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          Unit Five

Peripheral Intravenous Therapy
     Nursing Interventions R/T Anxiety &
         Discomfort with IV Infusion
   Individuals typically experience anxiety
    related to intravenous therapy
    ◦ Illness
    ◦ Unfamiliar environment
    ◦ Need for complex services and procedures
   Extreme anxiety can have physiological
    ◦ Spasm or constriction of veins due to the
      sympathetic response
      Blood shunted from peripheral circulation to vital
      Inhibits venous access
    ◦ Syncope related to the vasovagal response             2
         Anxiety & Discomfort (cont’d)
   Psychological preparation increases coping
    ◦ Relaxes the client
    ◦ Facilitates initiation of IV therapy for the nurse
   Client teaching
    ◦ Time
      Building rapport and relaying caring
      Allowing time for questions
    ◦ Explanations
      Overcoming communication barriers
    ◦ Honesty
      How long the IV may be in place
      Why IV access is needed
      Acknowledge associated pain and discomfort          3
         Anxiety & Discomfort (cont’d)
   Pain reduction
    ◦ Advise patient of measures that may decrease
    ◦ Assure patient that you will be as efficient as
    ◦ Employ appropriate physical, pharmacological,
      and psychological measures to minimize
   Professionalism
    ◦ Express confidence and expertise
    ◦ Reinforce positive aspects of the procedure

                  Latex Allergy Precautions
   Patients at risk for latex-related reactions –
    ◦   Women constitute 75% of all reported cases
    ◦   Asthma
    ◦   Allergy history
    ◦   Occupational exposure to latex
    ◦   Fruit and vegetable allergies
           Avocados
           Bananas
           Chestnuts
           Kiwis and other tropical fruits
    ◦ Intermittent catheterization
    ◦ Chronic genitourinary or abdominal conditions
      requiring multiple surgeries
      Latex Allergy Precautions (cont’d)
 Report incidents of adverse reactions to
  latex or other materials used in medical
  devices to the FDA
 FDA recommendations to health
  professionals --
    ◦ Assess latex sensitivity while obtaining history
      for all patients
    ◦ Use devices made with alternative materials
    ◦ Be alert for an allergic reaction whenever latex-
      containing devices are used, especially when in
      contact with mucus membranes
    ◦ Alert clients with suspected allergic reaction to
      latex to possible latex sensitivity, and advise
      them to consider immunologic evaluation          6
      Latex Allergy Precautions (cont’d)
   FDA recommendations to health
    professionals (cont’d) --
    ◦ Advise clients to tell health professionals and
      emergency personnel about latex sensitivity
    ◦ Consider advising clients with a latex allergy to
      wear a medical identification bracelet
   Other allergies
    ◦ Must assess for allergies to foods, animals and
      insect matter, and environmental substances
    ◦ Iodine
      Often used in skin antisepsis
      Client may only recognize this as a shellfish allergy
    ◦ Adhesive
      Used in dressing tape                                   7
              Caring for an IV at Home
   Many clients receive IV therapy at home
    ◦ Limitations by 3rd party payers
    ◦ Personal preference
   Several types of IV therapy can be
    maintained outside of the hospital
    ◦   Antibiotics
    ◦   Chemotherapy
    ◦   Hydration and hyperalimentation
    ◦   Pain control
    ◦   HIV-related therapies
    ◦   Growth hormone and immunoglobulins
    ◦   Dobutamine (for severe CHF)
    ◦   Tocolytic therapy (to ↓ premature contractions)8
      Caring for an IV at Home (cont’d)
 Arm/hand movement may be limited, so
  client may need to relearn ADLs
 Ambulation with infusion equipment
 Instruct client against tampering with IV
  tubing, clamp, or dressing
 Advise client to keep the IV dry to minimize
  risk of infection
    ◦ Staphylococcus epidermis
    ◦ Staphylococcus aureus
 Teach client how to assess IV site for signs
  and symptoms of infection
 Provide list of symptoms or conditions for
  which client would need to call the doctor     9
               IV Preparation
*Physical preparation of the client for
  initiation of intravenous therapy includes
  safety, comfort, and positioning
 Safety
 ◦ Verify IV order
 ◦ Verify correct patient identification
 ◦ Validate that the ordered infusion is
   appropriate for the patient
 ◦ Confirm that the patient is not allergic to
   anything that is to be administered
 ◦ Review documentation of significant laboratory
   and diagnostic reports
 ◦ Maintain strict asepsis when preparing all
   products to be used for venipuncture/infusion 10
               IV Preparation (cont’d)
   Safety (cont’d) --
    ◦ Ensure that all supplies and equipment for
      venipuncture are sterile
    ◦ Check expiration dates
    ◦ Provide a safe environment for the patient
      during infusion therapy
        Bedrails
        Restraints
        Movement
        Ambulation
    ◦ Assess/select the vessel that is appropriate for
      the type of infusion ordered
    ◦ Instruct the client about what to report in terms
      of activity, discomfort, or signs/symptoms
      associated with a reaction                      11
              IV Preparation (cont’d)
   Comfort
    ◦ Restrictions in mobility and sustaining ADLs
      Prevent dislodgement of the cannula
      Avoid disconnection of any part of the infusion setup
      If any portion of the closed IV system were disrupted,
       contamination and infection could occur
    ◦ Use nondominant hand for IV access
    ◦ Avoid using veins in areas of flexion unless
    ◦ Allow completion of ADLs prior to IV insertion
    ◦ Provide loose-fitting clothing/hospital gown
      Allows for less restricted movement
      Does not impede fluid flow
      Easily removed for changing
    ◦ Provide for privacy                                   12
              IV Preparation (cont’d)
   Correct positioning
    ◦ Fowler’s position
    ◦ Maintain intended venipuncture site below
      heart level to promote venous filling
    ◦ Follow institutional protocol with regards to
      armboards, restraints, or stabilization devices
      Can cause nerve and muscle damage
      Must be removed at frequent intervals to assess
       circulatory status
    ◦ Protect insertion site from moisture and
    ◦ Hair may need to be removed prior to initiating
      IV therapy if it impedes vessel visualization, site
      disinfection, cannula insertion, or dressing
      adherence                                         13
               IV Preparation (cont’d)
   Correct positioning (cont’d) –
    ◦ Hair removal (cont’d) –
      Hair is to be removed by gently clipping it close to the
      Do not scratch the skin
      Do not shave the hair because of the potential for
       microabrasion and the introduction of contaminants
      Do not apply depilatories due to the possibility for
       skin irritation or allergic reactions
      An electric shaver may be used
        Check your institutional policy
        If the shaver does not belong to the patient, the shaving heads
         would need to be changed or disinfected between patient use

              IV Preparation (cont’d)
*IV preparation involves using the correct
  site preparation/maintenance materials
 Obtain the appropriate dressing materials
    ◦ Sterile gauze
    ◦ Sterile transparent, semipermeable dressing
   Cleanse the skin
    ◦ Use an antimicrobial barrier
      2% chlorhexidine or per institutional policy
      Available in the form of swab sticks, prep pads, or
       plastic, cotton-tipped squeezable vials
      These are one-time use only!
    ◦ Allow barrier to air dry

                   Vein Selection
*Intravascular access refers to entrance into
  arteries, veins, or capillaries
 The selected access site should provide the
  most appropriate access to the vessel
    ◦ Needs to be appropriate for intended therapy
    ◦ Must accommodate administration of the
      prescribed infusion
    ◦ Endeavor to minimize associated risks or
   Factors to consider with vein/site selection
    ◦ Patient’s age, health status, and diagnosis
    ◦ Condition of the site to be accessed
    ◦ Purpose, duration, and possible side effects of
      therapy                                         16
             Vein Selection (cont’d)
*Peripheral intravenous routes should be
  achieved in an upper extremity
 Venous cannulation should begin at the
  distal-most area of the upper extremity
  and proceed proximally
 Examine the upper extremities
    ◦ Predict the ease or difficulty of venous access
    ◦ Predetermine measures to facilitate successful
   Inspect the patient’s skin
    ◦ Assess for damaged areas
    ◦ Apply a tourniquet
    ◦ Use a flashlight for enhanced visualization   17
          Vein Selection (cont’d)
*Peripheral intravenous routes (cont’d) –
 Palpate the patient’s veins
 ◦ Determine condition of the vessel
 ◦ Locate deeper, larger veins that are stronger
   and more suitable for initiation of IV therapy
*The nurse needs to know which veins to
  avoid when preparing to perform
  venipuncture for purposes of peripheral
  intravenous therapy
 Do not use veins in an area with a recent
 Do not use veins in an area that has
  sustained 3rd degree burns                        18
             Vein Selection (cont’d)
*Veins to avoid (cont’d) –
 Avoid veins in the antecubital fossa
 Do not use veins that are irritated or
  sclerosed from previous use
    ◦ For a vein to be viable, it must be able to be
    ◦ To check for blanching, apply downward
      pressure over, or on each side of, a vein
    ◦ If the vein disappears with the pressure, then
      reappears when the pressure is removed, the
      vein is viable
    ◦ A sclerotic vein will not blanch
   Avoid veins in an extremity that is partially
    amputated                                          19
             Vein Selection (cont’d)
*Veins to avoid (cont’d) –
 Do not use veins in the lower extremities in
  ambulatory adults and children
    ◦ Use lower extremity sites only in an emergency
    ◦ Must have a written order
    ◦ Ensure agency has policy in place that upholds
      this procedure
   Never access an arteriovenous fistula,
    graft, or shunt that has been surgically
    placed for hemodialysis
    ◦ Do not use the affected arm itself for IV therapy
   Do not use veins in an extremity that is
    impaired as a result of a CVA                    20
          Vein Selection (cont’d)
*Veins to avoid (cont’d) –
 Do not use veins on the side of the body
  where a radical mastectomy with lymph
  node dissection/stripping has been
 Bypass veins in an extremity that has
  undergone reconstructive or orthopedic
 Avoid edematous extremities

             Cannula Selection
*Types of peripheral venous devices
 Steel needles
 Winged needles
 Catheters
*Steel needles are very rarely used anymore
*Winged needles, referred to as butterflies,
  have one or two “wings”
 Connect with a needle on one side and a
  segment of infusion tubing that ends in a
  hub and protective cap on the other
 ◦ Tubing varies in length from 3½ to 12 inches
 ◦ Tubing is primed with NS prior to insertion to
   prevent entry of air into the circulation        27
          Cannula Selection (cont’d)
*Butterflies (cont’d) –
 Wings are held upright during insertion to
  facilitate movement into the vein
 Once the needle is in the vein, the wings
  are taped to the skin to secure the device
 If secured properly, winged needles stay in
  the vein well
 Good means of venous access under
  certain circumstances
 ◦   Short-term infusions (24 hours or less)
 ◦   Seldom used for adult infusion therapy
 ◦   Can be used for one-time IV push medications
 ◦   May be used to draw blood                    28
           Cannula Selection (cont’d)
*Peripheral venous access catheters are the
  most commonly used IV device
 Used to enter superficial or deep veins
    ◦ Extremity
    ◦ Neck
    ◦ Head
   Two-part flexible cannula in tandem with a
    rigid needle or stylet
    ◦ Stylet is used to puncture and insert the
      catheter into the vein
    ◦ Connects with a clear chamber
      Allows for visualization of blood return
      Indicates successful venipuncture
      Facilitates removal of the needle          29
           Cannula Selection (cont’d)
*Catheters (cont’d) --
 Color-coded plastic cannula hub
    ◦ Indicates length and gauge of catheter
 Length ranges from ¼ inches to 12 inches
 Catheter is radiopaque
    ◦ Easily detected by radiology in case of embolus
*Types of catheters include the over-the-
  needle peripheral catheter (ONC) and the
  through-the-needle peripheral catheter
 The ONC is a flexible cannula that encases
  a steel needle or stylet device
    ◦ Most commonly used peripheral IV device       30
           Cannula Selection (cont’d)
*Types of catheters (cont’d) --
 ONC (cont’d) –
    ◦ Once the vein is accessed, the catheter is
      threaded into the vessel and the stylet is
   The TNC is the opposite of the ONC, as the
    flexible cannula is encircled by the steel
    ◦ Infrequently used
    ◦ The needle is withdrawn once venous access is
    ◦ Secured in a protective shield outside the body
      on the skin
            Cannula Selection (cont’d)
*Factors to consider when selecting a
  cannula –
 Use the smallest cannula that will deliver
  the prescribed infusate
    ◦ Adequate blood flow and hemodilution
    ◦ Causes minimal discomfort
   Delivery rate
    ◦   24 gauge cannula → approx 15-25mL/min
    ◦   22 gauge cannula → approx 26-36mL/min
    ◦   20 gauge cannula → approx 50-65mL/min
    ◦   18 gauge cannula → approx 85-105mL/min

          Achieving Venous Distention
   Apply a tourniquet
    ◦ A tourniquet is an encircling device consisting
      of a segment of rubber tubing that temporarily
      arrests blood flow to or from a distal vessel
    ◦ Apply tightly enough that venous blood flow is
      suppressed, but not so tight that it obstructs
      arterial flow
      Should be able to palpate pulse distal to the
    ◦ Do not leave a tourniquet in place longer than
      four to six minutes
      Tourniquet paralysis from injury to a nerve can occur
       if the tourniquet is applied too tightly or left for too
       long a period
   Apply warm compresses for 10-15 minutes                   35
    Achieving Venous Distention (cont’d)
 Place the extremity intended for
  venipuncture below the level of the
  patient’s heart for several minutes
 Have the patient open and close his or her
  fist, or squeeze and release the lowered
 Use an alcohol pad to gently rub the skin
  over the vein intended for venipuncture
    ◦ Alcohol and friction creates heat
    ◦ Enhances venous distention
   Pat the area of skin over the intended vein
    using light to moderate force to engorge
    the vein with blood                       36
          IV Equipment and Supplies
*Infusate containers and IV administration
 Infusate containers –
    ◦ Flexible plastic
    ◦ Semirigid plastic
    ◦ Glass
IV administration set = tubing that delivers
 fluid/medication from the infusate
 container to the patient
*All administration sets have a spike insert
 that fits into the administration set port of
 the infusate container, as well as a drip
 chamber, clamps, and an adapter             37
              IV Administration Sets
 On an administration set, the drip chamber
  is where the solution flows after leaving
  the infusate container and before entering
  the tubing
 A screw and roller clamp allows for flow
 A slide clamp functions as an on-off clasp
 A cannula hub can be attached to the
  sterile adapter at the end of the tubing
    ◦ The adapter can be straight, fitting directly into
      the cannula hub with a push ~OR~
    ◦ The adapter can be screwed on to the cannula
      hub, providing a firm attachment (Luer-Lok)
        IV Administration Sets (cont’d)
 The administration set determines the rate
  at which fluid can be delivered to the
  patient (i.e. the drop factor)
 Specialized tubings are used in specific
  settings and circumstances
    ◦ Extra large (macrobore) tubings
      Used in emergency surgical and trauma situations
      Rapid infusion of large volumes of blood or fluid
    ◦ Extra small (microbore) tubings
      Used for the delivery of small amounts of precisely
       controlled fluid or medication
      Special volume restriction (neonatal care, epidural

        IV Administration Sets (cont’d)
   Types of administration sets:
    ◦ Vented systems
      Used for vacuum infusate containers that don’t have
       their own built-in mechanisms for air displacement
      Glass and some semirigid bottles
    ◦ Nonvented systems
      Used with flexible plastic bags and other nonvacuum
    ◦ Primary administration sets
    ◦ Secondary administration sets
*Primary administration sets are also
  known as basic, or standard, sets
 Carries fluid directly to the patient through
  one tube                                               40
      IV Administration Sets (cont’d)
*Primary administration sets (cont’d) --
 Spiked into one (single line) or two (Y-type)
  main infusate container(s)
 May terminate in straight, flashtube, or
  Luer-Lok male adapters
 Available in macrodrip or microdrip in
  varying lengths
 Available with or without check valves,
  which prevent retrograde blood flow
 May contain one or several injection ports
 Can accept attachments
 ◦ Secondary administration tubings, extension
   tubings, flow control devices, filters, adapters   41
        IV Administration Sets (cont’d)
*Single line primary administration sets
  have one spike that is inserted into one
  infusate container; the tubing terminates
  with an adapter that connects to the
  cannula hub at the IV access site
*Y-type primary administration sets have
  two equal-length tubings that can each
  access an infusate container
 Access can be simultaneous or alternately
    ◦ Each tubing has its own roller clamp
    ◦ Each tubing may or may not have its own drip
   Frequently used in emergency, surgical,
    and critical care situations                     42
        IV Administration Sets (cont’d)
*Y-type administration sets (cont’d) –
 The solution reaches the patient via one
  common tubing
    ◦ Necessitates compatibility between the
 Blood administration tubings are Y-type
  sets, but differ from standard Y-type
  primary administration sets
 Should be used only with nonvacuum,
  flexible infusion containers where venting
  is unnecessary
    ◦ If vented containers are used, air can be drawn
      into the circulatory system, resulting in an air
      embolism                                         43
     IV Administration Sets (cont’d)
*Secondary administration sets are referred
  to as piggyback sets
 Used to deliver continuous or intermittent
  doses of fluid or medication
 Widely used because they negate the need
  for additional venipunctures and
  interruption of the primary infusion
 Usually connected with a needle or
  needleless adapter into an injection port
  immediately distal to the back-check valve
  of the primary tubing
 Some primary administration sets have a
  closed-system connection to a second line44
     IV Administration Sets (cont’d)
*Whenever an infusion line is breached, the
  possibility for introduction of contaminants
 IV line should not be broken to add
  accessory equipment unless absolutely
 Refer to your institution’s policy for adding
  equipment such as filters, extension sets,
  adapters, and connectors to infusion lines
*Needleless systems and needlestick safety
  systems are state-of-the-art in IV therapy
 Used to connect IV devices, administer
  fluids and medications, and sample blood    45
     IV Administration Sets (cont’d)
*Needleless systems (cont’d) –
 Eliminates up to 80% of needles
 ◦ Other than the initial stick to insert the cannula
   into the patient’s vein, there is no need for
   needles during IV therapy
*Blood exposure protocol –
 ◦ Wash needlestick punctures with soap & water
 ◦ Flush splashes to the nose, mouth, or skin with
 ◦ Irrigate splashes to the eyes with clean water,
   NS, or sterile ophthalmic irrigants
 ◦ Report the incident to the department
   responsible for managing exposures
 ◦ Start post-exposure treatment ASAP              46
   Mechanical Gravity Control Devices
*Mechanical gravity control devices are flow-
  regulating mechanisms that attach to the
  primary infusion administration set
 Manually set to deliver specified volumes
  of fluid per hour
 Available as dials or cylindrical controls
 Includes approximate flow markings that
  must be verified (i.e. counting gtt/min)
 Accuracy varies
 ◦ Discrepancies can be up to ± 25%
 ◦ Dependent upon patient’s condition, activity
   level, positioning, and venous pressure
     Mechanical Gravity Control (cont’d)
   Should generally be used for only short
    periods, such as transporting the patient
    ◦ IV tubing kinking/obstruction can restrict fluid
    ◦ Must be checked frequently for infusion

 Electronic Infusion Control Devices (EID)

*EIDs are state-of-the-art infusion-regulating
  mechanisms that deliver fluids and medications
 Powered by electricity and/or battery
 Safe and accurate (± 5%)
 Programmable for several infusates at different
  rates and volumes at the same time
 Sensors detect air in the line and pressure
 Signals infusion termination
 Alerts the nurse to problems via readouts, alarms,
  and flashing lights
                    EIDs (cont’d)
   Most newer EID models have built-in safety
    flow mechanisms
    ◦ Prevents unintended free flow of infusate into
      the patient if the administration set were to be
      removed from the machine
   NOTE: No EID is a substitute for regular
    patient observation and evaluation

          Initiation of Infusion Therapy
*Gather the necessary equipment/supplies
  to be optimally prepared for venipuncture
 Check the order
    ◦ Identify that the order is for the right patient
   Read the label on the infusate container to
    verify correct medication and dose
    ◦ Container should be compared directly with the
      physician’s order to be sure it is correct
    ◦ Verify pharmacy admixtures
 Verify infusate compatibility
 Check the expiration date of the infusate
 Evaluate the infusate container to ensure
  seals are intact                                       51
  Initiation of Infusion Therapy (cont’d)
*Gather equipment/supplies (cont’d) –
 Check the infusate fluid for clarity and
  presence of particulate matter
*Equipment preparation and setup should
  be completed away from the patient’s
  room in an environment that minimizes
  the chance for contamination
 Prior to starting an infusion, the correct
  infusate should be set up with a primary
  administration set (Skill 9-2, page 205)
 If secondary infusions are ordered or
  anticipated, choose a primary set with a
  check valve and injection ports              52
  Initiation of Infusion Therapy (cont’d)
*Equipment preparation(cont’d) –
 The interior of the tubing, both ends of the
  tubing, and the infusate must be kept
 NOTE: The nurse must obtain permission
  from the adult patient before performing
  venipuncture or it may constitute assault
  and battery

Step 1   Introduce yourself to the patient
Step 2   Ask the patient to state his/her
         full name, verifying identity with
         chart and ID bracelet
Step 3   Provide privacy
Step 4   Explain proposed procedure in
         terms the patient can understand
Step 5   Elevate the bed to prevent strain
Step 6   Place the patient in a semi-
         Fowler’s or Fowler’s position
Step 7   Protect clothing/bedding with a
         pad or towel
Step 8   Wash your hands                      54
          Venipuncture (cont’d)
Step 9    Set up all necessary supplies near
          the bed in the order they will be
Step 10   Select an appropriate vein based
          on the type of therapy and
          anticipated duration
Step 11   Apply a tourniquet 2-3 inches
          below the antecubital fossa for
          venous access in the arm or hand
Step 12   Prepare the site
Step 13   Apply gloves while the final
          antiseptic is drying
Step 14   Cannulate the vein               55
              Catheter Immobilization
   Once in place, the IV device must be
    ◦ Must allow for regular site assessment
    ◦ Need to prevent cannula movement or
    ◦ Maintain asepsis
    ◦ Prevent catheter-related infection
   Transparent, semipermeable dressings are
    most common
    ◦   Secures the vascular access device
    ◦   Allows for continuous visual inspection of site
    ◦   Allows bathing without saturating the dressing
    ◦   Requires less frequent changes than others
             Special Considerations
   Patients with altered skin and vessels
    ◦ Burns, fragile veins
    ◦ Do not use a tourniquet
    ◦ Use alternative measures per institutional
      policy for skin antisepsis to prevent further
      irritation and discomfort
   Patients with peripheral edema
    ◦ May need to use landmarks to identify a vein
    ◦ Client is at risk for unidentified infiltration due
      to edema
    ◦ Vein may collapse due to pressure from excess
   Obese patients
    ◦ May have deeply imbedded vessels                  57
        Special Considerations (cont’d)
   Obese Patients (cont’d) --
    ◦ May need to use landmarks to identify a vein
    ◦ May need to employ a longer cannula to reach
      an appropriate vein
   Patients receiving anticoagulant therapy
    ◦ Avoid using a tourniquet, or, if necessary, apply
      as loosely as possible
    ◦ Avoid excess pressure when applying the skin
    ◦ Use the smallest cannula that will
      accommodate the vein and deliver the ordered
    ◦ Remove dressings gently and use an adhesive
      solvent                                          58
           Converting a Peripheral IV
   Converting a peripheral IV to an
    intermittent access device is necessary
    when discontinuing peripheral infusions
    while retaining venous patency
    ◦ IV access remains available in case it is needed
    ◦ Administration of intermittent medications
   Conversion is completed by attaching an
    intermittent infusion plug to the hub of the
    cannula (Refer to page 234, Skill 9-9)
    ◦ Also called a male adapter plug
    ◦ Formerly referred to as a heparin lock
      Heparin is no longer recommended for intermittent
       flushing because bacterial growth on the catheter
       may be intensified in its presence                  59
      Converting a Peripheral IV (cont’d)
 Intermittent line maintenance is achieved
  by assessing the IV site, checking for
  cannula patency, and flushing with 2cc NS
  every 8-12 hours
 Check for patency of the intermittent line
  by attaching the syringe to the intermittent
  plug and pulling back the plunger to elicit
  blood return
    ◦ If there is no blood return, gently inject the
      saline while palpating the infusion site
      If the cannula is out of the vein, the saline will
       infiltrate the surrounding tissue, causing it to rise and
       be cool to the touch
      If the cannula is placed correctly, the saline will enter
       the cannula and vein, maintaining patency               60
        Converting a Peripheral IV (cont’d)
   When any medication is administered into
    an intermittent infusion device, the
    protocol to be followed is the S-A-S method
    ◦ Slowly instill 2mL NS to clear the lock (S)
    ◦ Administer the prescribed medication (A)
    ◦ Flush with NS to clear the lock (S)
   Prior to implementing the S-A-S method –
    ◦   Wash your hands
    ◦   Assess the IV access site
    ◦   Don gloves
    ◦   Disinfect the cannula port
    ◦   Verify cannula and venous patency
         If resistance is met, do not exert pressure on the
          syringe plunger to restore patency                   61
      Converting a Peripheral IV (cont’d)
   Multiple medication orders –
    ◦ Instill NS between the administration of each
    ◦ Always flush with NS after all medications are
      injected in order to clear the cannula and
      maintain patency
   Maintain positive pressure during and after
    saline flushes
    ◦ Achieved by withdrawing the blunt cannula or
      needle as the last 0.5mL of NS is flushed
    ◦ Prevents the reflux of blood

        Adding a Fluid/Medication
*During infusion therapy, fluids or
  medications can be added in the following
  ways –
 Added to the primary infusate container
 Via secondary administration set
 Through an injection port in the primary
  administration tubing
 By direct injection into a vein that is not
  concurrently receiving infusates (bolus)
 NOTE: For all but the last method, the
  nurse must check for chemical, physical,
  and therapeutic compatibility between the
  medications and delivery systems          63
     Adding a Fluid/Medication (cont’d)
   Adding fluid/medication to the primary
    infusate container –
    ◦ This is usually done as an admixture by the
      pharmacy under asepsis
    ◦ If the nurse would need to add a medication,
      you would need to check for compatibility,
      additive concentration, and stability of the new
    ◦ Refer to page 229 (Skill 9-6)
    ◦ Never add a medication to an existing infusion
      container while it is hanging and infusing
      Drug would be delivered to the base of the container
      Bolus dose would be infused to the patient
      May result in serious complications, or even death
     Adding a Fluid/Medication (cont’d)
   Adding fluid/medication via secondary
    administration set (piggyback) –
    ◦ This method involves administering a
      medication or fluid that is initiated after the
      primary infusion is already in progress
    ◦ This is the most common means to administer
      intravenous medications concurrently with the
      primary infusion
    ◦ The piggyback line is coupled to the primary
      infusion line at the first injection port below the
      check valve
    ◦ The secondary infusion is able to function
      concurrently with the primary infusion only
      when suspended higher than the primary line
     Adding a Fluid/Medication (cont’d)
   Adding fluid/medication via piggyback
    (cont’d) –
    ◦ The primary line must have a back-check valve
    ◦ By opening the clamp on the secondary line,
      the primary infusion temporarily stops flowing
    ◦ When the piggyback infusion is complete and
      the infusate in its tubing falls below the level of
      the primary line drip chamber, the back-check
      valve opens and the primary infusion resumes
    ◦ Refer to page 231 (Skill 9-7)

     Adding a Fluid/Medication (cont’d)
   Adding fluid/medication through an
    injection port in the primary administration
    tubing (Refer to page 233, Skill 9-8) –
    ◦ This is termed an IV push medication
    ◦ Intravenous medications that would normally
      be delivered directly into the vein by bolus
      injection can be delivered through an injection
      port in the primary administration set if the
      patient already has a running IV
    ◦ The nurse must check for compatibility
      between the product already and the drug to be
      administered by IV push
      Failure to do so could cause a precipitate to form
      Precipitate could obstruct the infusion line, damage
       the vein, or embolize                                67
             Nonfunctioning IV Lines
*Checklist for determining the cause of a
  nonfunctioning peripheral IV line –
 Check IV site for infiltration, patency
 Check the infusate container
    ◦ Fluid level
    ◦ Height
 Check the tubing for kinking
 Check the air vent and filter
 Ensure the clamp is open
 Check the positioning of the patient
 Check the temperature of the solution
 Ensure the tubing is correct for the infusate
*IV documentation includes labeling
 The main purpose for labeling is to denote
  IV start, stop, and discontinuation times
 Labels must be affixed to infusate
  containers, administration set tubing, and
  dressing sites
 Placement of labels
 ◦ IV site
    Place next to the dressing
    Include the date and time of cannulation
    Indicate the type of device used
      Length
      Gauge
    Identification (nurse’s initials)          69
               Documentation (cont’d)
   Placement of labels (cont’d) --
    ◦ Allergy labels
      On and in the patient’s chart
      In the patient’s room and on the patient’s bed
      All communication with other personnel and
       departments regarding allergies and drug reactions
      Attach appropriate identification bracelet to the
    ◦ Administration set tubing
      Include date and time of initiation/change
    ◦ Infusate container(s)
        Start date and time
        Flow level strips
        Added medications
        Never write directly on an IV bag (use label instead)   70
            Documentation (cont’d)
*Accurate charting for intravenous infusions
  should include these components –
 Date and time of insertion
 Which vein was cannulated
    ◦ Be specific (know your peripheral venous
    ◦ Document why you chose a particular vein if
    ◦ Document the condition of the vein in terms of
      its softness or hardness and resiliency
   Device used
    ◦ Brand name and style
    ◦ Gauge and length
                Documentation (cont’d)
What to include in your charting (cont’d) –
 Infusate administered
    ◦ Name of medication/fluid
    ◦ Rate of infusion
   Method of infusion
    ◦ Gravity
    ◦ EID
      Controller or pump mode
      Name brand and model number
 Type of dressing applied
 Remedial information
    ◦ Number/location of attempted cannulations
    ◦ Condition of the failed site(s)             72
         Documentation (cont’d)
What to include in your charting (cont’d) –
 Patient’s response to the procedure
 ◦ Reaction/comments

*Be sure to document in these areas --
 Nurse’s notes
 Infusion and equipment flow sheets
 Nursing care plan
 Intake and output records
 Laboratory, radiology, and other ancillary
  department requisitions                      73
Local and Systemic
   of IV Therapy
   Local Complications of IV Therapy
Local complications = adverse reactions that
 occur at or close to the IV insertion site
 ◦ Constitutes the majority of complications in IV
 ◦ Usually less serious than systemic problems
*Types of localized infusion-related
 complications include infiltration,
 thrombosis, phlebitis, thrombophlebitis,
 and allergic reaction to the IV catheter
*Infiltration refers to the inadvertent
 administration of nonvesicant solution into
 the surrounding tissue                              75
            Local Complications (cont’d)
   Causes of infiltration
    ◦   Dislodgement of the cannula from the vein
    ◦   Puncture of the vein wall during venipuncture
    ◦   Friction of the catheter against the vein wall
    ◦   Use of a high pressure infusion device
    ◦   Irritating infusate that weakens the veins
   Signs and symptoms of infiltration
    ◦   Skin is taut and/or cool to the touch
    ◦   Dependent edema
    ◦   Absence of blood backflow
    ◦   Pinkish blood return
    ◦   Slowing of the infusion rate                     76
              Local Complications (cont’d)
   Infiltration complications
    ◦ Ulceration may appear after days/weeks
    ◦ Compartment syndrome
           Fluid builds up inside an inflexible compartment
           Pressure on nerves, muscles, and vessels
           Functional muscle changes occur within 4-12 hours
           Ischemic nerve damage occurs within 24 hours
   Preventing infiltration
    ◦   Assess IV site (blood return is not an indicator)
    ◦   Pain may or may not be present
    ◦   Extremity comparison
    ◦   Infusion should stop running if pressure is
        applied 3 inches above the catheter site          77
         Local Complications (cont’d)
   Treatment of infiltration
    ◦ Infuse antidote through the IV if applicable,
      then remove the IV
    ◦ Apply warm compresses for antineoplastic
      agents, and cool compresses for most other
    ◦ Notify the physician
    ◦ Elevate the extremity if this promotes comfort
      for the patient
*Extravasation is the inadvertent
  administration of vesicant medication or
  solution into the surrounding tissue
 Requires an incident report                          78
         Local Complications (cont’d)
   Treatment of extravasation
    ◦ Dependent on a variety of factors
      Pharmaceutical manufacturer’s labeled uses and
      Properties and severity of extravasated agent
    ◦ Treatment determined before IV removed
    ◦ Do no apply excessive pressure to the site to
      avoid establishment of perfusion
    ◦ Ongoing observation and assessment of site
      (i.e. motion, sensation, circulation)
    ◦ Do not use extremity for subsequent IV
    ◦ Notify the physician                              79
         Local Complications (cont’d)
   Infiltration documentation
    ◦ Use the INS Infiltration Scale
      Extravasation always graded at 4
    ◦ Document written and verbal communication
    ◦ Chart nursing and medical interventions
    ◦ Document patient’s response to incident and
   Drugs associated with extravasation
    necrosis include –
       Calcium chloride           Calcium gluconate
       Dopamine                   Vancomycin
       Vincristine                Streptozocin
Infusion Nurses Society Infiltration Scale

Grade                              Criteria

 0      No symptoms

 1      Skin blanched and cool to touch
        1 inch edema
        Pain may or may not be present
 2      Skin blanched and cool to touch
        1 - 6 inch edema
        Pain may or may not be present
 3      Skin blanched, translucent, and cool to touch
        Gross edema (>6 inches)
        Mild-to-moderate pain; possible numbness
 4      Skin blanched, translucent, tight, discolored, and bruised
        Gross, deep, pitting edema

 *May have circulatory impairment and severe pain with
     infiltration of blood product, irritant, or vesicant            81
         Local Complications (cont’d)
*Thrombosis occurs when blood flow
 through the vein is obstructed by a local
    ◦ If thrombosis is IV-related, it has resulted from
      injury to the endothelial cells of the venous wall
    ◦ Injury leads to platelet aggregation at the site
      of injury, which forms the thrombus
    ◦ Major complication of central venous catheters
   Signs and symptoms of thrombosis
    ◦ Earache or jaw pain
    ◦ Edema, redness at insertion site
    ◦ Tachycardia, tachypnea
            Local Complications (cont’d)
   S/S of thrombosis (cont’d) –
    ◦   Malaise
    ◦   Unilateral arm or neck pain
    ◦   Absence of pulse distal to the obstruction
    ◦   Digital coldness, cyanosis, and/or necrosis
   Treatment of thrombosis
    ◦ Never flush with force to remove an occlusion
    ◦ Discontinue IV and restart with a new catheter
      at a different site
    ◦ Notify the physician for assessment of
      circulatory status
           Local Complications (cont’d)
*Phlebitis = inflammation of the vein
    ◦ Endothelial cells in the venous wall become
      irritated and rough, allowing platelets to adhere
    ◦ Capillary permeability increases, and protein
      leaks out into the interstitial space
    ◦ Area more susceptible to mechanical or
      chemical irritation
   Signs and symptoms of phlebitis
    ◦   Localized redness and swelling
    ◦   Warm and tender to the touch
    ◦   Palpable “cord” along the vein
    ◦   Sluggish infusion rate
    ◦   Increased temperature                        84
         Local Complications (cont’d)
   Prevention of phlebitis
    ◦ Use of larger veins for hypertonic solution
    ◦ Use of central line for long-term IV therapy
    ◦ Use of the smallest IV cannula appropriate for
      the ordered infusate
    ◦ Rotation of IV sites per agency protocol
    ◦ Change IV bag per agency protocol
    ◦ Appropriate stabilization of the catheter
    ◦ Correct venipuncture technique
    ◦ Good handwashing
*Phlebitis is graded according to INS scale
Infusion Nurses Society Phlebitis Scale

Grade                              Criteria

 0      No symptoms

 1      Erythema (redness of the skin due to capillary congestion)
        Pain may or may not be present
 2      Pain at access site
        Erythema and/or edema
 3      Pain at access site
        Erythema and/or edema
        Streak formation
        Palpable venous cord
 4      Pain at access site
        Erythema and/or edema
        Streak formation
        Palpable venous cord >1 inch in length
        Purulent drainage
       Local Complications (cont’d)
*INS practice criteria for phlebitis requires
 established guidelines for treatment in
 Policy and Procedures Manual
 ◦ All vascular access sites should be routinely
   assessed for signs or symptoms of phlebitis
 ◦ Discontinue IV at first sign of phlebitis and
   remove the intravenous device
 ◦ Grade ≥2 report to physician and file incident
 ◦ Observe peripheral catheter site for 48 hours
   after device has been removed
 ◦ Document incident, intervention, treatment,
   corrective action, and patient education         87
         Local Complications (cont’d)
   Types of phlebitis
    ◦ Mechanical
    ◦ Chemical
    ◦ Bacterial
   Causes of mechanical phlebitis
    ◦ Insertion of a cannula that is too small for the
    ◦ Improper taping of the cannula hub so that the
      catheter tip rubs the vein wall
    ◦ Manipulation of the catheter during infusion
   Causes of chemical phlebitis
    ◦ Excessively rapid infusion
            Local Complications (cont’d)
   Causes of chemical phlebitis (cont’d) –
    ◦ Infusion of irritating substances
         Acidic solutions (Dextrose, KCL, antibiotics)
         pH level falls the longer the solution is stored
    ◦ Improperly mixed medications
    ◦ Presence of particulate matter in the solution
   Causes of bacterial phlebitis
    ◦   Poor aseptic technique
    ◦   Incorrect cannula insertion procedure
    ◦   Inadequate stabilization of cannula hub
    ◦   Lengthy catheter dwell time
         Local Complications (cont’d)
*Thrombophlebitis occurs when thrombosis
 is accompanied by inflammation
    ◦ May become obstructive if IV not discontinued
   Complications of thrombophlebitis
    ◦ Embolism
    ◦ Septicemia
    ◦ Acute bacterial endocarditis
   Causes of thrombophlebitis
    ◦ Use of leg veins for venipuncture
    ◦ Use of hypertonic or highly acidic infusates
   Signs and symptoms of thrombophlebitis
    ◦ Local tenderness and warmth                     90
            Local Complications (cont’d)
   S/S of thrombophlebitis (cont’d) –
    ◦   Appearance of a red line above the IV site
    ◦   Hardening of the vessel
    ◦   Sluggish flow rate
    ◦   Edema in the limbs
    ◦   Diminished arterial pulses
    ◦   Mottling or cyanosis of the extremities
   Treatment of thrombophlebitis
    ◦ Notify the physician, remove IV catheter and
      restart in opposite extremity using new
    ◦ Apply warm, moist compresses to the area for
      20 minutes for comfort                       91
           Local Complications (cont’d)
   Documentation of thrombophlebitis
    ◦   Chart all observable symptoms
    ◦   Document patient’s complaints/reactions
    ◦   Chart nurse’s actions
    ◦   Document information regarding new
*Allergic reaction to the IV catheter
 Symptoms include red streak over the vein
 Treatment of a localized allergic reaction
    ◦ Discontinue the IV
    ◦ Notify the physician
    ◦ Use different material for new IV in another site
    Systemic Complications of IV Therapy
 Septicemia
 Embolism
    ◦ Pulmonary
    ◦ Air
    ◦ Catheter
 Pulmonary Edema
 Speed Shock
 Allergic Reaction
*Septicemia = a febrile disease caused by
  microorganisms in the circulatory system
    ◦ Major complication that occurs from cannula or
      infusate contamination                       94
         Systemic Complications (cont’d)
   Signs and symptoms of septicemia
    ◦   Fever, flushing, profuse diaphoresis
    ◦   Altered mental status
    ◦   Nausea/vomiting, abdominal pain
    ◦   Tachycardia, hypotension
   Treatment of septicemia
    ◦   Monitor patient
    ◦   Culture IV catheter per order/agency protocol
    ◦   Administer antimicrobial therapy as ordered
    ◦   Administer oxygen if needed
    ◦   Administer IV fluids
    ◦   Observe for bleeding (all body orifices)        95
         Systemic Complications (cont’d)
   Prevention of septicemia
    ◦   Good handwashing
    ◦   Careful inspection of IV solutions
    ◦   Appropriate infusion site dressing
    ◦   Rotate IV sites
*Pulmonary embolism is associated with IV-
 related thrombus
    ◦ Dislodged from the wall of the vein
    ◦ Carried by the venous circulation through the
      right side of the heart to the pulmonary artery
   Signs and symptoms include shortness of
    breath, cyanosis, chest pain, tachypnea             96
         Systemic Complications (cont’d)
   Prevention of a pulmonary embolism
    ◦   Manage local complications immediately
    ◦   Do not apply pressure to regain IV patency
    ◦   Inspect medication/fluid for particulate matter
    ◦   Avoid venipuncture in lower extremities
   Treatment of a pulmonary embolism
    ◦ Position patient on the left side, trendelenburg
    ◦ Administer oxygen
    ◦ Transfer to ICU
*Air embolism is most frequent in central
 lines, and results from small amounts of
 air in the circulatory system                        97
       Systemic Complications (cont’d)
   Causes of an air embolism
    ◦ Incorrect IV insertion
    ◦ Excessive catheter manipulation
    ◦ Loose connections in the IV tubing
   Complications of an air embolism
    ◦ Accumulation of small bubbles forms larger
      bubbles that can block pulmonary capillaries
    ◦ Blockage may be fatal due to sudden vascular
   Symptoms of an air embolism
    ◦ Cyanosis, hypotension, ↑ venous pressure
    ◦ Rapid loss of consciousness                    98
       Systemic Complications (cont’d)
   Treatment of air embolism
    ◦ Immediately place the client on the left side
      with head down
      Air becomes trapped in the right atrium
      Prevents air from entering the pulmonary artery
    ◦ Administer oxygen
    ◦ Notify the physician ASAP
    ◦ May need to administer CPR
*Catheter embolism can occur during
 catheter insertion if appropriate placement
 technique is not observed
    ◦ Catheter tip can shear off and become a free-
      floating embolus
    ◦ Can occur in both OTC and TNC                      99
         Systemic Complications (cont’d)
   Treatment of catheter embolism
    ◦ Apply a tourniquet high on the extremity to
      impede venous flow
    ◦ Cardiac catheterization may be needed to
      remove the tip
    ◦ Notify the physician and radiologist
    ◦ Start an IV in the opposite arm to prepare for
      angiography for visualization
   Symptoms of catheter embolism
    ◦   Hypotension
    ◦   Tachycardia, chest pain
    ◦   Cyanosis
    ◦   Loss of consciousness                          100
       Systemic Complications (cont’d)
   Prevention of a catheter embolism
    ◦ Never place an IV over a joint
      Flexing may cause the catheter to break
      If unavoidable, use splint to prevent bending
   Documentation of catheter embolism
    ◦ Vital signs, symptoms, level of consciousness
    ◦ Appearance of catheter upon removal
*Pulmonary edema is caused by rapid
  administration of large volumes of fluid
  that leads to circulatory overload
 Prevention of pulmonary edema includes
  monitoring the patient frequently and
  using an EID for IV therapy                          101
        Systemic Complications (cont’d)
   Symptoms of pulmonary edema
    ◦ Increased blood pressure
    ◦ Distended neck veins
    ◦ Shortness of breath, rales
    ◦ Orthopnea (sensation of breathlessness in the
      recumbent position)
    ◦ Copious frothy sputum
*Speed shock = systemic reaction to rapid
  or excessive infusion that overloads the
  system; may result in cardiac arrest
 Symptoms of speed shock
    ◦ Flushing of the head and neck
    ◦ Severe headache, chest pain                 102
       Systemic Complications (cont’d)
   Causes of speed shock
    ◦ Leaving the flow clamp open on the IV tubing
    ◦ IV pump programming error
    ◦ Incorrect drip rate calculation
   Prevention of speed shock
    ◦ Always dilute IV push medications to the
      appropriate concentration
    ◦ Always administer IV push medications over
      the amount of time recommended per agency
*Allergic reaction at the systemic level is
 considered a hypersensitivity reaction that
 can be mild or severe                               103
         Systemic Complications (cont’d)
   Symptoms of an allergic reaction
    ◦   Localized pain, edema, and/or redness
    ◦   Wheezing, bronchospasm
    ◦   Headache
    ◦   Palpitations, agitation, confusion
    ◦   Intestinal cramping, nausea/vomiting
    ◦   Development may vary from rapid to delayed
   Treatment of an allergic reaction
    ◦   Stop the infusion
    ◦   Keep the vein open with NS
    ◦   Administer oxygen if needed
    ◦   Ensure emergency equipment is available      104
       Systemic Complications (cont’d)
   Complications of an allergic reaction
    ◦ Severe hypersensitivity to IV therapy
      Profound physiological response to an antigen
      Abnormal immune response to an allergen
    ◦ May include anaphylaxis
*Anaphylaxis = severe allergic reaction
    ◦ Immune response to allergen
    ◦ Large quantities of histamine released
    ◦ Massive peripheral dilation occurs
      Decreased blood flow to vital organs
    ◦ May lead to shock and death within minutes if
       Medication/Fluid Interactions
*Incompatibility = unintended effects from
 mixing fluids and/or medications
 ◦ Action may be neutralized, intensified, or
 ◦ Precipitation may occur
    Crystallization of particles
    Occlusion of the IV line
    Vessel injury
*Significant drug-drug interactions involve
 medications that are incompatible with
 other products
 ◦ Sodium bicarbonate
 ◦ Phenytoin (Dilantin)                         106
 Medication/Fluid Interactions (cont’d)
*Drug-drug interactions (cont’d) –
 ◦ Aminoglycosides (gentamicin, neomycin)
 ◦ Digitalis glycoside
 ◦ Barbiturates
    Secobarbital (Seconal)
    Pentobarbital (Nembutal)
    Phenobarbital (Luminal)
 ◦ Chlordiazepoxide (Librium)
 ◦ Diazepam (Valium)
 ◦ Theophylline


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