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Peripheral IVs

Peripheral IVs

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Peripheral IVs. Pediatric Challenges. Smaller Veins Active Challenging Need an assistant All ages Scared of shots. VASCULAR ACCESS DEVICE (VAD) SELECTION ALGORITHM. Expected duration >1 month?. NO. YES. Determine length of therapy and need for vascular access. - PowerPoint PPT Presentation

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Page 1: Peripheral IVs

Peripheral IVs

Page 2: Peripheral IVs

Pediatric Challenges

• Smaller Veins• Active• Challenging• Need an assistant• All ages

–Scared of shots

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VASCULAR ACCESS DEVICE (VAD) SELECTION ALGORITHM

Expected duration >1 month?

NO YES

Determine length of therapy and need for vascular access

7-30 days

Determine length of therapy

> 1 year

Choose PICC, Tunneled CVC or Port (See Notes)

Choose Tunneled CVC or Port (See

Notes)

1. Consider the need for single vs. multi-lumen CVC, and select the least number of lumens to deliver the required therapy.

2. Consider patient’s current and future setting; (i.e. Home Care?)

3. Select device that is least invasive, with lowest risk of complications, which will last the duration of therapy.

4. Device selection should consider input from the patient/family, safety, patient activity, comfort, body image and medical history.

5. Consider anticipated changes in patient’s medical status?

6. Is vascular access for nutrition only? If so, have enteral feeds been considered?

OTHER DECISIONS TO BE MADE WHEN SELECTING VAD:

* Infusate appropriate for peripheral IV:• < 500 mOsm/L• pH 5-9• Non irritant, non vesicant or vesicant

Using assessment tool is there adequate

vascular integrity?

Choose PICC or Non-tunneled

CVC

Choose Peripheral

IV and reassess

daily*

NOYES

NOYES

0-5 days

Is Infusate appropriate for peripheral IV *

1 month-1 year

Choose PICC

*REMINDER: Discuss IV access on a daily basis during Family Centered Care Rounds.

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Prepare Patient

• Infant– Ask parent or someone familiar to assist

during procedure if possible– During the procedure, provide patient

with pacifier – Use soothing voice– Provide music

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Prepare Patient• Toddler

– Explain procedure in simple terms– Use medical play– Hold their hand– Allow to have their security item (toy,

blanket)– Limit explanation to 10 minutes and

prepare just before the procedure

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Prepare Patient

• Preschooler– Prepare just before– Show procedure on a doll first to lessen

anxiety– Inform patient that it’s okay to cry, just

don’t move– Count 1,2, 3…

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Prepare Patient• School age

– Make sure they understand which part of the body will be involved

– Provide detailed explanation– Use a doll to show procedure or other

medical play interventions– Allow to participate in small tasks during

the procedure– Limit explanations to 20 minutes and

prepare ahead of time

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Prepare Patient• Adolescent

– Provide detailed explanation– Use visuals during explanation and

correct terminology– Allow time for discussion– If possible, allow them to choose

when to begin the procedure– Allow them to help during the

procedure

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Preparing the PatientAdditional Tips• Always have a helper

to hold • Use family to help

support/distract child• May need to mummy

wrap active toddlers• Tell child to be brave,

but that it’s OK to cry

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Afterwards…• Rewards

– Have stickers available after IV insertion. Kids love stickers!!

– Cuddle infants after IV insertion

– Have parents/siblings tell child how brave they were

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IV Sites• Infants

– Hands– Feet– Scalp

• Toddlers – Hands– Feet– Scalp only if <18

months

• School Age – Hands– Feet

• Adolescents– Hands– Arms – Avoid feet

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IV SitesDigital Dorsal veins

Dorsal Metacarpal veins

Dorsal venous network

Cephalic veinBasilic vein

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IV Sites

Cephalic vein Median Cubital vein

Accessory Cephalic vein Basilic vein

Cephalic vein Median antebrachial vein

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IV Sites-Feet

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IV Sites-Scalp

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IV Sites

• Tips– Use a tourniquet– Warm extremity– Tap/flick– Palpate with the same

finger– Look at all extremities

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Areas to Avoid• Red sclerotic veins• Blown veins• Areas of swelling or

tenderness• Arteries• Infected lesions• Fistulas• AV shunts• Paralyzed extremities

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IV Complications

• Infiltration– Swelling– Pain– Cool to touch– Compare both

extremities– IV pump will

continue to run

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Grade Clinical Criteria <4kg

Clinical Criteria >4kg

0 No symptoms No symptoms

1 Skin blanched Edema <1CM in any directionCool to touchWith or without pain

Skin blanched Edema <2.5 CM in any directionCool to touchWith or without pain

2 Skin blanched Edema 1-4 CM in any directionCool to touchWith or without pain

Skin blanched Edema 2.5-15 CM in any directionCool to touchWith or without pain

3 Skin blanched, translucentGross edema >4 CM in any direction Cool to touchMild –moderate pain

Skin blanched, translucentGross edema >15 CM in any direction Cool to touchMild –moderate painPossible numbness

4 Skin blanched, translucentSkin tight, leaking or with blistering Skin discolored bruised, swollenGross edema >4 CM in any directionDeep pitting tissue edemaCirculatory impairment Moderate to severe painInfiltration of any blood product, irritant, or vesicant.

Skin blanched, translucentSkin tight, leaking or with blistering Skin discolored bruised, swollenGross edema >15 CM in any directionDeep pitting tissue edemaCirculatory impairment Moderate to severe painInfiltration of any blood product, irritant, or vesicant.

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Interventions for Infiltration

Do not immediately remove IVStop infusionElevate effected extremityDetermine infusateIf infusate is a vesicant, refer to Nursing Policy III-306  Monitoring and Management of Infiltration/ExtravastionIf infusate is not a vesicant, remove IVNotify physicianRestart new IV if continued therapy is necessaryContinue assessment of site and surrounding tissue, PRN

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Check it HOURLY!

• “The RN is responsible for observing the IV site for signs of infiltration at least hourly and notifying the physician for orders for all IV infiltrates or other delays related to IV therapy.”– II-101 Safe Administration of Parenteral Therapy, Including

Drugs Given Via the Intrathecal Route –Pharmacy and Therapuetics Policy

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IV Complications

• Phlebitis– Pain– Red,tender– Heat, inflamed– Streaks along vein– Chances increase

drastically after 3 days

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Grade Clinical Criteria0 No symptoms

1 Erythema at access site with or without pain

2 Pain at access site with erythema and/or edema

3 Pain at access site with erythema and/or edemaStreak formationPalpable venous cord

4 Pain at access site with erythema and/or edema Streak formation Palpable venous cord >2.5 CM in lengthPurulent drainage

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IV Complications

• Extravasations– Due to

administration of vesicant substance

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Interventions for ExtravasationExtravasated drug Intervention

Hyperosomotic solutions(>600 mosm/1)Calcium gluconate/chlorideDextrose> 10%Parenteral NutritionPotassium> 40meq/1Radio contrast Media

Antidote Hyaluronidase is used to treat extravasations by promoting the drug’s diffusion throughout the tissue bed and increasing its rate of absorption, especially when combine with the use of warm compresses.

Apply warm pack to aid drug absorption

Nafcillin PenicillinRifampin VancomycinAcyclovir

AminophyllineDigoxin ValiumMannitol

(Antidote:Hyaluronidase)Apply warm pack to aid drug absorption.

SympathomimeticsDopamineEpinephrineNorepinephrinePhenylephrineVasopressin

Antidote: Phentolamine – May cause excessive vasodilation.

If Necrosis present Contact Attending physician

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IV Complications

• Infection– Very important to

use aseptic technique and using equipment right after removal from packaging

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Other things…

• A. Drawing blood from existing venous access may risk losing the IV access.

• B.  Blood cultures can not be sent from any established peripheral line

– III-203 Saline Well Guidelines/Blood Draw from an Established Venous Access

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It is the CCHMC Policy…

• “If the procedure on a patient is not successful after three (3) attempts, assistance and advice from a more experienced, qualified professional should be requested.”

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IV Supplies• Equipment

1. Select appropriate size steel needle or plastic cannula based on patient's size. 2.  Assemble equipment using aseptic technique. -   Steel needle or plastic cannula -   Normal saline flush -   Extension tubing -   Gauze pads -   Padded armboard -   Tape -   Protective cup for IV site -   Tourniquet -   Transparent dressing for cannula use -   Gloves -  Chlorhexadine swabstick (iodine for CHG sensitivity)

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What Size should I use?Sizes• 24g

– Used for infants– Used for small short

veins• 22g

– Used for toddlers and school age

– Good for obtaining blood

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Sizes continued…

• 20 g– Used for adolescents

• 18 g– Used for large veins, large volumes, or

trauma patients– Often placed in the O.R.

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IV Catheters

Types• AngioCaths

– Must utilize safety needles

• Abbocath– May still see these around

• Do not have safety needle features

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IV Insertion• Procedure

– Prepare patient (consider patient’s developmental age when preparing for the procedure)

– Prepare IV supplies– Select catheter size– Insert IV into patient– Monitor IV per policy

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IV Insertion• Insertion directions

– Prepare site, alcohol area for 20 seconds

– Quick stick through skin

– Direct method– Watch for blood return– Advance– Disconnect stylet– Flashback, then

advance

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IV Insertion

• Use a 1” piece to secure t-connector• Keep site visible• Restrain board (not arm)• Use IV board (only if needed)

– Right size• Small• Medium• Large• Padded

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IV Insertion• Use minimal amount of tape• Use Securement Device• Sterile dressing

– Must keep dry

• Keep site visible– Allows you to

• Catch injuries early• Gives you the ability to check site every hour

and before medications

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Policies to Check Out…• II-101 Safe Administration of Parenteral Therapy, Including

Drugs Given Via the Intrathecal Route (Pharmacy and Therapuetics Policy Book)

• III-301 IV Insertion (Nursing Policies, Procedures and Standards Manual)

• III-203 Saline Well Guidelines/Blood Draw from an Established Venous Access (Nursing Policies, Procedures and Standards Manual)• III-306 Monitoring and Management of

Infiltration/Extravasation

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Key Points

• Find out if patient is right or left handed

• Encourage movement of fingers, can hold a pencil, do homework, toy, doll etc

• Make sure tape is NOT too tight• Chart site check every hour

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IV Key Points• Always have a person to

hold• Use butterflies for quick

in and out blood draws i.e. clinics

• Use distal sites first• Tell patient what you are

going to do before you do it

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IV Key Points

• Practice• Practice• Practice

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Other ways to obtain blood…

• Heel Stick• Finger Stick

– Heel and Finger sticks: blood can be collected in a Capillary tube or the small microtainers

• Butterfly Needles– 27, 25, 23, 21

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SME Contact Information

• Mary Hamilton– 6-4334– [email protected]