Insertion: Half the Battle!

Pre-insertion checklist

Cross check your order with the IV solution

Prime your tubing before getting started

Check patient’s allergiesIV PoleIV SuppliesIV catheter of choiceDouble check patient’s

identity- Are you sure? Ask pt for his/her name.

Collect the supplies • Items needed to start an IV

– Tourniquet– Antiseptic– Alcohol pads– Tape– Dressing – Label for site– Barrier– Gloves-- Needle/catheter

Prime the tubing

• Open the package per manufacturer’s recommendations. Inspect the equipment.

• Slide roller clamp up close to drip chamber.• Close the roller clamp. • Remove protective cuff on fluid container. • Remove the protective cover over the piercing pin

on the tubing and the bag, maintaining sterility.

Connect tubing to IV bag, hang set

Spike the piercing pin into the bag in an aseptic manner.Squeeze the drip chamber 1/3-1/2 full.Hang the container on an IV pole.Maintaining sterility of the end of the tubing, loosen

the protective cap.Invert all Y-sites for better filling and to prevent air

trapping.Open the roller clamp and allow solution to flow,

removing all air bubbles from the tubing- this is called “priming” the tubing (also GI tube feeds)

• After priming the tubing, close the clamp and tighten the protective cover at the end of the tubing.

• Loop the tubing over the IV pole for protection and availability for use.

Universal Precautions

• Consider exposure to bloodborne pathogens

• Recommends protective barriers and appropriate use- policy/nurse judgemt.– Gloves– Gowns– Masks– Goggles

Hair Removal-FYI, rarely needed for IV mgmt.

• Clipping vs. shaving• INS Standards of

Practice discourages– The use of razors

because micro-abrasions alter the integrity of the skin

– If necessary, hair should be removed with

scissors/clippers

Patient Positioning

• Ideally…...– Comfortable supine position– Arm extended 45 degree angle– Maintain insertion site below level of heart

• Alternative– Sitting 45-90 degree angle as tolerated– Arm abducted 30 degrees– Maintain insertion site below level of heart

Control the Environment

Adjust lightingAdjust height of bedAsk visitors to leave during the procedureDraw curtain if semiprivate roomIintroduce yourself “Have you had an IV before?” -explain procedure if needed -ask how much difficulty there has been in starting IV’s in the past -a preferred location

Provide information and answer questions

– Check for allergies especially iodine– Explain why IV is needed– How venipuncture is done– Degree of discomfort– IV limits movements– Possible discomforts while IV is infusing

Venous Assessment

• Assessment should include both extremities'

• Team up for a look !!!!!!

• Fundamental: Why do we infuse

into veins not arteries?

Optimal Vein Conditions

• Soft, straight, elastic

• Supported by intact, elastic skin

• Springy, easily palpated

• Easily stabilized

Key Points to Remember• Good lighting• Distal to Proximal (saves sites more proximal

for future IV starts)• Alternate arms whenever possible• Avoid areas of flexion• Site should be free of trauma, abrasions or

cuts• Schlerosed, thrombosed (clotted) or varicosed

veins should be avoided

Prepare your site

• Clip excessive hair. You can use scissors; tape will pick up excessive hair- pain

• Visualize/landmark (fingernail mark?)• Cleanse according to your institution’s Policy

and Procedure• Chlorhexidine/alcohol options • Once cleansed do not touch the site. If you

palpate the vein, the skin must be cleansed again

Select your cannula

Smallest gauge needed Less trauma to the vein Greater blood flow around the tip reducing the risk

of phlebitisAlways open per manufacturer’s instruction; not

by punching the cannula through the wrappingCheck for errors in packagingCheck to see that the needle extends beyond

catheter

Catheters (and needles) are sized by their diameter, which is called the gauge. The smaller the diameter, the larger the gauge. Therefore, a 22-gauge catheter is smaller than a 14-gauge catheter.

Catheter Sizes

14-16 G—Trauma, possible OR, plasma pheresis, anesthesia

18G-blood, surgery, anesthesia20G-procedures, large volumes, transfusions,

heart monitor22G-IV fluids, medication, COMMON24G –26G-non viscous intermittent

medications, last resort, Flow must be 100cc or less if infusing on a pump

Venipuncture Technique

• After skin prepping, apply tourniquet • Ascertain the integrity of the IV Catheter• Position in front of the limb with your dominant

hand in alignment with the vein to be punctured.• Stabilize the vein by placing thumb below intended

site and draw skin toward you, pulling the skin taut

How to hold the catheter- options

• Butterfly: Grasp the wings between your thumb and forefinger with the bevel facing upward. Squeeze the wings together

• Over the needle: Grasp the flash back chamber and the color-coded hub with the dominant hand and remove the cover, then hold the hub and flash back chamber between thumb and forefinger. BEVEL UP!

Venipuncture

• Place the needle, bevel side up, parallel with and directly above the vein

The “poke”

• Insert Needle At approx. 30 degree angle to the skin

For IV placement (vs blood draw)

• After skin and vein are penetrated and a flash back of blood is observed, lower the needle to a 10 –15 degree angle and slowly advance about 3-4 millimeters farther into the vein.

• This is required because the catheter is shorter than the needle; thus, backflow may occur before the catheter tip is fully in the vein

Placing an IV

• Gradually advance only the catheter, gently • Leave the stylet (needle) in place to occlude

the catheter to prevent bleeding (some leaking may occur- this is normal)

Placing an IV

RELEASE THE TOURNIQUETCollapse vein by placing a finger ½ inch above the

insertion sitePlace the stylet in sharps container . . .Never reinsert the stylet into the catheter.Attach tubing to hub of needle maintaining sterilityApply clear occlusive dressing or gauze dressing up to

the hub of the catheter but not covering itMake sure to loop tubing and tape it well.

Stabilizing Cannula

• Try not to place tape on occlusive dressings• Do not encircle extremity with tape• Do not allow tape to cover cannula or

insertion site

Securing Techniques

Goals:– To prevent dislodging of IV catheter– Prevent phlebitis– Secure to prevent movement – Circulation is not inhibited

Chevron Method

U Method

H Method

Loop tubing and secure

What’s wrong with this picture?

IV POLICE

Tubing Dressing Transparent: Semi-permeable membrane that allows for visual

inspection of site. Change:

With site changeIf seal is brokenDressing is wet and lifting up

Sterile 2X2 used only if client is allergic to transparent dressings. Tape all four corners. Change dressing every 24-48 hours.

Dressing should be labeled with:Date & timeGauge of cannulaYour initials & title

Dispose of your sharps immediately !!!

A majority of needlesticks occur to other nurses who come to help ‘clean’ up.

Documentation

• If it’s not noted, it was not done

•Gauge size•Identify the site•Length of catheter•Dressing type•Date/time of insertion

•Prepping procedure

•Patient allergies

•Patient education

•Patient tolerance

•Local anesthetic

• Insertion difficulties

• Number of sticks

• Inserter initials

Patient Teaching• Allowed range of motion• To maintain dryness of dressing• Position of involved extremity when

ambulating• Call for assistance if:

Dressing begins to feel wetPain developsRedness developsSwelling developsBlood backs up into tubingIV pump is beeping

Catheter Flushing

Heparin Flushing Volume of flush 10u/ml for peripheral 100u/ml for central NEEDS AN MD ORDER

Saline Flushing Studies indicating that for peripheral flushing it is

as effective as heparin Not utilized as often in home care

Catheter Flushing

• SASH Flushing– This flushing method is used to ensure that

medication incompatible with heparin gets flushed through the catheter with saline then is flushed with heparin

• Saline• Administer medication• Saline• Heparin

Catheter Flushing

• Positive Pressure Flushing– Technique that prevents blood from backing up

into the catheter by keeping pressure on the syringe plunger while pulling out of the injection cap. Don’t completely empty your syringe of flush

• Effects of valve products• e.g. Posiflow

Extension Set/Cap Changes

• Change per facility policy• Use aseptic technique• Utilize luer lock connections• Never use clamps, scissors or hemostats• Know volume capacity of add-ons

Extension tubing

• Prevents manipulation of the IV catheter

• Easily grasped for injections

• Safeguards catheter dislodgement by advantage of looped tubing

Site Maintenance

• Follow your facilities policies• Fluid hang time

– Usually 24 hours for TPN– Could be 48-72 hours for most medications

• Venipuncture site rotation– Usually 48-96 hours– If poor access, notify physician and document

reason– Get a PRN site change order from MD

Site Monitoring

• Observe every 1-2 hours on continuous flow IV• Observe every 8 hours on heparin or saline lock• Document at least every shift• Goals

– To assure proper infusion of intravenous solution

– Reduce risk of complication– Early detection of IV related complications

Evaluation of therapy

Patient Assessment to include:

Renal and Cardiac status is evaluated before initiating IV therapy.Comparison of I&O measurements.Vital SignsSkin TurgorDaily WeightsUrinary Specific Gravity Lab Values

Site Maintenance

• Dressing Change Intervals– Transparent Dressing: change with site change or

occlusive seal broken– Gauze Dressing: Change every 48 hours or when

soiled and PRN• Tubing Change

– Every 24-72 hours as dictated by your institution’s policy

Documentation

• IV Flow Sheet• Nurses Notes• Medicine Record• I&O• Weight• Vital Signs• Care Plan

– Alteration in fluid/electrolytes– Potential for Injury in relation to IV therapy

Heparin/Saline Locks

A heparin lock may consist of a catheter with tubing ending in a resealable rubber injection port, or a needless system such as a reflux valve. Many options are on the market.

Termination of IV site

• Gather supplies, wash hands and don gloves• Clamp tubing to stop IV infusion.• Withdraw catheter slowly flush with the skin• Cover with 2x2 dry sterile dressing.• Raise the extremity above the heart and apply

firm pressure for 1 minute • Assess catheter – CHECK THE TIP; also look for

abrasions or shearing evidence• Document

Troubleshooting Slow Drip RatesCheck for infiltrationCheck for kinking of the tubingCheck for phlebitisReadjust clamp on tubing above/below previous

area of pinchingCheck air vent on administration set if indicatedCheck catheter for patency by lowering the bag of

fluid below the level of the site, you will see blood back up

Cather tip may be pressed against a vein valve

• Venous spasm may occur—heat may help relax vein to relieve the spasm

• Check height of the container above the patient

• Do not irrigate traumatized vessel• Assess pump function• If in doubt, pull it out.

Admixing- or- Attached vial of powder

To a bag• Stabilize injection port with one hand• Insert the needle through the center of the

rubber stopper with the other• Inject the medication.• Rotate bag to spread medication. • Label bag with correct medication added

label

Admixing

To a bottleInsert the needle through the rubber sealRotate the bottle to spread medication Label with correct medication order

-Admixtures should not be performed on infusing IV solutions !!! -Prevents delivering a bolus of the drug to the patient

Complications

Arterial Puncture- rare for “poke”

• Signs & Symptoms– Color of blood– Pulsatile flow of blood– Retrograde flow of blood– Blanches when flushed

Arterial Puncture

Causes• Failure to identify the artery• Deep insertion approach• Excessive probing

Prevention • Identify artery• Remain superficial• Avoid fishing & probing

Intervention• Remove needle/catheter

immediately• Apply direct pressure for 5-

10 minutes by clock• Compression dressing

Never infuse into an artery!- drug goes to?

Phlebitis- inflammation of vein and surrounding areas

• Signs & Symptoms– Pain or tenderness along the vein– Erythema– Swelling or edema– Palpable cord– Warmth– Drainage

Phlebitis

Classification

• Mechanical• Chemical• Bacterial

Causes of Mechanical Phlebitis

• Excessive manipulation of the catheter• Catheter gauge too large for the vein• Improper insertion technique (poked

through?)• Inadequate stabilization of the catheter• Patient factors

Causes of Chemical Phlebitis

• Infusion of hypertonic or hypotonic solutions or medications

• Particulate matter• Infusion rate too rapid for the vein• pH of the solution too acid or alkaline

Causes of Bacterial Phlebitis

• Compromised aseptic technique when accessing the vein or the infusion system

• Improper skin preparation• Contaminated infusate• Extended catheter dwell time

Intervention for Phlebitis

– Remove short peripheral catheters– Obtain cultures if infection is suspected– Cleanse the site with an antimicrobial solution– Apply warm, moist compresses– NSAIDS, mild exercise– Modify medication if chemical phlebitis is suspected-

notify provider/MD

Prevention of Phlebitis

Use only one catheter per insertion attemptAppropriate catheter sizeAssess appropriateness of the catheter for the specific

therapyEmploy proper site preparation and careStabilize the IV catheter adequatelyUse strict aseptic technique for admixture, flushing and

infusion managementDilute/slow down irritating medicationsInstruct patient or caregiver in signs and symptoms Rotate peripheral IV site at established intervals

INS Grade

Clinical Criteria--Phlebitis

0 No Symptoms

1 Redness at access site with or without pain

2 Pain at access site with erythema and/or edema

3 Pain at access site with erythema and/or edema. Streak formation. Palpable venous cord

4 Pain at access site with erythema and/or edema. Streak formation. Palpable venous cord>1 inch in length. Purulent drainage

Local Site Infection

• Signs & Symptoms– Drainage from insertion site– Erythema– Swelling– Pain or tenderness– No systemic symptoms

Site Infection Causes Contamination of insertion

site Improper skin prep Improper site maintenance Patient condition Handwashing techniques Aseptic techniques

Prevention Strict adherence to sterile &

aseptic techniques

Intervention Notify physician Manage according to

causative agent and type of catheter

May include: culture antibiotics daily dressing changes catheter removal &

replacement

Preventative Measures

• Interruption of transmission requires– Good handwashing techniques

– Strict adherence to aseptic technique

– Practice of Standard/Universal Precautions

Ecchymosis/Hematoma

• The infiltration of blood into the tissues. A hematoma occurs if the bleeding is uncontrolled at the venipuncture site, creating a hard lump

• Identified as a swelling above the IV site; bruising may be immediate or slow

Ecchymosis/Hematoma -Causes

Unskilled venipuncturePatient with tendency to bruise easilyPatient on anticoagulant or long-term steroid

therapyMultiple entries into the veinInadequate pressure to the siteApplying a tourniquet to the same extremity

immediately after an unsuccessful IV attempt or current IV in place.

Echcymosis/Hematoma -Interventions

• Remove catheter• Apply firm pressure to the IV site• Elevate the extremity• Do no use the affected extremity until

bleeding has completely stopped

Ecchymosis/Hematoma -Prevention

• Skilled venipucture• Do not reapply a tourniquet to the affected

extremity until bleeding has completely stopped

• Apply firm pressure to prevent bleeding into subcutaneous tissue when catheter removed

Infiltration• The inadvertent administration of a non-vesicant

solution or medication into surrounding tissues• Edema at the insertion site• Skin may appear taut or stretched• Blanching or coolness of the skin• Infusion may be sluggish or stopped• Tenderness at the site

Extravasation The inadvertent administration of a vesicant

(highly irritating/destructive) solution or medication into surrounding tissues (phenergan, some abx, others)

• Severe pain or burning during infusion• Blotchy redness around the insertion site• Edema at the insertion site• Slowing or stopping of the infusion rate

Infiltration/Extravasation -Causes

• Improper selection of the catheter or site—catheter gauge too large, or small thin-walled veins

• Traumatic insertion• IV catheter inadequately secured• IV site is over a joint• Inappropriate route or rate of administration

for the solution/medication

Infiltration -Intervention

• Stop the infusion and remove the catheter• Elevate the extremity to improve circulation

and absorb the fluid• Initiate a new infusion in the opposite

extremity, if indicated• Document

Extravasation -Interventions

Discontinue infusion immediately, leave the catheter in place

Notify the physicianHave antidote available if indicatedAspirate residual medication and bloodDiscontinue the catheterElevate the extremity to improve circulationObserve the site frequently for signs of erythema,

palpable cord or necrosisPhotograph the site

Infiltration-Prevention

Choose appropriate vein and catheterAvoid areas of flexion when inserting a catheterObtain assistance when inserting an IV in a hyperactive

patientMinimize trauma when initiating venous accessSecure the IV catheterProtect the IV site from excessive movement or pressure by

the use of arm boards or restraints per policyAssess the site frequentlyEducate the patient regarding the signs and symptoms of

infiltration.

Extravasation-Prevention

Same as Infiltration PLUS:• Anticipate extravasation when administering a

vesicant -an agent capable of causing or forming a blister or causing tissue destruction• Consider the placement of a central catheter• When in doubt—pull it out!• Educate the patient regarding recognition of

potential problems and action required

Catheter Occlusion

• Resistance when instilling solution/drug

• Difficulty infusing solutions

• Inability to flush catheter

• Inability to aspirate blood

• Rate of infusion slows or stops

Causes of Catheter Occlusion

• Blood Draw• Transfusion• Reflux of blood• Failure to flush• Incompatible medication • Poor solubility• Mechanical Failure—kinking, clamps, or

malposition

Occlusion--Intervention

• Attempt flush with 10 mL SYRINGE only!• Don’t force!• Remove peripheral catheter, restart in

another vein• Alteplase for Central Line Catheters

Syringe Selection & PSI

Macklin D. “What's physics got to do with it” JVAD. Summer 1999

“Larger syringes create less pressure when used to withdraw and/or flush”

The laws of physics dictate that given equal force on two syringes, that a small-cylinder syringe (like a 2-3 ml) will exert more pressure than a larger syringe (like a 10 ml) for IV lines, and for the patient’s vein. The high pressure may “blow” the patient’s vein, as in tear it, creating extravasation/bleed.

Nerve Damage/Stimulation

• Signs & Symptoms– Numbness– Tingling– Weakness

Nerve Damage/StimulationCauses• Rare• Irritation to the nerve

during insertion• Improper arm positioning• catheter outside of vein

Prevention• Appropriate assessment• support the arm• Avoid unnecessary probing• Advance slowly & gently

Intervention• Stop advancement • Restart using slower

motion• If sensations continue

catheter should be removed

Catheter Embolism

• Signs & Symptoms– Visible shearing---only

identified when catheter removed

Catheter EmbolismCauses• Damage to catheter• Reinserting stylet into catheter• Aggressive stylet removal

Prevention • Remove from packaging per

manufacturer’s recommendation

• Do not reinsert stylet after removal

• Avoid use of clamps and scissors

Intervention• To prevent migration of

retained apply direct pressure

• Retrieve fragments if visualized

• Notify physician

Catheter-Related Bloodstream Infection

• Signs & Symptoms – Fever & chills– Elevated temp– Increased WBC– Positive cultures– Hypotension– Vascular collapse– Shock– Death– More prevalent in Central Line

Catheter-Related Bloodstream Infection

CausesContaminated

equipment or solutions Improper hand washing

and aseptic technique during catheter insertion and care

Improper set-up and handling of infusion equipment and solution

Sources of Bacterial Contamination

• Patient’s skin• Hands of medical personnel• Hub contamination• Insertion site contamination• Another site of infection, i.e., GI or Urinary

tract infection• Contaminated fluids

Catheter-Related Bloodstream Infection

• Risk factors– Insertion of a IV catheter into a patient who

already has an infection– Frequent manipulation of the intravenous system– Duration of catheterization– Prolonged hospitalization before central venous

catheterization– Catheter insertion in the internal jugular vein

Catheter-Related Bloodstream Infection

Prevention Strict adherence to sterile & aseptic techniques Strict hand washing before initiating any infusion procedure Clip excessive hair at insertion site Cleanse the IV insertion site with an antimicrobial solution and

friction Use maximum sterile barrier precautions for central line insertions Disinfect ports/hub before accessing with an antiseptic solution Change all solutions and tubing according to facility policy D/C catheter ASAP Ongoing staff training and education

Catheter-Related Bloodstream Infection

InterventionNotify physicianEvaluate symptoms for possible causesMonitor Vital SignsObtain 2 blood culturesIf catheter is discontinued, aseptically remove and

send tip for culture(Catheter related infection is documented by isolation of the same organism from a catheter tip and the two blood cultures with no other apparent source for clinical S/Sx of infection

Culturing Infected Catheters

• Remove dressing securing site, thoroughly cleanse site with 70% alcohol, air dry.

• Remove the cannula without touching it or dragging it on the client’s skin

• After the cannula has been removed, clip approximately ½-1 inch of catheter with sterile scissor, drop into a sterile specimen cup