A patient’s weight can also be a factor in your choice of forearm veins. In an obese patient, for example, you may not be able to see veins in the forearm. You may be able to palpate a healthy vein by knowing the typical locations. Veins in the antecubital fossa and above shouldn’t be used routinely for insertion of peripheral catheters. These sites may limit the patient’s range of motion, interfere with blood sampling, and prevent the use of these veins for midline and PICC insertions. Starting at a distal site and making subsequent venipunctures proximal to the previous sites is crucial. Starting at a distal site and making subsequent venipunctures proximal to the previous sites is crucial. Starting at a distal site and making subsequent venipunctures proximal to the previous sites is crucial. When a complication develops at a proximal site, you won’t be able to use veins distal to this site because the fluids and medication will infuse into the damaged site, compounding the problem. Veins in all aspects of the wrist shouldn’t be used for venipuncture because of their close proximity to nerves. Besides the risk of causing pain, preventing movement at these sites may be impossible, increasing the risk of complications. Other sites to avoid include: • veins below a previous I.V. infiltration • veins below a phlebitic area • sclerosed or thrombosed veins • areas of skin inflammation, disease, bruising, or breakdown • an arm affected by a radical mastectomy, edema, blood clot, or infection • an arm with an arteriovenous shunt or fistula.
Veins in the fingers and thumb may be easily visible when a tourniquet is placed; however, they are prone to complications and can’t support a catheter for long periods. They have a smaller diameter, which allows little or no blood flow around the catheter.
Avoiding nerves Nerves are located close to superficial veins in many locations on the hand and arm, especially in the wrist and antecubital fossa. Venipuncture shouldn’t be performed on the palm side of the wrist. Even the large cephalic vein at the level of the wrist should be avoided. Recent research has demonstrated that the superficial branch of the radial nerve crosses the cephalic vein at least once and up to three times as it extends from the wrist up the forearm. To avoid all these possible intersections when using the cephalic vein, the venipuncture should be made 4 to 5 inches above the level of the wrist. This may not be possible in all patients, depending on the number of available venous sites and the length of therapy. When your patient complains of tingling, a pinsand- needles sensation, or numbness, a nerve may be damaged. Immediately remove the catheter and choose another venipuncture site. Don’t probe around after piercing the skin or use a plunging or jabbing technique to insert the catheter.
A vein that’s suitable for venipuncture should feel round, firm, elastic, and engorged—not hard, bumpy, or flat. Inspect and palpate it for problems. Some veins that appear suitable at first glance feel small, hard, or knotty on palpation. A vein sclerosed from previous I.V. therapy isn’t suitable for venipuncture. To palpate a vein, place one or two fingertips (not the less-sensitive thumb) over it and press lightly. Then release pressure to assess the vein’s elasticity and rebound filling. To increase the sensation in your fingers, practice palpating veins on friends or coworkers. Always practice while wearing gloves, as gloves must be worn during venipuncture procedures to reduce your exposure to blood. To acquire a highly developed sense of touch, palpate before every cannulation— even if the vein looks easy to cannulate.
This is particularly important for older adults whose vein walls are thinner and will rupture more easily if over engorged.
Choosing the right size Depending on the vein used, the I.V. cannula should usually be 3⁄4 inch to 11⁄4 inches long. To reduce the risk of phlebitis, the catheter should be as small in diameter as possible so it takes up less space in the vein. This allows better blood flow around the catheter, lessening the risk of phlebitis. When selecting a catheter, consider the patient’s condition and the type of solution you’ll be running through the catheter in the next 72 to 96 hours. Using the smallest-gauge catheter in the largest vein possible will reduce the mechanical and chemical irritation to the vein wall. Keep these general guidelines in mind: • 24- to 22-gauge for children and elderly patients • 24- to 20-gauge for medical patients and postoperative surgical patients • 18-gauge for surgical patients and for rapid blood administration. Blood can be infused through smallergauge catheters, but the flow rate will be slower. • 16-gauge for trauma patients and those requiring large volumes of fluid rapidly.
IV Statistics 85% of all hospitalized patients have some type of IV therapy 118 million IV catheters inserted yearly
PHLEBITIS Inflammation of the vein wall—precursor to sepsis What causes phlebitis? IV left in too long Cannula too large Vein in poor condition Acidic solution or high osmolality Infusion rate too fast
PreventionsChoose vein appropriately Location Size Soft, spongy, resilient No pain or tenderness or redness with injection
INFILTRATION Leaking of nonvesicant fluid into tissues surrounding the vein Check IV site every two hours Complications Nerve compression requiring fasciotomy
INFECTION Cellulitis: An acute, spreading, bacterial infection below the surface of the skin characterized by redness (erythema), warmth, swelling, and pain. Usually localized. Sepsis: clinical symptoms of systemic illness, such as fever, chills, malaise, hypotension, and mental status changes. Sepsis can be life threatening.
INFECTION > 200,000 infections per year More than 60,000 patients die annually from bloodstream infections caused by intravenous therapy Cost for one patient is $56,000 Annual US total = $2.3 billion
Causes Poor insertion site Squad starts Unsterile start IV left in too long— change q 96 hours! Hub contamination
Other sites to avoid include:• veins below a previous I.V. infiltration• veins below a phlebitic area• sclerosed or thrombosed veins• areas of skin inflammation, disease, bruising, or breakdown• an arm affected by a radical mastectomy, edema, blood clot, or infection• an arm with an arteriovenous shunt or fistula.
STARTING AN IV Talk with patient Gather equipment Set up fluid and tubing on pump Check patient order and ID band & allergies Wash your hands!! Select a vein Select a catheter size
1. Apply tourniquet 5-6 inches above insertion site2. Never leave tourniquet on longer than one minute3. Then Remove tourniquet and prepare equipment
STARTING AN IV (CONT.) Open equipment and connect flush to J- loop Loosen caps of IV and J-loop but leave in place for sterility. (They should just slide off when you pick up the device). Cleanse skin with chlorhexidine gluconate solution in back & forth motion X 30 seconds Allow to dry for 30 seconds
STARTING AN IV (CONT.) Immobilize vein Position needle 10-15 degree angle over site Insert cannula bevel up Watch for blood backflow Advance cannula Only try twice before calling another RN to help
Advance cannula while holding stylet stationary Release tourniquet!!
Stabilize the hub of the canula22. Withdraw stylet while putting pressure on vein above injection site
Stabilize the hub of the canulaApply pressure above while inserting the tubinginsertion site to slow bleeding Saline flush is already attached and tubing flushed and ready 23. Insert tubing or prn adaptor
It may get messy sometimes, but with experience this will be minimized
• Flush with saline to clear tubing and insure IV has not infiltrated.3. Stabilize tubing with tape to prevent IV from pulling out while applying the sterile dressing.
Leave the end of the hubof the canula outside the dressing so that tubing can be changed without removing the dressing.1. Apply clear sterile dressing. Cover site and hub, not tubing
CONTINUOUS INFUSION: SECURING THE NEEDLEWhen starting a continuous infusion, you must secure the right-angle, non-coringneedle to the skin. If the needle hub is flush with the skin, apply a transparentsemipermeable dressing over the entire site. If the needle hub isn’t flush with theskin, place a folded sterile dressing under the hub, as shown. Then apply adhesiveskin closures across it. Secure the needle and tubing, using the chevron-taping technique with sterile tape.
http://www.youtube.com/watch?v=tfQbbCx6xFU&feature=relatedhttp://www.youtube.com/watch?v=ZcCWTEsEqPg&feature=related Apply a transparent semi-permeable dressing over the entire site. firstname.lastname@example.org.