What do we already know? Standard Precautions – All specimens should be treated as if they are...

What do we already know?

• Standard Precautions– “All specimens should be treated as if they are

hazardous and infectious.” p. 326 Phillips• Asepsis • Anatomy of a vein• Circulation physiology• SNS “fright or flight”• Therapeutic communication

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Use of a Tourniquet: Tension

• Purpose: impede venous flow to heart• Wider : less likely to impede arterial flow• Use tighter tension:– Hypotensive (hypovolemia)– Obese

• Lighter tension:– Elderly– Veins easily seen & palpated

• Use of BP cuff: just below diastolic2

Use of a Tourniquet: Duration

• No more than 1 minute at a time– IV start: Shunting of blood to collateral circulation– Phlebotomy: hemoconcentration; falsely high

values for protein-based analysis.• Release & reapply after 2 min.

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Use of a Tourniquet: Position

• Phlebotomy: 3-4 inches above collection site• IV: 5-6 inches above insertion site

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Evaluating Veins

• Round, firm elastic, engorged• NOT: hard, bumpy or flat• Valves• Don’t keep tourniquet on too long• Alternate: BP cuff to 30-40 mm Hg• Anxiety, cold, hypotensive: veins will

disappear.

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Avoid…

• Fistula &/or vascular graft• Mastectomy side• Hematoma• Drawing above an IV site (phlebotomy)• Healed burn areas• Skin inflammation, disease, bruising, or

breakdown• Sclerosed or thrombosed veins

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Order of draws

• To prevent specimen contamination with tube additives

• Blood culture tubes (yellow top)

• Plain tubes: non-additives (red)

• Coagulation tubes

• Additive tubes

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Filling Multiple Tubes

• Fill tube until vacuum is exhausted• Carefully remove tube and fill additional

tubes in proper order• Invert tubes as they are filled• As final tube is filling……….

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The Butterfly Needle

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Special Situations

• Patient has IV• Timing of peak and trough levels– peak 1.5-2 hrs. after dose completed– trough just before dose

• Blood alcohol levels - legal issues and “chain of custody”

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Specimen Integrity and Pre-Analytic Errors

• Patient Identification• Hemolysis• Hemoconcentration• Correct Tube, Correct Order of draw• Mixing• Labeling• Specimen contamination

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Complications

• Allergies to antiseptic• Pain• Anxiety/fainting• Hematoma• Infection of site• Vein or nerve damage• Arterial puncture

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General considerations

• Start low– Nondominant arm if possible

• Palm side of wrist only if necessary• Legs, feet, ankles – only w/MD order• Dorsum of hand: avoid abx, KCL, vesicant

agents• Antecubital – nice large vein – avoid for

routine use• Forearm – good sites for IV

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Selecting a Vein

• Patient’s medical history• Age, size, general condition• Condition of veins• Type of solution• Condition of vein• Duration of therapy• Cannula size• Patient activity• Patients receiving anticoagulation therapy

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When starting an IV, Avoid Veins…

• Below a previous I.V. infiltration• Below a phlebotic area• Previously areas listed earlier – Fistula &/or vascular graft– Mastectomy side– Hematoma– Healed burn areas– Skin inflammation, disease, bruising, or

breakdown– Sclerosed or thrombosed veins

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Site preparation

• Do not shave; clipping OK• Solutions– Chlorhexidine gluconate (recommended)– Iodophor (povidone-iodine)– 70% isopropyl alcohol

• 15 – 20 seconds• If allergic to prep solution use 70% alcohol for

30 seconds

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Taping

• INS: sterile tape under transparent dressing.• No tape directly on transparent dressing• Gauze under hub to stabilize prn

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Educate patient

• Limitations on movement or mobility• Explain all alarms if EID used• Instruct to call for assistance• Report redness, tenderness, or swelling• Inform that site will be checked by

nurse frequently

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Complications - systemic

• Septicemia• Fluid overload & pulmonary edema• Air embolism• Catheter embolism

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Systemic Complication: SepticemiaCause

•Febrile disease: microorganisms and their toxic products introduced into the circulatory system•Health care-associated intravascular device-related bloodstream infection is associated with 12% – 28% mortality rate

Signs and symptoms

• Fluctuating fever, tremors, chattering teeth

• Profuse, cold sweat• Nausea and vomiting• Diarrhea• Abdominal pain• Tachycardia• Increased respirations• Evidence of decreased

perfusion• Elevated WBC

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Systemic Complication: Septicemia

Prevention

• Good hand hygiene• Carefully inspecting IV solutions• Use of only freshly opened solutions• Use of 2% chlorhexidine with alcohol• Implement central line bundles• Use of Luer-Lok connections• Cover infusion sites with sterile dressing• Limit use of add-on devices• Change peripheral cannula after 72 –96 hours• Staff education• Remove peripheral cannula at first sign of inflammation

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