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Peripheral IV Therapy
 

Peripheral IV Therapy

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Developed for use by IV Team members during new hire RN orientation at a community hospital. SMEs were two IV Team members.

Developed for use by IV Team members during new hire RN orientation at a community hospital. SMEs were two IV Team members.

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  • Peripheral IV TherapyView more presentations from Cathy Lewis.<br /><object type="application/x-shockwave-flash" data="http://static.slidesharecdn.com/swf/ssplayer2.swf?doc=peripheralivtherapy-ppt-090508111540-phpapp01&stripped_title=peripheral-iv-therapy&userName=CaliforniaCathy" width="350" height="288"><param name="movie" value="http://static.slidesharecdn.com/swf/ssplayer2.swf?doc=peripheralivtherapy-ppt-090508111540-phpapp01&stripped_title=peripheral-iv-therapy&userName=CaliforniaCathy"></param><embed src="http://static.slidesharecdn.com/swf/ssplayer2.swf?doc=peripheralivtherapy-ppt-090508111540-phpapp01&stripped_title=peripheral-iv-therapy&userName=CaliforniaCathy" width="350" height="288" type="application/x-shockwave-flash"></embed></object>
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  • When skin is tight it is taut, not 'taught' Just a little spelling advice.
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  • Super users group
  • Ask participants to tell you how the factors influence resistance and pressure, i.e., more or less?

Peripheral IV Therapy Peripheral IV Therapy Presentation Transcript

  • Peripheral Intravenous Therapy Principles and Practice Hospital Name
  • What You Will Learn Today
    • Cooperative roles of professional staff
    • Staff nurse responsibilities for peripheral lines
    • Routine care and maintenance for peripheral lines
    • A systematic and organized way to monitor
    • How to use the INS Rating Scales for phlebitis and infiltration
    • Steps to minimize the potential for complication
    • Principles of flow
    • How to troubleshoot a peripheral IV
  • Cooperative Roles PATIENT
    • Simple Insertions
    • Monitoring
    • Maintenance
    • Troubleshooting
    • Insertions
      • Peripheral
      • Midlines
      • PICC
    • Consultation
    VAT R.N. Unit R.N. Physician Unit L.P.N. Procedure Area R.N. I.R.
  • Unit RN Responsibilities for Peripheral IV Lines
    • Ongoing assessment
    • Maintenance
      • Cleaning/redressing
      • Ensuring that the IV is securely taped
      • Cap/tubing changes according to hospital policy and procedure
    • Uncomplicated starts and routine changes
  • Policies and Procedures for Infusion Nursing
  • Care & Maintenance Routines
    • Intact dressing means all 4 edges are sealed
    • Peripheral site, cap, and tubing changes are q72 hrs
    • New cap with each new IV, or when unable to clear blood
    • Change antecubital and paramedic IVs within 24 hours or as soon as patient condition permits
    • IVs inserted in the nursing home, hosp., and clinics are acceptable
  • Reasons to Monitor
    • Patient’s response to therapy
    • Confirms accurate delivery of fluid/meds
    • Detects imminent complications
    MONITORING IS KEY TO COMPLICATION PREVENTION
  • When Should You Monitor?
    • Factors to consider
      • Type of therapy, age, mental status, overall physical condition, type of access device, practice setting
    MONITORING SHOULD BE SYSTEMATIC AND ORGANIZED
  • Bag to Catheter Tip Assessment
    • See handout
    • Fluid container, tubing and flow rate, in-line filter, electronic infusion device, arm board, IV site dressing, vascular access device, insertion site, catheter tip
  • Possible Complications
    • Local
      • Infiltration, extravasation, phlebitis, occlusion
      • Local complications occur more often than systemic
    • Systemic
      • Circulatory overload, allergic reaction, septicemia, embolism
    TARGET PHLEBITIS RATE IS LESS THAN 5%
  • Today’s Focus on Complications
    • Phlebitis
    • Infiltration
    • Extravasation
    • Catheter-Related Infection
  • Phlebitis
    • Inflammation of vein intima
    • Types
      • Mechanical
      • Chemical
      • Infectious
    Phlebitis may not appear until 24h after the cannula has been removed
  • How to Protect the Intima and Minimize or Delay Onset of Phlebitis
    • Utilize principles of asepsis/sterility
    • Minimize friction against intima wall
    • Minimize particulate matter
    • Minimize effects of pH and osmolality
    • Rotate sites according to P&P
    • Change site at first sign of pain, tenderness, redness, or irritation
  • Minimize Friction Against Intima Wall
    • Use smallest size catheter, as appropriate
    • Insert catheter away from areas of flexion
    • Stabilize catheter well
      • Dressing, arm board, restraint, as needed
    Venous Free Flow Around Catheter is GOOD! Movement of Catheter is BAD!
  • Minimize Particulate Matter
    • Use needles with microfilters to draw up meds from vials
    • Mix meds with recommended solutions or diluents
    • Make sure admixtures are thoroughly dissolved
    • Do not combine incompatible solutions
    • Use particulate in-line filters when appropriate
  • Minimize Effects of pH and Osmolality
    • Use smallest gauge catheter possible so that more blood can dilute medications/solutions
    • Dilute known irritating meds as much as possible
    • Use port of a compatible free-flowing infusion to push IV meds, again more dilution
    • Use slowest appropriate administration rate
    • For hypertonic or acidic solutions, use large veins and consider central lines
  • pH
    • Blood pH 7.35-7.45 Neutral solution is 7.0
    • Acid solutions are less than 7
      • Dextrose solutions have additives for stability during sterilization and storage - acidic (3.5-6.5 )
      • Some solutions have additives to increase pH
      • Additives may contribute to drug incompatibility
    • Neutralize Acidic Solutions/Medications
      • Add buffers when appropriate
    Acidic Solutions Predispose V. to Phlebitis Back
  • How does this size catheter minimize possibility of phlebitis? Baxter Illustration
  • Common Meds
    • Amiodarone (4.08)
    • Ancef (4.5-7)
    • Dilaudid (4-4.5)
    • Dobutamine (2.5-4.5)
    • Dopamine (2.5-5)
    • Fentanyl (4-7.5)
    • Flagyl (5-7)
    • Gentamycin (3-5.5)
    • KCL (4-8)
    • Morphine Sulfate (2.5-7)
    • Nitroglycerin (3-6.5)
    • Solucortef (7-8)
    • Solumedrol (7-8)
    • Valium (6.2-6.9)
    • Vancomycin (2.4-4.5)
    • Versed (3)
    • Lipid Emulsions
    FYI. Heparin increases pH and rarely causes phlebitis
  • IV Fluid (mOsm/L) (pH range)
    • D5W (252.2) (4.5 3.5-6.5)
    • NS (308) (5.0 4.5-7.0)
    • D5 .2NS (314) (4.0 3.5-6.5)
    • Ringers (310) (5.5 5.0-7.5)
    • LR (274) (6.5 6.0-7.5)
    • Mannitol (274) (5.0 4.5-7.0)
    • 0.45 NS (154) (5.0 4.5-7.0)
    • Sterile H2O (0) (5.5 5.0-7.0)
  • Phlebitis Assessment
    • Use INS Phlebitis Scale
    • Once a patient develops phlebitis, DC IV and monitor site frequently for development of thrombophlebitis - evidenced by palpable cord
    • Ask about pain
    • Monitor for signs of systemic infection
  • Which Grade? Cause is mechanical
  • Which Grade? Cause is chemical
  • Which Grade? Photo: C. Lewis
  • Nursing Intervention: Phlebitis
    • Stop infusion, DC IV, and thoroughly assess
    • Disinfect venipuncture site
    • Apply pressure to stop bleeding
    • Intermittent warm moist heat
      • 20 min. 3-4 times per day with MD order
      • Or cold compress, if indicated
    • If catheter-related infection suspected, remove catheter aseptically and send for culture
    • For purulent drainage, culture prior to cleaning the site
    • Notify MD
  • Infiltration
    • Def. Non vesicant infusion outside of vein
    • Appearance changes as severity increases
      • First, feeling of tightness at venipuncture site
      • Then, skin appears stretched or taut when enough fluid is trapped in the subcutaneous tissue
        • Fluid may seep to dependant areas
      • Blanching and coolness appears next
      • The infusion may or may not slow in rate
      • Patients may not have pain if solution is isotonic
    Symptoms will be more difficult to recognize early if skin turgor is poor
  • 1, 2, and 3 courtesy of Baxter 1 3 4 2 4 adapted from Baxter
  • Extravasation
    • Def. Infiltration of vesicant solutions that are osmotically active, ischemia producing, or that cause direct cellular toxicity
    • Erythema and tissue changes appear very quickly and progress, depending on the amount of infiltrated vesicant
  • Infiltration Assessment
    • Can be difficult to assess, particularly if no pain or infusion is at a slow rate
    • Compare to other extremity
      • Also check dependent areas - gravity may pull fluid down
    • Apply tourniquet or pressure proximal to catheter – should stop or slow flow
      • If infiltrated, flow may continue despite venous obstruction
    • Blood return is an unreliable indicator
    • When in doubt, change catheter site
  • Nursing Intervention: Infiltration and Extravasation
    • Stop infusion, DC IV, and thoroughly assess
    • Intervention based on assessment
      • Warm, moist or cool compress
        • Cool compress for known irritant (e.g., KCl, X-ray contrast)
      • Dressings usually not necessary; use with caution
      • Restart IV in opposite arm
    • For extravasation, follow unit protocols, notify M.D., fill out a Drug Report Form, and monitor closely
    • Document infiltration and extravasation in medical record
  • Grade 1 Photo: C. Lewis Photo: C. Lewis
  • Grade 2 Photo: C. Lewis
  • Grade 3 Photo: C. Lewis
  • Grade 4 Photo: C. Lewis
  • Which Grade?
    • Blood infusion
    Photo: C. Lewis
  • Which Grade?
    • Pt. c/o burning
    • IV removed 1 hr. 45 min. ago
    • Intermittent ice applied
    Dobutamine Infusion Photo: C. Lewis
  • Catheter-Related Infection
    • Local or systemic
    • CVC occurance is greater than with peripheral catheters
    • Factors that increase likelihood
      • Catheter dwell time
      • Age and physical condition of patient
      • Immunosuppression therapy
  • Prevention of Catheter-Related Infection
    • Good handwashing technique
    • Observe aseptic/sterile technique when mixing and administering solutions/medications
    • Good site inspection at appropriate intervals for patient
    • Ensure that dressing remains intact
    • Change site and administration set every 72 hours
  • Principles of Flow
    • In intravenous therapy…
      • pressure is the force that is generated to overcome systemic resistance to deliver IV fluid
      • resistance is the force that is working against IV fluid flow
  • Resistance and Pressure = Flow
    • Resistance slows flow
    • Pressure increases flow
    • In order to keep flow constant, one must adjust to compensate for a change in the other
    • Blood vessel diameter
    • Catheter diameter
    • Tubing diameter
    • Length of tubing
    • Fluid viscosity
    • Flow regulation clamps
    How Do These Factors Influence Resistance and Pressure?
    • Height of bag
    • Pump mechanism
    • External pressure bag
    • Size of syringe
    P R
  • Troubleshooting
    • Catheter occlusion
    • Rate too slow
    • Pain, no sign of phlebitis or infiltration
    • Venous spasm
  • Catheter Occlusion
    • Two types - can be partial or complete
    • Thrombotic
      • Thrombus due to fibrin or coagulated blood products within or surrounding the catheter
    • Mechanical
      • Catheter malposition, drug or mineral precipitates, lipid residue
  • Signs and Symptoms
    • Frequent alarms in the absence of observable physical or mechanical obstruction
    • Change in ability to infuse or aspirate from catheter
    • Pain upon infusion
    • Kinked or clamped catheter or administration set
    • Obstructed in-line filter
    • Drug and mineral precipitates or lipid residue
    Thrombotic Mechanical
  • Nursing Intervention: Occlusion
    • First check for mechanical obstruction - it’s the easiest.
      • Clamps, tubing, in-line filter
    • Then check the catheter. If unable to flush with a 5cc or larger syringe, do not force it. DC the catheter.
  • Rate Too Slow
    • Check for mechanical cause
      • Catheter crimped in anatomic area of flexion
      • Tubing is crimped, kinked
        • Either under the patient or inside the pump
      • Tubing dangling below the bed (it requires force to push fluid “upstream” – esp. if patient is hypertensive)
      • BP cuff inflation increases venous pressure
      • Restraints
      • Occluded filter or air vent
  • Rate Too Slow, cont.
    • Check for other causes
      • Cannula too small for fluid viscosity
      • Fluid temperature too low - venous spasm
      • Cannula tip up against vessel wall or next to bifurcation of vein
      • Undetected infiltration, phlebitis, or thrombus
  • Pain, no sign of phlebitis or infiltration
    • Assess for other possible causes
      • Dressing too tight?
      • Venous spasm?
      • Temp. of solution too low?
      • pH of solution too low?
      • Could medication use more dilution?
    • Pain may precede physical signs of phlebitis
      • Either fix the pain or DC and restart IV
  • Venous Spasm
    • Sudden involuntary contraction of vessel wall
    • Feels painful and IV flow will reduce or stop
    • Can result from trauma, irritation from chemical or temp. extremes, vasovagal reaction to pain or anxiety
    • Nursing intervention
      • Slow the rate, apply warm compress, add diluent, add buffer (with M.D. order), or DC IV
  • Why Does a Pump Not Alarm When the IV is Infiltrating?
    • Because pumps alarm when they sense a proportional rise in resistance, compared to the the previously measured baseline.
    • Interstitial resistance is less than venous resistance -- that is, until the skin becomes adequately distended and starts exerting pressure.
  • Hot Tip for Pumps
    • Stop all infusions prior to adding additional equipment, filters or extension sets. This will allow the pump to take a new baseline resistance and reset the pumping pressure when you restart it.