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