Fundamentals - All IV

A peripherally inserted central catheter (PICC) is a long catheter inserted through a vein of the

antecubital fossa (inner aspect of the bend of the arm) or the middle of the upper arm.

Determine the facility policy for dressing/gauze changes on

any VAD; document any changes you do

The Bloodborne Pathogen Standards from the Occupational Safety and Health Administration (OSHA) requires the use of catheters with an engineered safety mechanism to

prevent needle sticks.

Explain to patient ways to bring veins to the surface for easy cannulation such as:

--Staying hydrated --Heat packs --Gloves

To prevent extravasation

--Closely monitor IV site and dressing. --Always use infusion pump

A macro drip chamber is

--Depends on Manufacturer

A specific administration set is

required for specific types of infusions, such as blood transfusion.

In acute care/surgical service settings, infusion devices called

"infusers" may be found; require no power source, powered by positive pressure from a collapsing balloon or roller returning to its coiled position. (elastomeric balloons, spring-coiled syringes and containers, and a multi-chambered fluid container placed in a mechanical roller); deliver a preset infusion rate, and fluid volume is determined by the size of the fluid container; however, most hold only 50 to 100 mL.

An acute hemolytic transfusion reaction caused by an incompatible blood transfusion is a

"sentinel event"

The International Society of Blood Transfusion (ISBT) universal bar-coding system ensures the right blood for the right patient; includes four components on the blood label both in bar code and in eye-readable format, which are

(1) a unique facility identifier (2) the lot number relating to the donor (3) the product code (4) the ABO group (A, AB, O) and Rh type of the donor.

Treatment for extravasation involves

(consult your agency's policy), discontinuing the IV line, applying a cool compress to the area, antidote (if applicable)should be prescribed and administered immediately since some medications, if infused into the tissue rather than the vein, can cause severe tissue damage

Treatment for infiltration involves

(consult your agency's policy), discontinuing the IV line, elevating the extremity, apply a warm compress at the site to help absorb the fluid

The 20 gauge catheter is

--1-1/4 -inch length --Adequate for all therapies --Most anesthesiologists prefer not to use a smaller size than this for surgery cases --65 mL/min (3900 mL/hr)

The 22 gauge catheter is

--Adequate for most therapies, blood can infuse without damage --38 mL/min (2280 mL/hr)

3 'CALM' interventions include

--Alleviate dry mouth: move tongue around gums and gently put pressure on tongue tip to activate saliva; hold and/or sip water --Squeeze ball: breathe in w/squeeze, out while it reshapes --Trace square: breathe in along one side, out along another --Tense and relax: shorten to 3 areas, such as feet (dig in heels, then let feet flop), knees (draw together with in-breath, relax with out-breath), hands

To prevent infiltration

--Carefully select site and catheter. --Secure the catheter carefully.

Veins to avoid include

--veins on the palmar side of the wrist because the median nerve is located close to veins in this area, making the venipuncture more painful and difficult to stabilize. --The cephalic vein which begins above the thumb and extends up the entire length of the arm, the sensory branch of the median nerve can intersect with the cephalic vein up to three times from its origin to about 4 to 5 inches up the lateral aspect of the arm. Damage to the nerve can result in permanent loss of function or complex regional pain syndrome

An example of a hypotonic solution is

0.45% sodium chloride (0.45% NS), commonly called half normal saline

Examples of isotonic solutions are

0.9% sodium chloride, commonly called normal saline (NS), and lactated Ringer's (LR).

To choose the correct IV gauge, consider

16 gauge for trauma clients, rapid fluid volume 18 gauge for surgical clients, rapid blood administration 22 to 24 gauge all other clients (adults)

IV gauge colors

16g - Gray 18g - Green 20g - Pink 22g - Blue 24g - Yellow 26g - purple (rarely used 16g, 24g, 26g) think: I'd turn green if somebody came at me with an 18g, twenty TWO rhymes with blue, and pink is just the other one

In adults, the PICC length ranges from

18 to 29 inches (45-72 cm) with the tip residing in the superior vena cava (SVC). When anatomic or pathophysiologic changes prohibit placing the catheter into the SVC, it is placed in a mid-clavicular location, but is associated with much higher rates of thrombosis

The best IV gauge for receiving large quantities of fluids at a rapid rate or blood or blood products is

18-gauge

Blood flow in the SVC is approximately

2 L/min compared with about 200 mL/min in the axillary vein.

'CALM' service is intended to enable and support patients to achieve

a calm state; using strategies to prevent and/or interrupt panic states triggered by medical procedures

For most adults, the catheter gauge for infusing fluids and medication is

20- to 22-gauge

The best gauge catheter for children, older adults, and anyone who has small or fragile veins is

22- to 24-gauge

Isotonic solutions have an approximate electrolyte content of

300 mEq/L

Change IV blood tubing within

4 hours. These fluids are thick and can clog the tubing.

Change tubing used to infuse propofol (Diprivan) every

6 to 12 hours. These fluids are thick and can clog the tubing.

A micro drip chamber is

60 gtt/ml micro drops; 'tiny, little' drops

To prevent skin tears, remove the adhesive on a StatLock with

70% alcohol.

Short peripheral catheters are allowed to dwell (stay in) for

72 to 96 hours but then require removal and insertion at another venous site.

Secondary tubing can be left for reuse for

72 to 96 hours, depending on your facility's policy. Of course, discard it immediately if it becomes contaminated.

A peripherally inserted venous catheter is usually replaced every

72 to 96 hours; when insertion time is unknown, if there is question of sterility, or per agency's policy.

Intermittent IVs/saline locks/Hep-loks should be flushed every

8-12 hours when not in use

IV access sites are sterilized with

alcohol, chlorhexidine, and povidone-iodine; must be allowed to air-dry completely to reduce the microbial count effectively

Draw blood samples in the extremity opposite from

all catheters.

Drugs which are venous irritants (cause phlebitis) and have a pH less than 5 include

amiodarone (Cordarone), vancomycin (Vancocin), and ciprofloxacin (Cipro I.V.)

When cannulating a patient with edema in the extremities

Apply digital pressure over the selected vein to displace edema using an alcohol pad. Cannulation must be quick.

Special considerations for older adult clients, clients who are taking anticoagulants, or clients who have fragile veins include

Avoid tourniquets. Use a blood pressure cuff instead. Do not slap the extremity to visualize veins. Instruct the client to hold his hand below the level of his heart. Avoid using the back of the client's hand

peripherally inserted central catheter (PICC)

a catheter used for long-term intravenous access and inserted in the basilic or cephalic vein just above or below the antecubital space with the tip of the catheter resting in the superior vena cava

Infusions are carried out using either a

a gravity infusion or an electronic infusion pump.

over-the-needle catheter

a plastic catheter that fits over a needle and is used to pierce the wall of a vein to initiate intravenous access

A closed system IV is

a plastic container that doesn't allow air in but depends on atmospheric pressure and gravity to collapse the bag

Prevent infiltration by

Catheter stabilization—use smallest catheter appropriate; avoid area of flexion, or use arm board. Avoid placing restraints at the IV site. Make successive venipunctures proximal to the previous site. Monitor site frequently; educate patient about activities and signs and symptoms. Central venous catheters—obtain a brisk blood return before using the catheter for infusion. Frequently assess proper positioning of port access needle. Stabilize it well, and protect from clothing.

Fluid leakage around a Luer-Lok indicates

a potential for infection and should be changed out

Extension tubing is

a short piece of IV tubing that has a male adapter at one end and a female adapter at the other (used to extend length of primary tubing; may have features such as stopcock, ports etc...)

A cannula is

a tube inserted into a vessel or channel

IV documentation should include

Date and time of insertion Name of the nurse (you) who inserted the VAD Insertion site and appearance/vein that was used for insertion Catheter size and type of VAD used Type of dressing/securement device/barrier precautions IV fluid and rate (if applicable) Number of insertion attempts and locations of attempts before successful insertion and conditions of site-attempted cannulations type of infusion pump used and setting patient and family education provided related to IV therapy Client response Per facility policy, document re-checks throughout therapy

An infusion catheter is also known as

a vascular access device (VAD)

Infiltration is suspected when

IV rate slows Increasing edema around site Patient report of skin tightness; blanching or coolness of skin; burning, tenderness, or general discomfort at the insertion site; fluid leaking from puncture site; absence of a blood return (though this may not be reliable with a short peripheral catheter)

If a patient on IV therapy is discovered with distended neck veins, increased blood pressure, tachycardia, shortness of breath, crackles in the lungs and edema

Slow the IV rate to keep the vein open in accordance with facility policy. Raise the head of the bed. Assess vital signs. Adjust rate as prescribed. Anticipate administration of diuretics.

Factors which may influence the development of panic states

Lower body weight First time donors 'Fear of fainting' Concerns about health hazards Disgust Fear of fear Pain Medications - hypnotics anxiolytics Smoking, alcohol and other substance misuse Younger age group 13-19% adolescents

The screw-type connection port for IV lines and needleless injections is called a

Luer-Lok

Techniques used to increase the intrathoracic pressure and prevent air embolism during IV set change include:

Placing the patient in a flat position to ensure that the catheter exit site is at or below the level of the heart Asking the patient to perform a Valsalva maneuver by holding his or her breath and bearing down Timing the IV set change to the expiratory cycle when the patient is spontaneously breathing Timing the IV set change to the inspiratory cycle when the patient is receiving positive-pressure mechanical ventilation.

If at an IV site, warmth; edema; induration; red streaking; with accompanying patient symptoms of fever, chills, and malaise are discovered (cellulitis)

Promptly discontinue the infusion and remove catheter. Elevate the extremity. Apply warm compresses three to four times/day. Culture the site and cannula if drainage is present. Administer: Antibiotics, Analgesics, Antipyretics

Cool trick for figuring out the drip factor

Remember: "TV will make you deaf over time" TV x DF (drip factor, such as 10 gtt/ml) ________________________________ = flow rate time (in minutes)

To prevent IV thrombus or phlebitis

Rotate sites at least every 72 hrs. Assess IV site using a phlebitis scale so phlebitis can be identified early Avoid the lower extremities. Use hand hygiene. Use surgical aseptic technique.

the most commonly used vascular access devices (VADs) for peripheral IV therapy are

Short infusion/peripheral catheters; usually placed in the veins of the arm or dorsal surface of the hand; range from 14-26 gauge and 3/4 to 1-1/4 inches Another catheter used for peripheral IV therapy is a midline catheter

Treat infiltration by

Stop infusion and remove short peripheral catheter immediately after identification of problem. Apply sterile dressing if weeping from tissue occurs. Elevate extremity. Warm or cold compresses may be used according to the solution infiltrated and organizational policy. Warm compresses increase circulation to the area and speed healing. Cool compresses may be used to relieve discomfort and reduce swelling. Insert a new catheter in the opposite extremity. For all central venous catheters, obtain a study to determine the cause of the problem. For implanted port, remove and insert a new port access needle. Rate the infiltration using the INS Infiltration Scale and document

If at an IV site infusing a non-irritating fluid, pallor, swelling, coolness or dampness or slowed infusion is discovered (infiltration)

Stop the infusion and remove the catheter. Elevate the extremity. Encourage active range of motion. Apply cold or warm compress based on the type of solution that infiltrated the tissue. Check with provider to determine whether IV therapy is still needed. If so, restart the infusion proximal to the site or in another extremity.

Drawing blood from catheters for blood culture should not be done within

an hour of completion of antimicrobial infusions

There are two methods for inserting a peripheral IV catheter. The direct method involves

piercing the skin immediately over the vein and approximately ½ inch below the proposed IV site.

The Joint Commission requires that all patients who have central lines placed in the hospital must have education on prevention of catheter-related bloodstream infection (CR-BSI). Before catheter insertion, educate the patient and family about:

The type of catheter to be used Hand hygiene and aseptic technique for care of the catheter The therapy required Alternatives to the catheter and therapy Activity limitations Any signs or symptoms of complications that should be reported to a health care professional

To prevent fluid overload in a patient receiving IV therapy

Use an infusion pump. Monitor I&O

central venous catheter

a blood-vessel access device usually inserted into the subclavian or jugular vein with the distal tip resting in the superior vena cava just above the right atrium; used for long-term intravenous therapy or parenteral nutrition

A heparin lock is

an intravenous catheter inserted into a vein and left in place for the intermittent administration of medication through its port or as an open line for emergency situations and intermittently flushed with a heparin solution to maintain patency

To initiate IV access, apply a tourniquet

above the antecubital fossa or approximately 4 to 6 inches (10 to 15 centimeters) above the anticipated site.

If an IV solution is not available with the prescribed additives (such as vitamins and electrolytes) already included, they should be

added in the pharmacy department under a laminar flow hood.

Certain medications, can cause serious adverse reactions and should be delivered with an electronic infusion pump for accurate dosage control, never given by IV bolus, such as

potassium chloride

After removing the dressing from a midline or central venous catheter, note the

external catheter length. If the length has changed, follow agency policy or notify the health care provider about the length change. A repeat chest x-ray may be needed, and careful assessment of the type of therapy and remaining length of therapy will likely be required.

In emergent situations, VAD catheters can be used also in the

external jugular vein of the neck.

When using a secondary infusion set, to maintain sterility and patency, the primary IV fluid can be

back flushed if compatible

The preferred site for insertion of a PICC line is the

basilic vein; the cephalic vein can be used if necessary

When both ends of an IV set are manipulated or replaced, it must be

be changed every 24 hours.

When greeting a patient who has anxiety

be confident of yourself and skills

Because hypertonic solutions can be extremely irritating to the patient's veins, some must only

be infused through a central line.

For patients receiving infusion therapy for long periods, a significant number of unfiltered particles could

block the blood flow through the pulmonary circulation, microcirculation in the spleen, kidneys, and liver; and contribute to development of phlebitis in peripheral veins.

Before giving a drug through an implanted port, always check for

blood return.

Never administer IV medication through tubing that is infusing

blood, blood products, or parenteral nutritional solutions

Infiltration (where fluids from an IV leak from intended vein to surrounding tissues) is sometimes called

extravasation; but extravasation implies the IV catheter has dislodged

Because isotonic fluids don't move water into or out of the body's cells, patients are at risk for

fluid overload, especially older adults

When a patient has a saline aka heparin lock, it must be

flushed usually with normal saline, 5 to 10 mL, before and after you administer each medication or at regular intervals; each facility has it's own procedures and policies

When first taking out an IV bag for infusion, check

for leaks by gently squeezing, color, clarity, expiration date

After removing the dressing, when removing the catheter, place a

gauze pad over the injection site without applying pressure and remove catheter parallel to skin without lifting; then apply firm pressure, if on anticoagulants, pressure must be applied for 5-10 minutes; assess site, tape new gauze pad over site

If you have trouble finding a vein, try

gently stroking the extremity below the intended IV site from distal to proximal or place a warm blanket or towel on the extremity for a couple of minutes.

Specialty IV pumps require dedicated

cassette tubing

When initiating IV therapy in pediatric patients, use the smallest

catheter available, usually a 22- to 26-gauge.

Avoid taking blood pressures in an extremity with any type of

catheter in place.

The veins most often used for initiating intravenous (IV) therapy are the

cephalic, basilic, and median cubital veins (dorsal venous arch, metacarpal vein) in the hand and forearm

the initials CRNI stand for

certified registered nurse infusion; a certification given after examination by The Infusion Nurses Certification Corporation (INCC)

Before solutions are infused, all central vascular access devices require confirmation of tip location by

chest radiograph; or by the use of newer ultrasound systems, such as the Sherlock PICC tip location system

When preparing a catheter insertion site on a 'hairy' patient

clip DON'T shave the hair

If the patient has excessive body hair, do not shave the area; instead,

clip the hair with scissors. Shaving can cause microabrasions that increase the risk for infection.

When setting the IV flow rate, it is often helpful to move the roller clamp

closer to the drip chamber, as this makes it easier to reach the roller clamp and adjust the flow rate while counting the drops in the drip chamber.

Avoid using veins in an extremity with

compromised circulation, distal to previous IV sites, sclerosed or hardened veins, bruised areas, areas where there are valves or bifurcations

The Joint Commission publishes new and updated National Patient Safety Goals (NPSGs) every year. One major goal is improving the safety of high-alert drugs. An example of these drugs is

concentrated electrolyte solutions (e.g., potassium chloride), which require restricted access, prominent warnings about the concentration, and storage in a secured location.

Avoid rubbing an uncooperative IV site extremity vigorously or flicking the vein as this can cause the vein to

constrict or a hematoma to form

Hypertonic fluids are used to

correct fluid, electrolyte, and acid-base imbalances by moving water out of the body's cells and into the bloodstream. Parenteral nutrition solutions are hypertonic; total parenteral nutrition (TPN) solutions have an osmolarity greater than 1400 mOsm/L.

When initiating an IV, if a patient has fragile skin or excessive hair, place the tourniquet

over the sleeve of the gown to protect the skin and avoid pulling the hair; or use a blood pressure cuff inflated to just under the patient's diastolic BP

Phlebitis is characterized by

pain, increased skin temperature, and redness along the vein.

Extravasation is characterized by

pain, stinging or burning at the site, swelling, and redness

Venipuncture at or near the insertion site of a midline catheter or PICC could

damage the catheter and add to areas of venous inflammation

A short secondary administration set, also known as a piggyback set, is attached to the primary set at a Y-injection site and is used to

deliver intermittent medications.

To initiate IV access, place the patient's extremity in a

dependent position

Before initiating a hypertonic solution (which is irritating to a patient's veins), check facility's policy to

determine the appropriate intravenous route.

When rapid or forceful procedures are applied to veins they can

develop venospasms

Examples of hypertonic solutions are

dextrose 10% in water (D10W) and dextrose 5% in 0.9% sodium chloride (D5NS).

Phlebitis is commonly treated by

discontinuing the IV line and applying a moist, warm compress over the area.

Before and after handling the IV system

do hand hygiene

Drugs with vasoconstrictive action, are vesicants that can cause extravasation and include

dopamine, or chemotherapeutic agents, such as vinblastine

The most appropriate veins for peripheral catheter placement include the

dorsal venous network, basilic, cephalic, and median veins, as well as their branches

A transparent protective dressing/covering is often used over intravenous insertion sites to allow

easy visualization of the site for signs of inflammation

Infiltration results when the IV catheter is dislodged and fluid infuses into the tissue. It is characterized by

edema, pallor, decreased skin temperature around the site, and pain.

When an IV administration set is used for infusion of lipid solutions, change it

every 24 hours. These fluids are thick and can clog the tubing.

Hypotonic solutions are administered to

expand the intracellular space; infused to rehydrate the cells of patients who have hypertonic fluid imbalances, to treat gastric fluid loss and dehydration from excessive diuresis.

Most admixed drugs commonly used today are filtered before they reach the bedside because concerns with using IV filters include

the possibility for their rupture, most commonly associated with the exertion of high pressure exceeding the limit tolerated by the specific filter. Some drugs are retained inside the filter because of their chemical nature or molecule size.

The 'nocebo effect' refers to

the practitioner's suggestions of side effects of treatments which cause symptoms before treatment even takes effect

To start a continuous infusion, you'll need

the prescribed bag of fluid and an infusion set (tubing).

An isotonic fluid has

the same osmolality as blood

When delivering infusion therapy choose a gauge that is

the smallest possible as the larger the gauge, the more likely to cause phlebitis

In central IV therapy, the vascular access device (VAD) is placed in the central circulation, specifically within

the superior vena cava (SVC) near its junction with the right atrium.

It is important to secure an IV catheter to keep it from becoming dislodged or moving around in the vein and causing trauma. Techniques for securing an IV catheter differ, familiarize yourself with

the technique used at your facility

To find a vein in obese clients may require

the use of anatomical landmarks

Percutaneous means

through the skin

If indwelling catheter sutures are loose or broken,

notify the health care provider to replace them. IV catheter sutures are being replaced with securement devices in some facilities.

When removing an intravenous catheter, the steps are

--Close roller clamp (While stabilizing the catheter and avoiding putting pressure on it at all times) --Pull the transparent dressing and tape toward the insertion site to avoid injuring the vein --Inspect the catheter's tip, if it is not intact, notify the provider immediately -apply a tourniquet high on the extremity where the IV line was located and follow your facility's policy for further intervention. --Inspect catheter site for signs of infection: pain, redness, swelling, and drainage

If at an IV site infusion, hematoma/ecchymosis is discovered

--Do not apply alcohol. --Apply pressure after IV catheter removal. --Use warm compress and elevation after bleeding stops.

To prevent thrombus from catheter tip breakage in patient's vein

--Do not reinsert the stylet into the catheter. --Check to be sure the IV catheter is intact at time of catheter removal.

To maintain patency of IV access

--Do not stop a continuous infusion or allow blood to back up into the catheter for any length of time. Clots can form at the tip of the needle or catheter and can be lodged against the vein wall, blocking the flow of fluid. --Instruct the client not to manipulate flow rate device, change settings on IV pump, or lie on the tubing. --Make sure the IV insertion site dressing is not too tight. --Flush intermittent IV catheters with appropriate solution after every medication administration or every 8 to 12 hrs. when not in use. --Monitor site and infusion rate at least every hour

The 14-16 gauge catheter is

--For trauma and surgical patients requiring rapid fluid resuscitation --Needs to be in a vein that can accommodate it

To prevent IV hematoma/ecchymosis

--Minimize tourniquet time. --Remove the tourniquet before starting IV infusion. --Maintain pressure after IV catheter removal.

If after an IV removal, the catheter tip is discovered missing

--Place a tourniquet high on the extremity to limit venous flow. --Prepare for removal under x-ray or via surgery. --Save the catheter after removal to determine the cause.

The 18 gauge catheter is

--Preferred size for surgery --Vein needs to be large enough to accommodate the catheter --110 mL/min (6600 mL/hr)

If at an IV site infusion, throbbing, burning pain, erythema, increased temperature, slowed infusion, visible/palpable 'red line vein' is discovered (thrombus/phlebitis)

--Promptly discontinue the infusion and remove the catheter. --Elevate the extremity. --Document the size of the infiltrated area, estimate the amount of fluid present, and monitor the site. --Apply a cold compress to minimize the flow of blood, then apply a warm compress to increase circulation. --Check with provider to determine whether IV therapy is still needed. If so, restart the infusion in the other extremity. --Culture the site and catheter if drainage is present.

When placing an IV catheter, after you pierce the skin:

--Re-visualize the vein and reduce the angle of the catheter before advancing it into the vein --Thread the catheter a short distance into the vein, pull the needle back so that the tip is not extending past the end of the catheter. --Then thread the catheter into the vein until the hub of the catheter is resting against the skin at the insertion site. --Remove the needle the rest of the way, activate the safety device, and dispose of the needle in the sharps container. --Secure the flexible catheter in place for the administration of fluids and medications.

To prevent IV associated cellulitis

--Rotate sites at least every 72 hr --Avoid the lower extremities. --Use hand hygiene. --Use surgical aseptic technique

Interventions to help with anxiety:

--Safety behaviors: focus on something helpful from the past: friend, medicine --Control: patient instructs whether to stop for a break and when to continue; give signal for stop/pause and proceed --Partial distractor: another person takes some focus away from procedure --Moderate distractor: suggest focusing on a simple puzzle or picture (too complex and anxiety increases

The 24-26 gauge catheter is the

--Smallest, shortest ( 3/4 inch length) --Not ideal for viscous infusions --Expect blood transfusion to take longer --Preferred for infants and small children --24 mL/min (1440 mL/hr)

If at an IV site infusion irritating/vesicant fluids, pain, burning, redness or swelling is discovered (extravasation)

--Stop infusion and notify provider. --Follow facility protocol, which may include infusing an antidote through the catheter before removal.

When starting an older patients' IV, remember their skin tends to be thinner and their veins more fragile and superficial with a tendency to roll. You should

--Use a tourniquet sparingly to avoid bruising or tearing the skin --Pull the skin below the insertion site taut to stabilize the vein when inserting a catheter --Use a lower angle of insertion to avoid puncturing the posterior wall of the vein. --Try to avoid the veins in the hand and the dominant arm --Use a smaller catheter, such as a 22-gauge --Use minimal tape to avoid irritating or traumatizing the skin; use a mesh dressing instead --Use an arm board or protective device to protect the IV site if patient is confused or restless

Before beginning a procedure, it is useful to determine whether to control anxiety, the patient would rather:

--Use his/her own belief system or be taught a new coping skill --Look/turn away --Have silence/have procedures explained

For trauma and surgical patients requiring rapid fluid resuscitation Needs to be in a vein that can accommodate it

--Verify that the prescription for completeness, appropriateness --For adults, choose a site for placement in the upper extremity. --DO NOT USE THE WRIST. --Choose the patient's nondominant arm when possible. --Choose a distal site, and make all subsequent venipunctures proximal to previous sites. --Do not use the arm on the side of a mastectomy, lymph node dissection, lymphedema, arteriovenous shunt, dialysis graft or fistula, or paralysis. Using veins in the extremity affected by these conditions requires a physician's request. --Avoid choosing a site in an area of joint flexion. --Avoid choosing a site in a vein that feels hard or cordlike. --Avoid choosing a site close to areas of cellulitis, dermatitis, or complications from previous catheter sites.

Saline/heparin locks are flushed

--before and after medication administration to preserve patency --8 to 12 hours, or as institution policy

To regulate the flow rate of a piggyback or secondary infusion,

--open the roller clamp on the secondary tubing completely and use the roller clamp on the primary tubing to adjust the flow rate. --When the secondary infusion is complete, the primary infusion resumes. If the primary infusion's rate differs from that of the secondary infusion, adjust the rate ASAP after the secondary infusion is complete.

All patients with IV access are at risk for developing IV-related complications, such as

--phlebitis and infiltration. --At higher risk are: those receiving hypertonic, acidic, or irritating fluids or medications; patients with fragile veins; and pediatric patients; they require especially frequent assessment.

There are many advantages to infusion therapy, the biggest disadvantages are

--the effect is so immediate, there is no time before an adverse reaction takes place --venous irritation --septicemia from infection

Central venous catheters and midlines can be used for obtaining blood samples after a careful assessment of

--the risks versus the benefits. If your patient has no peripheral venipuncture sites or is fearful of needles, using the central venous catheter may be appropriate. --The risks associated with obtaining blood samples from a central venous catheter are numerous. This procedure requires additional hub manipulation, which is a major cause of catheter-related bloodstream infection (CR-BSI). --Consider the laboratory tests needed and the types of fluids that have recently been infused. Heparin interferes with coagulation studies. Electrolytes in the fluid may alter the results of serum electrolytes. --Antibiotics such as vancomycin may interfere with measuring the peak serum levels of the drug.

Problems with plastic IV bags include

--they are not compatible with insulin, nitroglycerin, lorazepam (Ativan), fat emulsions, and lipid-based drugs; they adhere to the walls of the PVC container, making it impossible to know exactly how much medication the patient is receiving; losses may be in excess of 20 mL --The middle graduations have been shown to be 10% above or below the actual amount of fluid, but the first and last markings could be inaccurate by as much as 40%

Before administering blood

--use 2 patient identifiers --two qualified health care professionals review MAR/blood --Make sure the 4 ISBT identifiers are on the blood label

If an IV site appears to have been infected, you should

notify the provider immediately. If cultures are ordered, obtain a specimen for culture from the insertion site. Also, with sterile scissors, cut off the tip of the IV catheter and place it in a sterile container. Send both to the laboratory for culture.

If there is an adverse finding when checking an IV, the nurse should

notify the provider, determine if IV is still desired; change IV site with new kit

To alleviate IV insertion pain, you can

numb the IV insertion site with a local anesthetic, such as lidocaine 1%; after checking for patient allergies. Inject 0.1 to 0.2 mL intradermally, just enough to produce a wheal, using a 25- to 26-gauge ⅝-inch needle. Inject the local anesthetic on the side of the vein, not into the vein.

Short peripheral catheters should not be routinely used for

obtaining blood samples. This additional manipulation could lead to vein irritation that requires removal of the catheter.

A secondary infusion set may be used with subsequent medications depending

on the compatibility of the drugs.

A dedicated administration set is

one that must be used with a specific manufacturer's infusion controlling device.

An ONC is an

over the needle catheter

If the patient is critically ill or requires long-term IV therapy, the provider typically considers a

peripherally inserted central catheter (PICC).

There are two methods for inserting a peripheral IV catheter. The indirect method involves

piercing the skin along the side of the vein and then angling the catheter toward the vein.

Infusion therapy is

the delivery of medications in solution and fluids directly into the veins of the vascular system by parenteral route (piercing of skin or mucous membranes)

To keep air from entering IV tubing and being infused, be sure

the drip chamber is at least half full. Gently squeezing the chamber two or three times helps accomplish this.

To prevent systemic anticoagulation and subsequent bleeding, be sure to aspirate the heparin from

the dwell-lumen of hemodialysis catheters before use.

Time taping the IV bag helps you check at a glance that

the fluids are infusing over the correct period of time.

To protect the patient's skin after an IV catherization, place a small gauze pad under

the hub of the IV catheter to elevate it and keep it from exerting pressure on the patient's skin. Replace the gauze pad if it becomes wet or soiled.

Position the clear IV dressing over the vein so that it extends to

the lip of the hub of the catheter; leaving the connection between the catheter hub and the IV tubing uncovered to facilitate changing the tubing.

An introducer needle is

the needle inside an over-the-needle catheter used to pierce the wall of a vein to initiate intravenous access that is withdrawn and discarded after the catheter is properly positioned within the vein

The drip or drop factor is

the number of drops per milliliter delivered by a particular drip chamber

An IV flash chamber is

the portion of an over-the-needle catheter that allows observation of a blood return when the catheter enters a vein

A central line insertion or handling requires

thorough hand hygiene; draping of the patient from head to toe with a sterile barrier; insertion nurse wears sterile gloves, gown, and mask; attendants are masked; traffic in and out of the room must be minimized; Chlorhexidine for skin disinfection; subclavian sites are preferable to internal jugular and upper arm veins. PICC lines are preferable to subclavian vascular access devices (VADs).

To minimize pain during a pediatric IV catheterization procedure, use a

topical anesthetic such as LMX (lidocaine) or EMLA (eutectic mixture of lidocaine and prilocaine) cream to numb the site

Another word for 'cloudiness' in a medication is

turbidity

Before beginning an IV catheterization procedure

Check the provider's prescription (e.g., solution, rate). Follow the rights of medication administration (including compatibilities of all IV solutions). Examine the solution to be infused for clarity, leaks, and expiration date. Prime tubing as indicated. Perform hand hygiene. Identify the client Assess the client for allergies to products used in initiating and maintaining IV therapy (latex, tape, iodine). Provide explanations, education Place client in comfortable position Don clean gloves before insertion. Assess extremities and veins. If hair removal is needed, clip it with scissors or shave it with an electric shaver Select vein by choosing: Distal veins first on the nondominant hand. A site that is not painful or bruised and will not interfere with activity. A vein that is resilient with a soft, bouncy feeling

Care must be taken not to exert too much pressure on venous catheters (excess pressure could result in rupture or forcing a blood clot into circulation), use

use 5-10 mL normal saline by syringe (3 mL for short peripheral catheters) to flush the catheter carefully before each use while applying slow, gentle pressure to the syringe plunger; aspirate for a brisk blood return from the catheter lumen. Thrombolytic agents such as alteplase (Cathflo Activase) may be needed to dissolve blood clots

Mechanically regulated IV devices are

used to deliver intermittent medications such as antibiotics or continuous pain medications in community-based health or home care setting.

Syringe pumps work by

using an electronic or battery-powered piston to push the plunger continuously at a selected milliliter-per-hour rate.

A patient can progress rapidly from panic to hyperventilation and then to

a vasovagal reaction

Reports of tingling, feeling "pins and needles" in the extremity, or numbness during the venipuncture procedure can indicate

nerve puncture. If any of these symptoms occur, stop the IV insertion procedure immediately, remove the catheter, and choose a new site.

For older patients with a loss of skin turgor and poor vein condition and for active patients receiving infusion therapy in an ambulatory clinic or home care; cannulation of the hand is

not appropriate

Hypertonic fluids have

a higher osmolality than blood

Hypotonic fluids have

a lower osmolality than blood

If the patient's IV therapy is expected to be longer than 6 days,

a midline catheter or PICC should be chosen

To begin an IV, you will need an IV kit or the components which are

a tourniquet or a blood-pressure cuff, an antimicrobial wipe, several small gauze pads, tape, a transparent dressing, and gloves

Medications are added to a new IV fluid container, not to

an IV container that is already hanging

saline lock

an intravenous catheter inserted into a vein and left in place for the intermittent administration of medication through its port or as an open line for emergency situations and intermittently flushed with normal saline solution to maintain patency

vascular access device (VAD)

an umbrella term that includes a variety of catheters, cannulas, and infusion ports that allow intermittent or continuous access to a blood vessel

A generic administration set is

appropriate for most infusions.

Filters should be placed

as close to the catheter hub as possible.

When changing an IV bag and discovering air bubbles in the tubing, you should

attach a needleless syringe to port below air bubble and aspirate air out

When removing a mid or central line

explain procedure will not be painful, clip any sutures, remove the dressing and withdraw the catheter in short segments, stop if there's resistance, never apply force to the catheter; force could cause the catheter to break and embolize to the heart or pulmonary circulation; use distraction techniques and deep breathing to relax the patient; if catheter is still 'stuck, replace the dressing and apply heat; allow time for the vein wall to relax, keep the extremity warm and dry and have the patient to drink warm liquids, use relaxing medications if the catheter cannot be removed after several hours; imaging studies can determine whether the cause is a thrombosis instead of venospasm.

Ambulatory pumps are generally used for

home care patients; come is a wide range of sizes, with some requiring a backpack, usually weigh less than 6 pounds; for continuous infusions, such as parenteral nutrition, pain medication, and many programmable drug schedules. Frequent battery recharging or replacement is usually necessary.

IV sites should be checked

hourly

Solutions with an electrolyte content of 375 mEq/L or more are considered

hypertonic.

phlebitis

inflammation of a vein

Blood should not be drawn from a venipuncture site proximal to (above) an

infusing peripheral catheter because the infusing fluid could alter the results of the test to be performed.

Smart pumps are

infusion pumps with dosage calculation software, designed to reduce adverse drug events (ADEs); libraries of drug information are stored in the pump manufacturer's medical management system with dosing limits, especially for high-alert drugs; may have a wireless network connection for auto-update of library; records avoided potential errors; has dose-track technology so that the correct patient receives the correct medication and dose; the "smarter" the pump, the more extensive the programming steps are, the more alarms that the nurse must respond to, the more skill required to use the device

Avoid writing on IV bags with pens or markers, because

ink seepage through plastic could contaminate the solution

Nursing assessment for all infusion systems should be systematic. Begin with the

insertion site and work upward, following the tubing Assess the integrity of the dressing, making sure it is clean, dry, and adherent to the skin on all sides. Check all connections on the administration set, and ensure that they are secure. Be sure they are not taped. Check the rate of infusion for all fluids by either counting drops or checking the infusion pump. Assess the amount of fluid that has infused from the container. Is it accurate, or is it infusing too fast or too slow? Adjust the rate to the prescribed flow rate. Check all labels on fluid containers for the patient's name and fluid or medication. Be sure that the correct solution is being infused!

TPN should not be infused in peripheral circulation because

it can damage blood cells and the endothelial lining of the veins.

Fluids should not hang more than 24 hrs. unless

it is a closed system (pressure bags for hemodynamic monitoring).

Infiltration occurs when

leakage of a non-vesicant IV solution or medication into the extravascular tissue Peripheral catheter has punctured opposite vein wall Obstruction of blood flow causing backflow through original entrance site Inflammatory process causing fluid leakage at the capillary level Fibrin sheath fully encasing a central venous catheter leading to retrograde flow and leakage from venipuncture site Damaged septum of implanted port Dislodged port access needle

Hypotonic solutions have an electrolyte content of

less than 250 mEq/L

Flush catheters immediately after each use. Delay in disconnecting the intermittent administration set and flushing the catheter could cause

lumen occlusion from blood that backflows into the lumen when the infusion pressure is lower than venous pressure.

Post-placement care of PICC or central lines requires

meticulous dressing changes and care of all parts of the IV system, such as keeping ports and stopcocks clean and hanging bags using sterile technique. Review daily the need for the patient's VAD. The incidence of CR-BSI increases each day the device is in place. As soon as it is determined that the patient no longer needs the IV line, it should be removed

According to a study by Lang et al. using 'warning language' before a procedure such as "Sharp stick now." or "This might hurt a little." caused

more not less anxiety and discomfort; warning language should be avoided

Hypotonic fluids are used to

move water into cells to expand them

Electronic infusion devices are

programmable to deliver fluids in milliliter increments, some can be programmed as fractions of a milliliter; some allow the rate to be programmed to taper or ramp up and down at the beginning and ending of the infusion; may allow secondary syringe infusion, secondary infusion rate, remote site programming, adjustable infusion pressure, and integration into the nurse call system; have a variety of alarms, such as air-in-line, upstream and downstream occlusion, infusion complete, and low-battery or power warnings; have a mechanism to stop infusing fluid or medication when the cassette or tubing is removed from the pump

Bathing water is a source of contamination to an external catheter,

protect the external catheter, dressing, and all attached tubing plastic trash bags or devices specially designed for this purpose

All IV fluids must be administered carefully, but hypertonic solutions are particularly risky. These solutions

pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that can result in pulmonary edema, particularly in patients who have cardiac or renal disease.

When changing a catheter dressing, remove it by

pulling laterally from side to side. It can also be removed by holding the external catheter and pulling it off toward the insertion site. Never pull it off by pulling away from the insertion site because this could dislodge the catheter!

The degree of phlebitis/infiltration/extravasation is often documented using a scale that

ranges from 0 for no symptoms to 4, the most severe. When determining the degree of phlebitis, use the most severe symptom.

When you use an armboard, you must periodically

remove it to allow the patient to move the joint and assess the extremity for any skin irritation, discomfort, or circulatory impairment

Filters may be part of the administration set or may be separate add-on pieces. Their purpose is to

remove particulate matter, microorganisms, and air from the infusion system. Pore sizes/filter uses follow: 5 microns: intended to remove gross particles 1.2 microns used to filter lipid-containing parenteral nutrition 0.22 microns intended to remove all particles and microorganisms. 170 to 220 microns a standard blood filter ranges from and removes micro-clots and other debris caused by blood collection and storage. 20, 40, or 80 microns: micro-aggregates: degenerating platelets, white blood cells, fibrin strands. Leukocyte-removal filters: white blood cells that cause febrile and allergic blood transfusion reactions, cytomegalovirus, and some herpes viruses.

A hemodialysis catheter is critical to the management of

renal failure and must function well; it should not be used for administration of other fluids or drugs except in an emergency

If during central catheter use, the patient reports unusual pain or sensation, it may be necessary to

repeat the x-ray to confirm placement

In addition to the usual sites you'd use for initiating IV therapy in adults, you can also use infants'

scalp and foot veins

For all catheters, immediately after the catheter comes out of the skin, apply digital pressure with a dry gauze dressing to stop any bleeding. Apply a sterile occlusive gauze dressing with an antiseptic ointment as per agency protocol or procedure. When a central venous catheter is removed, a tract between the skin and vein creates a conduit for air to be pulled into the vein. The ointment

seals off the tract. After removal, measure the catheter length and compare it with the length documented on insertion. If the entire catheter length was not removed, contact the health care provider immediately! Removal of tunneled catheters and implanted ports requires surgical techniques and is usually performed by nurse practitioners or physicians.

Because infants and children are not always able to protect an IV site, be sure to

secure the catheter and tubing well and to use an arm board or commercially available protective device to help prevent accidental removal.

time tape

self-adhesive, coated tape used for labeling an intravenous infusion, for example, with the time it was started

Hypertonic solutions are infused to treat patients who have

severe hyponatremia. Depending on the type of hypertonic fluid infused, it can provide patients with calories, free water, and some electrolytes.

Extravasation results in

severe tissue damage manifested as blistering, tissue sloughing, or necrosis

Use of veins on the dorsal surface of the hands should be reserved for

short-term infusion of non-vesicant and non-irritant solutions.

The part of the catheter that goes over the needle is made of

silicon or Teflon

All fluids used to flush catheters should be obtained from

single-dose containers or prefilled syringes. Vials used for multiple doses contribute to medication errors and increase the risk for contamination.

When checking an IV site, check the

site for: redness, swelling, pain, firmness, skin temperature; solution, tubing, and flow rate

Securement devices like the StatLock require the use of a

skin protectant (e.g., Skin-Prep) before applying the device. The protectant prevents skin tearing when the device is removed.

A good IV vein is

soft when touched, bounces back after pressure is put on it, will not be in the way of procedures or interfere with patient's ADLs

When setting up/changing IV tubing careful attention is given to maintaining the sterility of the

spike and the connection end of the tubing to prevent introduction of microorganisms into the catheter and bloodstream.

When preparing an IV bag for infusion,

spike the bag of fluid and prime the tubing LABEL: added ingredients to the bag, amount, date, time, initials or signature and any other information your facility's policy, time tape to monitor flow rate

Another word for needle is

stylet

Antibiotics, small volume infusions and patient-controlled analgesia are frequently delivered with

syringe pumps.

If blood sampling from a central venous catheter is the best alternative, vigorous cleaning of the connections with 70% alcohol is necessary. Use methods that do not require needles. Use

vacuum tubes attached directly to the catheter hub which eliminate the need to transfer the blood from a syringe into the tubes. For small-diameter catheters, the vacuum in the tube may cause the catheter to temporarily collapse, preventing the backflow of blood into the tube. In this situation, small syringes should be used because they create less pressure on aspiration, the opposite of what small syringes do on injection. Transfer of the blood from the syringe to the vacuum tube requires the use of a special transfer device to avoid the use of needles.

PICCs should be inserted early in the course of therapy before

veins of the extremity have been damaged from multiple venipunctures and infusions.

Before infusing a medication through tubing that is infusing another medication

verify compatibility of medications

Needleless system ports should be cleaned

vigorously for 30 seconds with a 70% alcohol wipe, paying special attention to the screw ridges

Before adding more lines or a syringe to an IV port

wipe it with an alcohol wipe

Bacteriostatic normal saline is limited to no more than 30 mL in a 24-hour period in adults. By using 10 mL before and after each dose of medication, it is easy to exceed this limitation. Check

your agency's policy and procedure about specific flushing amounts.