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Initiating and Discontinuing IV Infusion NUR 304 Learning Objectives At the end of the discussion and video presentation, the students will be able to: 1. 2. 3. 4. Adhere to strict aseptic technique while performing the procedure. State the purposes of IV infusion. Describe essential steps when initiating a peripheral intravenous infusion. Calculate flow rate correctly. INTRODUCTION Peripheral venous cannulation is when a plastic or metal tube is inserted for intravenous (IV) therapy, such as IV fluids and/or drugs or the transfusion of blood products. Also for the administration of dyes and contrast media during clinical investigations. INTRODUCTION Device used is a peripheral venous catheter (PVC) commonly referred to as a cannula. Selection of an Appropriate Cannula PVC must never occlude a vein; Critically ill and the situation is an emergency Selection of an Appropriate Cannula (hypovolemic shock), rule does not apply. Hence, we insert a larger device to “push the fluids” into the patient’s system as quickly as possible for rapid treatment. It should be replaced every 72 hours, but should be flushed, usually with 0.9% NaCl every 46 hours Types of IV Cannula COLOR SIZE COMMON APPLICATIONS Orange - 14G – treaters or emergency for rapid transfusion of blood or viscous fluids. Grey - 16G – same as above Types of IV Cannula - 17G – blood transfusions, rapid transfusion of large volumes of viscous fluids. Green - 18G - blood transfusions, parenteral nutrition, stem cell harvesting and cell separation, large volume of fluids White Types of IV Cannula Pink - 20G – blood transfusions, large volume of fluids. Blue - 22G – blood transfusions, most medications and fluids. Types of IV Cannula Yellow – 24G – medications, short term infusions, fragile veins, children Purple - 26G – neonatal Venipuncture Sites Site chosen for venipuncture varies with the: 1.Client’s age 2.Length of time the infusion is to run 3.Type of solution used, and the 4.Condition of the veins Venipuncture Sites Adults: veins in the hand and arm are commonly used Infants: veins in the scalp and dorsal foot veins are often used. Metacarpal, basilic and cephalic veins are commonly used for intermittent or continuous infusions. Venipuncture Sites the ulna and radius act as natural splints at these sites, and the client has greater freedom of arm movements for activities such as eating. Although basilic and median cubital veins in the antecubital space are convenient sites for venipuncture, they are usually used for Venipuncture Sites blood draws, bolus injections of medication, and insertion sites for a peripherally inserted central catheter line. Venipuncture Sites Practice Guidelines VEIN SELECTION use distal veins of the arm first use the client’s nondominant arm whenever possible select a vein that is: * easily palpated & feels soft & full * naturally splinted by a bone Practice Guidelines VEIN SELECTION large enough to allow adequate circulation around the catheter. avoid using veins that are in areas of flexion; highly visible, since they tend to roll away from the needle; damaged by previous use, phlebitis, infiltration or sclerosis; continually distended with blood, or knotted or tortous; Practice Guidelines VEIN SELECTION in a surgically compromised or injured extremity (e.g. following a mastectomy) because of possible impaired circulation and discomfort for the client. INITIATING A PERIPHERAL INTRAVENOUS INFUSION Purposes of IV Infusion: 1. Supply fluid when clients are unable to take in an adequate volume of fluids by mouth. 2. Provide salts and other electrolytes needed to maintain electrolyte balance. 3. Provide glucose (dextrose), the main fuel for metabolism. 4. Provide water-soluble vitamins and medications. 5. Establish a lifeline for rapidly needed medications. Assessment: Assess the following: Vital signs (PR, RR & BP) for baseline data Skin turgor Allergy to latex (e.g. tourniquet), tape or iodine Bleeding tendencies Status of veins to determine puncture site Equipment: infusion set sterile parenteral solution IV pole adhesive or non-allergenic tape clean gloves tourniquet antiseptic swabs IV catheter sterile gauze dressing or transparent occlusive dressing arm splint if required towel or pad antiseptic ointment (check agency policy) electronic infusion device or pump if necessary Preparatory Phase: 1. Prepare IV solution & administration set. Utilize 10 Rights of medication administration Check IV solution to make sure it is the correct solution with the prescribed additives. Check expiration date – IV solution bag Check for discoloration or particulate matter Initiating an IV Infusion Place a time tape on the solution container with the prescribed infusion rate, time it begun, & time of completion. Remove the administration set from its package, label the tubing with the date and time, & then close roller clamp. Remove the protective cover from the IV solution port. Initiating an IV Infusion Remove the protective cover from the spike on the IV administration set, making sure the spike remains sterile. Position the spike into the port of the solution container. If the solution is in a glass bottle, clean 1st the rubber stopper with an alcohol swab, then insert the spike through the rubber stopper. Initiating an IV Infusion Make certain the tubing is clamped then hang the IV solution container on an IV pole. Adjust the pole so that the container is suspended about 1 m (3 ft.) above the client’s head. Rationale: This height is needed to enable gravity to Initiating an IV Infusion overcome venous pressure & facilitate flow of the solution into the vein. Lightly compress the drip chamber & fill it halfway. If extension tubing is used, attach it to the end of the administration set. Initiating an IV Infusion Prime the tubing by opening the roller clamp & allow the fluid to slowly fill the tubing. Rationale: The tubing is primed to prevent the introduction of air into the client. Air bubbles smaller than 0.5ml usually do not cause problems in the peripheral lines. Initiating an IV Infusion Inspect the tubing for air. If air bubbles remain in the tubing, flick it with the fingernail to mobilize the bubbles. Recap the end of the tube firmly. Initiating an IV Infusion : Performance Phase 1. Locate the vein for inserting the IV catheter. Select a vein that is most distal on the hand or arm. Avoid using an arm or hand that has a dialysis graft or fistula or the affected arm of a mastectomy client. Rationale: Because of possible impaired circulation & discomfort for the client. Initiating an IV Infusion : Performance Phase 2. Place a linen saver pad under the client’s arms. Rationale: to protect linens. 3. Place client’s arm in a dependent position & apply tourniquet 4 – 6 inches above the selected site. Explain that the tourniquet will feel tight. Rationale: The tourniquet must be tight enough to obstruct Initiating an IV Infusion : Performance Phase venous flow but not tight that it occludes arterial flow. 4. Palpate the radial pulse. If no pulse is present, loosen the tourniquet & reapply it with less tension. Rationale: Obstructing arterial flow inhibits venous filling. Initiating an IV Infusion : Performance Phase 5. Palpate the vein & press it downward, making sure that it rebounds quickly. If vein is not adequately dilated, instruct client to open & close his fist, apply warm compress, lightly tap the vein or stroke the extremity from distal to proximal below the selected venous site. Rationale: Actions help fill the Initiating an IV Infusion : Performance Phase vein. Opening & closing fist helps by contracting the muscles which in turn, compress the distal veins, forcing blood along the veins and distending them. 6. After selecting the vein, gently tourniquet. release the Initiating an IV Infusion : Performance Phase 7. If excessive hair is present at the venipuncture site, clip it. Rationale: Shaving is usually not recommended because of the potential for microabrasions which can increase the risk of infection. 8. Put on clean gloves. Initiating an IV Infusion : Performance Phase 9. Choose the appropriate IV catheter based on the size of the vein & the solution to be used 10.Open the catheter package using aseptic technique. 11.Reapply the tourniquet & clean the site of insertion using an antiseptic swab that contains 2% tincture of iodine, alcohol or Initiating an IV Infusion : Performance Phase chlorhexidine. Avoid using chlorhexidine in infants under 2 months of age. 12. Clean the area using circular motion moving from the center and going outward for several inches. Rationale: This motion carries microorganisms away from the site of entry. Initiating an IV Infusion : Performance Phase 13. Allow the antiseptic to dry on the skin. 14. Using the nondominant hand, stabilize the vein by stretching the skin, making sure not to contaminate the insertion site. 15. Inform client that you are about to insert the catheter & that, he may feel a little uncomfortable. Initiating an IV Infusion : Performance Phase 16. Pick – up the catheter: Wing-tipped (butterfly) catheter – Grasp the catheter by the wings using the thumb & forefinger of the dominant hand- bevel up. Remove protective cap from the needle. Over-the-needle catheter: Grasp the catheter by the hub, using the thumb and Initiating an IV Infusion : Performance Phase forefinger of the dominant hand –bevel-up. 17. Hold the catheter at a 20-30 degree angle then pierce the skin. 18. Lower the catheter so that it is parallel to the skin & advance the catheter into the vein. Watch for flashback of blood into the chamber of the catheter or the tubing of the winged catheter. Initiating an IV Infusion : Performance Phase 19. Advance catheter. Wing-tipped catheter: fully advance the catheter. Over-the-needle catheter: advance the catheter to half its length. Withdraw the needle while advancing the catheter fully into the vein. Initiating an IV Infusion : Performance Phase 20.While holding the catheter in place with one hand, release the tourniquet with the other hand. 21. Using aseptic technique, quickly connect the administration set adapter to the IV catheter. Initiating an IV Infusion : Performance Phase 22. Still stabilizing the catheter, slowly open the roller clamp & allow the IV fluid to flush the catheter. Adjust the flow rate according to physician’s order. 23. Cover the insertion site with a sterile semipermeable transparent dressing. If the site isn’t clean & dry, clean the site with an Initiating an IV Infusion : Performance Phase antiseptic swab & allow it to dry before applying the dressing. open the package containing the dressing. Using aseptic technique, remove the protective backing from the dressing making sure not to touch the sterile surface. cover the insertion site & the hub or winged Initiating an IV Infusion : Performance Phase portion of the catheter with the dressing. Do not cover the tubing of the administration set. Gently pinch the transparent dressing around the catheter hub to secure it. Smooth the remainder of the dressing so that it adheres to the skin. Initiating an IV Infusion : Performance Phase 24. Loop the administration tubing & place a piece of tape over the catheter tubing connection & loop section of the tubing. 25. Label the dressing with the date & time of insertion, catheter size & own initials. 26. If insertion site is near a joint, place armboard under the joint & secure with tape. Discontinuing an IV Infusion : Performance Phase Verify physicians order, identify patient and explain procedure. Assist the client to a comfortable position. Place a linen-saver pad under the extremity that contains the IV catheter. Close the roller clamp on the administration set. Carefully remove the IV dressing and tape that is securing the tubing. Apply a sterile 2×2 gauze pad above the IV insertion site and gently remove the catheter, directing it straight along the vein. Do not press down on the gauze pad while removing the catheter. Discontinuing an IV Infusion : Performance Phase Immediately apply firm pressure with the gauze pad over the insertion site. Hold pressure for 2 to 3 minutes; longer if bleeding persists. Remove the soiled 2×2 gauze pad and replaces it with a sterile 2×2 gauze pad. Secures it with a piece of 1-inch tape. Dispose of the IV catheter in the appropriate sharps container. Discard the IV tubing, linen-saver pad, IV solution container, and gloves in the appropriate trash container, according to agency policy. IV Flow Rate Calculation Formula: Total Fluid in ml Total hours X IV set calibration 60 minutes IV set calibration: Check the IV set package Macroset- 20 macrodrops (gtts)/ ml Microset (Secondary Inlet)- 60 microdrops (ugtts)/ml Infusion set Macroset ● IV Flow Rate Calculation Calculate for the flow rate: 1. Administer 1000 ml of D5 NSS for 8 hours. 2. Administer 200 ml/hr of D5W.