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Basic Vascular Access Ice Ppt Presentation.Ppt2 Basic Vascular Access Ice Ppt Presentation.Ppt2 Presentation Transcript

  • Basic IV Therapy and Central Vascular Access Devices Infusion Care Experts, Inc. Precision Placements Presented by
  • Objectives
    • Participant will:
    • Describe the peripheral and central venous anatomy as well as the application of infusions to the appropriate venous access sites and devices
    • Differentiate between the four(4) Central Venous Access devices and understand advantages, disadvantages, potential complications, nursing care and maintenance of the specific devices
    • Accurately observe, monitor, report and document the status of a peripheral and central venous site
    • Be able to demonstrate the principles of asepsis and standard precautions in the management of infusion therapy
    • Demonstrate peripheral IV insertion (IV catheter over the needle ) and PICC dressing change with adherence to sterile technique
  • Anatomy of a Vein
    • Tunica Intima :
    • The layer of smooth endothelial cells lining the length of the blood vessel
      • Innermost layer
      • Has one thin layer of cells (endothelial lining)
      • Irritating this layer causes thrombus formation
    • Tunica Adventitia :
    • The outermost layer of vein
      • Supports and surrounds vessel
      • Blood supply of this layer called Vaso Vasorum
    • Tunica Media:
    • Middle layer of vein
      • Composed of muscular and elastic tissue
      • Contains nerve fibers
      • Collapses or distends with pressure
    View slide
  • Anatomy of a Vein vs. an Artery
    • VEINS:
    • superficial in sub-Q tissue
    • valves
    • do not pulse
    • dark red blood
    • 3 layers
    • ARTERIES:
    • deeper in sub-Q tissue
    • no valves
    • pulse
    • bright red blood
    • 3 layers
    VEIN ARTERY
    • Tunica Intima:
    • Tunica Media:
    • Tunica Adventitia :
    View slide
  • Vein Identification Basilic Cephalic Digitals Dorsal Metacarpals
  • Vein Information Chart Vein Location Size Catheter Considerations Digital Veins N/A Do Not Use Metacarpal Veins 24-20g
    • Not first choice in the elderly
    • Only infuse isotonic or near isotonic solutions or medications
    Cephalic Vein 24-20g
    • Large vein, easy to access
    • Useful for infusing isotonic, near isotonic and chemically irritating medications
    Basilic Vein 24-20g
    • Difficult to access and to stabilize
    • Large, palpable vein-moves easily
  • Basilic Vein Vein Identification Median Antebrachial
  • Vein Information Chart …Continued Vein Location Size Catheter Considerations Median Antebrachial Vein N/A
    • Flat, small in diameter
    • Decreased hemodilution
    • Avoid these veins due to increase of infiltration and painful access
    • Median Antecubital Vein
    • Median Basilic
    • Median Cubital
    • Median Cephalic
    N/A
    • Avoid peripheral infusion
    • Reserve for blood lab draws
    • Reserve for future needs
    • PICC & Midline
    • Renal patients
    • Emergency use only
  • Nerves of the Upper Extremities
  • Nerves of the Hand and Wrist
  • Important Concepts
    • Osmolarity :
      • Measure of solute concentration
      • Normal blood plasma Osmolarity is 290-340 mOsm/L and is considered Isotonic
        • Example: D 5 W, LR, 0.9Nss
      • Osmolarity higher than 340 mOsm/L is considered Hypertonic
        • Example: D5.45Nss, D5LR, 10% and > dextrose concentrations
      • Osmolarity lower than 290 mOsm/L is considered Hypotonic
        • Example: 0.45Nss and 0.33Nss
    • pH :
      • Hydrogen ion concentration
      • Normal blood pH is 7.35-7.45
      • Solutions with a pH < 6.0 are Acidic
      • Solutions with a pH > 8.0 are Alkaline
  • Important Terms
    • Phlebogenic Drugs : Cause irritation to the inner lining of the vein
      • Examples:
      • Amphotericin B Phenytoin Erythromycin Pentamidine
      • Dobutamine Ganciclovir Potassium Chloride Phenobarbitol
      • Foscarnet Chemotherapeutic Agents Gentamycin Doxycycline
      • Penicillins (Oxacillin ,Nafcillin,Unasyn,Methicillin) Morphine
  • Important Terms
    • Vesicants :
      • Drugs that have properties that when inadvertently infused into the SubQ tissue can cause severe tissue damage
      • Necrosis can lead to grafts, possibly loss of limb
        • Examples: Vancomycin, Dopamine, Dextrose concentrations > 10% and Chemotherapy
    • Infiltration :
      • Inadvertent administration of non-vesicant infusion onto the SubQ tissue
    • Extravasations :
      • Inadvertent administration of vesicant infusion into the SubQ tissue
  • Intravenous Fluids Hydration
    • Dextrose Solutions :
      • Provide calories
      • 5% dextrose = 5g dextrose in 100ml
      • Hypotonic dextrose hydrates the intracellular compartment
      • Hypertonic dextrose pulls water from the intracellular compartment and decreases swelling
    • Sodium Chloride Solutions :
      • Provide ECF replacement
      • Hypotonic saline (0.45% or less) can be used to supply daily salt and water requirements
      • 0.9% Sodium Chloride is the only solution to be used with blood components
    • Hydrating Solutions :
      • Combination of dextrose and hypotonic sodium chloride
      • Hydrates patients in dehydrated state
      • Promotes diuresis
    • Multiple Electrolyte Solutions/ Lactated Ringers :
      • Solution most like the body’s electrolyte content
  • Intravenous Fluids Antibiotics
    • A. Aminoglycosides (Gentamycin, Amikacin and Tobramycin) OTO and NEPHRO TOXIC
    • B. Cephalosporins ( Rocephin,Ancef and Kefzol ) Related to Penicillin so check allergy history.
    • C. Penicillins (Nafcillin,Ampicillin,Timentin,
    • Oxacillin, and Unasyn)
    • D. Tricyclic Glycopeptides (Vancomycin)
    • OTO and NEPHRO TOXIC
  • Aminoglycosides and Tricyclic Glycopeptides
    • Drugs that are oto and nephro toxic require blood monitoring levels. Amikacin,Gentamycin,Tobramycin and Vancomycin require monitoring. The Trough levels are drawn just prior to the start of an infusion. Peak levels are drawn 30-60 minutes after the completion of an infusion. Typically drug levels are started after the fifth dose to allow adequate time for the drug to reach consistent blood levels.
  • Intravenous Fluids TPN/ PPN
    • Total Parenteral Nutrition: TPN provides nutrients (carbohydrates, protein, fat, minerals, and trace elements) through the veins. Has greater than 10% Dextrose Concentration.
      • Indications: severe malnutrition, bowel rest, obstruction, short bowel syndrome, malabsorbtion, hyperemesis, intractible diarrhea and motility disorders.
      • Peripheral Parenteral Nutrition: PPN provides some nutrients and has lower calories and dextrose concentration than TPN. PPN must be lower than 10% Dextrose concentration. Is typically indicated for short term supplement or when central venous access is not available.
  • Intravenous Fluids Pain Management
    • Morphine
    • Dilaudid
      • Morphine and Dilaudid can be given IV ,SUB-Q and IM.
      • Pain control analgesia pumps (PCA) are often used to deliver pain management and offer the patient continuous pain management with bolus ability.
  • Complications of Pain Management
    • Nausea
    • Vomiting
    • Increased sedation
    • Constipation
    • Respiratory depression
  • Intravenous Fluids Chemotheraputic Agents
    • Preferred way to administer Chemotherapy is through a central venous access device.
    • Side Effects of Chemotherapy:
    • Nausea
    • Vomiting
    • Fatigue
    • Anorexia
    • Hair Loss
  • Checklist for Peripheral IV Insertion
    • Check physician's orders
    • Identify patient -2 identifiers
    • Check for allergies
    • Informed consent
    • Patient teaching
    • Standard precautions
  • Intravenous Nurses Society Standards
    • Use the smallest gauge and shortest length catheter to accommodate the prescribed therapy
    • A peripheral IV (short cannula, midline catheter) is not appropriate for continuous vesicant chemotherapy, TPN, solutions or medications with a pH < 5 or >9 and/or a serum osmolarity > 500 mOsm/L
  • Criteria for Vein Selection
    • Distal Branches of Large Veins
    • Veins below Antecubital Fossa
    • Palpable, Soft to Firm and Visible
    • Adequate size for the type of infusion being administered
    • Considerations:
    • Length of therapy
    • Purpose and type of infusion
    • Patient activity
    • Predisposing medical conditions
  • Catheter Selection
    • Over the needle
      • Insyte autoguard
    • Winged catheter
      • Butterfly
    • Midline
    Flashback Chamber Hub t
  • Vein Selection
    • Considerations
    • What are you giving?
    • Length of therapy
    • Vein integrity
    • Previous venipunctures
    • Clinical assessment
    • Patient compliance
    • Specifically :
    • Avoid areas of flexion
    • Avoid boney prominences
    • Avoid nerves
    • Distal to proximal
    • Avoid bruised and edematous area
    • Alternate arms
  • Vein Dilation
    • Technique
    • Tourniquet
    • BP cuff
    • Gravity
    • Fist clenching
    • Tapping vein
    • Warm compress
    • Multiple tourniquets
  • Venipuncture Technique
    • Gather Supplies
    • Wash Hands
    • Explain Procedure to your patient
    • Set up clean area
    • Prepare for venipuncture in a position that will be stable for both you and your patient
  • Venipuncture Technique
    • Apply Tourniquet and proceed :
    • Apply gloves
    • Antimicrobial scrub and place tourniquet 4-6” above puncture site
    • Pull skin below puncture site to stabilize and prevent vein from rolling
    • Insert needle, bevel up , at a 15- 30 0 - angle (low and slow)
    • When blood in flashback chamber occurs, lower angle of catheter and advance catheter with stylet as a unit into the vein, approximately 1/8” just enough to ensure catheter is in the vessel
    • STOP !
  • Venipuncture Technique
    • Advance catheter off the stylet until ENTIRE catheter is in the vessel
    • Release tourniquet
    • Apply manual pressure just above the site that you imagine where the catheter tip is
    • Remove stylet (hit safety button)
    • Connect the extension tubing with the valve cap
    • Tape hub/wings of catheter
    • Flush with .9NSS and check for blood return
    • Apply transparent dressing
  • Peripheral IV Dressings
    • Dressing
    • Gauze dressing with tape(48 hour dressing change)
    • Tegaderm occlusive dressing
    • Dressing change with IV catheter change (72-96 hours)
    • Labeling
    • Venipuncture site label
      • Date and time
      • Type and length of catheter
      • Nurse’s initials
    • Label administration set
      • Tubing changes
    • Label solutions container
  • Venipuncture Technique
    • Attach infusion and regulate flow
    • Label administration set tubing and bags
    • Dispose of needles in sharps containers
    • Document procedure
  • Venipuncture Technique
    • Documentation
    • Date and time of insertion
    • Manufacturer’s brand name and style of device
    • Gauge and length
    • Specific name and/or location of accessed vein
    • # of attempts
    • Infused by regulator tubing or electronic pump
    • Patient’s response
    • Signature
  • Peripheral IV Removal
    • Technique
      • Use dry sterile gauze to apply pressure until bleeding stops
      • Apply band-aid or gauze and tape
      • Examine catheter integrity and dispose
      • Document site assessment and catheter integrity
      • Keep dressing clean and dry until scab forms
  • Peripheral IV Demonstration
    • Skills validation
  • IV Rate Calculations A. Total Volume X drops/ml = Drops/Min. Total Time in Minutes B. Drip Rates of IV Tubing ( check package) Formulas
  • IV Rate Calculations
    • Example:
    • 1000ml D/W to infuse over 12 hours
    • 1000ml x 10gtts/ml
    • ---------------------- =14DropsMin.(13.8) 720
  • Midline Catheter
    • Peripheral IV catheter whose tip terminates in the proximal upper extremity
    • No vesicants through this line
      • Increased dwell time (up to 2-4 weeks)
      • Open ended (Flush S-A-S-H )
      • Closed ended (Flush S-A-S )
    • Insertion and Removal
    • Care and Maintenance : dressing,flush,site observation
    • S-A-S = Saline - Administration - Saline
    • S-A-S-H = Saline - Administration - Saline – Heparin(100units/ml)
  • Central Venous Anatomy Cephalic Vein Basilic Vein Superior Vena Cava Innominate Vein Or Brachiocephalic Vein Subclavian Vein Jugular Vein Axillary Vein
  • Central Venous Access Devices
    • Central Venous Catheter
      • tip is located in the Superior Vena Cava
    • Greatest hemodilution of vascular system
    • SVC is the largest vein in venous anatomy
    • SVC: turbulent blood flow
    • Appropriate location for vesicant therapy, TPN, long-term IV therapy, solutions/medications with a pH < 5 or > 9 and or serum osmolality > 500 mOsm/L
    • Tip confirmation must be verified post insertion
  • Central Venous Access Tip Placement
  • Peripherally Inserted Central Catheter (PICC)
    • PICC
      • Tip terminates in the SVC
      • Dwell time is (up to) 6 months - 1 year
      • Open or closed ended
      • 1-2 lumens
    • Insertion and removal
    • Advantages
    • Disadvantages
    • Complications :
    • Fibrin Sheath/Tail
    • Clotted catheter
    • PICC Migration
    • Interventions:
    • Cathflow Activase Instillation (2 mg. x 2 /lumen)
    • Cathflow Activase Instillation (2 mg. x 2 /lumen)
    • PICC exchange
      • Exchange
      • Repairs of Groshongs are no longer done
    Peripherally Inserted Central Catheter (PICC)… Continued
    • Care and maintenance
      • Dressing Change – 24 hrs. post insertion. Thereafter, weekly and PRN for transparent dressings and 3x/week for gauze dressings. Strict adherence to sterile technique is required.
      • Flushing – Most PICC lines are flushed with Normal Saline and Heparin Lock Flush/per facility policy and MD order. (usual amounts are 10ml Normal Saline and 5ml Heparin flush of 100 units/ml).
      • Note: GROSHONG PICC’s do not require Heparin Flush because they are closed ended catheters with a valve at the end.
      • Cap and Extension Changes – The cap and extension tubing are changed with each dressing change weekly and after every blood draw.
    Peripherally Inserted Central Catheter (PICC)
  • Implanted Ports- AKA portacaths, ports,mediports and passports
    • Port implanted in the SQ tissue, catheter tip terminates in the SVC
      • Design: 1-2 lumens, reservoir, septum, catheter
      • Dwell time can be greater than 1 year
      • Open or closed ended
    • Insertion and removal
    • Advantages
    • Disadvantages
    • Care and maintenance
      • Routine flushing: Monthly
      • Huber needle only : Needle and dressing change weekly
    • Complications/ Interventions (Pinch off syndrome, Sludge)
  • What is Pinch Off Syndrome?
    • Pinch Off Syndrome is the compression of a catheter as it passes between the clavicle and first rib at the costoclavicular space.
  • Non-Tunneled Catheters - Triple lumen, Subclavian, CVC
    • Short-term emergent central catheter
        • 1-3 Lumens
        • Open ended only
    • Insertion and removal
    • Advantages
    • Disadvantages
    • Care and maintenance
    • Complications and interventions
  • Tunneled Catheters - Hickman,Groshong
    • Central line catheter tunneled under SubQ tissue with tip placement in SVC
      • 1-3 Lumens
      • Open or closed ended
      • Dwell time: long-term IV therapy (> 1 year)
    • Insertion and removal
    • Advantages
      • Dacron cuff
    • Disadvantages
    • Care and maintenance
    • Complications and interventions
  • Documentation
    • Specific to your institution’s policy and procedure
    • Flushing protocols
      • Solution, amount and technique
    • Dressing, tubing and cap changes
    • Measurement as appropriate
    • Site assessments
    • Interventions taken
    • Any other pertinent information
  • Demonstration of Central Line Dressing Change
    • Skills Validation
  • Complications
    • Infiltration :
    • Inadvertent administration
    • of an IV fluid in
    • surrounding SQ tissue
    • around area of vein
    • (non-vesicant)
    • Interventions :
    • DC IV; Restart
    • Compress?
    • Phlebitis :
    • Injury to the endothelial
    • lining of the vein
    • Bacterial
    • Mechanical
    • Chemical
    • Interventions :
    • DC IV; Restart
    • Compress?
  • Phlebitis Infusion Phlebitis - inflammation of the vein associated with infusion phlebitis as seen in this photograph.
  • Complications
    • Cellulitis :
    • Infection of SQ tissue
    • Characteristic of a circular
    • pattern, with redness,
    • induration and exudate
    • Interventions :
    • DC IV
    • Topical antibiotics (apply
    • with sterile dressing)
    • Monitor for septicemia
    • Sepsis :
    • The presence of infectious
    • microorganisms or other
    • toxins in the blood stream
    • Interventions :
    • Restart IV
    • Obtain cultures
    • Notify physician
    • Monitor patient daily
    • Antimicrobial therapy as ordered
  • Complications Cellulitis adhering to aseptic technique is vital in the prevention of intravenous related infections. Asepsis should be maintained at insertion, during clinical use and at removal of the device.
  • Sepsis
  • Complications
    • Thrombosis :
    • Formation of blood clot in
    • the catheter lumen
    • Formation of a blood clot
    • within a blood vessel
    • Interventions :
    • Thrombolytics
    • PREVENTION:
    • Flush immediately after
    • infusion
    • Appropriate tip locations
    • Appropriate size catheter in
    • relation to vein size
    • Catheter Related
    • Embolism :
    • Air embolisms
    • Catheter embolism
    • Interventions :
    • PREVENTION
    • This is an EMERGENCY
    • Turn patient on left side and
    • place in Trendelenberg
    • position
    • Nasal oxygen
    • Prepare for resuscitation
    • 911
  • Thrombosis
  • PICC Line Embolism/Rupture
    • You are the key to prevention –
    • ONLY syringes that are 10cc’s and larger should be used on a PICC line. Smaller syringes generate a higher pressure that can cause the catheter to rupture.
  • Complications
    • Catheter Occlusions :
    • Occlusions may be due to
    • blood, fibrin, drug,
    • precipitate or lipids/sludge
    • build up
    • Interventions :
    • PREVENTION
    • Flush catheter immediately
    • after infusion
    • Flush between
    • incompatible drugs
    • Thrombolytics
    • Catheter Malposition or Migration :
    • Can occur during insertion
    • or spontaneously sometime
    • after insertion
    • Interventions :
    • LISTEN to your patient
    • Follow up x-rays when
    • indicated
  • Complications
    • Extravasation :
    • Inadvertent administration of a vesicant solution or medication
    • into the surrounding tissues resulting in potential blistering,
    • necrosis and tissue sloughing
    • Interventions :
    • PREVENTION
    • Stop infusion
    • Don’t remove cannula – aspirate
    • Notify physician
    • Pharmacological intervention, if appropriate (controversial)
    • Compress (controversial)
    • Immobilization and elevation
    • Follow up
  • Extravasation
  • Blood Sampling Through CVAD
    • Direct or Indirect Methods can be used :
    • Turn off all IV infusions in multi-lumen device for a minimum of one full minute prior to taking sample.
    • Flush lumen that you are using for sampling with 5ml/Ns.
    • Attach vacutainer or attach sterile syringe to lumen and obtain 5-10ml of blood in a collection tube or syringe for discard.
    • If using a vacutainer use collection tubes and obtain blood for sampling. If using a syringe withdraw blood for sampling.
    • When using a syringe: Maintain sterility of sample transfer in syringe to collection tubes with ‘blood transfer device.
    • Remove vacutainer or syringe and flush lumen with 10-20ml/Ns.
    • 7. Change valve cap ( cap must be changed with every blood draw).
    • 8. Reconnect infusion to new cap and use SAS for close ended CVAD’s and SASH for open ended CVAD’s.
  • Legal Considerations
    • Get informed and written consent
      • For PIVs -verbal consent
      • For CVADs- written informed consent with risks and benefits outlined.
    • Inform patient of all VAD options
    • Know tip placement of each CVAD before using it
      • This also refers to patients readmitted with ports, tunneled lines, etc…
  • Legally Speaking
    • Know and follow all of your facility’s policies and procedures. If you are not sure where to find them ask a colleague or supervisor/ manager so that you can become familiar with them.
    • Always use concise and accurate documentation.
    • Don’t use CVAD without a blood return unless the reason for the absence has been determined.
  • Questions and Review for Test
  • Congratulations ! Thank You for Your Participation
    • It has been my pleasure to have you in this class today.
    • The greatest gift in learning something new is putting that knowledge into practice and then sharing what you know with someone else.
    • Go and use your new found or renewed knowledge and Practice! Practice! Practice!
    • You are all Winners!