Peripheral Iv Cannulation

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Peripheral Iv Cannulation

  1. 1. PERIPHERAL INTRA-VENOUS (I.V.) CANNULATION http://www.nationwidechildrens.org/GD/DocumentManagement
  2. 2. Introduction <ul><li>I.V. equipment and therapies have become more complex </li></ul><ul><li>The number of patients in hospitals receiving I.V therapy (includes medication administration for acute incidents eg. I.V. Morphine, for pain relief), is 80% plus. </li></ul><ul><li>It is important to understand the legal aspects/implications of practicing I.V. procedures/therapy. </li></ul>
  3. 3. Your Responsibilities <ul><li>You are responsible for obtaining and adhering to organisational guidelines. (Includes scope of practice guidelines) </li></ul><ul><li>You need to: </li></ul><ul><li>Have appropriate theory and skill preparation. </li></ul><ul><li>Maintain your individual accreditation in compliance with institutional or hospital guidelines. </li></ul>
  4. 4. Liability and Litigation <ul><li>Litigation is usually undertaken in the case of: </li></ul><ul><li>Infiltration/Extravasation </li></ul><ul><li>Phlebitis </li></ul><ul><li>Air embolism </li></ul><ul><li>Breakage of I.V./C.V.C. in situ </li></ul><ul><li>Haematomas causing compression injury. </li></ul>
  5. 5. Prevention <ul><li>In the case of infiltration, there would be no case for litigation if the following standard practices were followed: </li></ul><ul><li>I.V. site was observed immediately after starting the infusion/or whilst administering the medication. </li></ul><ul><li>Infiltration was noted </li></ul><ul><li>Infusion/medication administration was stopped immediately and I.V. was removed. </li></ul><ul><li>Incident was documented. </li></ul>
  6. 6. Prevention cont. <ul><li>If infiltration was allowed to develop into oedema of the arm or wrist, there is a strong case of litigation as lawyers can use equations to determine how long the infusion was left unmonitored. </li></ul><ul><li>To allow infiltration to develop to this stage indicates a failure to observe standard practices. </li></ul>
  7. 7. Prevention cont. <ul><li>Preventing complications for the patient and nurse: </li></ul><ul><li>Know your organisations policy on I.V. therapy. </li></ul><ul><li>Check and inspect the I.V. Site regularly. </li></ul><ul><li>Ask the patient how the I.V. site feels. </li></ul><ul><li>Document </li></ul><ul><li>Troubleshoot and report any problems. </li></ul>
  8. 8. Prevention cont. <ul><li>Ensure your practice is up to standard. </li></ul><ul><li>The nurse who inserted the I.V. needs to be able to explain: </li></ul><ul><li>Vein selection and what criteria was used. </li></ul><ul><li>Criteria for the selection of I.V. gauge. </li></ul><ul><li>Method used to check if the device was working. </li></ul><ul><li>Venous anatomy and physiology. </li></ul>
  9. 9. Prevention cont. <ul><li>The nurse looking after a patient with an I.V. infusion, needs to explain: </li></ul><ul><li>The standard operating procedure for the infusion pump being used. </li></ul><ul><li>Type of solution or medication being infused. It’s side effects and interventions. </li></ul>
  10. 10. Documentation <ul><li>The following must be documented when practicing I.V. therapy: </li></ul><ul><li>Time and date </li></ul><ul><li>Name of vein accessed </li></ul><ul><li>Gauge and length of I.V. cannula </li></ul><ul><li>Solution being administered and rate of flow. </li></ul><ul><li>Use of pump or gravity I.V. set. </li></ul><ul><li>Assessment of I.V. site. </li></ul><ul><li>Patient response </li></ul><ul><li>Any interventions taken to resolve an I.V. problem. </li></ul><ul><li>Notification of Doctor. </li></ul>
  11. 11. Anatomy and Physiology of the Forearm and Hand <ul><li>Muscles and tendons </li></ul><ul><li>Nerves </li></ul><ul><li>Arteries </li></ul><ul><li>Veins </li></ul>
  12. 12. Muscles and Tendons of the Forearm and Hand <ul><li>Biceps Brachii – Large conspicuous muscle lies anterior to the humerous. It is inserted by the biceps brachii tendon at the tuberosity of the radius. </li></ul><ul><li>The biceps brachii tendon is deep in the ante cubital fossa and lies to the side and beneath the radial artery. </li></ul><ul><li>The broad flat part of this tendon is called the Bicipital Aponeurosis that descends across the brachial artery and fuses with the fascia of the forearm flexor muscles. </li></ul><ul><li>The biceps brachii flexes and supinates the forearm </li></ul>
  13. 13. Muscles and tendons cont. <ul><li>Brachioradialis muscle: </li></ul><ul><li>Origin is at the anterior distal surface of the humerous. </li></ul><ul><li>It runs along the radial (thumb) aspect of the forearm. </li></ul><ul><li>It forms a long tendon that inserts at the styloid process of the radius. </li></ul><ul><li>It flexes the forearm </li></ul>
  14. 14. Muscles and Tendons cont. <ul><li>Superficial flexor muscles include: </li></ul><ul><li>Palmaris Longus </li></ul><ul><li>Flexor Carpi Radialis </li></ul><ul><li>Flexor carpi Ulnaris </li></ul><ul><li>Flexor Digitorum Superficialis </li></ul><ul><li>This group of muscles is attached proximally to the humerous. </li></ul><ul><li>They end more than halfway down to the wrist, in long tendons (which take the names of the muscles of origin) </li></ul><ul><li>These tendons tunnel under the flexor retinaculum, into the palm and insert into the bases of the metacarpal bones. </li></ul><ul><li>Responsible for flexion, abduction, adduction of the palm. </li></ul>
  15. 15. Muscles and Tendons cont. <ul><li>Superficial extensor muscles include: </li></ul><ul><li>Extensor Carpi Ulnaris </li></ul><ul><li>Extensor Digitorum </li></ul><ul><li>Extensor Carpi Radialis Brevis </li></ul><ul><li>Extensor Digiti Minimi </li></ul><ul><li>These muscles descend down the posterior medial aspect of the forearm and above the wrist they divide into tendons. </li></ul><ul><li>The tendons of the extensor digitorum divide into four and tunnel under the extensor retinaculum, they diverge on the dorsum of the hand, one tendon to each finger. </li></ul>
  16. 16. Muscles of the forearm <ul><li>http://www.paddlebal.com/paddes/Accesories/wristbuilder/anatomy2,jpeg </li></ul>
  17. 17. Nerves of the Forearm and Hand <ul><li>Supplied by four main nerves: </li></ul><ul><li>Musculocutaneous nerve </li></ul><ul><li>Median nerve </li></ul><ul><li>Radial nerve </li></ul><ul><li>Ulna nerve </li></ul><ul><li>These nerves originate from the brachial plexus in the shoulder. </li></ul>
  18. 18. Nerves cont. <ul><li>Musculocutaneous nerve </li></ul><ul><li>Supplies motor fibres to biceps brachii </li></ul><ul><li>Supplies sensory fibres to the lateral forearm </li></ul><ul><li>Located between the biceps and brachialis muscles. At the elbow it continues as the Lateral Cutaneous nerve of the forearm. It passes beneath the Cephalic Vein and runs adjacent to it. </li></ul><ul><li>It divides to form the posterior and anterior branch of the Lateral Cutaneous nerve, which descend along the radial border of the forearm to the wrist. </li></ul>
  19. 19. Nerves cont. <ul><li>Median nerve </li></ul><ul><li>Supplies motor fibres to flexor muscles in the anterior aspect of the arm. </li></ul><ul><li>Supplies sensory fibres to the radial half of the palm. </li></ul><ul><li>Located in the upper arm adjacent to the biceps brachii </li></ul><ul><li>Crosses in front of the radial artery deep into the forearm. </li></ul><ul><li>Descends down the medial aspect of the forearm. </li></ul><ul><li>Emerges between the tendons of the flexor muscles to supply the hand. </li></ul>
  20. 20. Nerves cont. <ul><li>Injury to the Median Nerve results in: </li></ul><ul><li>Inability to pronate the forearm </li></ul><ul><li>Inability to flex the wrist properly </li></ul><ul><li>Second phalanges of index and middle finger cannot be flexed. </li></ul><ul><li>Thumb cannot be flexed or abducted resulting in the inability to pick up small objects. </li></ul>
  21. 21. Nerves cont. <ul><li>Ulnar Nerve </li></ul><ul><li>Supplies motor fibres to the anteromedial flexor muscles and skin in the ulnar aspect of the arm. </li></ul><ul><li>It is deep and protected by the flexor carpi ulnaris muscle. </li></ul><ul><li>Runs along the anterior aspect of the forearm, emerges approximately 5cm below the wrist, divides into branches supplying the hand. </li></ul>
  22. 22. Nerves cont. <ul><li>Injury to the Ulnar Nerve results in: </li></ul><ul><li>Impaired flexion and adduction of the wrist. </li></ul><ul><li>Difficulty in spreading fingers, hand can become clawed. </li></ul>
  23. 23. Nerves cont. <ul><li>Radial Nerve </li></ul><ul><li>Supplies motor fibres to the muscles on the posterior aspect of the arm, forearm and hand. </li></ul><ul><li>Supplies sensory fibres to the skin in the same area. </li></ul><ul><li>Located under the triceps brachii muscle </li></ul><ul><li>In the upper arm. </li></ul><ul><li>Descends down the posterior aspect of the arm where it forms several branches, located under the posterior extensor muscle. </li></ul><ul><li>Two main branches of the Radial Nerve- deep and superficial terminal branch. </li></ul>
  24. 24. Nerves cont. <ul><li>Radial nerve cont. </li></ul><ul><li>The superficial terminal branch descend behind the brachii radial muscle, lateral to the radial artery. It curves around the side of the radius (approximately 7cm from the wrist) over the top of the wrist where it divides into five dorsal digital nerves. </li></ul>
  25. 25. Nerves cont. <ul><li>Injury to the Radial Nerve results in: </li></ul><ul><li>Inability to extend the hand at the wrist – wrist drop. </li></ul><ul><li>Loss of sensation to the skin of the radial aspect of the hand. </li></ul>
  26. 26. Nerves of the forearm <ul><li>http.//www.shoulderdystocionfo.com/images/anatomy.chest_434,jpg </li></ul>
  27. 27. Blood Vessels <ul><li>Peripheral Veins </li></ul><ul><li>Take oxygenated blood back to the heart. </li></ul><ul><li>It is a low pressure system (veins can collapse). </li></ul><ul><li>The walls of the vessels are small and thin but muscular and are able to contract and expand. </li></ul><ul><li>Veins contain valves which aid in maintaining blood flow in one direction. </li></ul><ul><li>Veins are generally more superficial. </li></ul>
  28. 28. Arterial Supply to the forearm <ul><li>htpp://www.medicalook.com/systems_images/Arteries_of_the_upper.jpg </li></ul>
  29. 29. Blood Vessels cont. <ul><li>Peripheral Arteries </li></ul><ul><li>Transport oxygenated blood from the heart to tissues. </li></ul><ul><li>They have thick muscular walls. </li></ul><ul><li>They do not require valves due to pulsation and high pressures, they do not collapse. </li></ul><ul><li>They are deep and protected. </li></ul>
  30. 30. Blood Vessels cont. <ul><li>Blood vessel structure: </li></ul><ul><li>Tunica Interna </li></ul><ul><li>Inner layer </li></ul><ul><li>Elastic endothelial lining </li></ul><ul><li>Basement membrane </li></ul><ul><li>Tunica Media </li></ul><ul><li>Middle layer </li></ul><ul><li>Contains nerve fibres and smooth muscle lining </li></ul><ul><li>Tunica Externa </li></ul><ul><li>Outer layer </li></ul><ul><li>Contains fiberous connective tissue, gives strength to arterial wall, will resist rupture due to thickness. </li></ul>
  31. 31. Arteries cont. <ul><li>Brachial Artery continues down from the axilliary artery, ends approximately 1cm distal to the elbow joint. </li></ul><ul><li>It then divides into the radial and ulnar arteries. </li></ul><ul><li>The brachial artery is superficial, covered only by skin and fascia of the Bicipital Aponeurosis. </li></ul><ul><li>The median nerve runs along side it. </li></ul>
  32. 32. Arteries cont. <ul><li>Radial artery is a more direct continuation of the brachial artery. </li></ul><ul><li>Smaller than the ulnar artery </li></ul><ul><li>Begins approximately 1cm below the bend of the elbow. </li></ul><ul><li>Descends along the lateral side of the forearm to the wrist </li></ul><ul><li>The radial pulse is felt on the radial aspect of the wrist (thumb side), where the artery passes in front of the radius bone. </li></ul><ul><li>As the radial artery passes over the wrist it bifricates into the superficial palmar branch. </li></ul><ul><li>The radial artery also passes under the carpal bones of the thumb to form the deep palmar arch </li></ul><ul><li>Digital arteries branch from both arches to supply the fingers. </li></ul>
  33. 33. Arteries cont. <ul><li>Ulnar artery is the larger terminal branch of the brachial artery. </li></ul><ul><li>Begins below the bend of the elbow and courses down the medial aspect of the forearm and wrist. </li></ul><ul><li>It crosses the palmar surface of the hand where it forms the main component of the superficial palmar arch. </li></ul><ul><li>Arteries on the dorsum of the hand are mostly deep and protected by the overlying tendons and faciae. </li></ul>
  34. 34. Venous Supply to the Forearm <ul><li>Htpp://www.medicalook.com/systems_images/veins_of_the_upper_Extremit.jpg </li></ul>
  35. 35. Blood Vessels - Veins <ul><li>Divided into two groups Superficial and Deep </li></ul><ul><li>Superficial veins show considerable individual variation. </li></ul><ul><li>They are subcutaneous in the fasciae and are easily palpable. </li></ul>
  36. 36. Superficial Veins cont. <ul><li>Cephalic Vein begins in the dorsal venous network on the posterior dorsum of the hand (radial aspect). </li></ul><ul><li>Ascends along the lateral border of the forearm </li></ul><ul><li>Forms the median cubital vein in front of the ante cubital fossa. The median cubital vein can sometimes be large and transfer most of the blood from the cephalic vein to the upper bascilic vein. The proximal cephalic vein may be absent or diminished. </li></ul><ul><li>Accessory cephalic vein ascends from the wrist, moves medially up the posterior forearm and turns over to the ante cubital fossa. </li></ul>
  37. 37. Superficial Veins cont. <ul><li>Basilic Vein begins in the dorsal venous network and ascends along the posterior ulnar side of the wrist. </li></ul><ul><li>In the forearm it inclines around the medial anterior surface. </li></ul><ul><li>It forms one of the large veins of the ante cubital fossa as it ascends into the upper arm to join the right axillary vein </li></ul>
  38. 38. Superficial Veins cont. <ul><li>Median Vein drains the palmar venous arch. </li></ul><ul><li>Ascends anterior in the forearm to join the median cubital vein or the basilic vein. </li></ul><ul><li>May divide below the elbow and join both the above veins. </li></ul>
  39. 39. <ul><li>http://www//ebaying.com/05/i/000/b9/80/3259_1_501.JPG </li></ul>
  40. 40. Veins cont. <ul><li>Deep veins </li></ul><ul><li>Accompany arteries. </li></ul><ul><li>Usually in pairs on either side of the artery and are connected by short crosslinks. </li></ul><ul><li>The deep veins are relatively small. </li></ul><ul><li>Most of the blood in the fore arm is returned by the superficial veins. </li></ul><ul><li>They are not advised for use for routine I.V. access due to their close proximity to arteries and nerves. </li></ul>
  41. 41. Deep veins cont. <ul><li>Radial veins drain the dorsal metacarpal veins and run alongside the radial artery. </li></ul><ul><li>Ulnar veins drain the palmar venus arch and run alongside the ulnar artery. </li></ul><ul><li>These veins join up to form the deep brachial vein in the elbow. A large venous branch can also connect them to the median cubital vein. </li></ul>
  42. 42. Complications of I.V. Therapy <ul><li>http://www.connection.iww.com/.../ch46/jpg/46_008.jpg </li></ul>
  43. 43. Complications cont. <ul><li>5% of all nosocomial infections result from I.V. therapy. </li></ul><ul><li>80-85% of hospital patients receive I.V. therapy. </li></ul><ul><li>There is an estimated 40-60% incidence of complications from I.V. therapy. </li></ul>
  44. 44. Infiltration/Extravasation <ul><li>Definition: </li></ul><ul><li>Diffusion or accumulation of injected fluid into the subcutaneous space. </li></ul><ul><li>Cause: </li></ul><ul><li>Cannula displaced out of the vein wall. </li></ul><ul><li>S&S: </li></ul><ul><li>Swelling and pain </li></ul><ul><li>Slowing of the infusion </li></ul><ul><li>Coolness of the skin </li></ul>
  45. 45. Infiltration/Extravasation cont. <ul><li>Prevention: </li></ul><ul><li>Appropriate selection of site and cannula </li></ul><ul><li>Proper stabilisation of the cannulation and tubing </li></ul><ul><li>Frequent checking of the insertion site. </li></ul><ul><li>Intervention: </li></ul><ul><li>Remove I.V. cannula immediately </li></ul><ul><li>Apply ice (early) or warm compress (late) to aid absorption. </li></ul><ul><li>Use recommended antidote or treatment for specific drug extravasations. </li></ul>
  46. 46. Haematoma <ul><li>Definition: </li></ul><ul><li>Localised collection of extravasated blood, usually clotted, in an organ or tissue. </li></ul><ul><li>Cause: </li></ul><ul><li>Blood leaking out of the vein into the tissue due to puncture or trauma. </li></ul><ul><li>S&S </li></ul><ul><li>Swelling, tenderness and discolouration. </li></ul><ul><li>Prevention </li></ul><ul><li>Proper device insertion </li></ul><ul><li>Pressure over site on removal </li></ul><ul><li>Intervention </li></ul><ul><li>Apply appropriate pressure bandage, monitor. </li></ul>
  47. 47. Phlebitis <ul><li>Definition: </li></ul><ul><li>Inflammation of the vein </li></ul><ul><li>Cause: </li></ul><ul><li>Poor aseptic technique </li></ul><ul><li>High osmolarity I.V. infusions or drugs </li></ul><ul><li>Trauma to the vein during insertion/incorrect cannula gauge </li></ul><ul><li>Prolonged use of the same site </li></ul>
  48. 48. Phlebitis cont. <ul><li>Symptoms: </li></ul><ul><li>Tenderness, redness, heat and oedema </li></ul><ul><li>Advanced-induration, palpable venous cord. </li></ul><ul><li>Prevention: </li></ul><ul><li>Smooth insertion </li></ul><ul><li>Aseptic technique </li></ul><ul><li>Stabilisation and secure taping of all tubing </li></ul><ul><li>Rotation of the site </li></ul><ul><li>Replace loose and contaminated dressings </li></ul><ul><li>Dilution of drugs </li></ul><ul><li>Frequent observation of site </li></ul>
  49. 49. Phlebitis cont. <ul><li>Intervention: </li></ul><ul><li>Remove cannula and apply warm compresses. </li></ul><ul><li>Observe for signs of infection </li></ul><ul><li>If phlebitis is advanced antibiotics may be required. </li></ul>
  50. 50. Thrombophlebitis <ul><li>Definition: </li></ul><ul><li>Formation of a thrombus and inflammation in the vein, usually occurs after phlebitis. </li></ul><ul><li>Cause: </li></ul><ul><li>Injury to the vein </li></ul><ul><li>Infection </li></ul><ul><li>Chemical irritation </li></ul><ul><li>Prolonged use of the same vein </li></ul>
  51. 51. Thrombophlebitis cont. <ul><li>S&S: </li></ul><ul><li>Tenderness/redness </li></ul><ul><li>Heat/oedema </li></ul><ul><li>Cordlike appearance of the vein </li></ul><ul><li>Slowing of the I.V. infusion </li></ul><ul><li>Prevention: </li></ul><ul><li>Smooth insertion </li></ul><ul><li>Asepsis </li></ul><ul><li>Stabilisation of I.V. cannula and tubing </li></ul><ul><li>Correct administration of drugs </li></ul><ul><li>Change cannula frequently (72hrs) </li></ul><ul><li>Intervention: </li></ul><ul><li>Remove I.V. cannula </li></ul><ul><li>Observe for signs of infection </li></ul>
  52. 52. Venespasm <ul><li>Definition: spasm of the vein wall. </li></ul><ul><li>Cause: </li></ul><ul><li>Anxiety </li></ul><ul><li>Cold I.V. fluids </li></ul><ul><li>Drug irritation </li></ul><ul><li>Trauma to the vein during cannula insertion </li></ul><ul><li>S&S: </li></ul><ul><li>Pain </li></ul><ul><li>Slowing of the I.V. infusion </li></ul><ul><li>Blanching at the insertion site </li></ul><ul><li>Vein difficult to palpate </li></ul>
  53. 53. Venespasm cont. <ul><li>Prevention: </li></ul><ul><li>Warm arm bath prior to cannula insertion </li></ul><ul><li>Reassurance </li></ul><ul><li>Allow infusions to come to room temperature. </li></ul><ul><li>Interventions: </li></ul><ul><li>Warm compresses </li></ul><ul><li>Slow infusion rate </li></ul><ul><li>Reassurance </li></ul>
  54. 54. Occlusion <ul><li>Definition: slowing or cessation of fluid infusion due to: </li></ul><ul><li>Fibrin formation in or around the tip of the cannula </li></ul><ul><li>Mechanical occlusion (kink) of the cannula </li></ul><ul><li>Cause: </li></ul><ul><li>Cannula not flushed </li></ul><ul><li>Kinking of the cannula </li></ul><ul><li>Back flow or interrupted flow </li></ul><ul><li>S&S: </li></ul><ul><li>I.V. not running </li></ul><ul><li>Blood in the line </li></ul><ul><li>Discomfort </li></ul>
  55. 55. Occlusion cont. <ul><li>Prevention: </li></ul><ul><li>Check I.V. site regularly </li></ul><ul><li>Flushing of cannula frequently </li></ul><ul><li>Avoid increased venous pressure proximally to the cannula (BP cuff) </li></ul><ul><li>Intervention: </li></ul><ul><li>Check for kinks in cannula </li></ul><ul><li>Raise I.V. flask higher </li></ul><ul><li>Remove cannula </li></ul>
  56. 56. Infection <ul><li>Definition: Pathogen in the surrounding tissue of the I.V. site. </li></ul><ul><li>Cause: </li></ul><ul><li>Lack of asepsis </li></ul><ul><li>Prolonged use of the same site </li></ul><ul><li>S&S: </li></ul><ul><li>Tenderness and swelling </li></ul><ul><li>Erythema/purulent drainage </li></ul>
  57. 57. Infection cont. <ul><li>Prevention: </li></ul><ul><li>Frequent checking of the site </li></ul><ul><li>Intervention: </li></ul><ul><li>Remove cannula </li></ul><ul><li>Antibiotics may be required </li></ul><ul><li>Documentation </li></ul>
  58. 58. Other complications <ul><li>Fluid overload </li></ul><ul><li>Electrolyte imbalance </li></ul><ul><li>Transfusion reactions </li></ul><ul><li>Air embolus </li></ul>
  59. 59. Resources and References <ul><li>Journal of intravenous nursing, Vol 18 (2), 1998 </li></ul><ul><li>“ Reducing the risks of complications in I.V. therapy” Dougherty, RN. Nursing Standard, Oct 22 (12), 1997 </li></ul><ul><li>Principles of anatomy and physiology, Gerard J. Tortora, Nicholas P. Anagnostakos. Fifth Edition </li></ul><ul><li>The Joanna Briggs Institute, Best Practice Management of Peripheral Intravenous Devices 11/02/2008 http://www.joannabriggs.edu.au/best_practice/bp3.php </li></ul>
  60. 60. I.V. Cannulation Technique <ul><li>Identification & selection of a suitable vein: </li></ul><ul><li>Patients medical history </li></ul><ul><li>Age, body size and general condition </li></ul><ul><li>Type of blood sample required for I.V. fluid/medication to be infused </li></ul><ul><li>Expected duration of I.V. therapy </li></ul><ul><li>Your skill at venepuncture or cannulation </li></ul>
  61. 61. Technique cont. <ul><li>For I.V therapy that is to continue for several days, start with the most distal location available and move up as necessary. </li></ul><ul><li>For an obese patient the hand veins may be the only accessible site. </li></ul><ul><li>The cephalic vein can offer a comfortable site in a thin patient, if placed to avoid interfering with flexion. </li></ul>
  62. 62. Technique cont. <ul><li>Proficiency is achieved by: </li></ul><ul><li>Practicing on real patients and all types of arm sites. </li></ul><ul><li>Observe the procedure several times, then try yourself under supervision. </li></ul><ul><li>Ask for feedback </li></ul><ul><li>Do not be discouraged by failures, you may have a few </li></ul><ul><li>CARDINAL RULE : Do not persist after two (2) unsuccessful attempts on the same patient. Get a more experienced member of staff to help. </li></ul>
  63. 63. Technique cont. <ul><li>Choosing the site: Adult patient </li></ul><ul><li>Veins in the hands may be a good first choice. Allows for availability of more proximal sites. (Dorsal & Metacarpal Veins) </li></ul><ul><li>Lower arm veins are good for shorter term I.V. therapy. Leaves the patient’s hands free, larger arm veins do not become phlebetic as quickly. (Cephalic & Basilic Veins) </li></ul><ul><li>The antecubital fossa provides good veins for blood sampling as they are very prominent. They are not recommended for long term I.V. therapy as placement interferes with flexion. </li></ul><ul><li>Upper arm veins should only be used as a third choice, when all other sites have been used. </li></ul>
  64. 64. Technique cont. <ul><li>Veins used as a last resort: </li></ul><ul><li>The inner aspect of the arm: painful site, prone to bruising, phlebitis and infiltration. </li></ul><ul><li>Antecubital fossa: suitable for blood sampling and short term infusion due to position. </li></ul><ul><li>Legs, feet and ankles: requires medical approval as mobility is reduced and circulation can be compromised. </li></ul><ul><li>The dorsum of the foot and the saphenous vein of the ankle are the best sites to try if necessary. </li></ul>
  65. 65. I.V. sites http://www//ebaying.com/05/i/000/b9/80/3259_1_501.JPG
  66. 66. Technique cont. <ul><li>Sites to avoid: </li></ul><ul><li>Veins below previous I.V. infiltration or phlebetic sites. </li></ul><ul><li>Sclerosed or thrombosed veins. </li></ul><ul><li>Areas of skin inflammation, bruising or breakdown. </li></ul><ul><li>An arm affected lymphedema, node dissection after mastectomy, thrombosis, cellulitis or infection. </li></ul><ul><li>Arm with an arteriovenous shunt or fistula. </li></ul>
  67. 67. Cannulation Devices <ul><li>http://www.qub.ac.uk/cskills/iv_cannulation/different sizes.jpg </li></ul>
  68. 68. Vein Identification <ul><li>Dorsal Metacarpal Veins – usually prominent and visible, lie flat on the hand, easy to feel, easily accessible. </li></ul><ul><li>Hand provides a flat surface for stability. </li></ul><ul><li>Phlebitis and infiltration occur more easily due to small vein size and hand movement. </li></ul><ul><li>Haematomas form rapidly. </li></ul><ul><li>May not be appropriate for elderly patient’s due to diminished skin turgor and subcutaneous tissue. </li></ul><ul><li>Limited hand movement particularly for patients using crutches and frames. </li></ul><ul><li>22gauge or smaller/1 inch or shorter. </li></ul>
  69. 69. Vein Identification cont. <ul><li>Cephalic Veins begin in the dorsal venous network on the thumb side of the hand and ascends along the lateral border of the forearm. </li></ul><ul><li>Excellent route for I.V. infusions. </li></ul><ul><li>Larger vein, providing haemodilution for hypertonic or irritating solutions. </li></ul><ul><li>Arm bones act as a natural splint. </li></ul><ul><li>May be accessed from the wrist to the upper arm. Access in the wrist can result in phlebitis and infiltration due to hand movement. </li></ul><ul><li>Vein tends to roll during insertion of cannula device. </li></ul><ul><li>Use the smallest and shortest cannula to accommodate therapy. </li></ul><ul><li>22-18 gauge </li></ul>
  70. 70. Vein Identification cont. <ul><li>Basillic Vein begins in the dorsal venous network on the little finger side of the hand and ascends along the medial side of the forearm. </li></ul><ul><li>Straighter in the upper arm than the Cephalic vein, large and prominent vein. </li></ul><ul><li>Inconspicous positioning on the medial side of the forearm, results in this site often not being considered. </li></ul><ul><li>May be accessed anywhere along it’s course, vein tends to roll and may be awkward to access due to it’s position. </li></ul><ul><li>Can accommodate a larger cannula. </li></ul><ul><li>22-18 gauge </li></ul>
  71. 71. Vein Identification cont. <ul><li>Antecubital Veins located in the inner aspect of the elbow and are comprised of the Median Cubital, Accessory Cephalic and Basilic Veins </li></ul><ul><li>Often used for short term or emergency access, generally blood sampling only. </li></ul><ul><li>Last resort site for I.V. therapy or PICC line or midline catheter. </li></ul><ul><li>Painful site due to numerous nerve endings in this area. </li></ul><ul><li>All gauge sizes are suitable. </li></ul>
  72. 72. Locating a suitable vein <ul><li>Inspect and palpate </li></ul><ul><li>Vein should feel FIRM, ROUND, ELASTIC and ENGORGED. </li></ul><ul><li>Do not use if vein feels KNOTTY, HARD or SMALL. </li></ul><ul><li>AVOID ARTERIES – when cannulating in the antecubital fossa, palpate for arterial pulsation. </li></ul><ul><li>Assess both arms before making final selection, ask patient about past experiences. </li></ul>
  73. 73. Cannula Selection <ul><li>Use the smallest cannula that will achieve the desired outcome – </li></ul><ul><li>24 gauge can infuse 3 litres in 24hrs. </li></ul><ul><li>22 gauge can complete a 3 unit blood transfusion. </li></ul><ul><li>Cannula must be smaller than the vein to increase haemodilution, thereby reduce irritation and prevent mechanical phlebitis. </li></ul><ul><li>Solutions containing medications and Hypertonic solutions requuire larger veins to be cannulated to dilute the fluid and prevent mechanical phlebitis. </li></ul>
  74. 74. I.V. Therapy Equipment <ul><li>Cannula & Needles: </li></ul><ul><li>Mostly made from teflon or </li></ul><ul><li>Polyurethane. Completely </li></ul><ul><li>retractable stylets to prevent </li></ul><ul><li>Needle stick injury, are recent </li></ul><ul><li>Advancements. </li></ul><ul><li>Recessed needles and cannula </li></ul><ul><li>will replace exposed needles </li></ul><ul><li>eventually. </li></ul>
  75. 75. I.V. Equipment cont. <ul><li>I.V. administration sets (giving set) </li></ul><ul><li>Moving to a needless system </li></ul><ul><li>where a blunt cannula can be </li></ul><ul><li>used in the Y port (Interlink ®). </li></ul><ul><li>Tubing is being developed that </li></ul><ul><li>will not absorb drugs or ‘leech’ </li></ul><ul><li>plastic particles into the solution. </li></ul><ul><li>Non PVC tubing will be less toxic </li></ul><ul><li>when disposed of. </li></ul>
  76. 76. I.V. Equipment cont. <ul><li>I.V. Drugs & Solutions </li></ul><ul><li>Many solutions and antibiotics </li></ul><ul><li>now come pre-mixed in “add-a- </li></ul><ul><li>Line’ giving bags. </li></ul><ul><li>Computerised delivery systems </li></ul><ul><li>will replace infusion pumps. </li></ul><ul><li>These systems will be multi- </li></ul><ul><li>channel and deliver drugs and </li></ul><ul><li>fluids according to I.V. protocols </li></ul><ul><li>That are preprogrammed. </li></ul>
  77. 77. Equipment required for Cannulation <ul><li>Torniquet </li></ul><ul><li>Dressing pack </li></ul><ul><li>Absorbant pad “bluey” </li></ul><ul><li>Gloves </li></ul><ul><li>Selected I.V. cannula </li></ul><ul><li>Skin cleansing prep. </li></ul><ul><li>5 or 10ml syringes ( for saline flush and/or blood sampling) </li></ul><ul><li>3 way tap or bung </li></ul><ul><li>I.V. fluids and primed giving set. </li></ul><ul><li>Occlusive dressing ‘Opsite” or ‘Tegaderm’. </li></ul><ul><li>Tape </li></ul><ul><li>Blood tubes if blood sampling performed. </li></ul><ul><li>Aseptic Handwash for 1 min. required prior to donning gloves. </li></ul>
  78. 78. Preparation for the procedure <ul><li>Gather equipment and prime I.V. tubing before approaching the patient. </li></ul><ul><li>Explain the procedure, gain consent, reassure. </li></ul><ul><li>Position the patient to allow easy access to the desired site, ensure patient and yourself are comfortable. </li></ul><ul><li>Position the arm below heart level to encourage capillary filling. </li></ul><ul><li>Rub the arm (gently) to warm the skin and inspect the area of intended insertion. </li></ul><ul><li>If necessary cover the arm with warm packs to promote vasodilatation. </li></ul><ul><li>Be confident, but know your limitations. </li></ul>
  79. 79. 1. Applying the torniquet <ul><li>Apply 5-7cm below the antecubital fossa, if cannulating the hand or lower arm. </li></ul><ul><li>Tourniquet should be tight enough to trap venous blood in the veins without cutting off arterial flow. </li></ul><ul><li>Remove if veins are not filling up well. Allow vessels to refill then reapply the tourniquet. Veins may “rebound” and fill better. </li></ul><ul><li>In elderly patients, lift the tourniquet up, stretch the skin, and underlying tissues away from the venipuncture site. Gently lower the tourniquet. </li></ul><ul><li>Ask the patient to clench their fist several times to encourage the veins to become turgid and more rounded. </li></ul>
  80. 80. 2. Pre-Cannulation <ul><li>Identify desirable vein </li></ul><ul><li>Encourage vein to enlarge by lightly flicking to stimulate mechanical reflex dilation. </li></ul><ul><li>Palpate the vein, should feel elastic and resilient. </li></ul><ul><li>Shave or clip hair if necessary. </li></ul><ul><li>Cleanse site with skin prep. In a circular motion from inside out. </li></ul><ul><li>Allow to dry. Much of the solution’s germicidal action takes place during the drying period (+/- 1 min.) </li></ul>
  81. 81. 3. Vein stabilisation <ul><li>Immobilise vein: prevent rolling by maintaining vein in a taut, distended, stable position. </li></ul><ul><li>Hand vein: </li></ul><ul><li>- Grasp patient’s hand with your non-dominant hand. </li></ul><ul><li>- Place your fingers under the palm and fingers with your thumb on top of the patient’s hand. </li></ul><ul><li>- Pull hand downward to flex wrist and create an arch. </li></ul><ul><li>- Elbow remains supported on the bed. </li></ul><ul><li>- Stretch skin down over the knuckles with your thumb to stabilise vein. </li></ul><ul><li>- Keep a firm grip during insertion. </li></ul>
  82. 82. Vein stabilisation cont. <ul><li>Cephalic Vein: </li></ul><ul><li>Ask patient to clench their fist. </li></ul><ul><li>Pull fist down laterally. </li></ul><ul><li>Lower arm Vein: </li></ul><ul><li>Anchor vein below site of insertion with thumb and pull skin taut. </li></ul>
  83. 83. 4. Inserting the cannula <ul><li>Venepuncture: </li></ul><ul><li>Hold the needle (with syringe) bevel side up over the vein. </li></ul><ul><li>Enter the vein – in a smooth deft motion – at a 25-30 degree angle. </li></ul><ul><li>Observe for blood in the coloured hub of the needle. </li></ul><ul><li>Holding the syringe steady, remove your anchor ‘hand’ and use it to gently withdraw the syringe plunger until sufficient blood is obtained. </li></ul><ul><li>Collect cotton ball/gauze in your free hand, remove needle from the vein in a quick motion, immediately place the cotton ball/gauze over the puncture site and tape securely. </li></ul><ul><li>Maintain firm direct pressure over area for a few minutes (patient can be asked to do this), to stop the bleeding. </li></ul>
  84. 84. Inserting the cannula <ul><li>Cannulation: </li></ul><ul><li>Hold the flashback chamber of the cannula, not the coloured “hub”. </li></ul><ul><li>Hold the cannula over the vein, bevel side up and pointing in the direction of blood flow. </li></ul><ul><li>Use an approach angle of 15 degrees for superficial veins and 25-30 degrees for deeper veins. </li></ul>
  85. 85. 5. Inserting the cannula <ul><li>Insert the cannula through the skin with a smooth assertive motion. </li></ul><ul><li>Observe for “flask back” of blood into the flash chamber. This indicates that the vein has been penetrated successfully. </li></ul><ul><li>Lower the cannula angle and continue to advance the cannula 2-3mm further into the vein. </li></ul>
  86. 86. Inserting the cannula cont. <ul><li>With one hand, hold the stylet in place and use the other hand to advance the catheter over the stylet into the vein. </li></ul><ul><li>Release the tourniquet. </li></ul><ul><li>Remove the stylet whilst holding the cannula hub, minimise blood leakage by applying pressure to vein beyond cannula tip with finger. </li></ul><ul><li>NEVER reintroduce the stylet if the cannula does not feed into the chosen vein.The cannula can shear off and enter the patient’s circulation </li></ul>
  87. 87. Post-Cannulation <ul><li>Flushing with 5ml of normal saline checks patency of the vein. </li></ul><ul><li>Connect I.V. giving set, or tap to the cannula. </li></ul><ul><li>Cover with sterile transparent dressing, allows for observation of the insertion site, allowing for early detection of complications. </li></ul><ul><li>Label dressing with date and time of insertion and cannula size. </li></ul><ul><li>Stabilise tubing independently of the cannula, splint arm if necessary. </li></ul><ul><li>Commence I.V. infusion as required. </li></ul><ul><li>Reassure patient, dispose of equipment correctly, wash hands, document. </li></ul>
  88. 88. Troubleshooting <ul><li>Back flow stops when stylet is removed: </li></ul><ul><li>Opposite wall of the vein may have been pierced. </li></ul><ul><li>Retract cannula slightly without removing tourniquet, until “flash back” appears again. This indicates the tip of cannula is back in the lumen, quickly advance the cannula into the vein. </li></ul><ul><li>Release tourniquet. </li></ul><ul><li>Stop procedure if haematoma develops or if there is leakage from the insertion site. May occur in elderly patient’s due to fragile veins. </li></ul>
  89. 89. Troubleshooting cont. <ul><li>Venospasm can prevent cannula insertion, usually common in anxious patients. Reassure patient and allow them to rest for a short period. Warm arm bath can assist in correcting this problem. </li></ul><ul><li>Improper torniquet placement – too high, low, tight or loose, can cause insufficient engorgement of vein. </li></ul><ul><li>Failure to release torniquet promptly may cause bleeding outside the vein. </li></ul><ul><li>A tentative stop start approach can injure the vein. </li></ul><ul><li>Inadequate vein stretching which allows the cannula to push the vein to the side instead of entering. </li></ul>
  90. 90. Troubleshooting cont. <ul><li>Stopping to soon after insertion so that only the stylet, not the cannula has entered the lumen. Blood “flash back” disappears when the stylet is removed. Discontinue and restart procedure. </li></ul><ul><li>Failure to penetrate vein wall due to improper insertion angle causing the cannula to ride on top of, or below, the vein. Discontinue and restart the prodedure. </li></ul>
  91. 91. Resources and References <ul><li>Journal of intravenous nursing, Vol 18 (2), 1998 </li></ul><ul><li>“ Reducing the risks of complications in I.V. therapy” Dougherty, RN. Nursing Standard, Oct 22 (12), 1997 </li></ul><ul><li>Principles of anatomy and physiology, Gerard J. Tortora, Nicholas P. Anagnostakos. Fifth Edition </li></ul><ul><li>The Joanna Briggs Institute, Best Practice Management of Peripheral Intravenous Devices 11/02/2008 http://www.joannabriggs.edu.au/best_practice/bp3.php </li></ul><ul><li>All pictures for cannulation procedure:http://www.qub.ac.uk/cskills/iv_cannulation/iv_cannulation.htm </li></ul>

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