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Basic

Intravenous
Therapy
90-95% of patients in the
hospital receive some type
of intravenous therapy.

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This presentation will enhance
your knowledge of how to care

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Vein Anatomy and
Physiology

Veins are unlike arteries in
that they are 1)superficial, 2)
display dark red blood at skin
surface and 3) have no
pulsation

Vein Anatomy

- Tunica Adventitia
-

Tunica Media
Tunica Intima
Valves

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Tunica Adventitia the outer layer of the vessel  Connective tissue  Contains the arteries and veins supplying blood to vessel wall Previous Next .

Tunica Media the middle layer of the vessel  Contains nerve endings and muscle fibers  The vasoconstrictive response occurs at this layer Previous Next .

Tunica Intima the inner layer of the vessel One No layer of endothelials nerve endings Surface for platelet aggregation w/trauma and recognition of foreign object at this level PHLEBITIS Previous begins here Next .

Valves present in MOST veins  Prevent backflow and pooling  More in lower extremities and longer vessels  Vein dilates at valve attachment Previous Next .

difficult to immobilize and should be your LAST RESORT Metacarpal Vessels -Located between joints and metacarpal bones (act as natural splint) Digital -Formed by union of digital veins -Geriatric patients often lack enough connective / adipose tissue and skin turgor to use this area Previous Next .Veins of the Upper Extremities Digital Vessels -Along lateral aspects fingers. infiltrate easily. painful.

Veins of the Upper Extremities  Cephalic (Intern’s Vein) -Starts at radial aspect of wrist -Access anywhere along entire length (BEWARE of radial artery/nerve)  Medial Cephalic (“On ramp” to Cephalic Vein) -Joins the Cephalic below the elbow bend -Accepts larger gauge catheters. but may be a difficult angle to hit and maintain Previous Next .

Empties into the Basilic vein running parallel to tendons.Veins of the Upper Extremities  Basilic . Accepts larger gauge catheters. It is often overlooked becauses of its location on the “back” of the arm.BEWARE of Brachial Artery/Nerve Previous Next . . but flexing the elbow/bending the arm brings this vein into view  Medial Basilic . so it is not always well defined.Originates from the ulner side of the metacarpal veins and runs along the medial aspect of the arm.

intermittent or IV push method. We use these frequently for phlebotomy •Safety Over the needle catheters (ONC) .PROTECTIV ® Previous -ACUVANCE ® Next .Purposes of IV Therapy       To provide parenteral nutrition To provide avenue for dialysis/apheresis To transfuse blood products To provide avenue for hemodynamic monitoring To provide avenue for diagnostic testing To administer fluids and medications with the ability to rapidly/accurately change blood concentration levels by either continuous. Types of Peripheral Venous Access Devices •Butterfly (winged) or Scalp vein needles (SVN) – not recommended for non compliant patient as it can easily penetrate the vein wall causing extravasation.

Good veins are bouncy to the touch. .Start distally and use the shortest length/smallest gauge access device that will properly administer the prescribed therapy (BE AWARE: Blood flow in the lower forearm and hand is 95ml/min) Previous Next . using a latex tourniquet may provide better venous congestion .Starting a Peripheral IV  Finding a vein can be challenging . but are not always visible. .Go by “feel”.Use warm compresses and allow the arm to hang dependently to fill veins.If the patient is NOT allergic to latex. Arterial flow continues with maximum venous constriction. not by sight.A BP cuff inflated to 10mmHg below the known systolic pressure creates the perfect tourniquet.Avoid areas of joint flexion . .

IV Start Pain Management One of the most frequent contributors to patient dissatisfaction is painful phlebotomy and IV starts • Use 25-27g insulin syringe to create a wheal similar to a TB skin test on top of or just to side of vein with 0. It might be a good idea to anesthetize a couple of sites • Have the patient close their fist (NO PUMPING) prior to stick • Make sure the skin surface cleansing agent (alcohol/chlorhexidine) is dry prior to stick.1 -0. prior to stick.2 ml normal saline or 1% xylocaine without epinephrine • Topical anesthesia cream (ie EMLA) may be applied to children>37 weeks gestation 1 hr. Drawing this into the vein may stimulate the vasoconstrictive action of the tunica media layer Previous Next .

Adults: q 8hrs Previous w/1ml.9%NS [3ml heparinized saline for OB] Next . 0.Peds: q 6hrs.9%NS followed by 1ml heparinized (10units/ml) saline . <22ga 1ml 0.Flushing Peripheral IV’s Use prefilled saline and heparin flush syringes located in PYXIS Heparin flush concentrations available: -100u/ml (5ml in a 10ml syringe) -10u/ml (2ml in a 3ml syringe) Flushing intervals and amounts .

Dressing/Bag Changes Changing dressings Physician orders are required if a peripheral catheter is left in the same site for more than 3 days. It is best to have the pharmacy add medications to the infusion bags under laminare flow to reduce contamination Previous 1 2 3 4 5 6 TSM q 7 d Gauze q 2d 7 Changing bags and tubing 1 2 24 hrs 3 normally every 3d If respiked or meds added outside pharmacy Changing Sites 1 2 3 normally every 3d 4 5 6 7 Every 7 d c MD order Next .

Vescath. ext. PIC. Broviac PICC. Enters subclavian. upper arm or neck Completely internal. IJ Hickman. clavicle and nipple. Arm or leg placement Polyurethane $200-$400 Silicone $3500-$5000 Silicone / polyurethane $350-$500 Silicone catheter. Port is titanium or plastic w/self sealing diaphragm $3500-$5000 Various materials 2-3 2-3 1-2 1-2 2-3 Sutured Yes/entire life Yes. Triple Lumen.5ml heparinized saline (adults100units/ml. use or monthly if not accessed Done ONLY by IV team or dialysis nurses Brands/ Names Arrow Howe. Accces Port-A-Cath Bard. Quinton MD or speically trained RN @ bedside MD in OR Specially trained RN @ bedside MD in OR MD in OR Material/Co st Lumen Discontinue Previous Next . juglar vein near clavicular area Visible ext. Gesco. Tesio. Access is through skin into self sealing port using special non coring needle Visible externally. usually midway bet. PASV Bard. Subclavian. peds-10units/ml) after ea. Titanium or plastc port is implanted in a surgically created pocket and catheter is threaded into subclavian or int. juglar. EDPC. until internal Dacron cuff healed No Yes Yes Duration Short term 4-10 days Long term Long term Long term Mid term Flushes 5-10ml NaCl after use and daily 5-10ml NaCl after use and daily 5-10ml NaCl after use and daily 10ml NaCl followed by 4. Arrow Howe.or int. juglar vein.Central Venous Catheters Percutaneous Tunneled PICC’s Implanted Ports Dialysis Insertion MD @ bedside w/x-ray confirmation MD in OR under fluoroscopy MD/trained RN @bedside w/x-ray confirmation MD in OR under fluoroscopy MD in OR under fluoroscopy Location Visible externally. Tunneled under skin & threaded through subclavian or IJ Visible externally around antecubital fossa.

Central Venous Catheter Sites PICC (Peripherally inserted Central Catheter) Percutaneous(Subclavia n) Implanted Port (single or double lumen) Tunnelled (Hickman) Previous Percutaneous (IJ-Int. Jugular) Next .

peds/neonates: 5ml saline (preservative free for infants <1yr)  Transparent dressing change q 7 days & Previous prn PICC Next .CVC Care/Maintenance Percutaneous Tunneled  Flush after each access or daily for catheters>21ga. q 6 hrs <21 ga -adults: 10ml saline .

CVC Care/Maintenance  Flush after each use and weekly while accessed. Implanted Port <1yr) .10ml saline (preservative free for pts.followed by 4.5ml-5ml heparinized saline 100units/ml for adults 10units/ml for peds  Transparent dressing/ access needle change q Previous 7days Next . monthly when not acessed .

Monitor and document site condition: Site Care • Hourly for peds •Q 2 hr for adult * Indicates complication: •Infiltration •Phlebitis •Thrombosis •Cellulitis •Septicemia Previous Next .

Infiltration/Extravasation The most common cause is damage to the wall during insertion or angle of placement. STOP INFUSION and treat as indicated by Pharmacy. Medication package insert or drug reference book. Notify MD and document Previous Next .

red and warm.Phlebitis/Thrombophlebitis  Chemical . The device may need to be removed and warm compresses applied . Antiinflammatory and analgesic medications are often used no matter what the cause  Mechanical  Bacterial . Warm compresses may help while the infusate is stopped/changed. edema may accompany Previous Next .Caused by introduction of bacteria into the vein. Remove the device immediately and treat w/antibiotics.Infusate chemically erodes internal layers. The arm will be painful.Caused by irritation to internal lumen of vein during insertion of vascular access device and usually appears shortly after insertion.

Treated w/antibiotics Previous Next . .Red swollen area spreads from insertion site outwardly in a diffuse circular pattern .Cellulitis  Inflammation of loose connective tissue around insertion site.Caused by poor insertion technique .

Most often caused by poor insertion technique or poor site care .Caused by any free floating substances that require thrombolytic therapy for several months.  Air embolism. culture and treat appropriately Pulmonary edema.Discontinue device immediately. Keep insertion site below level of heart Previous Next .caused by air injected into IV system.Severe infection that occurs to a system or entire body . Increased risk w/lower ext.Septicemia/Pulmonary Edema/ Embolism  Septicemia .caused by rapid infusion  Pulmonary embolism .

 Vascular access device (VAD) leaking when flushed . All other devices must be replaced Call IV therapy team member for any concerns or questions. Previous Next .Verify that hub access cap is connected correctly  Patient complains of pain while VAD being flushed .Evaluate for kink in tubing or catheter tip against vein wall.Troubleshooting  Vascular access device will not flush/can’t draw blood .Assess for infiltration  VAD broken .PICC’s may be repaired.

2-3 ml/hr Neonates .5-1 ml/hr Only until rate order received Verification required for: •Insulin •Heparin •Potassium LPN’s CANNOT infuse blood products or high risk IV medications.0.Policy notes KVO rate: RN’s and LPN’s can start peripheral IV’s after initial training and observation by preceptor Adults .10 ml/hr Pediatrics . Previous •Digoxin •Chemotherapy LPN’s cannot push IV medications Next .

vanderbilt.IV Medication Administration  Many medications require patient monitoring that cannot be done on units where the nurse/patient ratios are greater than 1:2 All Medications Cannot Be Administered on All Units General Care Units: Can give meds requiring only basic physical assessment data Stepdown Units: Can give meds that require more invasive or frequent monitoring than is available on general care units Intensive Care Units: Can give  A patient can be moved to a meds that require more invasive or frequent monitoring than is available unit where the ratio is on the Stepdown units. appropriate for VANDERBILT URL LINK FOR IV invasive/frequent monitoring MEDICATIONS: or another nurse can be brought to care for the patient www.mc.edu/pharmacy/ivroo m/IVMedAdm061003.pdf during the med administration Previous Next .

Previous Next . You will find if the medication can be administered on your unit.IV Medication Administration Sample page from the Pharmacy med administration web site See “APPROVED FOR” section.

org  Infusion Nurses Society (INS) Previous  Professional Organization that sets the standards of care for clinicians practicing in the field of infusion therapy.  In a court of law.www. Next . the standards set by the INS are used to assess the infusion clinician’s performance.  Standards set by INS are reflected in our policies and procedures related to infusion therapy for health care providers.ins1.