Insertion: Half the Battle!

1. Insertion: Half the Battle!

2. Pre-insertion checklist • Cross check your order with the IV solution • Prime your tubing before getting started • Check patient’s allergies • IV Pole • IV Supplies • IV catheter of choice • Double check patient’s identity- Are you sure? Ask pt for his/her name.

3. Collect the supplies • Items needed to start an IV • Tourniquet • Antiseptic • Alcohol pads • Tape • Dressing • Label for site • Barrier • Gloves -- Needle/catheter

4. 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.

5. 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)

6. 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.

7. Universal Precautions • Consider exposure to bloodborne pathogens • Recommends protective barriers and appropriate use- policy/nurse judgemt. • Gloves • Gowns • Masks • Goggles

8. 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

9. 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

10. Control the Environment • Adjust lighting • Adjust height of bed • Ask visitors to leave during the procedure • Draw curtain if semiprivate room • Iintroduce 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

11. 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

12. Venous Assessment • Assessment should include both extremities' • Team up for a look !!!!!! • Fundamental: Why do we infuse into veins not arteries?

13. Optimal Vein Conditions Soft, straight, elastic Supported by intact, elastic skin Springy, easily palpated Easily stabilized

14. 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

15. 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

16. Select your cannula • Smallest gauge needed • Less trauma to the vein • Greater blood flow around the tip reducing the risk of phlebitis • Always open per manufacturer’s instruction; not by punching the cannula through the wrapping • Check for errors in packaging • Check to see that the needle extends beyond catheter

17. 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.

18. Catheter Sizes • 14-16 G—Trauma, possible OR, plasma pheresis, anesthesia • 18G-blood, surgery, anesthesia • 20G-procedures, large volumes, transfusions, heart monitor • 22G-IV fluids, medication, COMMON • 24G –26G-non viscous intermittent medications, last resort, Flow must be 100cc or less if infusing on a pump

19. 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

20. 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!

21. Venipuncture Place the needle, bevel side up, parallel with and directly above the vein

22. The “poke” Insert Needle At approx. 30 degree angle to the skin

23. 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

24. 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)

25. Placing an IV • RELEASE THE TOURNIQUET • Collapse vein by placing a finger ½ inch above the insertion site • Place the stylet in sharps container . . . • Never reinsert the stylet into the catheter. • Attach tubing to hub of needle maintaining sterility • Apply clear occlusive dressing or gauze dressing up to the hub of the catheter but not covering it • Make sure to loop tubing • and tape it well.

26. 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

27. Securing Techniques Goals: • To prevent dislodging of IV catheter • Prevent phlebitis • Secure to prevent movement • Circulation is not inhibited

28. Chevron Method

29. U Method

30. H Method

31. Loop tubing and secure What’s wrong with this picture? IV POLICE

32. Tubing Dressing • Transparent: Semi-permeable membrane that allows for visual inspection of site. • Change: • With site change • If seal is broken • Dressing 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 & time Gauge of cannula Your initials & title

33. Dispose of your sharps immediately !!! A majority of needlesticks occur to other nurses who come to help ‘clean’ up.

34. Documentation • 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 If it’s not noted, it was not done

35. 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 wet Pain develops Redness develops Swelling develops Blood backs up into tubing IV pump is beeping

36. 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

37. 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

38. 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

39. 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

40. Extension tubing • Prevents manipulation of the IV catheter • Easily grasped for injections • Safeguards catheter dislodgement by advantage of looped tubing

41. 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

42. 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

43. Evaluation of therapy • Patient Assessment to include: • Renal and Cardiac status is evaluated before initiating IV therapy. • Comparison of I&O measurements. • Vital Signs • Skin Turgor • Daily Weights • Urinary Specific Gravity • Lab Values

44. 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

45. 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

46. 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.

47. 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

48. Troubleshooting Slow Drip Rates • Check for infiltration • Check for kinking of the tubing • Check for phlebitis • Readjust clamp on tubing above/below previous area of pinching • Check air vent on administration set if indicated • Check 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

49. 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.

50. 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