Basic
Intravenous
Therapy
90-95% of patients in the
hospital receive some type
of intravenous therapy.
This presentation will enhance
your knowledge of how to care
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Vein Anatomy and
Physiology
Veins are unlike arteries in
that they are 1)superficial, 2)
display dark red blood at skin
surface and 3) have no
pulsation
Vein Anatomy
- Tunica Adventitia
- Tunica Media
- Tunica Intima
- Valves
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Tunica Adventitia
the outer layer of the vessel
Connective
tissue
Contains the
arteries and
veins supplying
blood to vessel
wall
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Tunica Media
the middle layer of the vessel
Contains nerve
endings and
muscle fibers
The
vasoconstrictive
response occurs at
this layer
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Tunica Intima
the inner layer of the vessel
One layer of endothelials
No nerve endings
Surface for platelet
aggregation
w/trauma and recognition of
foreign object at this level
PHLEBITIS begins here
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Valves
present in MOST veins
Prevent backflow and
pooling
More in lower
extremities and longer
vessels
Vein dilates at valve
attachment
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Veins of the Upper Extremities
Digital Vessels
-Along lateral aspects fingers,
infiltrate easily, painful, difficult to
immobilize and should be your LAST
RESORT
Metacarpal Vessels
Digital
-Located between joints and
metacarpal bones (act
as natural splint)
-Formed by union of digital veins
-Geriatric patients often lack
enough connective / adipose tissue
and skin turgor to use this area
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Veins of the Upper Extremities
Cephalic (Interns Vein)
-Starts at radial aspect of wrist
-Access anywhere along entire
length (BEWARE of radial
artery/nerve)
Medial Cephalic (On ramp
to Cephalic Vein)
-Joins the Cephalic below the elbow
bend
-Accepts larger gauge catheters,
but may be a difficult angle to hit
and maintain
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Veins of the Upper Extremities
Basilic
- Originates from the ulner side of
the metacarpal veins and runs
along the medial aspect of the
arm. It is often overlooked
becauses of its location on the
back of the arm, but flexing the
elbow/bending the arm brings this
vein into view
Medial Basilic
- Empties into the Basilic vein
running parallel to tendons, so it
is not always well defined.
Accepts larger gauge catheters.
- BEWARE of Brachial Artery/Nerve
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Purposes of IV Therapy
To provide parenteral nutrition
To provide avenue for dialysis/apheresis
To transfuse blood products
To provide avenue for hemodynamic monitoring
To provide avenue for diagnostic testing
To administer fluids and medications with the ability to
rapidly/accurately change blood concentration levels by either
continuous, intermittent or IV push method.
Types of Peripheral Venous Access Devices
Butterfly(winged) or Scalp vein needles (SVN) not recommended for non
compliant patient as it can easily penetrate the vein wall causing extravasation.
We use these frequently for phlebotomy
Safety Over the needle catheters (ONC)
- PROTECTIV -ACUVANCE
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Starting a Peripheral IV
Finding a vein can be challenging
- Go by feel, not by sight. Good veins are bouncy to the touch, but
are not always visible.
- Use warm compresses and allow the arm to hang dependently to
fill veins.
- A BP cuff inflated to 10mmHg below the known systolic pressure
creates the perfect tourniquet. Arterial flow continues with
maximum venous constriction.
- If the patient is NOT allergic to latex, using a latex tourniquet may
provide better venous congestion
- Avoid areas of joint flexion
- Start distally and use the shortest length/smallest gauge access
device that will properly administer the prescribed therapy
(BE AWARE: Blood flow in the lower forearm and hand is
95ml/min)
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IV Start Pain Management
One of the most frequent contributors to patient
dissatisfaction is painful phlebotomy and IV starts
Use 25-27g insulin syringe to create a wheal similar to a TB skin
test on top of or just to side of vein with 0.1 -0.2 ml normal saline
or 1% xylocaine without epinephrine
Topical anesthesia cream (ie EMLA) may be applied to children>37
weeks gestation 1 hr. prior to stick. It might be a good idea to
anesthetize a couple of sites
Have the patient close their fist (NO PUMPING) prior to stick
Make sure the skin surface cleansing agent (alcohol/chlorhexidine)
is dry prior to stick. Drawing this into the vein may stimulate the
vasoconstrictive action of the tunica media layer
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Flushing Peripheral IVs
Use prefilled saline and heparin flush syringes located in
PYXIS
Heparin flush concentrations available:
-100u/ml (5ml in a 10ml syringe)
-10u/ml (2ml in a 3ml syringe)
Flushing intervals and amounts
- Peds: q 6hrs.
<22ga 1ml 0.9%NS followed by 1ml
heparinized (10units/ml) saline
- Adults: q 8hrs
w/1ml. 0.9%NS [3ml heparinized saline for
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Dressing/Bag Changes
Changing dressings
Physician orders are 1 2 3 4 5 6 7
Gauze q TSM q 7 d
required if a peripheral 2d
catheter is left in the
same site for more Changing bags and tubing
than 3 days. 1 2
normally every 3d
3 24
hrs
If respiked or meds added
outside pharmacy
Changing Sites
It is best to have the
1 2 3 4 5 6 7
pharmacy add normally every 3d Every 7 d c MD order
medications to the
infusion bags under
laminare flow to reduce
contamination
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Central Venous Catheters
Percutaneous Tunneled PICCs Implanted Ports Dialysis
Insertion MD @ bedside MD in OR under MD/trained RN MD in OR under fluoroscopy MD in OR under
w/x-ray fluoroscopy @bedside w/x-ray fluoroscopy
confirmation confirmation
Location Visible externally. Visible ext. usually Visible externally Completely internal. Titanium or Visible externally.
Enters midway bet. around antecubital plastc port is implanted in a Arm or leg
subclavian, ext. clavicle and fossa, upper arm or surgically created pocket and placement
juglar,or int. nipple. Tunneled neck catheter is threaded into
juglar vein near under skin & subclavian or int. juglar vein.
clavicular area threaded through Access is through skin into self
subclavian or IJ sealing port using special non
coring needle
Material/Co Polyurethane Silicone Silicone / polyurethane Silicone catheter. Port is titanium Various materials
st $200-$400 $3500-$5000 $350-$500 or plastic w/self sealing diaphragm
$3500-$5000
Lumen 2-3 2-3 1-2 1-2 2-3
Sutured Yes/entire life Yes, until internal No Yes Yes
Dacron cuff
healed
Duration Short term 4-10 Long term Long term Long term Mid term
days
Flushes 5-10ml NaCl 5-10ml NaCl after 5-10ml NaCl after use 10ml NaCl followed by 4.5ml Done ONLY by IV
after use and use and daily and daily heparinized saline (adults- team or dialysis
daily 100units/ml; peds-10units/ml) after nurses
ea. use or monthly if not accessed
Brands/ Arrow Howe, Hickman, Broviac PICC, PIC, EDPC, Arrow Bard, Accces Port-A-Cath Bard, Tesio,
Names Triple Lumen, Howe, Gesco, PASV Vescath, Quinton
Subclavian, IJ
Discontinue MD or speically MD in OR Specially trained RN @ MD in OR MD in OR
Previous trained RN @ bedside Next
bedside
Central Venous Catheter
Sites
PICC (Peripherally Percutaneous(Subclavia
inserted n)
Central Catheter)
Implanted Port
(single or double
lumen)
Percutaneous (IJ-Int.
Tunnelled (Hickman)
Jugular)
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CVC Care/Maintenance
Percutaneous Tunneled
Flush after each access or daily for
catheters>21ga, q 6 hrs <21 ga
-adults: 10ml saline
- peds/neonates: 5ml saline
(preservative free
for infants <1yr) PICC
Transparent dressing change q 7 days &
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CVC Care/Maintenance
Flush after each use and weekly while
accessed; monthly when not acessed
Implanted Port
- 10ml saline (preservative free for pts.
<1yr)
- followed by 4.5ml-5ml heparinized
saline 100units/ml for adults
10units/ml for peds
Transparent dressing/ access needle change q
7days
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Monitor and Site Care
document
site
condition:
Hourly for
peds
Q 2 hr for adult
* Indicates
complication:
Infiltration
Phlebitis
Thrombosis
Cellulitis
Septicemia
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Infiltration/Extravasation
The most common cause is damage to
the wall during insertion or angle of
placement.
STOP INFUSION and
treat as indicated by
Pharmacy, Medication
package insert or drug
reference book.
Notify MD and
document
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Phlebitis/Thrombophlebitis
Chemical
- Infusate chemically
erodes internal layers. Warm
compresses may help while the
infusate is stopped/changed. Anti-
inflammatory and analgesic
medications are often used no
matter what the cause Bacterial
Mechanical
- Caused by irritation to - Caused by introduction
internal lumen of vein during of bacteria into the vein.
insertion of vascular access Remove the device
device and usually appears immediately and treat
shortly after insertion. The device w/antibiotics. The arm will be
may need to be removed and painful, red and warm; edema
warm compresses applied may accompany
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Cellulitis
Inflammation of loose
connective tissue around
insertion site.
- Caused by poor insertion
technique
- Red swollen area spreads from
insertion site outwardly in a diffuse
circular pattern
- Treated w/antibiotics
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Septicemia/Pulmonary Edema/
Embolism
Septicemia
- Severe infection that occurs to a system or entire body
- Most often caused by poor insertion technique or poor site
care
- Discontinue device immediately, culture and treat
Pulmonary edema- caused by rapid infusion
appropriately
Pulmonary embolism - Caused by any free floating substances
that require thrombolytic therapy for several months. Increased risk
w/lower ext.
Air embolism- caused by air injected into IV system. Keep
insertion site below level of heart
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Troubleshooting
Vascular access device will not flush/cant draw
blood
- Evaluate for kink in tubing or catheter tip against vein wall.
Vascular access device (VAD) leaking when flushed
- Verify that hub access cap is connected correctly
Patient complains of pain while VAD being flushed
- Assess for infiltration
VAD broken
- PICCs may be repaired. All other devices must be replaced
Call IV therapy team member for any concerns or
questions.
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Policy notes
KVO rate:
RNs and LPNs can start Adults - 10 ml/hr Only until rate
Pediatrics - 2-3 ml/hr order received
peripheral IVs after initial Neonates - 0.5-1 ml/hr
training and observation Verification required for:
by preceptor Insulin
Heparin
Potassium
Digoxin
LPNs CANNOT infuse Chemotherapy
blood products or high
risk IV medications. LPNs cannot push IV
medications
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IV Medication Administration
Many medications require All Medications Cannot Be
patient monitoring that cannot Administered on All Units
be done on units where the General Care Units: Can give meds
requiring only basic physical
nurse/patient ratios are assessment data
greater than 1:2 Stepdown Units: Can give meds
that require more invasive or
frequent monitoring than is available
on general care units
Intensive Care Units: Can give
A patient can be moved to a meds that require more invasive or
frequent monitoring than is available
unit where the ratio is on the Stepdown units.
appropriate for
invasive/frequent monitoring VANDERBILT URL LINK FOR IV
or another nurse can be MEDICATIONS:
brought to care for the patient [Link]/pharmacy/ivroo
during the med administration m/[Link]
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IV Medication
Administration
Sample page
from the
Pharmacy med
administration
web site
See
APPROVED
FOR section.
You will find if
the medication
can be
administered
on your unit.
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[Link]
Infusion Nurses Society (INS)
Professional Organization that sets the standards of
care for clinicians practicing in the field of infusion
therapy.
Standards set by INS are reflected in our policies and
procedures related to infusion therapy for health care
providers.
In a court of law, the standards set by the INS are used
to assess the infusion clinicians performance.
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