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.

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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

    1. 1. Peripheral Intravenous Therapy Principles and Practice Hospital Name
    2. 2. What You Will Learn Today <ul><li>Cooperative roles of professional staff </li></ul><ul><li>Staff nurse responsibilities for peripheral lines </li></ul><ul><li>Routine care and maintenance for peripheral lines </li></ul><ul><li>A systematic and organized way to monitor </li></ul><ul><li>How to use the INS Rating Scales for phlebitis and infiltration </li></ul><ul><li>Steps to minimize the potential for complication </li></ul><ul><li>Principles of flow </li></ul><ul><li>How to troubleshoot a peripheral IV </li></ul>
    3. 3. Cooperative Roles PATIENT <ul><li>Simple Insertions </li></ul><ul><li>Monitoring </li></ul><ul><li>Maintenance </li></ul><ul><li>Troubleshooting </li></ul><ul><li>Insertions </li></ul><ul><ul><li>Peripheral </li></ul></ul><ul><ul><li>Midlines </li></ul></ul><ul><ul><li>PICC </li></ul></ul><ul><li>Consultation </li></ul>VAT R.N. Unit R.N. Physician Unit L.P.N. Procedure Area R.N. I.R.
    4. 4. Unit RN Responsibilities for Peripheral IV Lines <ul><li>Ongoing assessment </li></ul><ul><li>Maintenance </li></ul><ul><ul><li>Cleaning/redressing </li></ul></ul><ul><ul><li>Ensuring that the IV is securely taped </li></ul></ul><ul><ul><li>Cap/tubing changes according to hospital policy and procedure </li></ul></ul><ul><li>Uncomplicated starts and routine changes </li></ul>
    5. 5. Policies and Procedures for Infusion Nursing
    6. 6. Care & Maintenance Routines <ul><li>Intact dressing means all 4 edges are sealed </li></ul><ul><li>Peripheral site, cap, and tubing changes are q72 hrs </li></ul><ul><li>New cap with each new IV, or when unable to clear blood </li></ul><ul><li>Change antecubital and paramedic IVs within 24 hours or as soon as patient condition permits </li></ul><ul><li>IVs inserted in the nursing home, hosp., and clinics are acceptable </li></ul>
    7. 7. Reasons to Monitor <ul><li>Patient’s response to therapy </li></ul><ul><li>Confirms accurate delivery of fluid/meds </li></ul><ul><li>Detects imminent complications </li></ul>MONITORING IS KEY TO COMPLICATION PREVENTION
    8. 8. When Should You Monitor? <ul><li>Factors to consider </li></ul><ul><ul><li>Type of therapy, age, mental status, overall physical condition, type of access device, practice setting </li></ul></ul>MONITORING SHOULD BE SYSTEMATIC AND ORGANIZED
    9. 9. Bag to Catheter Tip Assessment <ul><li>See handout </li></ul><ul><li>Fluid container, tubing and flow rate, in-line filter, electronic infusion device, arm board, IV site dressing, vascular access device, insertion site, catheter tip </li></ul>
    10. 10. Possible Complications <ul><li>Local </li></ul><ul><ul><li>Infiltration, extravasation, phlebitis, occlusion </li></ul></ul><ul><ul><li>Local complications occur more often than systemic </li></ul></ul><ul><li>Systemic </li></ul><ul><ul><li>Circulatory overload, allergic reaction, septicemia, embolism </li></ul></ul>TARGET PHLEBITIS RATE IS LESS THAN 5%
    11. 11. Today’s Focus on Complications <ul><li>Phlebitis </li></ul><ul><li>Infiltration </li></ul><ul><li>Extravasation </li></ul><ul><li>Catheter-Related Infection </li></ul>
    12. 12. Phlebitis <ul><li>Inflammation of vein intima </li></ul><ul><li>Types </li></ul><ul><ul><li>Mechanical </li></ul></ul><ul><ul><li>Chemical </li></ul></ul><ul><ul><li>Infectious </li></ul></ul>Phlebitis may not appear until 24h after the cannula has been removed
    13. 13. How to Protect the Intima and Minimize or Delay Onset of Phlebitis <ul><li>Utilize principles of asepsis/sterility </li></ul><ul><li>Minimize friction against intima wall </li></ul><ul><li>Minimize particulate matter </li></ul><ul><li>Minimize effects of pH and osmolality </li></ul><ul><li>Rotate sites according to P&P </li></ul><ul><li>Change site at first sign of pain, tenderness, redness, or irritation </li></ul>
    14. 14. Minimize Friction Against Intima Wall <ul><li>Use smallest size catheter, as appropriate </li></ul><ul><li>Insert catheter away from areas of flexion </li></ul><ul><li>Stabilize catheter well </li></ul><ul><ul><li>Dressing, arm board, restraint, as needed </li></ul></ul>Venous Free Flow Around Catheter is GOOD! Movement of Catheter is BAD!
    15. 15. Minimize Particulate Matter <ul><li>Use needles with microfilters to draw up meds from vials </li></ul><ul><li>Mix meds with recommended solutions or diluents </li></ul><ul><li>Make sure admixtures are thoroughly dissolved </li></ul><ul><li>Do not combine incompatible solutions </li></ul><ul><li>Use particulate in-line filters when appropriate </li></ul>
    16. 16. Minimize Effects of pH and Osmolality <ul><li>Use smallest gauge catheter possible so that more blood can dilute medications/solutions </li></ul><ul><li>Dilute known irritating meds as much as possible </li></ul><ul><li>Use port of a compatible free-flowing infusion to push IV meds, again more dilution </li></ul><ul><li>Use slowest appropriate administration rate </li></ul><ul><li>For hypertonic or acidic solutions, use large veins and consider central lines </li></ul>
    17. 17. pH <ul><li>Blood pH 7.35-7.45 Neutral solution is 7.0 </li></ul><ul><li>Acid solutions are less than 7 </li></ul><ul><ul><li>Dextrose solutions have additives for stability during sterilization and storage - acidic (3.5-6.5 ) </li></ul></ul><ul><ul><li>Some solutions have additives to increase pH </li></ul></ul><ul><ul><li>Additives may contribute to drug incompatibility </li></ul></ul><ul><li>Neutralize Acidic Solutions/Medications </li></ul><ul><ul><li>Add buffers when appropriate </li></ul></ul>Acidic Solutions Predispose V. to Phlebitis Back
    18. 18. How does this size catheter minimize possibility of phlebitis? Baxter Illustration
    19. 19. Common Meds <ul><li>Amiodarone (4.08) </li></ul><ul><li>Ancef (4.5-7) </li></ul><ul><li>Dilaudid (4-4.5) </li></ul><ul><li>Dobutamine (2.5-4.5) </li></ul><ul><li>Dopamine (2.5-5) </li></ul><ul><li>Fentanyl (4-7.5) </li></ul><ul><li>Flagyl (5-7) </li></ul><ul><li>Gentamycin (3-5.5) </li></ul><ul><li>KCL (4-8) </li></ul><ul><li>Morphine Sulfate (2.5-7) </li></ul><ul><li>Nitroglycerin (3-6.5) </li></ul><ul><li>Solucortef (7-8) </li></ul><ul><li>Solumedrol (7-8) </li></ul><ul><li>Valium (6.2-6.9) </li></ul><ul><li>Vancomycin (2.4-4.5) </li></ul><ul><li>Versed (3) </li></ul><ul><li>Lipid Emulsions </li></ul>FYI. Heparin increases pH and rarely causes phlebitis
    20. 20. IV Fluid (mOsm/L) (pH range) <ul><li>D5W (252.2) (4.5 3.5-6.5) </li></ul><ul><li>NS (308) (5.0 4.5-7.0) </li></ul><ul><li>D5 .2NS (314) (4.0 3.5-6.5) </li></ul><ul><li>Ringers (310) (5.5 5.0-7.5) </li></ul><ul><li>LR (274) (6.5 6.0-7.5) </li></ul><ul><li>Mannitol (274) (5.0 4.5-7.0) </li></ul><ul><li>0.45 NS (154) (5.0 4.5-7.0) </li></ul><ul><li>Sterile H2O (0) (5.5 5.0-7.0) </li></ul>
    21. 21. Phlebitis Assessment <ul><li>Use INS Phlebitis Scale </li></ul><ul><li>Once a patient develops phlebitis, DC IV and monitor site frequently for development of thrombophlebitis - evidenced by palpable cord </li></ul><ul><li>Ask about pain </li></ul><ul><li>Monitor for signs of systemic infection </li></ul>
    22. 22. Which Grade? Cause is mechanical
    23. 23. Which Grade? Cause is chemical
    24. 24. Which Grade? Photo: C. Lewis
    25. 25. Nursing Intervention: Phlebitis <ul><li>Stop infusion, DC IV, and thoroughly assess </li></ul><ul><li>Disinfect venipuncture site </li></ul><ul><li>Apply pressure to stop bleeding </li></ul><ul><li>Intermittent warm moist heat </li></ul><ul><ul><li>20 min. 3-4 times per day with MD order </li></ul></ul><ul><ul><li>Or cold compress, if indicated </li></ul></ul><ul><li>If catheter-related infection suspected, remove catheter aseptically and send for culture </li></ul><ul><li>For purulent drainage, culture prior to cleaning the site </li></ul><ul><li>Notify MD </li></ul>
    26. 26. Infiltration <ul><li>Def. Non vesicant infusion outside of vein </li></ul><ul><li>Appearance changes as severity increases </li></ul><ul><ul><li>First, feeling of tightness at venipuncture site </li></ul></ul><ul><ul><li>Then, skin appears stretched or taut when enough fluid is trapped in the subcutaneous tissue </li></ul></ul><ul><ul><ul><li>Fluid may seep to dependant areas </li></ul></ul></ul><ul><ul><li>Blanching and coolness appears next </li></ul></ul><ul><ul><li>The infusion may or may not slow in rate </li></ul></ul><ul><ul><li>Patients may not have pain if solution is isotonic </li></ul></ul>Symptoms will be more difficult to recognize early if skin turgor is poor
    27. 27. 1, 2, and 3 courtesy of Baxter 1 3 4 2 4 adapted from Baxter
    28. 28. Extravasation <ul><li>Def. Infiltration of vesicant solutions that are osmotically active, ischemia producing, or that cause direct cellular toxicity </li></ul><ul><li>Erythema and tissue changes appear very quickly and progress, depending on the amount of infiltrated vesicant </li></ul>
    29. 29. Infiltration Assessment <ul><li>Can be difficult to assess, particularly if no pain or infusion is at a slow rate </li></ul><ul><li>Compare to other extremity </li></ul><ul><ul><li>Also check dependent areas - gravity may pull fluid down </li></ul></ul><ul><li>Apply tourniquet or pressure proximal to catheter – should stop or slow flow </li></ul><ul><ul><li>If infiltrated, flow may continue despite venous obstruction </li></ul></ul><ul><li>Blood return is an unreliable indicator </li></ul><ul><li>When in doubt, change catheter site </li></ul>
    30. 30. Nursing Intervention: Infiltration and Extravasation <ul><li>Stop infusion, DC IV, and thoroughly assess </li></ul><ul><li>Intervention based on assessment </li></ul><ul><ul><li>Warm, moist or cool compress </li></ul></ul><ul><ul><ul><li>Cool compress for known irritant (e.g., KCl, X-ray contrast) </li></ul></ul></ul><ul><ul><li>Dressings usually not necessary; use with caution </li></ul></ul><ul><ul><li>Restart IV in opposite arm </li></ul></ul><ul><li>For extravasation, follow unit protocols, notify M.D., fill out a Drug Report Form, and monitor closely </li></ul><ul><li>Document infiltration and extravasation in medical record </li></ul>
    31. 31. Grade 1 Photo: C. Lewis Photo: C. Lewis
    32. 32. Grade 2 Photo: C. Lewis
    33. 33. Grade 3 Photo: C. Lewis
    34. 34. Grade 4 Photo: C. Lewis
    35. 35. Which Grade? <ul><li>Blood infusion </li></ul>Photo: C. Lewis
    36. 36. Which Grade? <ul><li>Pt. c/o burning </li></ul><ul><li>IV removed 1 hr. 45 min. ago </li></ul><ul><li>Intermittent ice applied </li></ul>Dobutamine Infusion Photo: C. Lewis
    37. 37. Catheter-Related Infection <ul><li>Local or systemic </li></ul><ul><li>CVC occurance is greater than with peripheral catheters </li></ul><ul><li>Factors that increase likelihood </li></ul><ul><ul><li>Catheter dwell time </li></ul></ul><ul><ul><li>Age and physical condition of patient </li></ul></ul><ul><ul><li>Immunosuppression therapy </li></ul></ul>
    38. 38. Prevention of Catheter-Related Infection <ul><li>Good handwashing technique </li></ul><ul><li>Observe aseptic/sterile technique when mixing and administering solutions/medications </li></ul><ul><li>Good site inspection at appropriate intervals for patient </li></ul><ul><li>Ensure that dressing remains intact </li></ul><ul><li>Change site and administration set every 72 hours </li></ul>
    39. 39. Principles of Flow <ul><li>In intravenous therapy… </li></ul><ul><ul><li>pressure is the force that is generated to overcome systemic resistance to deliver IV fluid </li></ul></ul><ul><ul><li>resistance is the force that is working against IV fluid flow </li></ul></ul>
    40. 40. Resistance and Pressure = Flow <ul><li>Resistance slows flow </li></ul><ul><li>Pressure increases flow </li></ul><ul><li>In order to keep flow constant, one must adjust to compensate for a change in the other </li></ul>
    41. 41. <ul><li>Blood vessel diameter </li></ul><ul><li>Catheter diameter </li></ul><ul><li>Tubing diameter </li></ul><ul><li>Length of tubing </li></ul><ul><li>Fluid viscosity </li></ul><ul><li>Flow regulation clamps </li></ul>How Do These Factors Influence Resistance and Pressure? <ul><li>Height of bag </li></ul><ul><li>Pump mechanism </li></ul><ul><li>External pressure bag </li></ul><ul><li>Size of syringe </li></ul>P R
    42. 42. Troubleshooting <ul><li>Catheter occlusion </li></ul><ul><li>Rate too slow </li></ul><ul><li>Pain, no sign of phlebitis or infiltration </li></ul><ul><li>Venous spasm </li></ul>
    43. 43. Catheter Occlusion <ul><li>Two types - can be partial or complete </li></ul><ul><li>Thrombotic </li></ul><ul><ul><li>Thrombus due to fibrin or coagulated blood products within or surrounding the catheter </li></ul></ul><ul><li>Mechanical </li></ul><ul><ul><li>Catheter malposition, drug or mineral precipitates, lipid residue </li></ul></ul>
    44. 44. Signs and Symptoms <ul><li>Frequent alarms in the absence of observable physical or mechanical obstruction </li></ul><ul><li>Change in ability to infuse or aspirate from catheter </li></ul><ul><li>Pain upon infusion </li></ul><ul><li>Kinked or clamped catheter or administration set </li></ul><ul><li>Obstructed in-line filter </li></ul><ul><li>Drug and mineral precipitates or lipid residue </li></ul>Thrombotic Mechanical
    45. 45. Nursing Intervention: Occlusion <ul><li>First check for mechanical obstruction - it’s the easiest. </li></ul><ul><ul><li>Clamps, tubing, in-line filter </li></ul></ul><ul><li>Then check the catheter. If unable to flush with a 5cc or larger syringe, do not force it. DC the catheter. </li></ul>
    46. 46. Rate Too Slow <ul><li>Check for mechanical cause </li></ul><ul><ul><li>Catheter crimped in anatomic area of flexion </li></ul></ul><ul><ul><li>Tubing is crimped, kinked </li></ul></ul><ul><ul><ul><li>Either under the patient or inside the pump </li></ul></ul></ul><ul><ul><li>Tubing dangling below the bed (it requires force to push fluid “upstream” – esp. if patient is hypertensive) </li></ul></ul><ul><ul><li>BP cuff inflation increases venous pressure </li></ul></ul><ul><ul><li>Restraints </li></ul></ul><ul><ul><li>Occluded filter or air vent </li></ul></ul>
    47. 47. Rate Too Slow, cont. <ul><li>Check for other causes </li></ul><ul><ul><li>Cannula too small for fluid viscosity </li></ul></ul><ul><ul><li>Fluid temperature too low - venous spasm </li></ul></ul><ul><ul><li>Cannula tip up against vessel wall or next to bifurcation of vein </li></ul></ul><ul><ul><li>Undetected infiltration, phlebitis, or thrombus </li></ul></ul>
    48. 48. Pain, no sign of phlebitis or infiltration <ul><li>Assess for other possible causes </li></ul><ul><ul><li>Dressing too tight? </li></ul></ul><ul><ul><li>Venous spasm? </li></ul></ul><ul><ul><li>Temp. of solution too low? </li></ul></ul><ul><ul><li>pH of solution too low? </li></ul></ul><ul><ul><li>Could medication use more dilution? </li></ul></ul><ul><li>Pain may precede physical signs of phlebitis </li></ul><ul><ul><li>Either fix the pain or DC and restart IV </li></ul></ul>
    49. 49. Venous Spasm <ul><li>Sudden involuntary contraction of vessel wall </li></ul><ul><li>Feels painful and IV flow will reduce or stop </li></ul><ul><li>Can result from trauma, irritation from chemical or temp. extremes, vasovagal reaction to pain or anxiety </li></ul><ul><li>Nursing intervention </li></ul><ul><ul><li>Slow the rate, apply warm compress, add diluent, add buffer (with M.D. order), or DC IV </li></ul></ul>
    50. 50. Why Does a Pump Not Alarm When the IV is Infiltrating? <ul><li>Because pumps alarm when they sense a proportional rise in resistance, compared to the the previously measured baseline. </li></ul><ul><li>Interstitial resistance is less than venous resistance -- that is, until the skin becomes adequately distended and starts exerting pressure. </li></ul>
    51. 51. Hot Tip for Pumps <ul><li>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. </li></ul>

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