Peripheral IV Therapy

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Information about Peripheral IV Therapy
Health & Medicine

Published on May 8, 2009

Author: CaliforniaCathy

Source: slideshare.net

Description

Developed for use by IV Team members during new hire RN orientation at a community hospital. SMEs were two IV Team members.

Peripheral Intravenous Therapy Principles and Practice Hospital Name

What You Will Learn Today Cooperative roles of professional staff Staff nurse responsibilities for peripheral lines Routine care and maintenance for peripheral lines A systematic and organized way to monitor How to use the INS Rating Scales for phlebitis and infiltration Steps to minimize the potential for complication Principles of flow How to troubleshoot a peripheral IV

Cooperative roles of professional staff

Staff nurse responsibilities for peripheral lines

Routine care and maintenance for peripheral lines

A systematic and organized way to monitor

How to use the INS Rating Scales for phlebitis and infiltration

Steps to minimize the potential for complication

Principles of flow

How to troubleshoot a peripheral IV

Cooperative Roles PATIENT Simple Insertions Monitoring Maintenance Troubleshooting Insertions Peripheral Midlines PICC Consultation VAT R.N. Unit R.N. Physician Unit L.P.N. Procedure Area R.N. I.R.

Simple Insertions

Monitoring

Maintenance

Troubleshooting

Insertions

Peripheral

Midlines

PICC

Consultation

Unit RN Responsibilities for Peripheral IV Lines Ongoing assessment Maintenance Cleaning/redressing Ensuring that the IV is securely taped Cap/tubing changes according to hospital policy and procedure Uncomplicated starts and routine changes

Ongoing assessment

Maintenance

Cleaning/redressing

Ensuring that the IV is securely taped

Cap/tubing changes according to hospital policy and procedure

Uncomplicated starts and routine changes

Policies and Procedures for Infusion Nursing

Care & Maintenance Routines Intact dressing means all 4 edges are sealed Peripheral site, cap, and tubing changes are q72 hrs New cap with each new IV, or when unable to clear blood Change antecubital and paramedic IVs within 24 hours or as soon as patient condition permits IVs inserted in the nursing home, hosp., and clinics are acceptable

Intact dressing means all 4 edges are sealed

Peripheral site, cap, and tubing changes are q72 hrs

New cap with each new IV, or when unable to clear blood

Change antecubital and paramedic IVs within 24 hours or as soon as patient condition permits

IVs inserted in the nursing home, hosp., and clinics are acceptable

Reasons to Monitor Patient’s response to therapy Confirms accurate delivery of fluid/meds Detects imminent complications MONITORING IS KEY TO COMPLICATION PREVENTION

Patient’s response to therapy

Confirms accurate delivery of fluid/meds

Detects imminent complications

When Should You Monitor? Factors to consider Type of therapy, age, mental status, overall physical condition, type of access device, practice setting MONITORING SHOULD BE SYSTEMATIC AND ORGANIZED

Factors to consider

Type of therapy, age, mental status, overall physical condition, type of access device, practice setting

Bag to Catheter Tip Assessment See handout Fluid container, tubing and flow rate, in-line filter, electronic infusion device, arm board, IV site dressing, vascular access device, insertion site, catheter tip

See handout

Fluid container, tubing and flow rate, in-line filter, electronic infusion device, arm board, IV site dressing, vascular access device, insertion site, catheter tip

Possible Complications Local Infiltration, extravasation, phlebitis, occlusion Local complications occur more often than systemic Systemic Circulatory overload, allergic reaction, septicemia, embolism TARGET PHLEBITIS RATE IS LESS THAN 5%

Local

Infiltration, extravasation, phlebitis, occlusion

Local complications occur more often than systemic

Systemic

Circulatory overload, allergic reaction, septicemia, embolism

Today’s Focus on Complications Phlebitis Infiltration Extravasation Catheter-Related Infection

Phlebitis

Infiltration

Extravasation

Catheter-Related Infection

Phlebitis Inflammation of vein intima Types Mechanical Chemical Infectious Phlebitis may not appear until 24h after the cannula has been removed

Inflammation of vein intima

Types

Mechanical

Chemical

Infectious

How to Protect the Intima and Minimize or Delay Onset of Phlebitis Utilize principles of asepsis/sterility Minimize friction against intima wall Minimize particulate matter Minimize effects of pH and osmolality Rotate sites according to P&P Change site at first sign of pain, tenderness, redness, or irritation

Utilize principles of asepsis/sterility

Minimize friction against intima wall

Minimize particulate matter

Minimize effects of pH and osmolality

Rotate sites according to P&P

Change site at first sign of pain, tenderness, redness, or irritation

Minimize Friction Against Intima Wall Use smallest size catheter, as appropriate Insert catheter away from areas of flexion Stabilize catheter well Dressing, arm board, restraint, as needed Venous Free Flow Around Catheter is GOOD! Movement of Catheter is BAD!

Use smallest size catheter, as appropriate

Insert catheter away from areas of flexion

Stabilize catheter well

Dressing, arm board, restraint, as needed

Minimize Particulate Matter Use needles with microfilters to draw up meds from vials Mix meds with recommended solutions or diluents Make sure admixtures are thoroughly dissolved Do not combine incompatible solutions Use particulate in-line filters when appropriate

Use needles with microfilters to draw up meds from vials

Mix meds with recommended solutions or diluents

Make sure admixtures are thoroughly dissolved

Do not combine incompatible solutions

Use particulate in-line filters when appropriate

Minimize Effects of pH and Osmolality Use smallest gauge catheter possible so that more blood can dilute medications/solutions Dilute known irritating meds as much as possible Use port of a compatible free-flowing infusion to push IV meds, again more dilution Use slowest appropriate administration rate For hypertonic or acidic solutions, use large veins and consider central lines

Use smallest gauge catheter possible so that more blood can dilute medications/solutions

Dilute known irritating meds as much as possible

Use port of a compatible free-flowing infusion to push IV meds, again more dilution

Use slowest appropriate administration rate

For hypertonic or acidic solutions, use large veins and consider central lines

pH Blood pH 7.35-7.45 Neutral solution is 7.0 Acid solutions are less than 7 Dextrose solutions have additives for stability during sterilization and storage - acidic (3.5-6.5 ) Some solutions have additives to increase pH Additives may contribute to drug incompatibility Neutralize Acidic Solutions/Medications Add buffers when appropriate Acidic Solutions Predispose V. to Phlebitis Back

Blood pH 7.35-7.45 Neutral solution is 7.0

Acid solutions are less than 7

Dextrose solutions have additives for stability during sterilization and storage - acidic (3.5-6.5 )

Some solutions have additives to increase pH

Additives may contribute to drug incompatibility

Neutralize Acidic Solutions/Medications

Add buffers when appropriate

How does this size catheter minimize possibility of phlebitis? Baxter Illustration

Common Meds Amiodarone (4.08) Ancef (4.5-7) Dilaudid (4-4.5) Dobutamine (2.5-4.5) Dopamine (2.5-5) Fentanyl (4-7.5) Flagyl (5-7) Gentamycin (3-5.5) KCL (4-8) Morphine Sulfate (2.5-7) Nitroglycerin (3-6.5) Solucortef (7-8) Solumedrol (7-8) Valium (6.2-6.9) Vancomycin (2.4-4.5) Versed (3) Lipid Emulsions FYI. Heparin increases pH and rarely causes phlebitis

Amiodarone (4.08)

Ancef (4.5-7)

Dilaudid (4-4.5)

Dobutamine (2.5-4.5)

Dopamine (2.5-5)

Fentanyl (4-7.5)

Flagyl (5-7)

Gentamycin (3-5.5)

KCL (4-8)

Morphine Sulfate (2.5-7)

Nitroglycerin (3-6.5)

Solucortef (7-8)

Solumedrol (7-8)

Valium (6.2-6.9)

Vancomycin (2.4-4.5)

Versed (3)

Lipid Emulsions

IV Fluid (mOsm/L) (pH range) D5W (252.2) (4.5 3.5-6.5) NS (308) (5.0 4.5-7.0) D5 .2NS (314) (4.0 3.5-6.5) Ringers (310) (5.5 5.0-7.5) LR (274) (6.5 6.0-7.5) Mannitol (274) (5.0 4.5-7.0) 0.45 NS (154) (5.0 4.5-7.0) Sterile H2O (0) (5.5 5.0-7.0)

D5W (252.2) (4.5 3.5-6.5)

NS (308) (5.0 4.5-7.0)

D5 .2NS (314) (4.0 3.5-6.5)

Ringers (310) (5.5 5.0-7.5)

LR (274) (6.5 6.0-7.5)

Mannitol (274) (5.0 4.5-7.0)

0.45 NS (154) (5.0 4.5-7.0)

Sterile H2O (0) (5.5 5.0-7.0)

Phlebitis Assessment Use INS Phlebitis Scale Once a patient develops phlebitis, DC IV and monitor site frequently for development of thrombophlebitis - evidenced by palpable cord Ask about pain Monitor for signs of systemic infection

Use INS Phlebitis Scale

Once a patient develops phlebitis, DC IV and monitor site frequently for development of thrombophlebitis - evidenced by palpable cord

Ask about pain

Monitor for signs of systemic infection

Which Grade? Cause is mechanical

Which Grade? Cause is chemical

Which Grade? Photo: C. Lewis

Nursing Intervention: Phlebitis Stop infusion, DC IV, and thoroughly assess Disinfect venipuncture site Apply pressure to stop bleeding Intermittent warm moist heat 20 min. 3-4 times per day with MD order Or cold compress, if indicated If catheter-related infection suspected, remove catheter aseptically and send for culture For purulent drainage, culture prior to cleaning the site Notify MD

Stop infusion, DC IV, and thoroughly assess

Disinfect venipuncture site

Apply pressure to stop bleeding

Intermittent warm moist heat

20 min. 3-4 times per day with MD order

Or cold compress, if indicated

If catheter-related infection suspected, remove catheter aseptically and send for culture

For purulent drainage, culture prior to cleaning the site

Notify MD

Infiltration Def. Non vesicant infusion outside of vein Appearance changes as severity increases First, feeling of tightness at venipuncture site Then, skin appears stretched or taut when enough fluid is trapped in the subcutaneous tissue Fluid may seep to dependant areas Blanching and coolness appears next The infusion may or may not slow in rate Patients may not have pain if solution is isotonic Symptoms will be more difficult to recognize early if skin turgor is poor

Def. Non vesicant infusion outside of vein

Appearance changes as severity increases

First, feeling of tightness at venipuncture site

Then, skin appears stretched or taut when enough fluid is trapped in the subcutaneous tissue

Fluid may seep to dependant areas

Blanching and coolness appears next

The infusion may or may not slow in rate

Patients may not have pain if solution is isotonic

1, 2, and 3 courtesy of Baxter 1 3 4 2 4 adapted from Baxter

Extravasation Def. Infiltration of vesicant solutions that are osmotically active, ischemia producing, or that cause direct cellular toxicity Erythema and tissue changes appear very quickly and progress, depending on the amount of infiltrated vesicant

Def. Infiltration of vesicant solutions that are osmotically active, ischemia producing, or that cause direct cellular toxicity

Erythema and tissue changes appear very quickly and progress, depending on the amount of infiltrated vesicant

Infiltration Assessment Can be difficult to assess, particularly if no pain or infusion is at a slow rate Compare to other extremity Also check dependent areas - gravity may pull fluid down Apply tourniquet or pressure proximal to catheter – should stop or slow flow If infiltrated, flow may continue despite venous obstruction Blood return is an unreliable indicator When in doubt, change catheter site

Can be difficult to assess, particularly if no pain or infusion is at a slow rate

Compare to other extremity

Also check dependent areas - gravity may pull fluid down

Apply tourniquet or pressure proximal to catheter – should stop or slow flow

If infiltrated, flow may continue despite venous obstruction

Blood return is an unreliable indicator

When in doubt, change catheter site

Nursing Intervention: Infiltration and Extravasation Stop infusion, DC IV, and thoroughly assess Intervention based on assessment Warm, moist or cool compress Cool compress for known irritant (e.g., KCl, X-ray contrast) Dressings usually not necessary; use with caution Restart IV in opposite arm For extravasation, follow unit protocols, notify M.D., fill out a Drug Report Form, and monitor closely Document infiltration and extravasation in medical record

Stop infusion, DC IV, and thoroughly assess

Intervention based on assessment

Warm, moist or cool compress

Cool compress for known irritant (e.g., KCl, X-ray contrast)

Dressings usually not necessary; use with caution

Restart IV in opposite arm

For extravasation, follow unit protocols, notify M.D., fill out a Drug Report Form, and monitor closely

Document infiltration and extravasation in medical record

Grade 1 Photo: C. Lewis Photo: C. Lewis

Grade 2 Photo: C. Lewis

Grade 3 Photo: C. Lewis

Grade 4 Photo: C. Lewis

Which Grade? Blood infusion Photo: C. Lewis

Blood infusion

Which Grade? Pt. c/o burning IV removed 1 hr. 45 min. ago Intermittent ice applied Dobutamine Infusion Photo: C. Lewis

Pt. c/o burning

IV removed 1 hr. 45 min. ago

Intermittent ice applied

Catheter-Related Infection Local or systemic CVC occurance is greater than with peripheral catheters Factors that increase likelihood Catheter dwell time Age and physical condition of patient Immunosuppression therapy

Local or systemic

CVC occurance is greater than with peripheral catheters

Factors that increase likelihood

Catheter dwell time

Age and physical condition of patient

Immunosuppression therapy

Prevention of Catheter-Related Infection Good handwashing technique Observe aseptic/sterile technique when mixing and administering solutions/medications Good site inspection at appropriate intervals for patient Ensure that dressing remains intact Change site and administration set every 72 hours

Good handwashing technique

Observe aseptic/sterile technique when mixing and administering solutions/medications

Good site inspection at appropriate intervals for patient

Ensure that dressing remains intact

Change site and administration set every 72 hours

Principles of Flow In intravenous therapy… pressure is the force that is generated to overcome systemic resistance to deliver IV fluid resistance is the force that is working against IV fluid flow

In intravenous therapy…

pressure is the force that is generated to overcome systemic resistance to deliver IV fluid

resistance is the force that is working against IV fluid flow

Resistance and Pressure = Flow Resistance slows flow Pressure increases flow In order to keep flow constant, one must adjust to compensate for a change in the other

Resistance slows flow

Pressure increases flow

In order to keep flow constant, one must adjust to compensate for a change in the other

Blood vessel diameter Catheter diameter Tubing diameter Length of tubing Fluid viscosity Flow regulation clamps How Do These Factors Influence Resistance and Pressure? Height of bag Pump mechanism External pressure bag Size of syringe P R

Blood vessel diameter

Catheter diameter

Tubing diameter

Length of tubing

Fluid viscosity

Flow regulation clamps

Height of bag

Pump mechanism

External pressure bag

Size of syringe

Troubleshooting Catheter occlusion Rate too slow Pain, no sign of phlebitis or infiltration Venous spasm

Catheter occlusion

Rate too slow

Pain, no sign of phlebitis or infiltration

Venous spasm

Catheter Occlusion Two types - can be partial or complete Thrombotic Thrombus due to fibrin or coagulated blood products within or surrounding the catheter Mechanical Catheter malposition, drug or mineral precipitates, lipid residue

Two types - can be partial or complete

Thrombotic

Thrombus due to fibrin or coagulated blood products within or surrounding the catheter

Mechanical

Catheter malposition, drug or mineral precipitates, lipid residue

Signs and Symptoms Frequent alarms in the absence of observable physical or mechanical obstruction Change in ability to infuse or aspirate from catheter Pain upon infusion Kinked or clamped catheter or administration set Obstructed in-line filter Drug and mineral precipitates or lipid residue Thrombotic Mechanical

Frequent alarms in the absence of observable physical or mechanical obstruction

Change in ability to infuse or aspirate from catheter

Pain upon infusion

Kinked or clamped catheter or administration set

Obstructed in-line filter

Drug and mineral precipitates or lipid residue

Nursing Intervention: Occlusion First check for mechanical obstruction - it’s the easiest. Clamps, tubing, in-line filter Then check the catheter. If unable to flush with a 5cc or larger syringe, do not force it. DC the catheter.

First check for mechanical obstruction - it’s the easiest.

Clamps, tubing, in-line filter

Then check the catheter. If unable to flush with a 5cc or larger syringe, do not force it. DC the catheter.

Rate Too Slow Check for mechanical cause Catheter crimped in anatomic area of flexion Tubing is crimped, kinked Either under the patient or inside the pump Tubing dangling below the bed (it requires force to push fluid “upstream” – esp. if patient is hypertensive) BP cuff inflation increases venous pressure Restraints Occluded filter or air vent

Check for mechanical cause

Catheter crimped in anatomic area of flexion

Tubing is crimped, kinked

Either under the patient or inside the pump

Tubing dangling below the bed (it requires force to push fluid “upstream” – esp. if patient is hypertensive)

BP cuff inflation increases venous pressure

Restraints

Occluded filter or air vent

Rate Too Slow, cont. Check for other causes Cannula too small for fluid viscosity Fluid temperature too low - venous spasm Cannula tip up against vessel wall or next to bifurcation of vein Undetected infiltration, phlebitis, or thrombus

Check for other causes

Cannula too small for fluid viscosity

Fluid temperature too low - venous spasm

Cannula tip up against vessel wall or next to bifurcation of vein

Undetected infiltration, phlebitis, or thrombus

Pain, no sign of phlebitis or infiltration Assess for other possible causes Dressing too tight? Venous spasm? Temp. of solution too low? pH of solution too low? Could medication use more dilution? Pain may precede physical signs of phlebitis Either fix the pain or DC and restart IV

Assess for other possible causes

Dressing too tight?

Venous spasm?

Temp. of solution too low?

pH of solution too low?

Could medication use more dilution?

Pain may precede physical signs of phlebitis

Either fix the pain or DC and restart IV

Venous Spasm Sudden involuntary contraction of vessel wall Feels painful and IV flow will reduce or stop Can result from trauma, irritation from chemical or temp. extremes, vasovagal reaction to pain or anxiety Nursing intervention Slow the rate, apply warm compress, add diluent, add buffer (with M.D. order), or DC IV

Sudden involuntary contraction of vessel wall

Feels painful and IV flow will reduce or stop

Can result from trauma, irritation from chemical or temp. extremes, vasovagal reaction to pain or anxiety

Nursing intervention

Slow the rate, apply warm compress, add diluent, add buffer (with M.D. order), or DC IV

Why Does a Pump Not Alarm When the IV is Infiltrating? Because pumps alarm when they sense a proportional rise in resistance, compared to the the previously measured baseline. Interstitial resistance is less than venous resistance -- that is, until the skin becomes adequately distended and starts exerting pressure.

Because pumps alarm when they sense a proportional rise in resistance, compared to the the previously measured baseline.

Interstitial resistance is less than venous resistance -- that is, until the skin becomes adequately distended and starts exerting pressure.

Hot Tip for Pumps Stop all infusions prior to adding additional equipment, filters or extension sets. This will allow the pump to take a new baseline resistance and reset the pumping pressure when you restart it.

Stop all infusions prior to adding additional equipment, filters or extension sets. This will allow the pump to take a new baseline resistance and reset the pumping pressure when you restart it.

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