and still have efficatious infusion.
Site of infusion at hand
- Requires a smaller gauge – usually 22 or 24
- More difficult in the elderly or someone with poor peripheral circulation
- Not ideal because of smaller gauge, more painful, hands are used for everything, greater chance of removal.
- Cephalic vein (medial bicept)
- --Excellent choice due to size and position of the vessel
- --May use larger bore catheters
- --For quick infusion of fluids or blood administration
(median cubital or basilic)
- Use only in an emergency
- Uncomfortable for the patient
- Easily occluded due to the position
Why not to use lower extremity veins
- Thromboses and varicosities
- Blood becomes stagnant
- Obtain an MD order for lower extremity cannulation
Sites to avoid
- Legs, feet and ankles
- Below a previous IV infiltration: fluid has infiltrated subq level.
- Below a phlebitic area
- Sclerosed or thrombosed veins
- Areas of skin inflammation, disease, bruising or breakdown
- Arm affected by a radical mastectomy, edema, blood clot or infection
- Arm with an AV shunt or fistula: vein and artery connected = fistula.
- Areas of Flexion
- Below a PICC or midline
Things to Consider in Assessment for IV:
- Is the vein straight
- Distal to proximal
- Firm, round in appearance or feel when palpated
- Avoid crossing joints
- You only get 3 sticks – maximum!!!! Three shall be the number of the sticking, and the number of the sticking shall be three. Four shalt thou not stick, neither stick thou two, excepting that thou proceedeth on to three. FIVE IS RIGHT OUT!
Things to consider in assessing IV practicality.
- Multiple or adjuvant therapy
- Patient’s current medical history and status
- Patient home environment
- Patient/caregiver abilities to participate
- Patient/caregiver preferences
- Skill of clinician inserting device
- Institution preference or experience
- Need for future therapies
- Cost of therapy
What is an Angiocath?
- Over-the-needle catheter
- Peripheral IV catheter
- Medication administration
- Blood transfusion
- Deliver small amounts of medication
- Draw blood samples
- Short term IV
Things to consider when chosing gauge size.
- Smaller gauge number = larger gaube diameter
- Blood administration necessitates a 16 -18 gauge: good for emergencies this size is good for high volume, more viscous solutions (like blood). Goal is for 16-18 whenever possible.
Pt education considerations
- Educate the patient as to the reason for the IV
- Make sure you have an order
- Don’t forget the rights of medication administration
Preparing IV fluids
- Two main groups IVF:
- Crystalloid: can cross semipermiable membrain. Most common
- Colloid: larger molecules, usually protiens (albumin, blood, steroids. Do not cross membrane
What to an check IV bag for before infusion...
- Right fluid
- Clarity (cloudy probably means its contaminated. Double check to see if the fluid is supposed to be coudy, but probably you'll want to throw it away and get another bag).
Types of infusions
- Continuous infusion: no defined stopping and starting point.
- Intermittant: will have defined durations. Can be secondary or piggyback.
- Bolus: Large amount of fluid all at once.
- Push: Must know duration of push as indicated by the drug reference book (micromedex)
Dont need to know these, just get used to looking at them.
- Begin infusion of NS at kvo rate
- Infuse bolus of 500cc LR over 1 hour; resume maintenance 100 cc NS/hr
- D5.45 @ 150cc/hr for 8 hours and then 75cc/hr for 24 hours
- 10meq KCl in 100cc NS over 1 hour
- D5.45 with 20meq KCl per liter at KVO
Priming the line
- Hold the fluid bag higher than drip chamber
- Squeeze drip chamber to fill 1/3 full
- Open the clamp and flush(purge) all air from tubing
- Maintain sterility of tip
- Reclamp tubing.
Stuff you need to have ready before starting insertion
- Recheck chart/patient for possible allergic rxn.
- Pad for the bed – patient may bleed
- Alcohol prep or prep used by facility
- IV catheter/angiocath
- IV tubing
- Gloves – always!
- Bag of IV fluid or flush
- Occlusive dressing
- A deep breath, a quick prayer, or have previously rubbed the Buddha's belly for luck.
Prepping for the stick
- Introduce yourself to the patient
- Explain the procedure
- Inspection: Apply the tourniquet approximately 6-12 inches above the site chosen
- Remember to breathe!!!!
- Palpate the site with your fingers
- – find the vein
- --Below a bifurcation
- --Stay away from pulsating arteries
- Put on gloves
- Clean the chosen site with alcohol (clean to dirty) or chloroprep (scrub) movement along the vein – friction and let the area dry. Sticking with wet alcohol will hurt like the dickens!
- Hold catheter in dominant hand
- Pull skin taught with non-dominant hand below the entry site
- With bevel up, enter the skin at about 30 degree angle in the direction of the vein
- Use a quick, short, jabbing motion – smooth
- Once you’re in – then make it parallel
- You need to get that “flash” so that you know you are in.
Success! Now what?
- Once you get the “flash,” advance the catheter
- RELEASE tourniquet
- Flush the line with 3-5 ml of normal saline to make sure that the line is patent
- Add the extension tubing
- Connect to IV drip Rx'd
- Secure the site: a secure cath can be left in for 5 days.
- Date and time of insertion
- Gauge and type of catheter
- Number of attempts (par is 3, no bogies allowed)
- Blood return in catheter; whether the IV flushes.
- Method of securing or stabilizing
- Type and rate of the IV fluid
- Patient's tolerance (pain, annoyance, inconvenience)
- Patient education
If at first you don't succeed and need to try again...
- Remember that you only get 2 or 3 sticks at most
- Take off the tourniquet
- Cover the site with gauze
- Go proximal, young man.
- Improper tourniquet placement
- Failure to release the tourniquet
- A tentative “stop and start” approach
- Inadequate vein stabilization
- Failure to recognize that the cannula has gone “through” the vein
- Stopping too soon after insertion
- Inserting the cannula too deep
- Failure to penetrate the vein wall
DO NOT RECAP THE NEEDLE! IT NEED TO GO TO SHARPS ASAP!
CHANGING THE SITE
- Most facilities the site needs to be changed every 72 hours – or when no longer patent
- Tubing every 72-96 hours – check the policy
- Obviously if the pt develops phlebitis, extravization, or some other unfortunate complication with the vein.
Flow Rate computations
- Administration set drop factor
- *Microdrip = 60 gtts/ml
- *Macrodrip = 10, 15, or 20 gtts/ml
- Volume of infusion (in mls) X drop factor = infusion rate (in mins)
- Time of infusion (in mins)
Maintenance of IV cath sites
- Monitor catheter site
- Check for signs or symptoms of infiltration or infection
- Change catheter site and tubing Q 72 hours or per hospital policy
- Change IV fluid bags Q 24 hours or per hospital policy
- Always flush catheters before and after medication administration. Flush is always done with normal saline.
- Do not force – if meet resistance, stop
- Flush per protocol – normally at least once a shift if line is not connected to continuous fluid infusion
- Swelling, blanching around IV sie
- Cool skin
- Slow flow rate
- What do you do?
- 1) Stop IV fluids
- 2) Pull IV out
- 3) compress
- 4) Elevate site above heart
- 5) check pulses to make sure you haven't done damage to purfusion.
- 6) restart proximal to bad site.
- Redness or tenderness at tip of catheter
- Puffy tissue over vein
- Elevated temperature
- If due to nfxn: culture to determine which/if antibiotics are needed.
- Remedy: restart IV in opposite arm.
- Possibly febrile
- Same remedies as phlebitis
- Burning / coolness
Medication has gone out of vein into tissues-->necrosis.
- Catheter Shearing
- Air Embolism
- Pulmonary Edema: looks for the SnSs
- Pay attention and assess, assess, assess!
What are your legal responsibilities?
- Nurse Practice Act: Know and be accountable