Infusion Therapy

1. CHECK THE PICC SITES (OR ANY IV SITE) EVERY SHIFT! 2. LOOK AT THE CIRCUMFLEX OF THE EXXTREMITY! LARGER = INFILTRATION. 3. CHECK THE LENGTH OF THE PICC LINE. IF IT IS GREATER THAN THE LAST DOCUMENTED, THEN THE PICC HAS COME OUT SOME 4. MAKE SURE TO LOOK AND DOCUMENT THAT THE TIP WAS INTACT DURING REMOVAL.

· With PICCs, CVCs, ANY IV LINE, REMEMBER: 1. 2. 3. 4.

D) Stop the infusion of the drug immediately.

A client receiving gentamycin intravenously reports that the peripheral IV insertion site has become painful and reddened. In what order will the nurse perform the needed actions to manage this problem? A) Report the patient's problem to the primary health care provider. B) Document findings and actions in the electronic health record. C) Change the IV insertion site to a new location. D) Stop the infusion of the drug immediately.

24 hours. Change blood tubing within 4 hours

Administration Sets · An Administration Set is the connection between the catheter and the fluid container. § Generic administration sets are appropriate for most infusions § Dedicated administration sets must be used with a specific manufacturer's infusion controlling device · Primary administration set is used to infuse the primary IV fluid by gravity or electronic infusion pump § A short Secondary Administration Set (piggyback set) is attached to the primary set at a Y-injection site and is used to deliver an intermittent medication. Once attached, these should remain in place, connected to the infusion system § Primary and Secondary administration sets can be used to infuse fluids (other than parenteral nutrition and lipids) for up to 96 hours until the closed system has been compromised. · Intermittent Administration Set is used to infuse multiple doses of medications through a catheter that has been capped with a needless connection device (when no primary fluid is being infused) § Remove the medication bag from the previous dose and attach the new one. Remove the sterile cap covering the distal end of the set and attach the set to the catheter. § These sets should be changed every __________________________________________________________________ · Maintaining sterility: administration sets are sterile in the fluid pathway and under the sterile caps. § The set is not packaged as completely sterile and cannot be added to a sterile field. § Be careful to maintain sterility of the spike and connection end of the tubing

96 hours until the closed system has been compromised.

Administration Sets · An Administration Set is the connection between the catheter and the fluid container. § Generic administration sets are appropriate for most infusions § Dedicated administration sets must be used with a specific manufacturer's infusion controlling device · Primary administration set is used to infuse the primary IV fluid by gravity or electronic infusion pump § A short Secondary Administration Set (piggyback set) is attached to the primary set at a Y-injection site and is used to deliver an intermittent medication. Once attached, these should remain in place, connected to the infusion system § Primary and Secondary administration sets can be used to infuse fluids (other than parenteral nutrition and lipids) for up to ___________________________________________________________ · Intermittent Administration Set is used to infuse multiple doses of medications through a catheter that has been capped with a needless connection device (when no primary fluid is being infused) § Remove the medication bag from the previous dose and attach the new one. Remove the sterile cap covering the distal end of the set and attach the set to the catheter. § These sets should be changed every 24 hours. Change blood tubing within 4 hours · Maintaining sterility: administration sets are sterile in the fluid pathway and under the sterile caps. § The set is not packaged as completely sterile and cannot be added to a sterile field. § Be careful to maintain sterility of the spike and connection end of the tubing

superior vena cava (SVC) near its junction with the right atrium (called the caval-atrial junction, CAJ)

Central Intravenous Therapy · In Central IV Therapy the vascular access device is placed in the central circulation, specifically within the __________________________________________ § Blood flow in the SVC is about 2L/min (compared with 200mL/min in the axillary vein) § Central Vascular Access Devices require confirmation of tip location at the CAJ by chest x-ray always before it is used and solutions are infused · Several Available Depending on Purpose, Duration, Insertion Site Available · Some have Antimicrobial and/or Heparin Coatings to reduce infection risk and improve longevity of use · Not all central-line catheters are approved for power injection used in radiologic tests. The catheter can rupture if it is not designed to handle the injection pressure necessary for some tests (pulmonary CT angiography)

The concentration of heparin used to lock hemodialysis catheters ranges from 1000-10,000 units/mL. To prevent systemic anticoagulation and subsequent bleeding, be sure to aspirate the heparin from the lumens before use.

Hemodialysis Catheters · Hemodialysis Catheters have very large lumens to accommodate the hemodialysis procedure or a pheresis procedure that harvests specific blood cells (dialysis). § They can be Tunneled or Nontunneled § These are critical to the management of renal failure and must function well · CRBSI and vein thrombosis are common problems; therefore this catheter should not be used for administration of other fluids or drugs except in an emergency. § No use except dialysis HANDS OFF!!! · Two lumens: venous & arterial § Arterial lumen (red) § Venous lumen (blue) · Heparin Lock: ______________________________________________________________________________________________

non-coring needle (Huber) that slices through the dense septum without coring out a small piece of it (by a specially trained nurse). Ports in the chest typically tolerate about 2,000 punctures, while those in the upper arm tolerate about 750 punctures

Implanted Ports · Implanted Ports are usually used for patients who are expected to require IV therapy for more than a year. · Insertion of Implanted Ports is done by a physician in the OR or Interventional Radiology Suite · Implanted Ports consist of a portal body, a dense septum over a reservoir, & a catheter § Can be Single or Double Access § A SubQ pocket is created to house device & then the incision is closed and no part of the catheter is visible externally (least impact on body image) · Be careful not to press firmly on bumps because it can cause pain · With Implanted Ports, the Venous ports can be placed on the upper chest or the upper extremity, while the catheter is in the subclavian or internal jugular · These are accessed using a ________________________________________________________________________________________________________ · Port access should be done by trained health professionals using a mask (mask on you and patient, patient turns head away during access) and aseptic technique. Before puncture, palpate the port to locate the septum and ensure that you are not puncturing the catheter. § There can be rebound when the needle is pulled from the septum, which can result in needle stick injury to the nurse · Implanted ports need to be flushed after each use and at least once a monthbetween courses of therapy to prevent clot formation ("locking" or "de-accessing"). Use a 10mL syringe with heparin 10 units/mL or NS. § These devices can withstand 5mL/sec at up to 300psi pressure · Before giving a drug through an implanted port, always check for blood return (with other CVCs, you get a chest x-ray). If no blood return, withhold the drug until patency is established. Serious extravasations of vesicant drugs can occur because a fibrin sheath (flap/tail) may occur at a tip of the catheter, clot it, and cause retrograde subcutaneous leakage. · When the port is not accessed, there is no need for an external dressing. · Implanted ports are commonly used for patients receiving chemotherapy, making them highly susceptible to infection

flushed after each use and at least once a monthbetween courses of therapy to prevent clot formation ("locking" or "de-accessing"). Use a 10mL syringe with heparin 10 units/mL or NS. § These devices can withstand 5mL/sec at up to 300psi pressure

Implanted Ports · Implanted Ports are usually used for patients who are expected to require IV therapy for more than a year. · Insertion of Implanted Ports is done by a physician in the OR or Interventional Radiology Suite · Implanted Ports consist of a portal body, a dense septum over a reservoir, & a catheter § Can be Single or Double Access § A SubQ pocket is created to house device & then the incision is closed and no part of the catheter is visible externally (least impact on body image) · Be careful not to press firmly on bumps because it can cause pain · With Implanted Ports, the Venous ports can be placed on the upper chest or the upper extremity, while the catheter is in the subclavian or internal jugular · These are accessed using a non-coring needle (Huber) that slices through the dense septum without coring out a small piece of it (by a specially trained nurse). Ports in the chest typically tolerate about 2,000 punctures, while those in the upper arm tolerate about 750 punctures · Port access should be done by trained health professionals using a mask (mask on you and patient, patient turns head away during access) and aseptic technique. Before puncture, palpate the port to locate the septum and ensure that you are not puncturing the catheter. § There can be rebound when the needle is pulled from the septum, which can result in needle stick injury to the nurse · Implanted ports need to be ___________________________________________________________________ -____________________________________________ · Before giving a drug through an implanted port, always check for blood return (with other CVCs, you get a chest x-ray). If no blood return, withhold the drug until patency is established. Serious extravasations of vesicant drugs can occur because a fibrin sheath (flap/tail) may occur at a tip of the catheter, clot it, and cause retrograde subcutaneous leakage. · When the port is not accessed, there is no need for an external dressing. · Implanted ports are commonly used for patients receiving chemotherapy, making them highly susceptible to infection

always check for blood return (with other CVCs, you get a chest x-ray). If no blood return, withhold the drug until patency is established. Serious extravasations of vesicant drugs can occur because a fibrin sheath (flap/tail) may occur at a tip of the catheter, clot it, and cause retrograde subcutaneous leakage.

Implanted Ports · Implanted Ports are usually used for patients who are expected to require IV therapy for more than a year. · Insertion of Implanted Ports is done by a physician in the OR or Interventional Radiology Suite · Implanted Ports consist of a portal body, a dense septum over a reservoir, & a catheter § Can be Single or Double Access § A SubQ pocket is created to house device & then the incision is closed and no part of the catheter is visible externally (least impact on body image) · Be careful not to press firmly on bumps because it can cause pain · With Implanted Ports, the Venous ports can be placed on the upper chest or the upper extremity, while the catheter is in the subclavian or internal jugular · These are accessed using a non-coring needle (Huber) that slices through the dense septum without coring out a small piece of it (by a specially trained nurse). Ports in the chest typically tolerate about 2,000 punctures, while those in the upper arm tolerate about 750 punctures · Port access should be done by trained health professionals using a mask (mask on you and patient, patient turns head away during access) and aseptic technique. Before puncture, palpate the port to locate the septum and ensure that you are not puncturing the catheter. § There can be rebound when the needle is pulled from the septum, which can result in needle stick injury to the nurse · Implanted ports need to be flushed after each use and at least once a monthbetween courses of therapy to prevent clot formation ("locking" or "de-accessing"). Use a 10mL syringe with heparin 10 units/mL or NS. § These devices can withstand 5mL/sec at up to 300psi pressure · Before giving a drug through an implanted port, __________________________________________________________________________________ · When the port is not accessed, there is no need for an external dressing. · Implanted ports are commonly used for patients receiving chemotherapy, making them highly susceptible to infection

1. Maintain or correct fluid balance 2. Maintain or correct acid-base balance or electrolytes 3. Administer medications 4. Replace blood or blood products

Infusion Therapy · Infusion Therapy: Delivery of medications & fluids parenterally (piercing of skin or mucous membranes) through vein, artery, etc. · Reasons for using infusion therapy: 1. 2. 3. 4. · IV therapy is the most common invasive therapy administered in hospital patients. · Infusion nurses initiate and maintain infusion therapy. They may perform any of these activities: 1. Develop EBP 2. Insert and maintain various types of peripheral, midline, and central venous catheters and subQ and intraosseous accesses 3. Monitor patient outcomes of infusion therapy 4. Educate staff, patient, and families regarding infusion therapy 5. Consult on product selection and purchasing decisions 6. Provide therapies such as blood withdrawal, therapeutic phlebotomy, hypodermoclysis, intraosseous infusions, and administrations of medications · The RN generalist is taught to insert peripheral IV lines. The RN is ultimately accountable for all aspects of infusion therapy and delegation of associated tasks.

only during the immediate period of resuscitation and not used longer than 24hr. after establishing access, efforts should be made to obtain IV access

Intraosseous (IO) Infusion Therapy · Intraosseous (IO) Infusion Therapy allow access to the rich vascular network in the red marrow of bones. Victims of trauma, burns, cardiac arrest, DKA, and other life-threatening conditions benefit from this therapy because often clinicians cannot access these patient's vascular systems for traditional IV therapy · Absorption rates of large volume parenteral (LPV) infusions/drugs administered via IO route are similar to those achieved with peripheral or central venous administrations · The IO route should be used ____________________________________________ · Contraindications to IO infusion: fracture in the bone used as a site § Conditions like osteoporosis, osteogenesis imperfecta, or conditions that weaken bone increase risk of fracture during IO insertion and may also be contraindications · 15-16 gauge needs designed for IO use are preferred, but any needle could be used to provide therapy and access the medullary space (marrow) § Drills have improved ease of IO insertion · Intraosseous (IO) Sites: proximal tibia (tibial tuberosity), distal femur, medial malleolus (inner ankle), proximal humerus, and iliac crest § Proximal Tibia Most Common Site · If IV access can't be obtained within minutes of resuscitation procedures, IO therapy may be attempted. The leg is restrained and site is cleaned. After successful insertion, the needle is secured to prevent movement out of bone. · The same doses of fluids and medications can be infused by IO therapy as an IV. And infusion pump may be used for rapid flow rates · During the procedure most patients rate pain as 2-3 out of 10. Lidocaine is used to anesthetize the skin, subQ tissue, and periosteum to promote comfort. Pain is also reported during infusion, and may be reduced by injecting 0.5mg/kg of preservative free lidocaine through the IO port before initiating the infusion. · Complications of Intraosseous (IO) Infusion Therapy: § Improper needle placement with infiltration into surrounding tissue is the most common complication. Accumulation of fluid under the skin at insertion site or on the other side of the limb indicates the needle is either not in far enough or is too fat into the limb and has protruded through the other side of the shaft. § Needle obstruction occurs when the puncture has been accomplished but flushing has been delayed § Osteomyelitis is an unusual but serious complication of IO therapy. § Compartment Syndrome: increased tissue pressure in confined anatomic spaces which decreases perfusion, leading to hypoxia and pain in the area. It is a rare compilation, but should be reported immediately · S/S: coolness, swelling, mottling, discoloration

Pain is also reported during infusion, and may be reduced by injecting 0.5mg/kg of preservative free lidocaine through the IO port before initiating the infusion.

Intraosseous (IO) Infusion Therapy · Intraosseous (IO) Infusion Therapy allow access to the rich vascular network in the red marrow of bones. Victims of trauma, burns, cardiac arrest, DKA, and other life-threatening conditions benefit from this therapy because often clinicians cannot access these patient's vascular systems for traditional IV therapy · Absorption rates of large volume parenteral (LPV) infusions/drugs administered via IO route are similar to those achieved with peripheral or central venous administrations · The IO route should be used only during the immediate period of resuscitation and not used longer than 24hr. after establishing access, efforts should be made to obtain IV access · Contraindications to IO infusion: fracture in the bone used as a site § Conditions like osteoporosis, osteogenesis imperfecta, or conditions that weaken bone increase risk of fracture during IO insertion and may also be contraindications · 15-16 gauge needs designed for IO use are preferred, but any needle could be used to provide therapy and access the medullary space (marrow) § Drills have improved ease of IO insertion · Intraosseous (IO) Sites: proximal tibia (tibial tuberosity), distal femur, medial malleolus (inner ankle), proximal humerus, and iliac crest § Proximal Tibia Most Common Site · If IV access can't be obtained within minutes of resuscitation procedures, IO therapy may be attempted. The leg is restrained and site is cleaned. After successful insertion, the needle is secured to prevent movement out of bone. · The same doses of fluids and medications can be infused by IO therapy as an IV. And infusion pump may be used for rapid flow rates · During the procedure most patients rate pain as 2-3 out of 10. Lidocaine is used to anesthetize the skin, subQ tissue, and periosteum to promote comfort. _______________________________________________________________________ · Complications of Intraosseous (IO) Infusion Therapy: § Improper needle placement with infiltration into surrounding tissue is the most common complication. Accumulation of fluid under the skin at insertion site or on the other side of the limb indicates the needle is either not in far enough or is too fat into the limb and has protruded through the other side of the shaft. § Needle obstruction occurs when the puncture has been accomplished but flushing has been delayed § Osteomyelitis is an unusual but serious complication of IO therapy. § Compartment Syndrome: increased tissue pressure in confined anatomic spaces which decreases perfusion, leading to hypoxia and pain in the area. It is a rare compilation, but should be reported immediately · S/S: coolness, swelling, mottling, discoloration

Proximal Tibia

Intraosseous (IO) Infusion Therapy · Intraosseous (IO) Infusion Therapy allow access to the rich vascular network in the red marrow of bones. Victims of trauma, burns, cardiac arrest, DKA, and other life-threatening conditions benefit from this therapy because often clinicians cannot access these patient's vascular systems for traditional IV therapy · Absorption rates of large volume parenteral (LPV) infusions/drugs administered via IO route are similar to those achieved with peripheral or central venous administrations · The IO route should be used only during the immediate period of resuscitation and not used longer than 24hr. after establishing access, efforts should be made to obtain IV access · Contraindications to IO infusion: fracture in the bone used as a site § Conditions like osteoporosis, osteogenesis imperfecta, or conditions that weaken bone increase risk of fracture during IO insertion and may also be contraindications · 15-16 gauge needs designed for IO use are preferred, but any needle could be used to provide therapy and access the medullary space (marrow) § Drills have improved ease of IO insertion · Intraosseous (IO) Sites: proximal tibia (tibial tuberosity), distal femur, medial malleolus (inner ankle), proximal humerus, and iliac crest § __________________ is Most Common Site · If IV access can't be obtained within minutes of resuscitation procedures, IO therapy may be attempted. The leg is restrained and site is cleaned. After successful insertion, the needle is secured to prevent movement out of bone. · The same doses of fluids and medications can be infused by IO therapy as an IV. And infusion pump may be used for rapid flow rates · During the procedure most patients rate pain as 2-3 out of 10. Lidocaine is used to anesthetize the skin, subQ tissue, and periosteum to promote comfort. Pain is also reported during infusion, and may be reduced by injecting 0.5mg/kg of preservative free lidocaine through the IO port before initiating the infusion. · Complications of Intraosseous (IO) Infusion Therapy: § Improper needle placement with infiltration into surrounding tissue is the most common complication. Accumulation of fluid under the skin at insertion site or on the other side of the limb indicates the needle is either not in far enough or is too fat into the limb and has protruded through the other side of the shaft. § Needle obstruction occurs when the puncture has been accomplished but flushing has been delayed § Osteomyelitis is an unusual but serious complication of IO therapy. § Compartment Syndrome: increased tissue pressure in confined anatomic spaces which decreases perfusion, leading to hypoxia and pain in the area. It is a rare compilation, but should be reported immediately · S/S: coolness, swelling, mottling, discoloration

are inserted by a doctor through the subclavian vein in the upper chest or internal jugular veins in the neck using sterile technique. The tip of the CVC resides in the superior vena cava (SVC) and is confirmed by a chest x-ray

Nontunneled Percutaneous Central Venous Catheter · Nontunneled Percutaneous Central Venous Catheter (CVCs) _________________________________________________________________ § Use of the Femoral Vein for insertion is Less Common. The rate of infection here is very high, so if used, it is removed as soon as possible. · CVCs are usually 7-10 inches long and have 1-5 lumens. They are available with antimicrobial coatings · The tip of the CVC resides in the superior vena cava (SVC) and is confirmed by a chest x-ray · Nontunneled Percutaneous Central Venous Catheter (CVCs) are most commonly used for Emergent, Trauma, Critical Care, & Surgery (they're a little more temporary) · No optimal dwell time § BUT, these catheters are commonly used for short term situations and are NOT the catheter of choice for home care or ambulatory clinic settings. · Insertion of a Nontunneled Percutaneous Central Venous Catheter (CVCs) requires the patient be in Trendelenburg Position w/Rolled Towel Between Shoulder Blades § This position may be contraindicated for patients with respiratory conditions, spinal curvatures, and increased intracranial pressure (especially older adults0 · Contraindications to CVC use: Trauma, surgery, radiation to the neck or chest · Warm, moist skin of neck and upper chest results in increased Risk of Central Line Infection with CVC § Prescence of a Tracheostomy further increases risk of infection

Emergent, Trauma, Critical Care, & Surgery (they're a little more temporary) · No optimal dwell time § BUT, these catheters are commonly used for short term situations and are NOT the catheter of choice for home care or ambulatory clinic settings.

Nontunneled Percutaneous Central Venous Catheter · Nontunneled Percutaneous Central Venous Catheter (CVCs) are inserted by a doctor through the subclavian vein in the upper chest or internal jugular veins in the neck using sterile technique. § Use of the Femoral Vein for insertion is Less Common. The rate of infection here is very high, so if used, it is removed as soon as possible. · CVCs are usually 7-10 inches long and have 1-5 lumens. They are available with antimicrobial coatings · The tip of the CVC resides in the superior vena cava (SVC) and is confirmed by a chest x-ray · Nontunneled Percutaneous Central Venous Catheter (CVCs) are most commonly used for ___________________________________________________ -_________________________________________________ · Insertion of a Nontunneled Percutaneous Central Venous Catheter (CVCs) requires the patient be in Trendelenburg Position w/Rolled Towel Between Shoulder Blades § This position may be contraindicated for patients with respiratory conditions, spinal curvatures, and increased intracranial pressure (especially older adults0 · Contraindications to CVC use: Trauma, surgery, radiation to the neck or chest · Warm, moist skin of neck and upper chest results in increased Risk of Central Line Infection with CVC § Prescence of a Tracheostomy further increases risk of infection

· 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 s/s of complications that should be reported

Nursing Care For Patients Receiving Intravenous Therapy · Educating the Patient: TJC requires that all patients who have central lines placed in the hospital must have education on the prevention of CLABSI. § Before catheter insertion, educate patient/family about: - - - - - § Provide written info before placement of a long term catheter and continue to assess patient knowledge § Conversation and pictures are helpful for patients who are literacy challenged § Patients who don't speak English need a translator

the limb opposite from all catheters. 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 being performed.

Nursing Care For Patients Receiving Intravenous Therapy · Performing the Nursing Assessment: all central VADs require documentation of tip location at the CAJ (usually by x-ray, electrocardiogram technology, or fluoroscopy) before beginning infusion. § Nursing assessments should be systemic. Start with the insertion site and work upward (following tubing). Know the type of catheter, length of catheter, tip location, insertion site, and perform a complete assessment. § Look for redness, swelling, hardness, or drainage. Check skin under dressing (especially for s/s of medical adhesive-related skin injury) § When a midline catheter or PICC is used, assess entire extremity and upper chest for s/s of phlebitis and thrombosis. § When a tunneled catheter is used, asses exit site, and entire length of the tunnel, and the point where the catheter enters the vein. For a well-healed catheter, it may not be possible to detect the vein entrance site; but on new catheters there could be a small puncture site with a suture/securement device § For implanted ports, assess incision and surgically created subQ pocket § Check dressings, make sure it is clean/dry and adherent on all sides. § Make sure tubing connections are secure and NOT taped § Check the infusion, dose, rate, volume, etc. Make sure the correct solution is being infused! § REMIND UAP TO AVOID TAKING BLOOD PRESSURES IN AN EXTREMITY WITH ANY TYPE OF CATHETER IN PLACE. · If a short peripheral catheter is being used for continuous infusion, the compression from BP cuff could increase venous pressure, causing fluid to overflow from the puncture site (infiltration). · If a midline or PICC is being used, compression from the BP cuff could increase vein irritation and lead to phlebitis § Draw blood samples in __________________________________________________________________________________________________ § Venipuncture at or near the insertion site of a midline or PICC could damage the catheter, add to areas of venous inflammation, and decrease perfusion.

AVOID TAKING BLOOD PRESSURES IN AN EXTREMITY WITH ANY TYPE OF CATHETER IN PLACE. · If a short peripheral catheter is being used for continuous infusion, the compression from BP cuff could increase venous pressure, causing fluid to overflow from the puncture site (infiltration). · If a midline or PICC is being used, compression from the BP cuff could increase vein irritation and lead to phlebitis

Nursing Care For Patients Receiving Intravenous Therapy · Performing the Nursing Assessment: all central VADs require documentation of tip location at the CAJ (usually by x-ray, electrocardiogram technology, or fluoroscopy) before beginning infusion. § Nursing assessments should be systemic. Start with the insertion site and work upward (following tubing). Know the type of catheter, length of catheter, tip location, insertion site, and perform a complete assessment. § Look for redness, swelling, hardness, or drainage. Check skin under dressing (especially for s/s of medical adhesive-related skin injury) § When a midline catheter or PICC is used, assess entire extremity and upper chest for s/s of phlebitis and thrombosis. § When a tunneled catheter is used, asses exit site, and entire length of the tunnel, and the point where the catheter enters the vein. For a well-healed catheter, it may not be possible to detect the vein entrance site; but on new catheters there could be a small puncture site with a suture/securement device § For implanted ports, assess incision and surgically created subQ pocket § Check dressings, make sure it is clean/dry and adherent on all sides. § Make sure tubing connections are secure and NOT taped § Check the infusion, dose, rate, volume, etc. Make sure the correct solution is being infused! § REMIND UAP TO _________________________________________________________________ - - § Draw blood samples in the limb opposite from all catheters. 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 being performed. § Venipuncture at or near the insertion site of a midline or PICC could damage the catheter, add to areas of venous inflammation, and decrease perfusion.

measure catheter length and compare with length documented on insertion. If the entire length was not removed, CALL THE DOCTOR.

Nursing Care For Patients Receiving Intravenous Therapy · Removing the Vascular Access Device: § To remove a short peripheral IV, lift opposite sides of the transparent dressing and pull laterally to remove the dressing while stabilizing the catheter. Withdrawal catheter from skin and cover the puncture site with dry gauze. Hold pressure until hemostasis occurs, and ensure the catheter tip is intact § Remove midline catheters and PICCs with the same slow, gentle motion used to insert the catheter. Veins can spasm with rapid/forceful techniques. Remove the dressing and withdrawal the catheter in short segments by pulling from the insertion site If you feel resistance, stop and don't apply force because extreme traction can cause catheter to break and embolize to heart/pulmonary circulation · Simple distraction and deep breathing may be sufficient to relax the patient and remove the catheter. If these fail, replace the dressing and apply heat (allows time for vein wall to relax). Ask patient to drink warm liquids. You may have to request meds to relax the vein if the catheter cannot be removed after several hours; x-rays might be needed to determine if thrombosis is the cause instead of venospasm. § Nontunneled Percutaneous central catheters are removed by clipping sutures and withdrawing the catheter in short segments. Venospasm doesn't usually occur because the vein used is so big § Prevent Air Emboli during Removal: position patient flat supine or Trendelenburg. Have patient hold their breath or perform Valsalva maneuver. If the patient is vented, time the removal to the delivery of an inhalation by the ventilator. Keep the catheter clamped during the procedure § After removal,________________________________________________________________ § RNs CAN'T remove Tunneled Catheters. Removal of tunneled catheters and implanted ports is done by doctor § RNs CAN remove PICCs & Nontunneled

pulling laterally from side to side (also 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 IT CAN DISLODGE THE CATHETER

Nursing Care For Patients Receiving Intravenous Therapy · Securing and Dressing the Catheter: tapes, sutures, and special securement devices can be used to secure the catheter and prevent complications. · For a short peripheral catheter, tape strips are most common; however, the tape should be CLEAN. Tape strips from IV kit are preferred. Don't use tape strips from a roll of tape that's been moved from room-to-room, from other procedures, or from uniform pockets. Pre-cutting tape and placing it on the bedrails, your uniform, or other objects should be avoided (it transmits microorganisms to the tape strip) · PICCs and Nontunneled percutaneous central catheters may be sutured in place; HOWEVER this creates additional breaks in the skin that can get infection. IF the sutures are loose/broken, tell the doctor to replace them. · Tunneled catheters usually have sutures in place near the skin exit site, which are removed after the tunnel has healed. Implanted ports also have sutures in place until the site is healed. After it is healed and when it is not accessed, no dressing is required § When an implanted port is accessed, the sterile occlusive dressings should cover the entire needle and site. · STERILE DRESSINGS used over the insertion site protect the skin and puncture site. § For a short peripheral catheter, transparent membrane dressings don't require routine changes. These usually do not dwell longer than a few days; and as long as the dressing is clean, intact, and dry, it don't need to be changed. § ANY VAD dressing should be changed when it gets soiled or loose § For central lines and midline catheters, tape and sterile gauze dressings or transparent membrane dressings can be used; change tape and sterile gauze dressings every 48 hours; change transparent membrane dressings every 5-7 days. · Usually the initial dressing is tape and gauze when these are first inserted, and they are changed within 24hr after insertion (bleeding is common) § When changing the dressing, remove it by _______________________________________________________________________________________________ § After removing the dressing from a midline catheter or any central venous catheter, note the catheter length and compare with the original length at insertion (report changes in length, cause a chest x-ray may be needed). · Protect the external catheter, dressing, and all tubing from water (source of contamination) Remind UAP to cover the extremity where the IV line is at when giving the patient a bath (or use plastic bag/warp taped over extremity to keep dressing/site dry) · Site protection might be needed for short peripheral catheters or for port access needles. Plastic shields can be placed over the site to prevent accidental bumping or pressure from clothing. Make sure that you can easily access the site frequently. Never place a restraint or opaque dressing over a peripheral IV site, especially when infusing an irritant or vesicant.

tape and sterile gauze dressings or transparent membrane dressings can be used; change tape and sterile gauze dressings every 48 hours; change transparent membrane dressings every 5-7 days.

Nursing Care For Patients Receiving Intravenous Therapy · Securing and Dressing the Catheter: tapes, sutures, and special securement devices can be used to secure the catheter and prevent complications. · For a short peripheral catheter, tape strips are most common; however, the tape should be CLEAN. Tape strips from IV kit are preferred. Don't use tape strips from a roll of tape that's been moved from room-to-room, from other procedures, or from uniform pockets. Pre-cutting tape and placing it on the bedrails, your uniform, or other objects should be avoided (it transmits microorganisms to the tape strip) · PICCs and Nontunneled percutaneous central catheters may be sutured in place; HOWEVER this creates additional breaks in the skin that can get infection. IF the sutures are loose/broken, tell the doctor to replace them. · Tunneled catheters usually have sutures in place near the skin exit site, which are removed after the tunnel has healed. Implanted ports also have sutures in place until the site is healed. After it is healed and when it is not accessed, no dressing is required § When an implanted port is accessed, the sterile occlusive dressings should cover the entire needle and site. · STERILE DRESSINGS used over the insertion site protect the skin and puncture site. § For a short peripheral catheter, transparent membrane dressings don't require routine changes. These usually do not dwell longer than a few days; and as long as the dressing is clean, intact, and dry, it don't need to be changed. § ANY VAD dressing should be changed when it gets soiled or loose § For central lines and midline catheters,_________________________________________________________________________ · Usually the initial dressing is tape and gauze when these are first inserted, and they are changed within 24hr after insertion (bleeding is common) § When changing the dressing, remove it by pulling laterally from side to side (also 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 IT CAN DISLODGE THE CATHETER § After removing the dressing from a midline catheter or any central venous catheter, note the catheter length and compare with the original length at insertion (report changes in length, cause a chest x-ray may be needed). · Protect the external catheter, dressing, and all tubing from water (source of contamination) Remind UAP to cover the extremity where the IV line is at when giving the patient a bath (or use plastic bag/warp taped over extremity to keep dressing/site dry) · Site protection might be needed for short peripheral catheters or for port access needles. Plastic shields can be placed over the site to prevent accidental bumping or pressure from clothing. Make sure that you can easily access the site frequently. Never place a restraint or opaque dressing over a peripheral IV site, especially when infusing an irritant or vesicant.

be used for infusion of vesicants (which can cause extravasation, like dopamine)

Peripheral Intravenous Therapy · Peripheral Intravenous Therapy usually requires short infusion catheters, and are usually placed in the arm veins. Another catheter used for peripheral IV therapy is a midline catheter · Midline Catheters can be 3-8 inches long, 3-5fr, and double or single lumen. They're inserted through veins of the upper arm using an ultrasound for guidance. The catheter tip lies no further than the axillary vein. § These have been found to reduce the number of IV cannulations (which reduces discomfort), increases patient satisfaction, and is more efficient. § Indications for Midline Catheters include fluids for hydration and drug therapy that are given longer than 6 days and up to 4 weeks, like antibiotics, heparin, steroids, and bronchodilators. § No current recommended dwell time § Sterile technique is used for insertion and dressing changes § Requires additional education for nurse to be qualified to insert § Midline Catheters should not __________________________________________________________ § Parenteral nutrition should not be infused via Midline Catheter § Do not draw blood from Midline Catheters routinely

1. Hand hygiene before palpating IV site 2. Clip hair, don't shave 3. Ensure skin is clean. If visible soiled, use soap and water 4. Wear clean gloves for insertion, don't touch site after application of antiseptics 5. Prepare clean skin with chlorhexidine, alcohol, or iodine with a back-and-forth motion for 30 seconds and allow to dry 6. Do not retouch the proposed insertion site. If you do, clean it again.

Peripheral Intravenous Therapy · Peripheral Intravenous Therapy usually requires short infusion catheters, and are usually placed in the arm veins. Another catheter used for peripheral IV therapy is a midline catheter · Short peripheral catheters are composed of a plastic cannula built around a sharp styler extending slightly beyond the cannula to allow for the venipuncture and advancement of the catheter into the vein. Site Selection and Skin Preparation: the most appropriate veins include the dorsal venous network: basilic, cephalic, and median veins and their branches § Cannulation of veins on the hand in not appropriate for older patients with loss of skin turgor and poor vein condition and for active patients receiving infusion therapy in an ambulatory care clinical or home care. Use of veins on the dorsal surface of the hands should be reserved as a last resort for short-term infusion of nonvesicant and nonirritant solutions in younger patients. § Winged needles ("butterfly needles") are easy to insert but are associated with a high frequency of infiltration. Usually used for single-dose drugs or drawing blood samples. § Catheter-related bloodstream infection (CRBSI) can occur. Prevention includes: 1. 2. 3. 4. 5. 6.

1. Verify that the prescription for infusion therapy is complete and appropriate for infusion through a short peripheral catheter 2. For adults, choose a site for placement in the upper extremity. DO NOT USE THE WRIST 3. Choose the patient's nondominant arm when possible 4. Choose a distal site and make all subsequent venipunctures proximal to previous sites. 5. Do not use the arm on the side of a mastectomy, lymph node dissection, arteriovenous shunt/fistula, or paralysis, avoid choosing a site in an area of joint flexion, in a vein that feels hard/cord-like, or in areas of cellulitis, dermatitis, or complications from previous IV sites. 6. WE AVOID putting these in lower extremities because of high risk of DVT 7. Choose a vein of appropriate length and width to fit the size of the catheter required for infusion. 8. Limit unsuccessful attempts to 2 per clinician and no more than 4 total.

Peripheral Intravenous Therapy · Peripheral Intravenous Therapy usually requires short infusion catheters, and are usually placed in the arm veins. Another catheter used for peripheral IV therapy is a midline catheter · Short peripheral catheters are composed of a plastic cannula built around a sharp styler extending slightly beyond the cannula to allow for the venipuncture and advancement of the catheter into the vein. § Short peripheral catheters are usually inserted into superficial veins of the forearm using sterile technique. Avoid use of veins in the lower extremities of adults, if possible, because of increased risk for DVT and infiltration. § Short peripheral catheters range in length from 3/4in to 1 & 1/4in with gauges from 26 (smallest) to 14 (largest) § Choose the smallest gauge capable of delivering the prescribed therapy with consideration of all the contributing factors (duration, vascular characteristics, comorbidities) § Recommended duration of Short peripheral catheters: no specific time frame! CDC and INS say that the catheter should be removed/rotated to new site based on clinical indications (phlebitis, warmth, tenderness, erythema, palpable venous cord, infection, or malfunction) § Assess Short peripheral catheters every 4 hours (q1-2h for vulnerable patients) § If patient's therapy is expected to be longer than 6 days, a midline catheter or a PICC should be used. § Placement Of Short Peripheral Catheters: 1. 2. 3. 4. 5. 6. 7. 8. § Ultrasound guided peripheral IV insertion allows for insertion into deeper veins, but should only be done by trained nurses.

perform usual ADLs, but avoid excessive physical activity. Muscle contractions in the arm from physical activity (heavy lifting) can lead to catheter dislodgement and possible lumen occlusion

Peripherally Inserted Central Catheter (PICC Line) · Complications with PICCs: Phlebitis, thrombophlebitis, DVT, Central Line Infection 1. When infections occur from a central line, it is called a central line associated bloodstream infection (CLABSI) 2. DVT and thrombosis threaten the integrity of the vein and decrease perfusion 3. CRBSI has been noted to be less common in PICCs than in other central venous catheters because of the insertion site in the upper extremity. The cooler, drier skin of the upper arm has fewer types and numbers of microorganisms · PICCs can accommodate infusion of all types of therapy because the tips lies in the SVC where the rapid blood flow quickly dilutes the fluids being infused. § NO limitations on the pH or osmolality of the fluids that can be infused through PICC § Patients needing lengthy courses of antibiotics, chemo, parenteral nutrition, and vasopressor agents can benefit from this type of catheter. · Dwell time for PICCs: Months to Years · PICCs can be used to Draw Blood (4fr recommended), Give Meds · Frequent entry into any central line should be minimized and treated with strict aseptic technique to prevent CRBSI. · Transfusion of blood through a PICC requires use of an infusion pump · Teach patients with PICCs to ____________________________________________________________________ § PICCs may be contraindicated in paraplegics who rely on their arms for mobility and in patients using crutches that provide support in the axilla

"Power PICCs" and be used for contrast injection at a maximum of 5mL/sec and a max pressure of 300psi.

Peripherally Inserted Central Catheter (PICC Line) · Peripherally inserted central catheter (PICC) is a long catheter inserted through a vein of the antecubital fossa or the middle of the upper arm. Nurses who insert these have to be specially trained to do so (PICC TEAM!!!) · PICC length ranges from 18-29 inches (45-74cm), with the tip residing in the superior vena cava (SVC) ideally at the caval-atrial junction (CAJ). § Placement of the catheter tip in veins distal to the SVC is avoided. This is often called, mid-clavicular catheter, is associated with much higher rates of thrombosis. · PICCs should be inserted early in the course of therapy before veins of the extremity have been damaged from multiple venipunctures and infusions. Insertion methods using guide-wires and ultrasound systems greatly improve insertion success. § The Basilic Vein is the Preferred site for insertion; cephalic can be used if needed § Brachial veins are not recommended because they are more difficult to access, are deeper in the arm, and are close to the brachial artery § Sterile Technique is used for insertion to reduce CRBSI risk (often at bedside). Before the catheter can be used for infusion, a chest x-ray indicating that the tip resides in the lower SVC is required when the catheter is not placed under fluoroscopy or with the use of the electrocardiogram tip-locator technique. · PICCs are available in Single, Dual, or Triple Lumen and with both the Groshong valve and the pressure-activated safety valve (PASV) · PICCs can come in __________________________________________

Basilic Vein

Peripherally Inserted Central Catheter (PICC Line) · Peripherally inserted central catheter (PICC) is a long catheter inserted through a vein of the antecubital fossa or the middle of the upper arm. Nurses who insert these have to be specially trained to do so (PICC TEAM!!!) · PICC length ranges from 18-29 inches (45-74cm), with the tip residing in the superior vena cava (SVC) ideally at the caval-atrial junction (CAJ). § Placement of the catheter tip in veins distal to the SVC is avoided. This is often called, mid-clavicular catheter, is associated with much higher rates of thrombosis. · PICCs should be inserted early in the course of therapy before veins of the extremity have been damaged from multiple venipunctures and infusions. Insertion methods using guide-wires and ultrasound systems greatly improve insertion success. § The _________________ is the Preferred site for insertion; cephalic can be used if needed § Brachial veins are not recommended because they are more difficult to access, are deeper in the arm, and are close to the brachial artery § Sterile Technique is used for insertion to reduce CRBSI risk (often at bedside). Before the catheter can be used for infusion, a chest x-ray indicating that the tip resides in the lower SVC is required when the catheter is not placed under fluoroscopy or with the use of the electrocardiogram tip-locator technique. · PICCs are available in Single, Dual, or Triple Lumen and with both the Groshong valve and the pressure-activated safety valve (PASV) · PICCs can come in "Power PICCs" and be used for contrast injection at a maximum of 5mL/sec and a max pressure of 300psi.

18-29 inches (45-74cm), with the tip residing in the superior vena cava (SVC) ideally at the caval-atrial junction (CAJ).

Peripherally Inserted Central Catheter (PICC Line) · Peripherally inserted central catheter (PICC) is a long catheter inserted through a vein of the antecubital fossa or the middle of the upper arm. Nurses who insert these have to be specially trained to do so (PICC TEAM!!!) · PICC length ranges from __________________________________ § Placement of the catheter tip in veins distal to the SVC is avoided. This is often called, mid-clavicular catheter, is associated with much higher rates of thrombosis. · PICCs should be inserted early in the course of therapy before veins of the extremity have been damaged from multiple venipunctures and infusions. Insertion methods using guide-wires and ultrasound systems greatly improve insertion success. § The Basilic Vein is the Preferred site for insertion; cephalic can be used if needed § Brachial veins are not recommended because they are more difficult to access, are deeper in the arm, and are close to the brachial artery § Sterile Technique is used for insertion to reduce CRBSI risk (often at bedside). Before the catheter can be used for infusion, a chest x-ray indicating that the tip resides in the lower SVC is required when the catheter is not placed under fluoroscopy or with the use of the electrocardiogram tip-locator technique. · PICCs are available in Single, Dual, or Triple Lumen and with both the Groshong valve and the pressure-activated safety valve (PASV) · PICCs can come in "Power PICCs" and be used for contrast injection at a maximum of 5mL/sec and a max pressure of 300psi.

1. Hand hygiene 2. Measuring upper arm circumference as a baseline before insertion 3. Maximal barrier precautions on insertion 4. Chlorhexidine skin antiseptics 5. Optimal catheter site selection and post-placement care with avoidance of the femoral vein for central venous access in adult patients 6. Daily review of line necessity with prompt removal of unnecessary lines 7. Other helpful interventions include: checklist of sterility during procedure, a line chart with equipment, and a stop sign on door to prevent unnecessary traffic during insertion.

Peripherally Inserted Central Catheter (PICC Line) · Regardless of where the PICC is inserted, the same precautions must be taken using the catheter related bloodstream infection (CRBSI) prevention bundle: 1. 2. 3. 4. 5. 6. 7. · INS recommendation for flushing PICC lines not actively used is 5mL of heparin (10 unites/mL) in a 10mL syringe at least daily when using a nonvalved catheter and at least weekly with a valved catheter. § Using 10mL of sterile saline to flush before and after medication administration; 20mL of sterile saline is flushed after drawing blood § Always use 10mL barrel syringes to flush any central line because the pressure exerted by a smaller barrel poses a risk of rupturing the catheter · In hospitalized client, measure upper arm circumference & external catheter at baseline, insertion, & q shift

10mL barrel syringes to flush any central line because the pressure exerted by a smaller barrel poses a risk of rupturing the catheter

Peripherally Inserted Central Catheter (PICC Line) · Regardless of where the PICC is inserted, the same precautions must be taken using the catheter related bloodstream infection (CRBSI) prevention bundle: 1. Hand hygiene 2. Measuring upper arm circumference as a baseline before insertion 3. Maximal barrier precautions on insertion 4. Chlorhexidine skin antiseptics 5. Optimal catheter site selection and post-placement care with avoidance of the femoral vein for central venous access in adult patients 6. Daily review of line necessity with prompt removal of unnecessary lines 7. Other helpful interventions include: checklist of sterility during procedure, a line chart with equipment, and a stop sign on door to prevent unnecessary traffic during insertion. · INS recommendation for flushing PICC lines not actively used is 5mL of heparin (10 unites/mL) in a 10mL syringe at least daily when using a nonvalved catheter and at least weekly with a valved catheter. § Using 10mL of sterile saline to flush before and after medication administration; 20mL of sterile saline is flushed after drawing blood § Always use ________________________________________________________________ · In hospitalized client, measure upper arm circumference & external catheter at baseline, insertion, & q shift

Q96H, SECONDARY TUBING Q24H OR IF THEY'RE DISCONNECTED/CLIENT IS IMMUNOCOMPROMISED THEN THEY ARE CHANGED EVERY TIME

TUBING CHANGES (per Cortese): Change IV TUBINGS AT LEAST EVERY 96 HOURS OR BY FACILITY POLICY PRIMARY LINES ______________________________________________________________

96 HOURS OR BY FACILITY POLICY

TUBING CHANGES (per Cortese): Change IV TUBINGS AT LEAST EVERY _____________________. PRIMARY LINES Q96H, SECONDARY TUBING Q24H OR IF THEY'RE DISCONNECTED/CLIENT IS IMMUNOCOMPROMISED THEN THEY ARE CHANGED EVERY TIME

125

The health care provider prescribes 1 L 5%D/0.45%NS to be infused over 8 hours. The nurse sets the rate at _______mL/hr of IV solution.

prevent the organisms on the skin from reaching the bloodstream

Tunneled Central Venous Catheters · Tunneled Central Venous Catheters are VADs that have part of the catheter lying in a subcutaneous tunnel, separating the points where the catheter enters the vein from where it exits the skin. § The separation is intended to ____________________________ § Tunneled Central Venous Catheters are usually inserted surgically and removed surgically § The cuffs usually contain antibiotics, which help reduce infection risk. The tissue granulates into the cuff, providing a mechanical barrier to microorganisms and anchoring the catheter in place. · Tunneled Central Venous Catheters can be Single, double, or triple lumen § Named for Creator: Broviac, Hickman, & Leonard Catheters · Tunneled Central Venous Catheters are mainly used when the need for infusion therapy is frequent and long term, such as needing parenteral nutrition for months, years, or the remainder of their lives. They are also used when several weeks or months of infusion therapy is needed and a PICC is not a good choice (paraplegics). Oncology patients may prefer these because they can't tolerate the multiple needle sticks needed for an implanted port · Tunneled Central Venous Catheters have Long-Term Use: Months, Years, Rest of Life

when the need for infusion therapy is frequent and long term, such as needing parenteral nutrition for months, years, or the remainder of their lives. They are also used when several weeks or months of infusion therapy is needed and a PICC is not a good choice (paraplegics). Oncology patients may prefer these because they can't tolerate the multiple needle sticks needed for an implanted port

Tunneled Central Venous Catheters · Tunneled Central Venous Catheters are VADs that have part of the catheter lying in a subcutaneous tunnel, separating the points where the catheter enters the vein from where it exits the skin. § The separation is intended to prevent the organisms on the skin from reaching the bloodstream § Tunneled Central Venous Catheters are usually inserted surgically and removed surgically § The cuffs usually contain antibiotics, which help reduce infection risk. The tissue granulates into the cuff, providing a mechanical barrier to microorganisms and anchoring the catheter in place. · Tunneled Central Venous Catheters can be Single, double, or triple lumen § Named for Creator: Broviac, Hickman, & Leonard Catheters · Tunneled Central Venous Catheters are mainly used _____________________________________________________________________________________________________________ · Tunneled Central Venous Catheters have Long-Term Use: Months, Years, Rest of Life