MUHAMMAD SAEDMUHAMMAD SAEDICU HEAD NURSEICU HEAD NURSEAGH-HUFOFAGH-HUFOF

ObjectivesObjectivesBy the end this course learners will be able to :

1. Define vene-puncture

2. List the indication &contraindication for IV cannulation

3. Discuss criteria for slecting a suitable venepuncture site

4. Describe methods of distending a vein.

5. Identify general rules for a venepuncture.

6. Explore the factors, which influence the flow rate of fluids.

7. State the method of monitoring the flow rate of fluids

8. List the common complication of venepuncture

9. Define osmosis, isotonic, hypotonic&hypertonic solution

10. Discuss effects of different solutions in our body.

INTRAVENOUS INTRAVENOUS THERAPY;THERAPY; It is the infusion of fluid into vein. The therapeutic goal is maintenance,

replacement, treatment, diagnosing, and palliation

(Supportive treatment with relieves but not cure disease e.g. DM )

VENIPUNCTURE: It is sterile technique that permits

insertion of a needle or a catheter into a vein .

INDICATION FOR VENIPUNCTURE:INDICATION FOR VENIPUNCTURE:

To maintain or replace body stores of water, electrolytes, vitamins, proteins, fats & calories in patients who cannot maintain an adequate intake by mouth.

To restore volume of blood components To administer safe & effective, continuous or intermittent

infusions of medications. To monitor Central Venous pressure To provide nutrition while resting the gastro-intestinal

tract. To keep a vein open in emergency To obtain blood samples for lab tests. To administer a bolus preparation or IV push medications

Contra-indicationContra-indication Oral medication can be given effectively Intramuscular medication can be given

effectively & comfortably (for frequent injections an IV route may be preferred )

Patient’s sensitive or allergic to IV equipment or medication.

Coagulation disorder ( unless IV’s needed to treat the condition )

Patient refuses IV treatment

Nursing Role & ManagementNursing Role & ManagementIt is prime responsibility of a nurse to select an appropriate site for venipuncture, type of cannula and be proficient in the technique of vein entry

Selection of a VeinSelection of a Vein• Peripheral vein provide the quickiest & easiest approach for the establishment of an IV access for administration of solutions & medication

• Thoroughly inspect patient’s extermities

• Most distal site of arm or hand is generally used first so that subsequent IV access sites can be moved progressively upwards

Selection of a VeinSelection of a Vein Avoid veins below or near previous infiltrated or phlebitis area,

sclerosis or thrombosed vein. Do not use an arm affected by edema, infection or

in hand with fistula. Arm on the side of mastectomy is avoided because

of impaired body flow & lymphatic system Non-dominant extremities should be accessed

first. Avoid sites that are easily moved or bumped In older clients use smaller gauge cannula & apply

minimal tourniquet pressure Use lower extremities as a last resort. Avoid areas of joint flexion & veins close to

arteries and deeper lying tissues.

Methods of Distending a VeinMethods of Distending a Vein

Apply manual compression above the site where cannula is to be inserted.

Have the client periodically clench the fist. Massage the area in the direction of venous flow. Apply tourniquet 2-6 inches above planned

insertion site (An alternative is to apply BP cuff ) Lightly tap the vein site. Ask patient to dangle his/her hand below heart

level for few minutes. For an infant, place his head lower than his body.

General Principles for a venipunctureGeneral Principles for a venipuncture

Have proper light & be organized & confident. Follow strict aseptic technique The nurse must wear non-sterile disposable

gloves. Excessive hair at the selected site should be

removed Cannulation of pulsating vessels should be

avoided. Use an angle of 45°to insert the cannula ( 5-15° in

older adults). Never re-insert the style back into the cannula

once it has been removed. All register nurses must be certified to perform

venipuncture.(According to AKUH policy ).

FACTORS AFFECTING FLOW RATEFACTORS AFFECTING FLOW RATE Flow is directly proportional to the

height of the liquid column. Flow is directly proportional to the

diameter of the tubing. Flow rate is inversely proportional to

the length of tubing. Flow is inversely proportional to the

viscosity of the fluid

OTHER FACTORS ARE :OTHER FACTORS ARE : Condition and position of patient Age Gauge of IV cannula Temperature Patients movement and activity Pressure gradient higher pressure to

lower Friction the interaction between fluid

molecules & surfaces of inner wall of IV tubing.

Potency of IV needle / cannula Knot or kink in the tubing

MONITORING THE FLOWMONITORING THE FLOW Intravenous fluid must be monitored

frquently to make sure that the fluid is flowing @ the intended rate.

Double-check the flow rate Check tubings for kinks Check position of patient & taping of

IV cannulaIntravenous fluid bag should be labeled indicating date & time the bag was hung, rate of flow, finishing time, initials & designation• Separate label for additives

CALCULATING FLOW RATECALCULATING FLOW RATEFORMULA :Drops / minute = Amt.of fluid to be infused/hr X DF

Time in minutesDROP FACTORS:Blood = 10Burretol = 60 microRegular = 15 macro

750 cc in 8 hours via regular setWhole Blood = 500cc Platelet = 50ccPRBC’s = 300cc Cryoprecipitate = 30ccFFP = 150 cc

COMPLICATIONS OF INTRAVENOUS CANNULATIONCOMPLICATIONS OF INTRAVENOUS CANNULATION

1. INFILTRATIONWhen a non-vesicant solution or medication enters the surrounding subcutaneous tissue.

Cause : Cannula dislodgement or perforation of wall of vein.

Signs & symptoms :Leakage of IV fluid, discomfort, fluid flow becomes slow or ceased,

sometimes absence of blood backflow.NURSING CARE• Stop infusion & remove cannula, elevate limb, apply warm

or cold compressors.• Using appropriate size & type of cannula & a good fixation

technique prevents this problem

COMPLICATIONS OF INTRAVENOUS CANNULATIONCOMPLICATIONS OF INTRAVENOUS CANNULATION2. EXTRAVASATIONIt is similar to infiltration, with an advertent administration of vesicant solution or medication into the surrounding tissue e.g chemotherapeutic agents, dopamine, calcium preparations,this can lead to blisters inflammation necrosis of tissue.

NURSING CARE, Signs & SymptomsSimilar to infiltration,use of antidoteaccording to the policy, throughoutneurovascular assessment of affectedextremity must be performed frequently.

COMPLICATIONS OF INTRAVENOUS CANNULATIONCOMPLICATIONS OF INTRAVENOUS CANNULATION3. PHLEBITIS:Inflammation of a vein related to a chemical or mechanical irritation or both.Cause : Risk of Phlebitis increases with the length of time IV line is in place,

site of cannula inserted, micro-organism at the time of insertion.Signs & SymptomsRedness, warm area, pain, tendernessNURSING CARE• Discontinue the IV apply cold compressors ( later on warm compressor),

keep the site elevated.• To avoid phlebitis, use strict aseptic techniques, rotate IV site every 72

hours as per policy or as needed. Daily dress the site or as needed

COMPLICATIONS OF INTRAVENOUS CANNULATIONCOMPLICATIONS OF INTRAVENOUS CANNULATION

4. THROMBOPHLEBITIS

Refers to the presence of a clot plus inflammation in the veinSigns & Symptoms :Localized pain, redness, warmth & swelling around the insertion site

followed by immobility. Flow rate gets sluggish, fever, malaise etc.NURSING CARE• Similar the phlebitis, use strict aseptic techniques, rotate IV site

every 72 hours as per policy or as needed. Daily dress the site or as needed

• It can be prevented by avoiding trauma to the vein & frequent observation of IV site

COMPLICATIONS OF INTRAVENOUS CANNULATIONCOMPLICATIONS OF INTRAVENOUS CANNULATION5. HEMATOMAIt results when blood leaks into tissues surrounding the IV insertion

site.Cause : Perforation of the opposite vein wall during venipuncture,

needle slipping out of the vein, insufficient pressure applied to the after cannula removal.

Signs & symptomsEcchymosed, swelling & leakage of blood @ the siteNURSING CARE• Remove needle or cannula, apply pressure with a sterile dressing, ice

compressor later on warm compressor• Hematoma can be prevented by ensuring adequate venous filling &

timely withdrawal of needle from the cannula during venipuncture. Be very cautious if patient is on anti-coagulants or has any bleeding disorders.

PATIENT EDUCATIONPATIENT EDUCATION

1.Teach patients self-care

2. Give awareness of Home Health Care facility provided by AKUH.

3. Instruct patients to carefully monitor for complications.

4. Demonstration & return demonstration will help re-inforce key points.

Commonly Used TERMS for IV Commonly Used TERMS for IV SolutionsSolutions

1. Osmosis – The movement of solvent to lower concentration of solvent, through a semi-permeable membrane

2. Crystalloid – Fluids that are clear, ie : isotonic, hypotonic,

3. Colloid – Fluids that contain proteins or starch molecules e.g blood products.

4. Osmolarity – The number of particles or amount of substance that is in a liter of solution. It is measured as milliosmoles per liter (mOsm/L). Plasma osmolarity is between 275-295 mOsm/L, 300 mOsm/L.

5. Isotonic – Isotonic fluids have the same osmotic pressure as that found in cells. They expand intravascular compartment & thus increase circulating volume e.g NS, RL. It can be given in hypotension caused by hypovolemia

Commonly Used TERMS for IV Commonly Used TERMS for IV SolutionsSolutions

6. Hypotonic – Osmolarity below 250 mOsm/L. These are fluids that have a lower osmotic pressure than the cell. It causes body fluids to shift out of the blood vessels & into the cells & interstitial space. They are administered for cellular hydration e.g ½ NS, 0.45% NaCl, 5% DW, 0.3% NaCl.

7. Hypertonic – If osmolarity exceeds from 375 mOsm/L. These fluid have greater osmotic pressure than the cell. It pulls fluid from the cells & the interstitial tissues into the vascular space. E.g 3% saline, 10%DW, 25%DW

8. Intra Cellular Space – Inside the cells

9. Interstitial Space – Between cells & blood vessels.

10. Extra Cellular / Intra vascular – Inside the blood vessels.

I have divided the IV’S into four I have divided the IV’S into four segments.segments.

1) Intravenous access2) The infusion set3) The fluid4) The arm

IV cannulaIV cannulaSmaller the gauge the greater the diameter.-

14G>24GUse the smallest cannula with the shortest

needle that will accommodate the prescribed therapy.

Avoid areas crossing jointStart distal and work your way up

Obtaining venous access in Obtaining venous access in difficult situationsdifficult situationsThe vein should be palpated by the

operator's index finger to determine the relative size of the vessel and the direction in which it runs.

A firm to hard non-compressible vein is indicative of thrombosis and not suitable for further efforts at venous access

Gentle slapping of the skin overlying the vein may make it more prominent. This slapping must not be too firm as pain may cause reflex vasoconstriction

The tourniquet

should be applied 5-10 cm proximal to the selected site.

This compression must be sufficient to permit arterial inflow whilst restricting venous outflow.

Sphygmomanometer cuff may be used

consensus opinion appears to indicate a choice of at or just below diastolic pressure

Transillumination Topical venodilatation may be achieved by

the application of 4% nitroglycerine ointment, smeared onto the skin and left for 2-3 minutes

. A prior injection of local anaesthetic does reduce the pain of intravenous cannulation without affecting the success.

GIVING UPGIVING UP Good veins are not a fixed asset, they come

and go surprisingly fast. Returning to a patient at a later time may reveal a pleasant surprise.

Accepting defeat and asking for help after reasonable effort is acceptable for any practical procedure.

Blood pressure cuffs and tourniquets should not used on an extremity where a peripheral device has been placed.

Fixation Fixation

Infusion sets/ Drip setsInfusion sets/ Drip sets

Macro-dripsets Micro-dripsets Blood sets-

have filters to prevent clots from entering circulation

Measured volume setsMeasured volume sets

Delivers specifically measured volumes- burette sets and dial and flow sets

Measured volume setsMeasured volume sets

Specialized tubing with an in-line graduated cylinder

This reduces the chance of fluid overloadUsed for pediatric patients

Removal of air- fill the drip chamber to half full with the stopper closed then open the stopper slowly, this is done to ensure less bubbling in the drip chamber and it also prevents excessive waste of fluids especially expensive chemotherapy drugs, albumin etc.

Another common problem is stopping of the fluid to inject drugs into the IV line and not restating the fluid,

Removal of airRemoval of air

Aseptic precautionsAseptic precautions

Aseptic precautionsAseptic precautions

Sterile precautionsSterile precautions

Drip Chamber too fullDrip Chamber too full

Turn bag and chamber upside down and squeeze chamber, pushing fluid back into the bag and allowing air in the chamber

Be careful not to allow air into the line

Use plain fluid line for medicationsUse plain fluid line for medications

•Pushes the medication in the line into circulation which can be dangerous-Inotropes, vasodilators, cardiac drugs etc.

•If a slow injection is done this can stop a vital drug for reaching the circulation in that period which can be fatal

Documentation Documentation

Extension SetExtension SetPlain tubing with connectors at both ends, one

plugging in to the drip set, the other into the IV cannula.

Gives additional length, additional drug ports, repeated use increases chance of infection

Additional length can be a problem, increasing the chance of having the IV pulled out - Use with caution.

The ArmThe ArmProblems in the arm that can prevent flow are

Constricting bandEdema at puncture siteCannula abutting the vein wall or valveAdministration set control valves.Look for complications which helps us to

remove the cannula- Redness, Pain, Swelling, Increased temperature

The ArmThe Arm

Fluid Bag Fluid Bag Height of the drip is an important factor to the flow rate, always label if any drug is added. Injections have to be made through the injection port only, not through the fluid container which is not sterile.

All the above devices have a few disadvantages

If the flow is stopped for any possible reasons that can be encountered like movement by the patient, inflation of the BP cuff, if the fluid is over, the only way it can be corrected is if the nurse is watching visually all the time to appreciate the following changes which is practically impossible in a busy unit, all these disadvantages can be overcome by using - Electromechanical Infusion Devices

Artificial intelligenceArtificial intelligence

Syringe pump Infusion pump

Electromechanical Infusion Electromechanical Infusion DevicesDevices

Advantages Constant flow If flow is stopped for any reason-machine gives an

alarm It can programmed to indicate if the fluid is getting

over Disadvantages They are expensive. Require expertise to use

Electromechanical Infusion Electromechanical Infusion DevicesDevicesMedications whose measurements need to

be precise must be on a pump (hemodynamic stabilizers, cardiac drugs, bronchodialators, etc…)

All pediatric fluids and medications must be on a pump

The difference between syringe pump and infusion pump is that syringe pump accommodates only syringes and maximum volume depends on the biggest syringe 50-100ml, in the infusion pump the fluid bag can be connected as a whole (500ml-1000ml) hence the need to change is less and it is less labour intensive.

The infusion set used in the infusion pump should be according to manufacturing specification or else it may not function properly.

Take home thoughtsTake home thoughts

As Always -Check • Right patient? • Right solution? • Right drug? • Right route? • Make sure you check the physicians Order!! Infusion therapy can be learned by practice and

more practice, and can easily be practiced by simple application of mind.