Basic IV Certification and Basic IV Certification and AdministrationAdministration

Five Mandatory “rights” for Five Mandatory “rights” for Administration of MedicationAdministration of Medication

• Right PatientRight Patient

• Right DrugRight Drug

• Right DoseRight Dose

• Right RouteRight Route

• Right TimeRight Time

Other checks that should be Other checks that should be made:made:

• Right diluentRight diluent

• Right infusion rateRight infusion rate

• When and what drug last givenWhen and what drug last given

• Any allergies?Any allergies?

Basic Principles of IV Basic Principles of IV therapytherapy

• Maintain line patencyMaintain line patency

• Protect integrity of catheterProtect integrity of catheter

• Protect from infectionProtect from infection

• Protect from air emboliProtect from air emboli

Equipment and how to use Equipment and how to use itit• Select IV tubing carefully to reflect the Select IV tubing carefully to reflect the

health status of the patient.health status of the patient.– A Crystalloid giving set ( basic IV giving set) is A Crystalloid giving set ( basic IV giving set) is

similar to a blood giving set but does not similar to a blood giving set but does not contain a filter- therefore should never be used contain a filter- therefore should never be used to infuse blood or blood products.to infuse blood or blood products.

– This type of system is used for fluid This type of system is used for fluid maintenance or fluid replacementmaintenance or fluid replacement

– Drop rates should be calculated accurately and Drop rates should be calculated accurately and flow rates checked regularlyflow rates checked regularly

Crystalloid Giving setCrystalloid Giving set

Blood setBlood set

• This contains a 170-200 micron filter net This contains a 170-200 micron filter net to remove debris from blood componentsto remove debris from blood components

• Debris is derived from WBC’s and platelets Debris is derived from WBC’s and platelets which are no longer functional and also which are no longer functional and also from cold insoluble protein and from cold insoluble protein and occasionally small clotsoccasionally small clots

• For optimum infusion the entire filter must For optimum infusion the entire filter must be covered with bloodbe covered with blood

• Delivers fluid at a standard rate of 20 Delivers fluid at a standard rate of 20 drops per mldrops per ml

Blood SetBlood Set

Burette systemsBurette systems

• MetrisetsMetrisets• VolutrolsVolutrolsDeliver 60 drops per mlDeliver 60 drops per ml

Allows closer monitoring of fluidAllows closer monitoring of fluidand electrolytesand electrolytes

Anatomy and Physiology of Anatomy and Physiology of VeinsVeins• Veins are composed of 3 layersVeins are composed of 3 layers• Tunica Intima (inner layer) composed ogf Tunica Intima (inner layer) composed ogf

endothelial lining which forms the valvesin endothelial lining which forms the valvesin veins. The smooth tissue assists blood flowveins. The smooth tissue assists blood flow

• Tunica Media (middle Layer) composed of Tunica Media (middle Layer) composed of muscular and elastic tissue and contains muscular and elastic tissue and contains nerve fibres which allow constriction and nerve fibres which allow constriction and dilation to occurdilation to occur

• Tunica adventitia(outer layer) composed Tunica adventitia(outer layer) composed of connective tissue which surrounds and of connective tissue which surrounds and supports the veinsupports the vein

Intravenous Therapy has three Intravenous Therapy has three main objectivesmain objectives

• To maintain daily body fluid To maintain daily body fluid requirementsrequirements

• To restore previous body fluid lossesTo restore previous body fluid losses

• To replace present body fluid lossesTo replace present body fluid losses

Fluid and Electrolyte Fluid and Electrolyte TherapyTherapy

• Types of fluidTypes of fluid

• IsotonicIsotonic

• HypotonicHypotonic

• HypertonicHypertonic

Medication administrationMedication administration

• Continuous InfusionContinuous Infusion

• Intermittent InfusionIntermittent Infusion

• IV Push /InjectionIV Push /Injection

Important factors in Important factors in administration of all IV administration of all IV

medicationsmedications• Environment: ensure as much as possible Environment: ensure as much as possible

that you are comfortable and feel that you are comfortable and feel confident about procedure and drug.confident about procedure and drug.

• Patient: positive ID of patient, allergies, Patient: positive ID of patient, allergies, health status, therapeutic compatibilities, health status, therapeutic compatibilities, side effects, effectiveness of medication.side effects, effectiveness of medication.

• Injection: cannula and line patency, Injection: cannula and line patency, asepsis, documentationasepsis, documentation

• Equipment: correct disposal of needles Equipment: correct disposal of needles and syringes, and medications.and syringes, and medications.

Potential problems of IV Potential problems of IV administrationadministration

• IncompatibilityIncompatibility

• Speed shockSpeed shock

• Vascular irritationVascular irritation

• Incomplete /inadequate mixing of Incomplete /inadequate mixing of drug with fluiddrug with fluid

• Inability to remove drug once Inability to remove drug once administered into blood streamadministered into blood stream

Guideline to avoid Guideline to avoid incompatibilitiesincompatibilities

• Do not add drugs to complex Do not add drugs to complex solutions such as blood, lipids, amino solutions such as blood, lipids, amino acids, or parental nutrition solutions.acids, or parental nutrition solutions.

• The more simple the solution , the The more simple the solution , the less likelihood of incompatibility.less likelihood of incompatibility.

• Follow the manufacturers Follow the manufacturers instructions and New Ethicals instructions and New Ethicals compendium re: compatibility and compendium re: compatibility and stability.stability.

Vascular traumaVascular trauma

• The inflammatory process that The inflammatory process that results by administration of drugs results by administration of drugs causes a roughening of the causes a roughening of the endothelial cells allowing platelets to endothelial cells allowing platelets to adhere and a thrombus to form. This adhere and a thrombus to form. This causes Thrombophlebitis. If aseptic causes Thrombophlebitis. If aseptic technique is poor, septic thrombosis technique is poor, septic thrombosis may occur. may occur.

Other ComplicationsOther Complications

• Air Embolism- rare in IV fluid Air Embolism- rare in IV fluid administration unless line not primed administration unless line not primed adequatelyadequately

• Catheter Embolism- may occur when Catheter Embolism- may occur when part of the plastic cannula is sheared part of the plastic cannula is sheared off by the introducer needle- do not off by the introducer needle- do not reintroduce the needle once it has reintroduce the needle once it has been fully or partially removedbeen fully or partially removed

PhlebitisPhlebitis

Symptoms: Symptoms: • Redness, swelling,pain and heat around cannula Redness, swelling,pain and heat around cannula

sitesite• Tender and painful to touchTender and painful to touch• Reduced flow of infusion- or has stopped altogetherReduced flow of infusion- or has stopped altogetherInterventions:Interventions:• Stop infusionStop infusion• Remove cannulaRemove cannula• Take swab if infectionTake swab if infection• Apply warm moist compress till pain resolvedApply warm moist compress till pain resolved• Elevate or rest armElevate or rest arm

Infiltration/extravasation into Infiltration/extravasation into surrounding tissuesurrounding tissue

• Causes tissue necrosis and pain.Causes tissue necrosis and pain.Symptoms:Symptoms:• Pain, Tightness, reduced IV rate, ”halo”of Pain, Tightness, reduced IV rate, ”halo”of

fluid in tissuefluid in tissueInterventions:Interventions:Stop infusion, disconnect tubing and Stop infusion, disconnect tubing and

aspirate from hub with 5ml syringe aspirate from hub with 5ml syringe aseptically… if unsuccessful - remove aseptically… if unsuccessful - remove cannula and mark site of oedemacannula and mark site of oedema

Clotted cannulaClotted cannula

Signs:Signs:• Blood has backed up the tubingBlood has backed up the tubing• Stop in FlowStop in FlowInterventions:Interventions:• Aspirate at hub using 10ml syringeAspirate at hub using 10ml syringe• If no return, gently attempt to irrigate with If no return, gently attempt to irrigate with

0.9%NaCl using a large bore syringe- this 0.9%NaCl using a large bore syringe- this exerts less pressure than a smaller syringe.exerts less pressure than a smaller syringe.

• If resistance felt, do not proceed… resite If resistance felt, do not proceed… resite cannula.cannula.

Circulatory overloadCirculatory overload

Caused by IV solution being infused too quickly.Caused by IV solution being infused too quickly.Effects: Effects: • Increased HR, BP, RR, Distended neck veins, Increased HR, BP, RR, Distended neck veins,

dyspnoea, gurgling/wheezing, Moist cough and dyspnoea, gurgling/wheezing, Moist cough and generalised discomfortgeneralised discomfort

Interventions: Slow rate TKVOInterventions: Slow rate TKVOPlace person in semi-fowler postion( elevated head)Place person in semi-fowler postion( elevated head)Notify Med staffNotify Med staffAdminister O2Administer O2Monitor patient closely and watch for OedemaMonitor patient closely and watch for Oedema

Speed ShockSpeed Shock

• A systemic reaction that occurs when A systemic reaction that occurs when a foreign body is rapidly introduced a foreign body is rapidly introduced into the bloodstream.into the bloodstream.

• Symptoms: severe headache, chest Symptoms: severe headache, chest pain, irregular pulse, decreased BP, pain, irregular pulse, decreased BP, loss of consciousness, shock cardiac loss of consciousness, shock cardiac arrestarrest

• Interventions: stay with patient, stop Interventions: stay with patient, stop infusion, ABC, notify medical staff.infusion, ABC, notify medical staff.

VenepunctureVenepuncture

• Aim: To obtain a blood sample for Aim: To obtain a blood sample for laboratory testing which will laboratory testing which will accurately reflect the in vivo levels of accurately reflect the in vivo levels of a given substancea given substance

Veins in antecubital regionVeins in antecubital region

• CephalicCephalic

• BasilicBasilic

• AccessoryAccessory

• MedianMedian

Recommended sequence for Recommended sequence for blood drawblood draw

• Blood cultureBlood culture

• Red top/gold topRed top/gold top

• Light blueLight blue

• Green topGreen top

• LavendarLavendar

• GreyGrey

Selection of vein siteSelection of vein site

• Fuller veins preferred: median cubital Fuller veins preferred: median cubital or cephalicor cephalic

• Palpate vein with index finger to Palpate vein with index finger to ascertain suitabilityascertain suitability

ProcedureProcedure• Assemble equipmentAssemble equipment• Position patient’s arm extended on a pillowPosition patient’s arm extended on a pillow• Wash hands/don glovesWash hands/don gloves• Apply tourniquet 8-10 cm above venepuncture siteApply tourniquet 8-10 cm above venepuncture site• Ask the patient to make a fist – vigorous pumping not requiredAsk the patient to make a fist – vigorous pumping not required• Gentle tapping on vein sometimes helpsGentle tapping on vein sometimes helps• Clean vein site with alc swab and allow to dry. Use 20/21g ndleClean vein site with alc swab and allow to dry. Use 20/21g ndle• Draw skin tight with other handDraw skin tight with other hand• With needle bevel facing upwards, penetrate skin at angle 10-With needle bevel facing upwards, penetrate skin at angle 10-

20 degrees, insert tube into holder, push stopper over needle20 degrees, insert tube into holder, push stopper over needle• When blood flows ask patient to relax hand and release When blood flows ask patient to relax hand and release

tourniquet slowlytourniquet slowly• Mix tubes with additives gently Mix tubes with additives gently • Ensure adequate blood taken for each testEnsure adequate blood taken for each test• Apply pressure to area with gauze on removal of needleApply pressure to area with gauze on removal of needle• Dispose correctly into sharps containerDispose correctly into sharps container

Paediatric VenepuncturePaediatric Venepuncture

• Have a parent hold child on kneeHave a parent hold child on knee

• Dorsal hand veins are preferred site Dorsal hand veins are preferred site in neonates and children under in neonates and children under 2years2years

• Use EMLA patches or creamUse EMLA patches or cream

• 23g butterfly needle recommended 23g butterfly needle recommended and paediatric blood tubesand paediatric blood tubes

CannulationCannulation

Choosing Cannula sizeChoosing Cannula size

• Diameter is Diameter is expressed in terms expressed in terms of gaugeof gauge– The higher gauge The higher gauge

numbers are narrowernumbers are narrower– The shortest and The shortest and

smallest cannula that smallest cannula that will deliver the will deliver the required fluid volume required fluid volume or medication should or medication should be chosenbe chosen

22g22g IV fluids and IV fluids and intermittent intermittent push injections push injections in children in children and elderlyand elderly

20g20g Drug bolus and Drug bolus and fat solutionsfat solutions

18-20g18-20g IV fluids and IV fluids and AB’s in adultsAB’s in adults

14-16g14-16g All adults All adults having surgeryhaving surgery

Cannulation sitesCannulation sites

• Start distally and Start distally and move proximallymove proximally

• Use non dominant Use non dominant handhand

• Ensure vein larger Ensure vein larger than venflonthan venflon

• Avoid sites around Avoid sites around jointsjoints

Cannulation ProcedureCannulation Procedure

Procedure continued…Procedure continued…• Prepare equipmentPrepare equipment• Apply tourniquetApply tourniquet• Identify veinIdentify vein• Cleanse site using persist swab or Cleanse site using persist swab or

betadine swabbetadine swab• Don glovesDon gloves• Place thumb 5cm below entry point of Place thumb 5cm below entry point of

vein and pull down anchoring veinvein and pull down anchoring vein• Maintain traction on skin whilst Maintain traction on skin whilst

inserting the cannulainserting the cannula• Insert at a 20-30degree angle with Insert at a 20-30degree angle with

bevel uppermostbevel uppermost• Flashback of blood into the cannula Flashback of blood into the cannula

will occur when vein penetratedwill occur when vein penetrated• Advance cannula a further 5mm .( the Advance cannula a further 5mm .( the

stylet is 1-2mm longer than the tip and stylet is 1-2mm longer than the tip and both need to be in the vein to allow both need to be in the vein to allow the cannula to be advanced smoothly.the cannula to be advanced smoothly.

• Firmly hold the flash chamber, Firmly hold the flash chamber, immobilising the needle and advance immobilising the needle and advance the catheter forward off the stylet into the catheter forward off the stylet into the vein until the hub is at the skin.the vein until the hub is at the skin.

• Release tourniquetRelease tourniquet• Secure hub with tapeSecure hub with tape• Withdraw stylet and attach needleless Withdraw stylet and attach needleless

port to hubport to hub• Flush with 10 mls NaclFlush with 10 mls Nacl

Cannulation trainingCannulation training

• This is available at Dunstan HospitalThis is available at Dunstan Hospital

Long term Venous Access Long term Venous Access devicesdevices

This is Intermediate Level 4 IV This is Intermediate Level 4 IV certification and requires specific certification and requires specific

training which may be undertaken at training which may be undertaken at Dunstan HospitalDunstan Hospital

• PICC’sPICC’s

• PortsPorts

• Hickman CathetersHickman Catheters

Peripherally Inserted Central Peripherally Inserted Central Catheters ( PICC’s)Catheters ( PICC’s)

PICCPICC

• Peripherally Inserted Central Peripherally Inserted Central CatheterCatheter

• PICC lines are suitable for:PICC lines are suitable for:– patients who require intermediate term patients who require intermediate term

venous access ( 5 days-5 months)venous access ( 5 days-5 months)– Patients who have adequate and Patients who have adequate and

accessible antecubital veinsaccessible antecubital veins

IndicationsIndications

• Lack of peripheral accessLack of peripheral access

• Hyperosmolar infusionsHyperosmolar infusions

• Vesicant therapy: chemo or antibiotic Vesicant therapy: chemo or antibiotic therapytherapy

Catheter InsertionCatheter Insertion

• Catheter is inserted into the basilic Catheter is inserted into the basilic vein above the elbow at the bedside vein above the elbow at the bedside or within the Radiology Dept and or within the Radiology Dept and guided by flouroscopy.guided by flouroscopy.

• The tip of the catheter sits within the The tip of the catheter sits within the Superior Vena Cava and must be Superior Vena Cava and must be verified by CXR verified by CXR

Weekly Catheter ManagementWeekly Catheter Managementby District Nursesby District Nurses

• Dressing to PICC siteDressing to PICC site

• Flush using ASASH techniqueFlush using ASASH technique

• Measurement of external length to Measurement of external length to ensure catheter tip has not migrated ensure catheter tip has not migrated out of SVCout of SVC

• Assessment for evidence of any Assessment for evidence of any change, ooze, pain, oedemachange, ooze, pain, oedema

Implanted portsImplanted ports

Implanted Port StructureImplanted Port Structure

• The port is The port is constructed of constructed of a resealable rubber a resealable rubber

septum septum

a chamber made from a chamber made from moulded plastic moulded plastic

a catheter which a catheter which connects to the connects to the base of the chamberbase of the chamber

InsertionInsertion

• The catheter is inserted into the subclavian, The catheter is inserted into the subclavian, jugular or cephalic vein and worked through jugular or cephalic vein and worked through to the lower third of the SVC. The tip must to the lower third of the SVC. The tip must lie above the right atriumlie above the right atrium

• The catheter is then tunnelled beneath the The catheter is then tunnelled beneath the skin to a subcutaneous pocket created on skin to a subcutaneous pocket created on the upper chest wall.the upper chest wall.

• The chamber is placed on a bony The chamber is placed on a bony prominence to provide stability during useprominence to provide stability during use

Port AccessPort Access

• Only Huber point needles must be used Only Huber point needles must be used to access an implanted portto access an implanted port

• These have a deflected point and side These have a deflected point and side opening to prevent coring of the opening to prevent coring of the septum.septum.

• This preserves the port for long term useThis preserves the port for long term use

• On removal of the needle the septum On removal of the needle the septum reseals itselfreseals itself

Huber needlesHuber needles

• When the needle is inserted the When the needle is inserted the silicone septum is traversed until the silicone septum is traversed until the needle stop is felt. Blood return needle stop is felt. Blood return indicates correct needle indicates correct needle engagement.engagement.

Care of an implanted PortCare of an implanted Port

• Accessed monthly if not in useAccessed monthly if not in use

• ASASH technique usedASASH technique used– AspirateAspirate– Saline FlushSaline Flush– Antibiotic admin if requiredAntibiotic admin if required– Saline flushSaline flush– Heparin LockHeparin Lock

That’s all folks !That’s all folks !

• Take a look at the PICC and Port Take a look at the PICC and Port modelsmodels

• And if interested in extending your And if interested in extending your scope of practice you could train up scope of practice you could train up to be certificated to this level.to be certificated to this level.

Kind regards and thanks for listening!Kind regards and thanks for listening!

Carolyn DobsonCarolyn Dobson