The document outlines guidelines for inserting intravenous cannulas including: 1. Only nurses certified in IV insertion will perform the procedure, or medical practitioners for patients under 14. 2. If insertion fails after two attempts by a nurse, a third attempt can be made or a medical practitioner will assist. 3. Proper vein selection, preparation, insertion technique and post-insertion care are described to minimize complications of IV therapy.

2. Aims 1. To gain peripheral venous access in order to: • administer blood products, medications nutritional components 2. To minimize the risk of complications when initiating IV therapy through: • careful choice of IV site • good insertion technique • aseptic preparation of infusions

3. Key points 1. Only nurses who have been certified as competent in the insertion of IV cannula will perform this procedure. 2. Where the patient is less than 14 years of the IV cannula will be inserted by a medical practitioner. The exception will be in the case neonates where neonatal trained nurses may insert an IV cannula if directed by a medical officer.

4. 3. In the case of two unsuccessful attempts at insertion, the operator will seek the assistance of another experienced nurse for one additional attempt. After a total three unsuccessful attempts the assistance of a medical practitioner will be sought. Selection of Catheter Site Choose a suitable vein. In adults, use long straight veins in an upper extremity away from the joints for catheter insertion - in preference to sites on the lower extremities. If possible avoid veins in the dominant hand and use distal veins first.

5. Key points 1. Only nurses who have been certified as competent in the insertion of IV cannula will perform this procedure. 2. Where the patient is less than 14 years of the IV cannula will be inserted by a medical practitioner. The exception will be in the case neonates where neonatal trained nurses may insert an IV cannula if directed by a medical officer.

7. Veins of the Hand 1. Digital Dorsal veins 2. Dorsal Metacarpal veins 3. Dorsal venous network 4. Cephalic vein 5. Basilic vein Veins of the Forearm 1. Cephalic vein 2. Median Cubital vein 3. Accessory Cephalic Vein 4. Basilic vein 5. Cephalic vein 6. Median antebrachial vein 1. Digital Dorsal veins 2. Dorsal Metacarpal veins 3. Dorsal venous network 4. Cephalic vein 5. Basilic vein

8. Check for the doctors order. Identify the pt. Wash hands prior to insertion. Bring all the necessary materials @ pt. bed sides. Explain procedure to the patient. Prepare IV infusion , open the seal of the IV bottles and close the IV clamp. Spike the infusate aseptically and fill the drip chamber to at least half & prime the tubing prior to insertion. Remove air bubbles if any & cover the distal end of tubing.

9. Don gloves and select appropriate venipuncture site. Apply torniquet 2-6 inches above proposed insertion site. Disinfect the selected site with skin cotton balls with alcohol and allow to dry. Do not touch the skin with the fingers after preparation solution has been applied and maintain aseptic technique while doing the procedure remains the cornerstone of prevention of cannula related infections. Inspect the cannula before insertion to ensure that the needle is fully inserted into the plastic cannula and that the cannula tip is not damaged.

10. 13. Ensure the bevel of the cannula is facing upwards to facilitate piercing of the skin by the bevel. 14. Using the appropriate cannula, pierce the skin w/ needle positioned on a 15-30 degree angle. Insert the needle and the cannula into the vein & apply gentle traction on skin may stabilize the vein under the skin. 15. Partially withdraw the needle and advance the cannula. 16. Release the torniquet. Apply gentle pressure over the vein just proximal to the entry site to prevent blood flow. Remove the needle from within the plastic catheter.

11. 17. Quickly connect end of the infusing tubing to the end cannula, secure connection and regulate the IV fluids 18. Cover the intravenous and surrounding area with a transparent dressing ensure that insertion site and the area proximal to the site are visible for inspection purposes. 19. Make an IV tag and write the name of the pt, type of IV fluids, incorporation if any, date and time IV fluid was started . 20. Dispose of all sharps in the appropriate sharps container, remove gloves and wash hands

12. Local Complication: Phlebitis is irritation of a vein that is not caused by infection, but from the mere presence of a foreign body (the IV catheter) or the fluids or medication being given. Symptoms are warmth, swelling, pain, and redness around the vein. The IV device must be removed and if necessary re-inserted into another extremity. To ease your patient's discomfort, apply warm packs. Document your patient's condition and interventions. If indicated, insert a new catheter at a different site, preferably on the opposite arm, using a vein or a smaller device and restart the infusion.

13. 2. Thrombophlebitis is similar to phlebitis but a thrombus (or clot) is in addition involved. As the IV cannula stays inside your body, it may irritate the vein leading the body to trigger its clotting mechanisms. This occurs when the catheter unintentionally enters the tissue surrounding the blood vessel. In this case the IV fluid and associated medications will go into the tissues and there will be a lump as an IV has been inserted

14. 3. Infiltration - occurs when I.V. fluid leaks into surrounding tissue. It's commonly caused by improper placement or dislodgment of the catheter. Patient movement may cause the catheter to slip out or through the lumen of the vessel. t is characterized by coolness and pallor to the skin as well as local edema It is usually not painful. It is treated by removing the intravenous access device and elevating the affected limb so that the collected fluids can drain away. Infiltration is one of the most common adverse effects of IV therapy and is usually not serious ..

15. 4. Hematoma is a collection of blood caused by internal bleeding. This happens when the catheter punctures through the vein and causes a hematoma 5. Extravazation the leaking of vesicant drugs (such as antineoplastics) into surrounding tissue, can cause severe local tissue damage, resulting in delayed healing, infection, tissue necrosis, disfigurement, loss of function, 6. Infection -Any break in the skin carries a risk of infection. Although IV insertion is a sterile procedure, skin-dwelling organisms such as candida albicans may enter through the insertion site around the catheter, or bacteria may be accidentally introduced inside the catheter from contaminated equipment.

16. 7. Venous Spasm - A sudden involuntary contraction of a vein or an artery resulting in temporary cessation of blood flow through a vessel. Systemic Complication: 1. Septicemia: a febrile disease process that results from the presence of microorganisms or their toxic products in the circulatory system. 2. Fluid overload & Pulmonary edema - caused by infusing excessive amounts of isotonic or hypertonic crystalloid solutions to rapidly, failure to monitor the IV infusion or too-rapid infusion of any fluid in a patient compromised by cardiopulmonary or renal disease

17. 3. Air embolism -Air entering the central vein, which is quickly trapped in the blood as it flows forward. Prevention is the key. 4. Shock - occurs when a foreign substance usually a medication is rapidly introduced into the circulation 5. Catheter embolism - a piece of the catheter off and travels through the vascular system. Treatment : Discontinue IV, apply a tourniquet above the site, take appropriate emergency measures, inspect catheter for rough edges that might indicate loss of fragments. Obtain order for x-ray to determine if fragments are present.

18. Prepared By: emma a. valero,rn,rm,man. clinical instructor phcm Thank you for listening