4. 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
8. INFILTRATION
Leaking of nonvesicant fluid into
tissues surrounding the vein
Check IV site every two hours
Complications
Nerve compression requiring
fasciotomy
12. 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.
13. 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
14. Causes
Poor insertion site
Squad starts
Unsterile start
IV left in too long—
change q 96 hours!
Hub contamination
17. Prevention
Hand washing
Sterile technique
Catheter size
Insertion site
Site inspection every two hours
Encourage patient to report any
discomfort
22. 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.
24. 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
25. 1. Apply tourniquet 5-6 inches above insertion site
2. Never leave tourniquet on longer than one minute
3. Then Remove tourniquet and prepare equipment
26. 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
28. 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
34. Stabilize the hub of the canula
22. Withdraw stylet while putting pressure on
vein above injection site
35. Stabilize the hub of the canula
Apply pressure above while inserting the tubing
insertion site to slow
bleeding
Saline flush is already attached and
tubing flushed and ready
23. Insert tubing or prn adaptor
36. It may get messy sometimes, but with experience
this will be minimized
37. • 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.
38. Leave the end of the hub
of 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
50. CONTINUOUS INFUSION: SECURING THE NEEDLE
When starting a continuous infusion, you must secure the right-angle, non-coring
needle to the skin. If the needle hub is flush with the skin, apply a transparent
semipermeable dressing over the entire site. If the needle hub isn’t flush with the
skin, place a folded sterile dressing under the hub, as shown. Then apply adhesive
skin closures across it.
Secure the needle and tubing, using the chevron-taping
technique with sterile tape.
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.