INTRAVENOUS THERAPY

2nd level preparation

Dr. Shaimaa Ebrahim

Out lines Anatomy of the vein Indications of IV therapy Types of IV fluids Formula for calculating I.V drip &

Documentation. Criteria for vein selection Vein -puncture I.V maintenance (procedure) Complications of I.V therapy

Local Systemic

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Dr.Shaimaa Ebrahim

Definition

“The intravenous management is safe,

effective delivery of treatment (fluid or

medicines) without discomfort or tissue

damage and without compromising venous

access, especially when long term therapy is

proposed”

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Dr.Shaimaa Ebrahim

Tunica Adventitiathe outer layer of the vessel

Connective tissue

Contains the

arteries and veins

supplying blood to

vessel wall

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Dr.Shaimaa Ebrahim

Tunica Mediathe middle layer of the vessel

Contains nerve endings

and muscle fibers

The vasoconstrictive

response occurs at this

layer

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Tunica Intimathe inner layer of the vessel

One layer of endothelial cells

No nerve endings

Surface for platelet aggregation

w/trauma and recognition of

foreign object at this level

PHLEBITIS begins here

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ValvesNot in all veins

Prevent backflow and

pooling

More in lower extremities

and longer vessels

Vein dilates at valve

attachment

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Indications

Fluid and electrolyte replacement

Patient cannot tolerate drugs/fluids orally

Blood sampling

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Dr.Shaimaa Ebrahim

Indications

90-95% of patients in the hospital receive

some type of intravenous therapy.

Administration of medicines

Administration of blood/blood products

Administration of Total parenteral

Nutrition(TPN)

Haemodialysis

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Advantages

Immediate effect

Control over the rate of administration

Some drugs cannot be absorbed by any other

route

Pain and irritation is avoided compared to some

substances when given SC/IM

Management in emergencies

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What are the characteristics of good vein ?

Visible Palpable Straight Soft not rigid Above previous insertion sites Refills when depressed Has a large lumen Well supported/immobile Bouncy/elasticity Not bridging joints

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Dr.Shaimaa Ebrahim

What veins should you avoid ?

Thrombosed / sclerosed / fibrosed Inflamed / bruised Thin / Fragile Mobile Near bony prominences Areas or sites of infection, edema or phlebitis Have multiple previous punctures Do not use if patient has IV fluid in situ

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Dr.Shaimaa Ebrahim

Site Choice

Identify a suitable vein

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Dr.Shaimaa Ebrahim 14

Vein Selection

Veins of the Hand

1. Digital Dorsal veins

2. Dorsal Metacarpal veins

3. Dorsal venous network

4. Cephalic vein

5. Basilic vein

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Dr.Shaimaa Ebrahim

Intravenous Therapy

Vein Selection

 Veins of the Forearm1. Cephalic vein2. Median Cubital vein3. Accessory Cephalic vein4. Basilic vein5. Cephalic vein6. Median antebrachial vein

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Dr.Shaimaa Ebrahim

What equipment do you need?

Cannulation Tray Non Sterile Gloves Alcohol wipes/Gauze swab/ cotton with

alcohol Tourniquet IV cannula Dressing to secure cannula/adhesive tape IV administration set Saline flush and sterile syringe or fluid to be

administered Sharps bin/sharp container/safety box

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Preparation

Check doctor order

Identify the patient

Consult with patient & Give explanation

Gain consent (oral agreement enough)

Position the patient appropriately and identify the

non-dominant hand / arm

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Preparation

Support arm on pillow or in other suitable

manner.

Check for any contra-indications e.g. infection,

damaged tissue, AV fistula etc.

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Cannulation

Encourage venous filling by: Correctly applying a tourniquet The tourniquet should be applied at a pressure

which is high enough to impede venous distension but not to restrict arterial flow)

Apply the tourniquet, 7-10 cm above site Opening & closing the fist Lowering the limb below the heart level

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Dr.Shaimaa Ebrahim

Cannulation

Remove tourniquet if not able to proceed Put on non-sterile gloves Re-apply the tourniquet, 7-10 cm above site Remove the protective sleeve from the needle

taking care not to touch it at any time Hold the cannula in your dominant hand,

stretch the skin over the vein to anchor the vein with your non-dominant hand (Do not re palpate the vein)

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Types of Intravenous Fluids22

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Calculating Intravenous Drip

The nurse calculate In drip by using the

following formula:

  volume  to be infused(ml) × drop factor= …= …

drop/mindrop/min

time in minutes

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Dr.Shaimaa Ebrahim

Drop factor

For ordinary I.V set (macro drips) = 15

For blood transfusion =10

For micro drips = 60

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Complications of IV Therapy

Classified according to their location

Lo c a l c o m p lic a tio n : at or near the

insertion site or as a result of

mechanical failure

Sys te m ic c o m p lic a tio ns : occur within the

vascular system, from the IV substance.

Can be serious and life threatening

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Dr.Shaimaa Ebrahim

Local complications

Occur due to trauma to the surrounding vein puncture site

Assessing and monitoring are the key components to early

intervention

Good vein puncture technique is the main factor related to

the prevention of most local complications associated with

IV Therapy.

Local complications include: hematoma, thrombosis,

phlebitis, post-infusion phlebitis, thrombophlebitis,

infiltration/extravasation, local infection, and or venous

spasm.

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Hematoma

Hematoma formation and echeymosis resulting from

the infiltration of blood into the tissues at the vein

puncture site

Related to false vein puncture technique

Use of large bore cannula in small vein leads to:

Trauma to the vein during insertion

Patients receiving anticoagulant therapy or long term

steroids

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Dr.Shaimaa Ebrahim

Hematoma Prevention Apply tourniquet just before vein puncture( not

more than 2 to 3 minutes)

Use a small needle in the elderly, patients on

steroids, hepatic patients, patients with thin veins &

thin skin, pt with thrombocytopenia.

Be gentle during insertion

Use proper direction and angle

Don’t retry more than one time

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Hematoma Treatment

Apply direct, light pressure for 3-5 minutes after

needle removal in sampling or cannulation

Have patient elevate extremity

Apply cold foments at the puncture site

Document and report

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Dr.Shaimaa Ebrahim

Thrombosis Trauma to the endothelial cells of the venous

wall causes red blood cells to adhere to the vein

wall, forms a clot or Thrombosis How to determine

Drip rate slows, line does not flush easily,

resistance is felt

Never force flush into the catheter

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Thrombosis Signs and Symptoms

Slowed or stopped infusion rate Inability to flush easily Fever and Malaise

Prevention Use pumps and controllers to manage flow rate Usage of Small size device for rate below50mL/hr Avoid areas of flexion Avoid lower extremities

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Dr.Shaimaa Ebrahim

Thrombosis

Treatment

Never force flush a cannula to remove an

occlusion

Disconnect the cannula

Notify the physician and assess the site for

circulatory impairment Have to Document

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Dr.Shaimaa Ebrahim

Phlebitis

Inflammation of the vein in which the endothelial

cells of the venous wall become irritated and cells

roughen, allowing platelets to adhere and

predispose the vein to inflammation-induced

phlebitis

Tender very painful when touch

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Phlebitis Mechanical:

When large catheter used for small vein Manipulation of the catheter: improper stabilization Improper insertion technique (large angle)

Chemical: vein becomes inflamed by irritating or vesicant solutions or medication

Irritation medication itself (as in chemotherapy/potassium)

Improperly mixed or diluted medicines Too-rapid infusions

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Dr.Shaimaa Ebrahim

Phlebitis

Chemical (cont):

The more acidic the IV solution the greater the

risk

Additives: Potassium

Length of device (should not exceed 72 hrs)

The slower the rate of infusion the less irritation

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Dr.Shaimaa Ebrahim

Bacterial Phlebitis

Also called Septic phlebitis: least common Inflammation of the intima of the vein Contributing factors

Dressing (infrequent) Time of the catheter Poor insertion technique Failure to perform site assessment Inadequate stabilization Poor aseptic technique

Failure to detect breaks in the integrity of the equipment Aseptic preparation of solutions Improper Hand washing and preparing the skin

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Dr.Shaimaa Ebrahim

Phlebitis

Immune system causes leukocytes to gather at

the inflamed site

Pyrogens stimulate the hypothalamus to raise

body temperature

Redness and tenderness increased

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Dr.Shaimaa Ebrahim

Phlebitis Signs and Symptoms

Redness at the site Site warm to touch Local swelling Palpable cord along the vein Sluggish infusion rate Increase in basal temperature of 1degree C or more

Prevention Use larger veins for hypertonic solutions Central lines for Infusions lasting longer than 5 days

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Dr.Shaimaa Ebrahim

Thrombophlebitis

Thrombophlebitis denotes a two fold injury:

thrombosis and inflammation

Related to: Use of veins in the lower extremity

Use of hypertonic or highly acidic infusion solutions

Causes similar to those leading to phlebitis

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Dr.Shaimaa Ebrahim

Thrombophlebitis

Signs and Symptoms Sluggish flow rate Edema in the limbs Tender and cord like vein Site warm to the touch Visible red line above venipuncture site Diminished arterial pulses Mottling and cyanosis of the extremities

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Dr.Shaimaa Ebrahim

Thrombophlebitis

Prevention Use veins in the forearm rather than the hands Do not use veins in a joint Assess site q 4 hr in adults, q 2 hr in children Catheter securing Infuse at rate prescribed Use the smallest size catheter to do the job Proper dilution

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Dr.Shaimaa Ebrahim

Thrombophlebitis

Prevention

Septic thrombophlebits can be prevented:

Appropriate skin preparation

Aseptic technique in the maintenance of catheter and

infusion

Keep using sterile IV set

Proper hand hygiene

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Dr.Shaimaa Ebrahim

Infiltration

Related to: Puncture of the distal vein wall during insertion Puncture of the vein wall by mechanical friction Dislodgement of the catheter from the intimae of

the vein Poor securing High delivery rate Over manipulation

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Dr.Shaimaa Ebrahim

Infiltration

Signs and Symptoms Coolness of the skin around site Taut skin/tense skin Dependent edema Absence of blood return “Pinkish” blood return Infusion rate slows /stoppage

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Dr.Shaimaa Ebrahim

Cellulitis Treatment

Use of topical antibiotics May need systemic antibiotics Document and report Use proper foments as physician order

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Dr.Shaimaa Ebrahim

Extravasation

Accidental administration of a vesicant solution into surrounding tissue

leakage of high osmolarity solutions or chemotherapy agents into the surrounding tissue, because the needle has punctured the vein and the infusion goes directly into the arm tissue.

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Dr.Shaimaa Ebrahim

Extravasation

Vesicant is a fluid or medication that causes the

formation of blisters, with subsequent sloughing

of tissues occurring from the tissue necrosis

Extravasations related to: Puncture of the distal wall

Mechanical friction

Dislodgement of the catheterDr.Shaimaa Ebrahim

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Examples of Vesicants

High concentration KCL pH is 5 to 7.8 Calcium gluconate pH is 6.2 Amphotericin B pH is 5.7 to 8 Dopamine pH is 2.5 to 5 Nipride pH is 3.5 to 6 10%, 25% or 50% dextrose pH is 3.5 to 6.5 Sodium bicarbonate pH is 7 to 8.5 Dilantin pH is 12 (Drano has a pH of 14)

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Dr.Shaimaa Ebrahim

Extravasations

Signs and Symptoms Complaints of pain or burning Swelling proximal or distal to the IV site Puffiness of the dependent part of the limb Skin tightness at the veinpuncture site Coolness of the skin Slow or stopped infusion Damp or wet dressing

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Dr.Shaimaa Ebrahim

Extravasations Prevention:

Use of skilled practitioners Knowledge about the vesicants Condition of the patients veins Drug administration technique

If continuous give in CVD/CVL/CVCOnly with brisk blood return of 3-5 ccMust Use a pump on vesicants given

peripherallyAssess for blood return frequentlyClose nursing monitoring

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Dr.Shaimaa Ebrahim

Venous spasm

A sudden involuntary contraction of a vein or resulting in temporary cessation of blood flow through a vessel.

Signs/symptoms: sharp pain at the IV site that travels up the arm, which is caused by a piercing stream of fluid that irritates or shocks the vein wall; slowing of the infusion

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Venous spasms cont

Documentation: patient complaints, duration of complaints, treatment, and length of time to resolve the problem

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Dr.Shaimaa Ebrahim

Systemic Complication

Septicemia: febrile disease process that results

from the presence of microorganisms or their

toxic products in the circulatory system

S/S: fluctuating fever, tremors, chattering teeth,

profuse cold sweat, nausea and vomiting,

diarrhea, abdominal pain, tachycardia, increased

respirations or hyperventilation, altered mental

status, hypotension.

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Dr.Shaimaa Ebrahim

Fluid overload & Pulmonary edema

Caused by infusing excessive amounts of isotonic or hypertonic crystalloid solutions rapidly, failure to monitor the IV infusion or too-rapid infusion of any fluid in a patient compromised by cardiopulmonary or renal disease.

S/S: restlessness, headache, increased in pulse

rate, cough, , shortness of breath, hypertension,

wide variance between intake and output, distended

neck veins, weight gain over a short period of time,

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Dr.Shaimaa Ebrahim

Air embolism

Air entering the central/peripheral vein, which is

quickly trapped in the blood as it flows forward.

S/S: complaints of palpitations, weakness, pulmonary

findings: dyspnea, cyanosis, tachypnea, wheezes,

cough, and pulmonary edema. Cardiovascular: “mill

wheel” murmur; weak thready pulse; tachycardia;

sub-sternal chest pain; hypotension; and jugular

venous distention.

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Dr.Shaimaa Ebrahim

Air embolism

Neurologic findings: change in mental

status, confusion, coma, anxiousness,

and seizures.

Prevention is the key.

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Dr.Shaimaa Ebrahim

Speed shock

Occurs when a foreign substance usually a

medication is rapidly introduced into the

circulation

S/S: dizziness, facial flushing, headache,

tightness in the chest, hypotension, irregular

pulse, progression of shock.

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Dr.Shaimaa Ebrahim

Cannulation

References Clinical Skills Education Centre

http://www.qub.ac.uk/cskills/index.htm

Standards for Infusion Therapy RCN http://www.rcn.org.uk/publications/pdf/standardsinfusiontherapy.pdf

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