Lect 5 cannulation students
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Transcript of Lect 5 cannulation students
INTRAVENOUS THERAPY
2nd level preparation
Dr. Shaimaa Ebrahim
Out lines Anatomy of the vein Indications of IV therapy Types of IV fluids Formula for calculating I.V drip &
Documentation. Criteria for vein selection Vein -puncture I.V maintenance (procedure) Complications of I.V therapy
Local Systemic
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Definition
“The intravenous management is safe,
effective delivery of treatment (fluid or
medicines) without discomfort or tissue
damage and without compromising venous
access, especially when long term therapy is
proposed”
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Tunica Adventitiathe outer layer of the vessel
Connective tissue
Contains the
arteries and veins
supplying blood to
vessel wall
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Tunica Mediathe middle layer of the vessel
Contains nerve endings
and muscle fibers
The vasoconstrictive
response occurs at this
layer
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Tunica Intimathe inner layer of the vessel
One layer of endothelial cells
No nerve endings
Surface for platelet aggregation
w/trauma and recognition of
foreign object at this level
PHLEBITIS begins here
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ValvesNot in all veins
Prevent backflow and
pooling
More in lower extremities
and longer vessels
Vein dilates at valve
attachment
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Indications
Fluid and electrolyte replacement
Patient cannot tolerate drugs/fluids orally
Blood sampling
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Indications
90-95% of patients in the hospital receive
some type of intravenous therapy.
Administration of medicines
Administration of blood/blood products
Administration of Total parenteral
Nutrition(TPN)
Haemodialysis
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Advantages
Immediate effect
Control over the rate of administration
Some drugs cannot be absorbed by any other
route
Pain and irritation is avoided compared to some
substances when given SC/IM
Management in emergencies
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What are the characteristics of good vein ?
Visible Palpable Straight Soft not rigid Above previous insertion sites Refills when depressed Has a large lumen Well supported/immobile Bouncy/elasticity Not bridging joints
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What veins should you avoid ?
Thrombosed / sclerosed / fibrosed Inflamed / bruised Thin / Fragile Mobile Near bony prominences Areas or sites of infection, edema or phlebitis Have multiple previous punctures Do not use if patient has IV fluid in situ
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Site Choice
Identify a suitable vein
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Dr.Shaimaa Ebrahim 14
Vein Selection
Veins of the Hand
1. Digital Dorsal veins
2. Dorsal Metacarpal veins
3. Dorsal venous network
4. Cephalic vein
5. Basilic vein
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Intravenous Therapy
Vein Selection
Veins of the Forearm1. Cephalic vein2. Median Cubital vein3. Accessory Cephalic vein4. Basilic vein5. Cephalic vein6. Median antebrachial vein
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What equipment do you need?
Cannulation Tray Non Sterile Gloves Alcohol wipes/Gauze swab/ cotton with
alcohol Tourniquet IV cannula Dressing to secure cannula/adhesive tape IV administration set Saline flush and sterile syringe or fluid to be
administered Sharps bin/sharp container/safety box
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Preparation
Check doctor order
Identify the patient
Consult with patient & Give explanation
Gain consent (oral agreement enough)
Position the patient appropriately and identify the
non-dominant hand / arm
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Preparation
Support arm on pillow or in other suitable
manner.
Check for any contra-indications e.g. infection,
damaged tissue, AV fistula etc.
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Cannulation
Encourage venous filling by: Correctly applying a tourniquet The tourniquet should be applied at a pressure
which is high enough to impede venous distension but not to restrict arterial flow)
Apply the tourniquet, 7-10 cm above site Opening & closing the fist Lowering the limb below the heart level
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Cannulation
Remove tourniquet if not able to proceed Put on non-sterile gloves Re-apply the tourniquet, 7-10 cm above site Remove the protective sleeve from the needle
taking care not to touch it at any time Hold the cannula in your dominant hand,
stretch the skin over the vein to anchor the vein with your non-dominant hand (Do not re palpate the vein)
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Types of Intravenous Fluids22
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Calculating Intravenous Drip
The nurse calculate In drip by using the
following formula:
volume to be infused(ml) × drop factor= …= …
drop/mindrop/min
time in minutes
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Drop factor
For ordinary I.V set (macro drips) = 15
For blood transfusion =10
For micro drips = 60
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Complications of IV Therapy
Classified according to their location
Lo c a l c o m p lic a tio n : at or near the
insertion site or as a result of
mechanical failure
Sys te m ic c o m p lic a tio ns : occur within the
vascular system, from the IV substance.
Can be serious and life threatening
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Local complications
Occur due to trauma to the surrounding vein puncture site
Assessing and monitoring are the key components to early
intervention
Good vein puncture technique is the main factor related to
the prevention of most local complications associated with
IV Therapy.
Local complications include: hematoma, thrombosis,
phlebitis, post-infusion phlebitis, thrombophlebitis,
infiltration/extravasation, local infection, and or venous
spasm.
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Hematoma
Hematoma formation and echeymosis resulting from
the infiltration of blood into the tissues at the vein
puncture site
Related to false vein puncture technique
Use of large bore cannula in small vein leads to:
Trauma to the vein during insertion
Patients receiving anticoagulant therapy or long term
steroids
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Hematoma Prevention Apply tourniquet just before vein puncture( not
more than 2 to 3 minutes)
Use a small needle in the elderly, patients on
steroids, hepatic patients, patients with thin veins &
thin skin, pt with thrombocytopenia.
Be gentle during insertion
Use proper direction and angle
Don’t retry more than one time
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Hematoma Treatment
Apply direct, light pressure for 3-5 minutes after
needle removal in sampling or cannulation
Have patient elevate extremity
Apply cold foments at the puncture site
Document and report
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Thrombosis Trauma to the endothelial cells of the venous
wall causes red blood cells to adhere to the vein
wall, forms a clot or Thrombosis How to determine
Drip rate slows, line does not flush easily,
resistance is felt
Never force flush into the catheter
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Thrombosis Signs and Symptoms
Slowed or stopped infusion rate Inability to flush easily Fever and Malaise
Prevention Use pumps and controllers to manage flow rate Usage of Small size device for rate below50mL/hr Avoid areas of flexion Avoid lower extremities
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Thrombosis
Treatment
Never force flush a cannula to remove an
occlusion
Disconnect the cannula
Notify the physician and assess the site for
circulatory impairment Have to Document
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Phlebitis
Inflammation of the vein in which the endothelial
cells of the venous wall become irritated and cells
roughen, allowing platelets to adhere and
predispose the vein to inflammation-induced
phlebitis
Tender very painful when touch
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Phlebitis Mechanical:
When large catheter used for small vein Manipulation of the catheter: improper stabilization Improper insertion technique (large angle)
Chemical: vein becomes inflamed by irritating or vesicant solutions or medication
Irritation medication itself (as in chemotherapy/potassium)
Improperly mixed or diluted medicines Too-rapid infusions
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Phlebitis
Chemical (cont):
The more acidic the IV solution the greater the
risk
Additives: Potassium
Length of device (should not exceed 72 hrs)
The slower the rate of infusion the less irritation
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Bacterial Phlebitis
Also called Septic phlebitis: least common Inflammation of the intima of the vein Contributing factors
Dressing (infrequent) Time of the catheter Poor insertion technique Failure to perform site assessment Inadequate stabilization Poor aseptic technique
Failure to detect breaks in the integrity of the equipment Aseptic preparation of solutions Improper Hand washing and preparing the skin
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Phlebitis
Immune system causes leukocytes to gather at
the inflamed site
Pyrogens stimulate the hypothalamus to raise
body temperature
Redness and tenderness increased
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Phlebitis Signs and Symptoms
Redness at the site Site warm to touch Local swelling Palpable cord along the vein Sluggish infusion rate Increase in basal temperature of 1degree C or more
Prevention Use larger veins for hypertonic solutions Central lines for Infusions lasting longer than 5 days
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Thrombophlebitis
Thrombophlebitis denotes a two fold injury:
thrombosis and inflammation
Related to: Use of veins in the lower extremity
Use of hypertonic or highly acidic infusion solutions
Causes similar to those leading to phlebitis
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Thrombophlebitis
Signs and Symptoms Sluggish flow rate Edema in the limbs Tender and cord like vein Site warm to the touch Visible red line above venipuncture site Diminished arterial pulses Mottling and cyanosis of the extremities
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Thrombophlebitis
Prevention Use veins in the forearm rather than the hands Do not use veins in a joint Assess site q 4 hr in adults, q 2 hr in children Catheter securing Infuse at rate prescribed Use the smallest size catheter to do the job Proper dilution
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Thrombophlebitis
Prevention
Septic thrombophlebits can be prevented:
Appropriate skin preparation
Aseptic technique in the maintenance of catheter and
infusion
Keep using sterile IV set
Proper hand hygiene
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Infiltration
Related to: Puncture of the distal vein wall during insertion Puncture of the vein wall by mechanical friction Dislodgement of the catheter from the intimae of
the vein Poor securing High delivery rate Over manipulation
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Infiltration
Signs and Symptoms Coolness of the skin around site Taut skin/tense skin Dependent edema Absence of blood return “Pinkish” blood return Infusion rate slows /stoppage
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Cellulitis Treatment
Use of topical antibiotics May need systemic antibiotics Document and report Use proper foments as physician order
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Extravasation
Accidental administration of a vesicant solution into surrounding tissue
leakage of high osmolarity solutions or chemotherapy agents into the surrounding tissue, because the needle has punctured the vein and the infusion goes directly into the arm tissue.
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Extravasation
Vesicant is a fluid or medication that causes the
formation of blisters, with subsequent sloughing
of tissues occurring from the tissue necrosis
Extravasations related to: Puncture of the distal wall
Mechanical friction
Dislodgement of the catheterDr.Shaimaa Ebrahim
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Examples of Vesicants
High concentration KCL pH is 5 to 7.8 Calcium gluconate pH is 6.2 Amphotericin B pH is 5.7 to 8 Dopamine pH is 2.5 to 5 Nipride pH is 3.5 to 6 10%, 25% or 50% dextrose pH is 3.5 to 6.5 Sodium bicarbonate pH is 7 to 8.5 Dilantin pH is 12 (Drano has a pH of 14)
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Extravasations
Signs and Symptoms Complaints of pain or burning Swelling proximal or distal to the IV site Puffiness of the dependent part of the limb Skin tightness at the veinpuncture site Coolness of the skin Slow or stopped infusion Damp or wet dressing
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Extravasations Prevention:
Use of skilled practitioners Knowledge about the vesicants Condition of the patients veins Drug administration technique
If continuous give in CVD/CVL/CVCOnly with brisk blood return of 3-5 ccMust Use a pump on vesicants given
peripherallyAssess for blood return frequentlyClose nursing monitoring
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Venous spasm
A sudden involuntary contraction of a vein or resulting in temporary cessation of blood flow through a vessel.
Signs/symptoms: sharp pain at the IV site that travels up the arm, which is caused by a piercing stream of fluid that irritates or shocks the vein wall; slowing of the infusion
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Venous spasms cont
Documentation: patient complaints, duration of complaints, treatment, and length of time to resolve the problem
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Systemic Complication
Septicemia: febrile disease process that results
from the presence of microorganisms or their
toxic products in the circulatory system
S/S: fluctuating fever, tremors, chattering teeth,
profuse cold sweat, nausea and vomiting,
diarrhea, abdominal pain, tachycardia, increased
respirations or hyperventilation, altered mental
status, hypotension.
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Fluid overload & Pulmonary edema
Caused by infusing excessive amounts of isotonic or hypertonic crystalloid solutions rapidly, failure to monitor the IV infusion or too-rapid infusion of any fluid in a patient compromised by cardiopulmonary or renal disease.
S/S: restlessness, headache, increased in pulse
rate, cough, , shortness of breath, hypertension,
wide variance between intake and output, distended
neck veins, weight gain over a short period of time,
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Air embolism
Air entering the central/peripheral vein, which is
quickly trapped in the blood as it flows forward.
S/S: complaints of palpitations, weakness, pulmonary
findings: dyspnea, cyanosis, tachypnea, wheezes,
cough, and pulmonary edema. Cardiovascular: “mill
wheel” murmur; weak thready pulse; tachycardia;
sub-sternal chest pain; hypotension; and jugular
venous distention.
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Air embolism
Neurologic findings: change in mental
status, confusion, coma, anxiousness,
and seizures.
Prevention is the key.
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Speed shock
Occurs when a foreign substance usually a
medication is rapidly introduced into the
circulation
S/S: dizziness, facial flushing, headache,
tightness in the chest, hypotension, irregular
pulse, progression of shock.
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Cannulation
References Clinical Skills Education Centre
http://www.qub.ac.uk/cskills/index.htm
Standards for Infusion Therapy RCN http://www.rcn.org.uk/publications/pdf/standardsinfusiontherapy.pdf
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