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Basic IV Therapy and Central Vascular Access
Devices
Precision Placements
Presented by
ObjectivesParticipant will:
• Describe the peripheral and central venous anatomy as well as the application of infusions to the appropriate venous access sites and devices
• Differentiate between the four(4) Central Venous Access devices and understand advantages, disadvantages, potential complications, nursing care and maintenance of the specific devices
• Accurately observe, monitor, report and document the status of a peripheral and central venous site
• Be able to demonstrate the principles of asepsis and standard precautions in the management of infusion therapy
• Demonstrate peripheral IV insertion (IV catheter over the needle ) and PICC dressing change with adherence to sterile technique
2
Anatomy of a Vein Tunica Intima:
The layer of smooth endothelial cells lining the length of the blood vessel
• Innermost layer
• Has one thin layer of cells (endothelial lining)
• Irritating this layer causes thrombus formation
Tunica Adventitia:
The outermost layer of vein
• Supports and surrounds vessel
• Blood supply of this layer called Vaso Vasorum
Tunica Media:
Middle layer of vein
•Composed of muscular and elastic tissue
•Contains nerve fibers
•Collapses or distends with pressure
Anatomy of a Vein vs. an Artery
VEINS:
superficial in sub-Q tissue
valves
do not pulse
dark red blood
3 layers3 layers
ARTERIES:
deeper in sub-Q tissue
no valves
pulse
bright red blood
3 layers3 layers
VEIN
ARTERY• Tunica Intima:Tunica Intima:
• Tunica Media: Tunica Media:
• Tunica AdventitiaTunica Adventitia:
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Vein Identification
BasilicCephalic
Digitals
DorsalMetacarpals
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Vein Information Chart
Vein Location
Size Catheter Considerations
Digital Veins N/A Do Not Use
Metacarpal Veins
24-20g • Not first choice in the elderly• Only infuse isotonic or near isotonic
solutions or medications
Cephalic Vein 24-20g • Large vein, easy to access• Useful for infusing isotonic, near isotonic and chemically irritating
medications
Basilic Vein 24-20g • Difficult to access and to stabilize• Large, palpable vein-moves easily
Basilic Vein
Vein Identification
Median Antebrachial
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Vein Information Chart…Continued
Vein Location
Size Catheter Considerations
Median Antebrachial
Vein
N/A • Flat, small in diameter• Decreased hemodilution
• Avoid these veins due to increase of infiltration and painful access
Median Antecubital
Vein
1. Median Basilic2. Median Cubital
3. Median Cephalic
N/A • Avoid peripheral infusion• Reserve for blood lab draws
• Reserve for future needs• PICC & Midline• Renal patients
• Emergency use only
Nerves of the Upper Extremities
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Nerves of the Hand and Wrist
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Important ConceptsOsmolarity:
• Measure of solute concentration
• Normal blood plasma Osmolarity is 290-340 mOsm/L and is
considered Isotonic
Example: D5W, LR, 0.9Nss
• Osmolarity higher than 340 mOsm/L is considered Hypertonic
Example: D5.45Nss, D5LR, 10% and > dextrose concentrations
• Osmolarity lower than 290 mOsm/L is considered Hypotonic
Example: 0.45Nss and 0.33Nss
pH:
• Hydrogen ion concentration
• Normal blood pH is 7.35-7.45
• Solutions with a pH < 6.0 are Acidic
• Solutions with a pH > 8.0 are Alkaline
Important Terms
Phlebogenic Drugs: Cause irritation to the inner lining of the vein
Examples:
Amphotericin B Phenytoin Erythromycin Pentamidine
Dobutamine Ganciclovir Potassium Chloride Phenobarbitol
Foscarnet Chemotherapeutic Agents Gentamycin Doxycycline
Penicillins (Oxacillin ,Nafcillin,Unasyn,Methicillin) Morphine
Important Terms
Vesicants:
• Drugs that have properties that when inadvertently infused into the SubQ tissue can cause severe tissue
damage
• Necrosis can lead to grafts, possibly loss of limb
Examples: Vancomycin, Dopamine, Dextrose concentrations > 10% and Chemotherapy
Infiltration:
• Inadvertent administration of non-vesicant infusion onto
the SubQ tissue
Extravasations:
• Inadvertent administration of vesicant infusion into the SubQ tissue
Intravenous FluidsHydrationDextrose Solutions:
• Provide calories
• 5% dextrose = 5g dextrose in 100ml
• Hypotonic dextrose hydrates the intracellular compartment
• Hypertonic dextrose pulls water from the intracellular compartment and decreases swelling
Sodium Chloride Solutions:
• Provide ECF replacement
• Hypotonic saline (0.45% or less) can be used to supply daily salt and
water requirements
• 0.9% Sodium Chloride is the only solution to be used with blood components
Hydrating Solutions:
• Combination of dextrose and hypotonic sodium chloride
• Hydrates patients in dehydrated state
• Promotes diuresis
Multiple Electrolyte Solutions/ Lactated Ringers:
• Solution most like the body’s electrolyte content
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Intravenous FluidsAntibiotics
• A. Aminoglycosides (Gentamycin, Amikacin and Tobramycin) OTO and NEPHRO TOXIC
• B.Cephalosporins ( Rocephin,Ancef and Kefzol ) Related to Penicillin so check allergy history.
• C. Penicillins (Nafcillin,Ampicillin,Timentin,
Oxacillin, and Unasyn)
• D. Tricyclic Glycopeptides (Vancomycin)
OTO and NEPHRO TOXIC
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Aminoglycosides and Tricyclic Glycopeptides
• Drugs that are oto and nephro toxic require blood monitoring levels. Amikacin,Gentamycin,Tobramycin and Vancomycin require monitoring. The Trough levels are drawn just prior to the start of an infusion. Peak levels are drawn 30-60 minutes after the completion of an infusion. Typically drug levels are started after the fifth dose to allow adequate time for the drug to reach consistent blood levels.
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Intravenous FluidsTPN/ PPN
• Total Parenteral Nutrition: TPN provides nutrients (carbohydrates, protein, fat, minerals, and trace elements) through the veins. Has greater than 10% Dextrose Concentration.– Indications: severe malnutrition, bowel rest,
obstruction, short bowel syndrome, malabsorbtion, hyperemesis, intractible diarrhea and motility disorders.
• Peripheral Parenteral Nutrition: PPN provides some nutrients and has lower calories and dextrose concentration than TPN. PPN must be lower than 10% Dextrose concentration. Is typically indicated for short term supplement or when central venous access is not available.
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Intravenous FluidsPain Management
Morphine
DilaudidMorphine and Dilaudid can be given IV ,SUB-Q and IM.
Pain control analgesia pumps (PCA) are often used to deliver pain management and offer the patient continuous pain management with bolus ability.
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Complications of Pain Management
Nausea
Vomiting
Increased sedation
Constipation
Respiratory depression
19
Intravenous FluidsChemotheraputic Agents
Preferred way to administer Chemotherapy is through a central venous access device.
Side Effects of Chemotherapy:
• Nausea
• Vomiting
• Fatigue
• Anorexia
• Hair Loss20
Checklist for Peripheral IV Insertion
Check physician's orders
Identify patient -2 identifiers
Check for allergies
Informed consent
Patient teaching
Standard precautions
Intravenous Nurses Society Standards
• Use the smallest gauge and shortest length catheter to accommodate the prescribed therapy
• A peripheral IV (short cannula, midline catheter) is not appropriate for continuous vesicant chemotherapy, TPN, solutions or medications with a pH < 5 or >9 and/or a serum osmolarity > 500 mOsm/L
Criteria for Vein Selection
Distal Branches of Large VeinsVeins below Antecubital FossaPalpable, Soft to Firm and VisibleAdequate size for the type of infusion being administered
Considerations:Length of therapyPurpose and type of infusionPatient activityPredisposing medical conditions
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Catheter Selection
1. Over the needle
• Insyte autoguard
2. Winged catheter
• Butterfly
3. Midline
Flashback Chamber Hub
t
Vein Selection
Considerations
• What are you giving?
• Length of therapy
• Vein integrity
• Previous venipunctures
• Clinical assessment
• Patient compliance
Specifically:
• Avoid areas of flexion
• Avoid boney prominences
• Avoid nerves
• Distal to proximal
• Avoid bruised and edematous area
• Alternate arms
Vein Dilation
Technique
• Tourniquet
• BP cuff
• Gravity
• Fist clenching
• Tapping vein
• Warm compress
• Multiple tourniquets
Venipuncture Technique
• Gather Supplies• Wash Hands• Explain Procedure to your
patient• Set up clean area• Prepare for venipuncture
in a position that will be stable for both you and your patient
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Venipuncture Technique Apply Tourniquet and proceed:
• Apply gloves
• Antimicrobial scrub and place tourniquet 4-6” above puncture site
• Pull skin below puncture site to stabilize and prevent vein from rolling
• Insert needle, bevel up, at a 15- 300- angle (low and slow)
• When blood in flashback chamber occurs, lower angle of catheter and advance catheter with stylet as a unit into the vein, approximately 1/8” just enough to ensure
catheter is in the vessel
STOP!
Venipuncture Technique
• Advance catheter off the stylet until ENTIRE catheter is in the vessel
• Release tourniquet
• Apply manual pressure just above the site that you imagine where the catheter tip is
• Remove stylet (hit safety button)
• Connect the extension tubing with the valve cap
• Tape hub/wings of catheter
• Flush with .9NSS and check for blood return
• Apply transparent dressing
Peripheral IV Dressings
Dressing
• Gauze dressing with tape(48 hour dressing change)
• Tegaderm occlusive dressing
Dressing change with IV catheter change
(72-96 hours)
Labeling
• Venipuncture site label
• Date and time
• Type and length of catheter
• Nurse’s initials
• Label administration set
• Tubing changes
• Label solutions container
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Venipuncture Technique
• Attach infusion and regulate flow
• Label administration set tubing and bags
• Dispose of needles in sharps containers
• Document procedure
Venipuncture Technique
Documentation
• Date and time of insertion
• Manufacturer’s brand name and style of device
• Gauge and length
• Specific name and/or location of accessed vein
• # of attempts
• Infused by regulator tubing or electronic
pump
• Patient’s response
• Signature
32
Peripheral IV Removal
Technique
• Use dry sterile gauze to apply pressure until bleeding stops
• Apply band-aid or gauze and tape
• Examine catheter integrity and dispose
• Document site assessment and catheter integrity
• Keep dressing clean and dry until scab forms
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Peripheral IV Demonstration
• Skills validation
34
IV Rate Calculations
A.Total Volume X drops/ml
= Drops/Min.
Total Time in Minutes
B. Drip Rates of IV Tubing ( check package)
Formulas
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IV Rate Calculations
Example:
1000ml D/W to infuse over 12 hours
1000ml x 10gtts/ml
---------------------- =14DropsMin.(13.8) 720
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Midline Catheter• Peripheral IV catheter whose tip terminates in the proximal upper extremity
• No vesicants through this line
• Increased dwell time (up to 2-4 weeks)
• Open ended (Flush S-A-S-H)
• Closed ended (Flush S-A-S)
• Insertion and Removal
• Care and Maintenance: dressing,flush,site observation
S-A-S = Saline - Administration - Saline
S-A-S-H = Saline - Administration - Saline – Heparin(100units/ml)
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Central Venous Anatomy
Cephalic Vein
Basilic VeinSuperior Vena Cava
Innominate Vein
Or Brachiocephalic Vein
Subclavian Vein Jugular Vein
Axillary Vein
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Central Venous Access Devices
• Central Venous Catheter
• tip is located in the Superior Vena Cava
• Greatest hemodilution of vascular system
• SVC is the largest vein in venous anatomy
• SVC: turbulent blood flow
• Appropriate location for vesicant therapy, TPN, long-term IV therapy, solutions/medications with a pH < 5 or > 9 and or serum osmolality > 500 mOsm/L
• Tip confirmation must be verified post insertion
39
Central Venous Access Tip Placement
40
Peripherally Inserted Central Catheter (PICC)
• PICC
• Tip terminates in the SVC
• Dwell time is (up to) 6 months - 1 year
• Open or closed ended
• 1-2 lumens
• Insertion and removal
• Advantages
• Disadvantages
41
•Complications :
1.Fibrin Sheath/Tail
2.Clotted catheter
3.PICC Migration
•Interventions:
1.Cathflow Activase Instillation (2 mg. x 2 /lumen)
2.Cathflow Activase Instillation (2 mg. x 2 /lumen)
3.PICC exchange
• Exchange
• Repairs of Groshongs are no longer done
Peripherally Inserted Central Catheter (PICC)…Continued
42
• Care and maintenance
• Dressing Change – 24 hrs. post insertion. Thereafter, weekly and PRN for transparent dressings and 3x/week for gauze dressings. Strict adherence to sterile technique is required.
• Flushing – Most PICC lines are flushed with Normal Saline and Heparin Lock Flush/per facility policy and MD order. (usual amounts are 10ml Normal Saline and 5ml Heparin flush of 100 units/ml).
Note: GROSHONG PICC’s do not require Heparin Flush because they are closed ended catheters with a valve at the end.
•Cap and Extension Changes –The cap and extension tubing are
changed with each dressing change weekly and after every blood draw.
•
Peripherally Inserted Central Catheter (PICC)
43
Implanted Ports- AKA portacaths, ports,mediports and passports
• Port implanted in the SQ tissue, catheter tip terminates in the SVC
• Design: 1-2 lumens, reservoir, septum, catheter
• Dwell time can be greater than 1 year
• Open or closed ended
• Insertion and removal
• Advantages
• Disadvantages
• Care and maintenance
• Routine flushing: Monthly
• Huber needle only: Needle and dressing change weekly
• Complications/ Interventions (Pinch off syndrome, Sludge)
44
What is Pinch Off Syndrome?
• Pinch Off Syndrome is the compression of a catheter as it passes between the clavicle and first rib at the costoclavicular space.
45
Non-Tunneled Catheters -Triple lumen, Subclavian, CVC
• Short-term emergent central catheter
• 1-3 Lumens
• Open ended only
• Insertion and removal
• Advantages
• Disadvantages
• Care and maintenance
• Complications and interventions 46
Tunneled Catheters - Hickman,Groshong
• Central line catheter tunneled under SubQ tissue with tip placement in SVC
• 1-3 Lumens
• Open or closed ended
• Dwell time: long-term IV therapy (> 1 year)
• Insertion and removal
• Advantages
• Dacron cuff
• Disadvantages
• Care and maintenance
• Complications and interventions47
Documentation
• Specific to your institution’s policy and procedure
• Flushing protocols
• Solution, amount and technique
• Dressing, tubing and cap changes
• Measurement as appropriate
• Site assessments
• Interventions taken
• Any other pertinent information
48
Demonstration of Central Line Dressing Change
• Skills Validation
49
Complications
Infiltration:• Inadvertent administration
of an IV fluid in
surrounding SQ tissue
around area of vein
(non-vesicant)
Interventions: • DC IV; Restart• Compress?
Phlebitis:• Injury to the endothelial
lining of the vein Bacterial Mechanical Chemical
Interventions:• DC IV; Restart• Compress?
50
Phlebitis
Infusion Phlebitis - inflammation of the vein associated with infusion phlebitis as seen in this photograph.
51
Complications
Cellulitis:• Infection of SQ tissue
• Characteristic of a circular
pattern, with redness,
induration and exudate
Interventions:• DC IV• Topical antibiotics (apply
with sterile dressing)• Monitor for septicemia
Sepsis:• The presence of infectious
microorganisms or other
toxins in the blood stream
Interventions:• Restart IV• Obtain cultures• Notify physician• Monitor patient daily• Antimicrobial therapy as ordered 52
Complications
Cellulitisadhering to aseptic technique is vital in the prevention of intravenous related infections. Asepsis should be maintained at insertion, during clinical use and at removal of the device.
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Sepsis
54
Complications
Thrombosis:• Formation of blood clot in
the catheter lumen• Formation of a blood clot
within a blood vessel
Interventions:•Thrombolytics
PREVENTION:• Flush immediately after
infusion• Appropriate tip locations• Appropriate size catheter in
relation to vein size
Catheter Related
Embolism:• Air embolisms• Catheter embolism
Interventions: • PREVENTION• This is an EMERGENCY• Turn patient on left side and
place in Trendelenberg
position• Nasal oxygen• Prepare for resuscitation• 911
55
Thrombosis
56
PICC Line Embolism/Rupture
• You are the key to prevention –
ONLY syringes that are 10cc’s and larger should be used on a PICC line. Smaller syringes generate a higher pressure that can cause the catheter to rupture.
57
ComplicationsCatheter Occlusions:• Occlusions may be due to
blood, fibrin, drug,
precipitate or lipids/sludge
build up
Interventions:• PREVENTION• Flush catheter immediately
after infusion • Flush between
incompatible drugs• Thrombolytics
Catheter Malposition or Migration:• Can occur during insertion
or spontaneously sometime
after insertion
Interventions:• LISTEN to your patient• Follow up x-rays when
indicated
58
Complications
Extravasation:• Inadvertent administration of a vesicant solution or medication
into the surrounding tissues resulting in potential blistering,
necrosis and tissue sloughing
Interventions:• PREVENTION
• Stop infusion
• Don’t remove cannula – aspirate
• Notify physician
• Pharmacological intervention, if appropriate (controversial)
• Compress (controversial)
• Immobilization and elevation
• Follow up 59
Extravasation
60
Blood Sampling Through CVADDirect or Indirect Methods can be used:
1. Turn off all IV infusions in multi-lumen device for a minimum of one full minute prior to taking sample.
2. Flush lumen that you are using for sampling with 5ml/Ns.
3. Attach vacutainer or attach sterile syringe to lumen and obtain 5-10ml of blood in a collection tube or syringe for discard.
4. If using a vacutainer use collection tubes and obtain blood for sampling. If using a syringe withdraw blood for sampling.
5. When using a syringe: Maintain sterility of sample transfer in syringe to collection tubes with ‘blood transfer device.
6. Remove vacutainer or syringe and flush lumen with 10-20ml/Ns.
7. Change valve cap ( cap must be changed with every blood draw).
8. Reconnect infusion to new cap and use SAS for close ended CVAD’s and SASH for open ended CVAD’s.
61
Legal Considerations
• Get informed and written consent
•For PIVs -verbal consent
•For CVADs- written informed consent with risks and benefits outlined.
• Inform patient of all VAD options
•Know tip placement of each CVAD before using it
This also refers to patients readmitted with ports, tunneled lines, etc…
62
Legally Speaking
• Know and follow all of your facility’s policies and procedures. If you are not sure where to find them ask a colleague or supervisor/ manager so that you can become familiar with them.
• Always use concise and accurate documentation.
• Don’t use CVAD without a blood return unless the reason for the absence has been determined.
63
Questions and
Review for Test
64
Congratulations !Thank You for Your Participation
• It has been my pleasure to have you in this class today. • The greatest gift in learning something new is putting that
knowledge into practice and then sharing what you know with someone else.
• Go and use your new found or renewed knowledge and Practice! Practice! Practice!
• You are all Winners!65
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