IV Therapy Module

Welcome to the IV Therapy Module!
Follow the steps below to successfully establish competence.

IV Therapy Module Objectives:
At the completion of this module, the caregiver will be able to discuss the indications, complications, and key steps for initiating IV therapy. The caregiver will also be able to identify and discuss the considerations associated with selecting and maintenance of IV sites.
(*Revised 9-2003)

Step #1
Read the attached module. The learning activities may be used as a study guide. This module has been designed to be completed within 30-45 minutes.

Step #2
The participant should complete and return the posttest.

IV Therapy Learning Activity

IV Therapy In the health care environment vascular access is performed to deliver fluid and medication, as well as for sampling the blood and it's components. Children report needlesticks to be the most distressing aspect of a hospital or out-patient experience. The following principles of care are integral to efforts to minimize needle related pain and distress in children – • Avoid or cluster needlesticks whenever possible • Use the IM route only if absolutely necessary • intervene early - if a child has a difficult experience with their initial venipuncture / IV start they will have heightened anxiety around subsequent procedures • Be developmentally appropriate Before the caregiver can perform vascular access they should have an understanding of the following: • Vascular anatomy and physiology • Basic steps for performing access • Complications and hazards • Growth and developmental implications This module is intended to be an introduction to vascular access. The caregiver should seek out additional specific information (i.e., policy and procedure) when performing vascular access in their area.

Before the caregiver can perform vascular access they should have an understanding of the following:

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IV Therapy Learning Activity Fill-In the names of the vessels in order as they exit the heart. Exiting the Heart

IV Therapy Basic Vascular Anatomy and Physiology The circulatory system consists of a series of blood vessels. The blood vessels in the human body form a network of tubes that carry blood away from the heart, transport it to the tissues of the body, and then return it to the heart. Arteries are vessels that carry blood from the heart to the tissues. Large, elastic arteries leave the heart and divide into medium-sized, muscular arteries that branch out into the various regions of the body. Arterioles are smaller -sized arteries that divide from medium arteries. Arterioles enter tissues, and branch into countless microscopic vessels. Capillaries are the microscopic vessels found in the tissues. Through the walls of the capillaries, substances are exchanged between the blood and body tissues. Venules are the small veins that are formed from groups of capillaries reuniting before leaving the tissues. Veins are the larger vessels formed from the venules which convey blood from the tissues back to the heart. Due to the design of the body's circulatory system the arteries receive blood being pumped directly from the heart. As a result arteries can be classified as high pressure / pulsatile vessels. Since the veins are the last vessels involved with returning blood to the heart they can be referred to as low pressure / non-pulsatile vessels.

_______________________

_______________________

_______________________

_______________________

_______________________ Back to the heart

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IV Therapy "Learning Activity"

IV Therapy The pressure in the veins is barely enough to balance the force of gravity pushing blood back down to the lower limbs. For this reason many veins, especially those in the limbs, contain valves to prevent backflow.

Explain how the veins prevent the backflow of blood in the lower limbs due to the force of gravity. _____________________________ ___________________________ _____________________________

Indications for Vascular Access The indications for vascular access may include the following: • fluid replacement • blood sampling • medication delivery • parenteral nutrition

Indications For Vascular Access may include: (Fill-In) ___________________________ ___________________________ ___________________________ ___________________________

Selecting A Site for Access Site selection is one of the most important considerations in preparing to start an IV or to obtain blood. The caregiver should always start from the most proximal portion of the extremity and move toward the distal. In addition, always remember to keep the number of attempts to a minimum (see hospital policy and procedure for the maximum number of attempts permitted by one individual). When selecting the site for venous access the caregiver should consider the following: l purpose and duration of IV therapy l age of the child l condition of the veins l skin integrity l patient preference

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IV Therapy "Learning Activity" Describe why the purpose and duration of an IV is important to consider? _________________________ _________________________

IV Therapy Purpose and Duration As the length of time for IV therapy increases, the patient's comfort and level of immobilization required becomes more important to consider. Ideally, the patient should receive the type of access appropriate for diagnosis (epidermolysis bullosa, cystic fibrosis, osteomyelitis, sickle cell anemia). For example, if a patient requires IV therapy for a long duration, they may require a more durable form of access (i.e. peripherally inserted central catheter or PICC). The caregiver should also ensure that the site selected and type of line selected will best support medications / fluids that may be irritating to the veins (i.e., Vancomycin, calcium and fluids with high dextrose concentration).

Describe when and why the lower extremities are commonly avoided when selecting and initiating an IV. _____________________________ _____________________________ _____________________________

Selecting A Site For Access Age of The Child The caregiver should be sensitive to patient’s age when selecting and initiating an IV. For example, if the child is walking, the lower extremities are commonly avoided due to the increased risk of thrombophlebitis, and the limitations it may place on the patient’s mobility. The caregiver should also avoid the patient’s “thumb-sucking digit.”

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IV Therapy "Learning Activity"

IV Therapy

Condition of The Veins The ideal site for venous access is the vein that can be visualized or palpated, smooth and straight enough to accept the catheter. Veins that have been damaged by frequent use and / or irritated by caustic medications should be avoided. These sites can be identified upon visual inspection as well as by transillumination. The characteristics common to damaged and / or irritated sites include: scarring, bruising, swelling, altered skin integrity (i.e., blister). The presence of valves in the veins may cause problems with proper vein cannulation.

The ideal site for venous access is the vein that can be __________________or _____________, __________________ and _____________ enough to accept the catheter. (Fill-In)

List the characteristics common to damaged and / or irritated sites. 1.___________________________ 2.___________________________ 3.___________________________ 4.___________________________

Patient Preference Whenever possible, especially with schoolaged patients, their desires and knowledge should be considered. Often the older child or parent may be able to tell the caregiver which sites they prefer as well as which sites have been successfully cannulated upon previous attempts.

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IV Therapy "Learning Activity"

IV Therapy Specific IV Sites Upper Extremity The cephalic, basilic, and median cubital veins in the forearm are most commonly used in the upper extremity. Often, the median cubital is attempted first. This may pose a problem in the future should a midline or a peripherally inserted central catheter (PICC) be needed by the child. In the dorsum of the hand, the most commonly used veins include the tributaries of the cephalic and basilic veins as well as the dorsal venous arch. Lower Extremity

The ______________ and the _________ veins in the forearm are the most commonly used in the upper extremity.

Often times the ________________ is attempted first. IN the dorsum of the hand, the most commonly used veins include tributaries of the _________ _________ as well as the ___________ arch.

The __________________ vein at the ankle is probable easiest to cannulate.

The saphenous veins, the median marginal veins, and the veins of the dorsal arch of the lower extremity may be accessed. Of these veins, the great saphenous vein at the ankle is probably easiest to cannulate. Scalp Veins The use of scalp veins may be more appropriate for infants. Due to the fragility of the infant’s vessels, the caregiver should frequently assess the site for complications. The caregiver should always remember to insert the IV in the direction of the heart. To avoid puncturing an artery, the caregiver should always palpate for a pulse prior to a venipuncture.

The use of _____________ veins may be more appropriate for infants.

The caregiver should always remember to insert the IV in the direction of the ____________.

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IV Therapy "Learning Activity"

IV Therapy Growth and Development Considerations Children are special individuals with their own needs. As they enter the hospital setting, many tests and procedures are done which are different to them and at times invasive. It is our responsibility to help the children feel at ease, to have patience with them, and to use our resources when available (i.e., Child Life). Prior to initiating an IV the caregiver should always communicate what the procedure may entail using appropriate terminology and support measures. Preparation and Pain Management Behavioral and pharmacologic interventions should be combined in an effort to relieve anxiety and pain.

It is our responsibility to help the children ____________________ to have _________________ and to use our _____________________ when available.

The caregiver should always be __________ but yet be careful not to use terms that may ___________ the patient and their support systems.

• •

List some Behavioral Interventions that • can be used to relieve anxiety and pain: •

Behavioral Interventions Parental presence is comforting to children and should be promoted whenever possible Be honest – explain in simple language what child will see, hear, taste, smell and feel using words, pictures and dolls Treatment rooms, if available, should be used for venipuncture so that a child can rest and relax in their bed Utilize “Positioning for Comfort” – a therapeutic approach to positioning children for painful procedures, which aims to minimize a child’s feelings of helplessness and vulnerability while promoting feelings of security and control. Refer to “Needle Pain Guidelines” for further age appropriate interventions

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IV Therapy "Learning Activity"

IV Therapy

List some Pharmacoloic Interventions that can be used to relieve anxiety and pain:

• •

Pharmacologic Interventions Children report that EMLA helps .. use it ! If it will be less than 20 minutes before the needlestick, utilize Fluorimethane (Cold Spray) immediately before venipuncture If 30 –90 minutes is available before the needlestick, apply EMLA to potential venipuncture sites Refer to “Needle Pain Guidelines” for dosage & administration information.

Child Life recommends that a consistent staff member or members conduct procedures. (i.e., blood draw, IV initiation) If available, Child Life should always be contacted to assist in preparing the patient and in providing diversional activities during the procedures. The caregiver may find it helpful to review the module “Impact of Illness on Growth and Development”.

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IV Therapy "Learning Activity" Fill-In the missing steps for “Initiating Peripheral IV Therapy” Perform _________ / __________ teaching and apply ___________________ if > 30 minutes to procedure 2. Assess the patient for ___________ sensitivity, and any other _________________.

IV Therapy

1.

Take patient to _____________________________.

3.

Put on _________and any other protective barriers.

4. 5. 6. 7.

Select the ____________________.

Prepare the skin with ________________.

8.

Provide ____________ traction______________ _____________________________ ____________

9.

Slowly advance the needle/catheter until___________.

Key Steps for Initiating Peripheral IV Therapy Perform patient / family teaching and apply EMLA cream if > 30 minutes to procedure (refer to growth and developmental considerations). If patient has undergone venipuncture before ask what helped them in the past. Assemble equipment, prepare tape, flush catheter and tubing if desired and if not collecting labs. Assess the patient for latex sensitivity and any other allergies (see policy and procedure for specific equipment). Take patient to treatment room (if available) and initiate behavioral supportive measures (e.g. positioning for comfort, distraction, relaxation) as appropriate. Perform hand washing. Put gloves on and any other protective barriers. Select the site. The caregiver may find it helpful to use a tourniquet to locate a site. Prepare the skin, wipe with alcohol, allow to dry, then wipe with providine (allow 30 seconds for skin contact). Provide counter-traction on the skin, with the other hand, insert needle/catheter at a 10 - 30 degree angle, with bevel up, either over or beside the vein. Slowly advance the catheter until blood returns, then lower the catheter and continue to advance, just enough to cover the stylet and catheter in the vein, then hold catheter and withdraw stylet enough to “hood” in side of catheter, then grasp the stylet and catheter together and continue to advance to the hub.

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IV Therapy "Learning Activity"

IV Therapy Key Steps for Initiating Peripheral IV Therapy Continued 10. Remove the tourniquet if in use. 11. Secure catheter in place using a sterile transparent occlusive dressing. 12. Attach the T-connector to the catheter followed by slowly flushing the system with normal saline. Observe for signs of infiltration and / or hematoma. 13. You may now chevron ¼ inch tape over the occlusive dressing. 14. Loop the tubing and t-connector near the site of entry and secure with tape, leave the T-connector exposed to permit tubing change when required. 15. Apply armboard, pad as necessary, to provide protection. 16. Mark the date, time, type and size of catheter used in appropriate place (i.e., chart, notes) per policy and procedure. 17. Adjust rate of solution flow according to amount prescribed or flush the site lock to maintain patency for intermittent use. 18. Observe and document patient's response / tolerance – ask patient “how was that for you?”, what helped, what didn’t? 19. Perform hand washing. When performing phlebotomy, the caregiver will perform steps 1-8, then collect the specimen per policy and procedure.

Attach the ___________________ to the catheter followed by slowly flushing it with normal saline. Loop the tubing and t-connector near the ________________________ and secure with tape, Leave the T-connector exposed to permit ____________________ when required.

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IV Therapy "Learning Activity"

IV Therapy When maintaining an IV the caregiver may find it helpful to perform a quick review of the following: Right solution? Appropriate volume and rate of flow per patient weight? √ Circulatory overload can occur more quickly and have more serious effects in children. Right equipment? Are system alarms functional? √ When working with children, medications / fluids should be administered with devices that permit accurate delivery (i.e., pumps). Right labeling? √ Labeling should include fluid, medications (if medication has been added), date, and time bottle / bag was hung and date and time to be changed per policy and procedure. Patency of the tubing? √ Check for kinks, air, blood, leaks and flattening. Are the clamps out of the child’s reach?

IV Checklist When maintaining an IV the caregiver may find it helpful to perform a quick review of the following: (Fill-In) ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________

Is √ √ √ √ √ √ √ √

the site free from complications? Pain / Tenderness Swelling Warmth or coolness Blanching Redness Vein hardness Wetness Patency of overall system, including the site

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IV Therapy "Learning Activity"

IV Therapy
Is the site free from complications? √ Vital signs (alterations can indicate IV complications). √ Urine Output √ Visible edema √ Cough or frothy sputum (may indicate fluid overload). √ General appearance of the child √ Fluid balance record (I & O) should be current for hourly and running volume totals. How frequently should the dressing be changed? It is generally recommended that the dressing be changed as needed when it becomes nonocclusive and / or soiled. Otherwise, the caregiver should refer to the policy and procedure for the specific protocol regarding the frequency of dressing changes for IV sites. How frequently should the site be changed? Peripheral IV sites should be changed as needed, such as if signs of infiltration, phlebitis or infection occur. Surgically implanted types of access (i.e., portacaths) are generally reaccessed in as few as 7 days or as many as 30 days depending upon frequency of use. The caregiver should refer to the policy and procedure for specific protocol. How frequently should the site be checked? It is generally recommended that IV site be checked at least every 1-2 hours.

How frequently should the dressing be changed? (Fill-In) _____________________________ _____________________________ _____________________________

How frequently should the site be changed? (Fill-In) _____________________________ _____________________________ _____________________________

How often should the site be checked? (Fill-In) _____________________________ _____________________________ _____________________________

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IV Therapy "Learning Activity" Children may have IV’s for the purpose of _____________________________ and / or

IV Therapy Caring for An Intermittent System Children may have IV’s for the purpose of continuous and / or intermittent infusion of medications and /or fluids. If the child has an IV for intermittent therapy only, a site lock system (e.g. heparin lock) may be used. The site lock system need only be accessed when the medications and / or fluids are administered. The site lock system may be a rubber chamber or device into which the IV infusion set (e.g. needless cannula) is inserted. Once the infusion is completed the caregiver should carefully remove the infusion equipment leaving the site lock intact. Site locks are usually flushed with a heparinized saline solution to prevent clotting in the cannula between infusions. The caregiver should check the current policy and procedure regarding the protocol for selecting a flush solution. Site locks are ideal for short-term therapy, and may allow children the opportunity to maintain such therapy independently at home.

infusion of medications and / or fluids. (Fill-In)

When performing vascular access for IV initiation the caregiver should observe for the following complications: (Fill-In) ._________________________ ._________________________ ._________________________ ._________________________ ._________________________ ._________________________ ._________________________

Complications Associated With Performing Vascular Access When performing vascular access for IV initiation the caregiver should observe for the following complications: infiltration, phlebitis, circulatory overload, air embolism, infection, clotting at the site, and skin irritation. If observed, notify physician/designee and document as per current charting policy. Refer to appropriate policy for further treatment.

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IV Therapy "Learning Activity"

IV Therapy Infiltration Infiltration may be caused by needle / catheter displacement and or blood leakage from the vein. Signs • • • and symptoms site swelling cool skin at site poor blood return and sluggish flow.

Describe the signs and symptoms of infiltration.

_____________________________ _____________________________ Describe the suggested interventions for treating infiltration. _____________________________ _____________________________ ___________________________

Interventions include: • stop the flow • remove needle or catheter.

Describe the signs and symptoms phlebitis _____________________________ ____________________________ Describe the suggested interventions for treating phlebitis. _____________________________ _____________________________

Phlebitis Phlebitis may be caused by injury to the vein associated with movement of the needle, or improper immobilization, too slow of a flow rate, overuse of the vein, and / or use of irritating solutions. Signs and symptoms include: • sluggish flow • warm-red site • swelling • hardness along the vein site • streaking on the skin along the tract of the catheter and / or the vein • site pain and / or tenderness • possible mild fever Interventions: • stop the flow, • remove needle or catheter • apply warm-moist compresses.

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IV Therapy "Learning Activity" Describe the signs and symptoms of infection. ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________

IV Therapy Infection Infection may be caused by improper aseptic technique during the initiation of an IV and / or poor maintenance. In addition the caregiver should note that the immunocompromised patient might be particularly susceptible to infection. Signs • • • • • • and symptoms include: site pain and / or tenderness swelling foul-smelling discharge elevated temperature chills blood culture positive for pathogens

Interventions include: • discontinue the IV • Seek a physician/designee’s order for local and /or systemic therapy Describe the suggested interventions for treating infection. ___________________________ ___________________________ Describe the signs and symptoms of air embolism. ___________________________ ___________________________ Describe the suggested interventions for treating air embolism. ___________________________ ___________________________ Air Embolism Air embolism may be caused by tubing improperly cleared of air. Signs and symptoms include: • cyanosis • decrease in blood pressure • weak rapid pulse • loss of consciousness • other clinical observations indicative of shock Interventions include: • notify the physician immediately • give oxygen as necessary • inspect system for air leaks • turn child on left side

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IV Therapy "Learning Activity"

IV Therapy Circulatory Overload Circulatory overload may be caused by a “too fast flow rate” and / or a “too large volume infused.” Signs and symptoms include: • elevated blood pressure • tachycardia • increased urine output • possible distention of the neck veins, gallop (an additional sound heard in the heart due to excessive fluid filling, may sound like “horses running”) • periorbital edema • bulging fontanel • dyspnea • rales • cough • frothy sputum Interventions include: • notify physician • slow the infusion to "keep vein open" (KVO) • raise the child to semi or high fowlers • give oxygen as needed • assist respirations as needed Clotting/Occlusion Clotting / occlusion may be caused by: • too slow a drip rate • inappropriate flushing to maintain patency • bleeding disorders • IV running dry • kinking of the catheter preventing flow • drug incompatibilities • the extended duration of use of site

Describe the signs and symptoms of circulatory overload. ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ________________________

Describe the suggested interventions for treating circulatory overload. ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________

Describe the signs and symptoms of clotting/occlusion. ___________________________ ___________________________ _______________

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IV Therapy "Learning Activity"

IV Therapy Signs and symptoms include: • no blood return upon aspiration • occluded IV flow • inability to flush • infiltration Interventions may include: • discontinue IV • restart if possible • monitor drip rate more closely Skin Irritation Skin irritation may be caused by injury to the skin due to taping, restraints, infiltration, and / or pressure. Sign and symptoms include: • redness at site • raised-irritated areas • itching and burning around the tape Interventions include: • remove irritant • reapply dressing over insertion site (hypoallergenic tape is available) • Re-investigate for allergies to skin prep, dressing and / or latex to avoid future exposure • Seek a physician/ designee order for topical therapy.

Describe the suggested interventions for treating clotting/occlusion. ___________________________ ___________________________ _______________ Describe the signs and symptoms of skin irritation. ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ________________________

Describe the suggested interventions for treating skin irritation.

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IV Therapy Module Resources

Broadwell Jackson, Debra and Rebecca B. Saunders. Child Health Nursing. Philadelphia: J.B. Lippincott, 1993. Taylor, Carol, et. al., Fundamentals of Nursing - The Art and Science of Nursing Care. Philadelphia: J.B. Lippincott, 1993. Textbook of Pediatric Advanced Life Support. American Heart Association, 1997. Whaley, Lucille F. and Donna Wong. Clinical Manual of Pediatric Nursing. St. Louis: C.V. Mosby Company, 1995.

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IV Therapy Post Test
Name: Department: 1. Select from below the indications for performing vascular access a. b. c. d. e. fluid replacement medication delivery enteral nutrition IV blood sampling a, b, and d are correct Date:

2. Choose the statement which best describes how to select a site for IV initiation and / or obtaining a blood sample. a. The caregiver should always start in the proximal portion of extremity and move more distal. b. The caregiver should always start in the distal portion of the extremity and move more proximal. c. The caregiver should select only the sites that have never been used. d. The caregiver should select only the site the patient agrees upon.

3. When selecting the site for venous access the caregiver should consider the following: a. b. c. d. e. patient’s ability to pay purpose and duration age of the child skin integrity b, c, and d are correct

4. Scarring, blisters, swelling, and bruising are all characteristics common to a damaged and/or irritated site. a. true b. false

5. Select the statement which best describe the technique performing venous access. a. to prepare alcohol. b. to prepare c. to prepare d. to prepare contact). the skin, wipe with povidine (allow 30 seconds for skin contact), followed by the skin, wipe with sterile gauze, followed by providine. the skin, wipe with alcohol. the skin, wipe with alcohol, followed by providine (allow 30 seconds for skin

6. When performing IV maintenance, the caregiver should check that he/she has the right solution, right labeling, right equipment, the appropriate volume and rate of flow per patient weight, and that the site is free from complications. a. true b. false

7. Signs and symptoms associated with infiltration include: a. b. c. d. site swelling poor blood return cool skin at site all of the above

8. If a patient with an IV should develop cyanosis, weak rapid pulse, loss of consciousness, and other signs indicative of shock, you should suspect an air embolism. a. true b. false

9. If an air embolism is suspected, the caregiver should turn the child to the left side, give oxygen as needed, and notify the physician/designee immediately. a. true b. false

10. It is generally recommended that a peripheral IV site be changed as needed. a. true b. false

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