2. Five Mandatory “rights” forFive Mandatory “rights” for
Administration of MedicationAdministration of Medication
• Right PatientRight Patient
• Right DrugRight Drug
• Right DoseRight Dose
• Right RouteRight Route
• Right TimeRight Time
3. Other checks that should be made:Other checks that should be made:
• Right diluentRight diluent
• Right infusion rateRight infusion rate
• When and what drug last givenWhen and what drug last given
• Any allergies?Any allergies?
4. Basic Principles of IV therapyBasic Principles of IV therapy
• Maintain line patencyMaintain line patency
• Protect integrity of catheterProtect integrity of catheter
• Protect from infectionProtect from infection
• Protect from air emboliProtect from air emboli
5. Equipment and how to use itEquipment and how to use it
• Select IV tubing carefully to reflect the healthSelect IV tubing carefully to reflect the health
status of the patient.status of the patient.
– A Crystalloid giving set ( basic IV giving set) is similarA Crystalloid giving set ( basic IV giving set) is similar
to a blood giving set but does not contain a filter-to a blood giving set but does not contain a filter-
therefore should never be used to infuse blood ortherefore should never be used to infuse blood or
blood products.blood products.
– This type of system is used for fluid maintenance orThis type of system is used for fluid maintenance or
fluid replacementfluid replacement
– Drop rates should be calculated accurately and flowDrop rates should be calculated accurately and flow
rates checked regularlyrates checked regularly
7. Blood setBlood set
• This contains a 170-200 micron filter net toThis contains a 170-200 micron filter net to
remove debris from blood componentsremove debris from blood components
• Debris is derived from WBC’s and plateletsDebris is derived from WBC’s and platelets
which are no longer functional and also fromwhich are no longer functional and also from
cold insoluble protein and occasionally smallcold insoluble protein and occasionally small
clotsclots
• For optimum infusion the entire filter must beFor optimum infusion the entire filter must be
covered with bloodcovered with blood
• Delivers fluid at a standard rate of 20 drops perDelivers fluid at a standard rate of 20 drops per
mlml
9. Burette systemsBurette systems
• MetrisetsMetrisets
• VolutrolsVolutrols
Deliver 60 drops per mlDeliver 60 drops per ml
Allows closer monitoring of fluidAllows closer monitoring of fluid
and electrolytesand electrolytes
10. Anatomy and Physiology of VeinsAnatomy and Physiology of Veins
• Veins are composed of 3 layersVeins are composed of 3 layers
• Tunica Intima (inner layer) composed ogfTunica Intima (inner layer) composed ogf
endothelial lining which forms the valvesin veins.endothelial lining which forms the valvesin veins.
The smooth tissue assists blood flowThe smooth tissue assists blood flow
• Tunica Media (middle Layer) composed ofTunica Media (middle Layer) composed of
muscular and elastic tissue and contains nervemuscular and elastic tissue and contains nerve
fibres which allow constriction and dilation tofibres which allow constriction and dilation to
occuroccur
• Tunica adventitia(outer layer) composed ofTunica adventitia(outer layer) composed of
connective tissue which surrounds and supportsconnective tissue which surrounds and supports
the veinthe vein
11.
12. Intravenous Therapy has threeIntravenous Therapy has three
main objectivesmain objectives
• To maintain daily body fluid requirementsTo maintain daily body fluid requirements
• To restore previous body fluid lossesTo restore previous body fluid losses
• To replace present body fluid lossesTo replace present body fluid losses
13. Fluid and Electrolyte TherapyFluid and Electrolyte Therapy
• Types of fluidTypes of fluid
• IsotonicIsotonic
• HypotonicHypotonic
• HypertonicHypertonic
15. Important factors in administrationImportant factors in administration
of all IV medicationsof all IV medications
• Environment: ensure as much as possible thatEnvironment: ensure as much as possible that
you are comfortable and feel confident aboutyou are comfortable and feel confident about
procedure and drug.procedure and drug.
• Patient: positive ID of patient, allergies, healthPatient: positive ID of patient, allergies, health
status, therapeutic compatibilities, side effects,status, therapeutic compatibilities, side effects,
effectiveness of medication.effectiveness of medication.
• Injection: cannula and line patency, asepsis,Injection: cannula and line patency, asepsis,
documentationdocumentation
• Equipment: correct disposal of needles andEquipment: correct disposal of needles and
syringes, and medications.syringes, and medications.
16. Potential problems of IVPotential problems of IV
administrationadministration
• IncompatibilityIncompatibility
• Speed shockSpeed shock
• Vascular irritationVascular irritation
• Incomplete /inadequate mixing of drugIncomplete /inadequate mixing of drug
with fluidwith fluid
• Inability to remove drug once administeredInability to remove drug once administered
into blood streaminto blood stream
17. Guideline to avoid incompatibilitiesGuideline to avoid incompatibilities
• Do not add drugs to complex solutionsDo not add drugs to complex solutions
such as blood, lipids, amino acids, orsuch as blood, lipids, amino acids, or
parental nutrition solutions.parental nutrition solutions.
• The more simple the solution , the lessThe more simple the solution , the less
likelihood of incompatibility.likelihood of incompatibility.
• Follow the manufacturers instructions andFollow the manufacturers instructions and
New Ethicals compendium re:New Ethicals compendium re:
compatibility and stability.compatibility and stability.
18. Vascular traumaVascular trauma
• The inflammatory process that results byThe inflammatory process that results by
administration of drugs causes aadministration of drugs causes a
roughening of the endothelial cellsroughening of the endothelial cells
allowing platelets to adhere and aallowing platelets to adhere and a
thrombus to form. This causesthrombus to form. This causes
Thrombophlebitis. If aseptic technique isThrombophlebitis. If aseptic technique is
poor, septic thrombosis may occur.poor, septic thrombosis may occur.
19. Other ComplicationsOther Complications
• Air Embolism- rare in IV fluidAir Embolism- rare in IV fluid
administration unless line not primedadministration unless line not primed
adequatelyadequately
• Catheter Embolism- may occur when partCatheter Embolism- may occur when part
of the plastic cannula is sheared off by theof the plastic cannula is sheared off by the
introducer needle- do not reintroduce theintroducer needle- do not reintroduce the
needle once it has been fully or partiallyneedle once it has been fully or partially
removedremoved
20. PhlebitisPhlebitis
Symptoms:Symptoms:
• Redness, swelling,pain and heat around cannula siteRedness, swelling,pain and heat around cannula site
• Tender and painful to touchTender and painful to touch
• Reduced flow of infusion- or has stopped altogetherReduced flow of infusion- or has stopped altogether
Interventions: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
21. Infiltration/extravasation intoInfiltration/extravasation into
surrounding tissuesurrounding tissue
• Causes tissue necrosis and pain.Causes tissue necrosis and pain.
Symptoms:Symptoms:
• Pain, Tightness, reduced IV rate, ”halo”of fluid inPain, Tightness, reduced IV rate, ”halo”of fluid in
tissuetissue
Interventions:Interventions:
Stop infusion, disconnect tubing and aspirate fromStop infusion, disconnect tubing and aspirate from
hub with 5ml syringe aseptically… ifhub with 5ml syringe aseptically… if
unsuccessful - remove cannula and mark site ofunsuccessful - remove cannula and mark site of
oedemaoedema
22. Clotted cannulaClotted cannula
Signs:Signs:
• Blood has backed up the tubingBlood has backed up the tubing
• Stop in FlowStop in Flow
Interventions:Interventions:
• Aspirate at hub using 10ml syringeAspirate at hub using 10ml syringe
• If no return, gently attempt to irrigate withIf no return, gently attempt to irrigate with
0.9%NaCl using a large bore syringe- this exerts0.9%NaCl using a large bore syringe- this exerts
less pressure than a smaller syringe.less pressure than a smaller syringe.
• If resistance felt, do not proceed… resiteIf resistance felt, do not proceed… resite
cannula.cannula.
23. 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, dyspnoea,Increased HR, BP, RR, Distended neck veins, dyspnoea,
gurgling/wheezing, Moist cough and generalisedgurgling/wheezing, Moist cough and generalised
discomfortdiscomfort
Interventions: Slow rate TKVOInterventions: Slow rate TKVO
Place person in semi-fowler postion( elevated head)Place person in semi-fowler postion( elevated head)
Notify Med staffNotify Med staff
Administer O2Administer O2
Monitor patient closely and watch for OedemaMonitor patient closely and watch for Oedema
24. Speed ShockSpeed Shock
• A systemic reaction that occurs when aA systemic reaction that occurs when a
foreign body is rapidly introduced into theforeign body is rapidly introduced into the
bloodstream.bloodstream.
• Symptoms: severe headache, chest pain,Symptoms: severe headache, chest pain,
irregular pulse, decreased BP, loss ofirregular pulse, decreased BP, loss of
consciousness, shock cardiac arrestconsciousness, shock cardiac arrest
• Interventions: stay with patient, stopInterventions: stay with patient, stop
infusion, ABC, notify medical staff.infusion, ABC, notify medical staff.
25. VenepunctureVenepuncture
• Aim: To obtain a blood sample forAim: To obtain a blood sample for
laboratory testing which will accuratelylaboratory testing which will accurately
reflect the in vivo levels of a givenreflect the in vivo levels of a given
substancesubstance
26. Veins in antecubital regionVeins in antecubital region
• CephalicCephalic
• BasilicBasilic
• AccessoryAccessory
• MedianMedian
27. Recommended sequence for bloodRecommended sequence for blood
drawdraw
• Blood cultureBlood culture
• Red top/gold topRed top/gold top
• Light blueLight blue
• Green topGreen top
• LavendarLavendar
• GreyGrey
28. Selection of vein siteSelection of vein site
• Fuller veins preferred: median cubital orFuller veins preferred: median cubital or
cephaliccephalic
• Palpate vein with index finger to ascertainPalpate vein with index finger to ascertain
suitabilitysuitability
29. 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 10-20With needle bevel facing upwards, penetrate skin at angle 10-20
degrees, insert tube into holder, push stopper over needledegrees, insert tube into holder, push stopper over needle
• When blood flows ask patient to relax hand and release tourniquetWhen blood flows ask patient to relax hand and release tourniquet
slowlyslowly
• Mix tubes with additives gentlyMix 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
30. Paediatric VenepuncturePaediatric Venepuncture
• Have a parent hold child on kneeHave a parent hold child on knee
• Dorsal hand veins are preferred site inDorsal hand veins are preferred site in
neonates and children under 2yearsneonates and children under 2years
• Use EMLA patches or creamUse EMLA patches or cream
• 23g butterfly needle recommended and23g butterfly needle recommended and
paediatric blood tubespaediatric blood tubes
32. Choosing Cannula sizeChoosing Cannula size
• Diameter isDiameter is
expressed in terms ofexpressed in terms of
gaugegauge
– The higher gaugeThe higher gauge
numbers are narrowernumbers are narrower
– The shortest andThe shortest and
smallest cannula thatsmallest cannula that
will deliver the requiredwill deliver the required
fluid volume orfluid volume or
medication should bemedication should be
chosenchosen
33. 22g22g IV fluids andIV fluids and
intermittent pushintermittent push
injectionsinjections inin
children andchildren and
elderlyelderly
20g20g Drug bolus andDrug bolus and
fat solutionsfat solutions
18-20g18-20g IV fluids and AB’sIV fluids and AB’s
in adultsin adults
14-16g14-16g All adults havingAll adults having
surgerysurgery
34. Cannulation sitesCannulation sites
• Start distally andStart distally and
move proximallymove proximally
• Use non dominantUse non dominant
handhand
• Ensure vein largerEnsure vein larger
than venflonthan venflon
• Avoid sites aroundAvoid sites around
jointsjoints
36. Procedure continued…Procedure continued…
• Prepare equipmentPrepare equipment
• Apply tourniquetApply tourniquet
• Identify veinIdentify vein
• Cleanse site using persist swab or betadineCleanse site using persist swab or betadine
swabswab
• Don glovesDon gloves
• Place thumb 5cm below entry point of veinPlace thumb 5cm below entry point of vein
and pull down anchoring veinand pull down anchoring vein
• Maintain traction on skin whilst inserting theMaintain traction on skin whilst inserting the
cannulacannula
• Insert at a 20-30degree angle with bevelInsert at a 20-30degree angle with bevel
uppermostuppermost
• Flashback of blood into the cannula willFlashback of blood into the cannula will
occur when vein penetratedoccur when vein penetrated
• Advance cannula a further 5mm .( the styletAdvance cannula a further 5mm .( the stylet
is 1-2mm longer than the tip and both needis 1-2mm longer than the tip and both need
to be in the vein to allow the cannula to beto be in the vein to allow the cannula to be
advanced smoothly.advanced smoothly.
• Firmly hold the flash chamber, immobilisingFirmly hold the flash chamber, immobilising
the needle and advance the catheterthe needle and advance the catheter
forward off the stylet into the vein until theforward off the stylet into the vein until the
hub is at the skin.hub is at the skin.
• Release tourniquetRelease tourniquet
• Secure hub with tapeSecure hub with tape
• Withdraw stylet and attach needleless portWithdraw stylet and attach needleless port
to hubto hub
• Flush with 10 mls NaclFlush with 10 mls Nacl
38. Long term Venous Access devicesLong term Venous Access devices
This is Intermediate Level 4 IV certificationThis is Intermediate Level 4 IV certification
and requires specific training which mayand requires specific training which may
be undertaken at Dunstan Hospitalbe undertaken at Dunstan Hospital
• PICC’sPICC’s
• PortsPorts
• Hickman CathetersHickman Catheters
40. PICCPICC
• Peripherally Inserted Central CatheterPeripherally Inserted Central Catheter
• PICC lines are suitable for:PICC lines are suitable for:
– patients who require intermediate termpatients who require intermediate term
venous access ( 5 days-5 months)venous access ( 5 days-5 months)
– Patients who have adequate and accessiblePatients who have adequate and accessible
antecubital veinsantecubital veins
41. IndicationsIndications
• Lack of peripheral accessLack of peripheral access
• Hyperosmolar infusionsHyperosmolar infusions
• Vesicant therapy: chemo or antibioticVesicant therapy: chemo or antibiotic
therapytherapy
42. Catheter InsertionCatheter Insertion
• Catheter is inserted into the basilic veinCatheter is inserted into the basilic vein
above the elbow at the bedside or withinabove the elbow at the bedside or within
the Radiology Dept and guided bythe Radiology Dept and guided by
flouroscopy.flouroscopy.
• The tip of the catheter sits within theThe tip of the catheter sits within the
Superior Vena Cava and must be verifiedSuperior Vena Cava and must be verified
by CXRby CXR
43. Weekly Catheter ManagementWeekly Catheter Management
by District Nursesby District Nurses
• Dressing to PICC siteDressing to PICC site
• Flush using ASASH techniqueFlush using ASASH technique
• Measurement of external length to ensureMeasurement of external length to ensure
catheter tip has not migrated out of SVCcatheter tip has not migrated out of SVC
• Assessment for evidence of any change,Assessment for evidence of any change,
ooze, pain, oedemaooze, pain, oedema
45. Implanted Port StructureImplanted Port Structure
• The port isThe port is
constructed ofconstructed of
a resealable rubbera resealable rubber
septumseptum
a chamber made froma chamber made from
moulded plasticmoulded plastic
a catheter whicha catheter which
connects to the baseconnects to the base
of the chamberof the chamber
46. InsertionInsertion
• The catheter is inserted into the subclavian,The catheter is inserted into the subclavian,
jugular or cephalic vein and worked through tojugular or cephalic vein and worked through to
the lower third of the SVC. The tip must liethe lower third of the SVC. The tip must lie
above the right atriumabove the right atrium
• The catheter is then tunnelled beneath the skinThe catheter is then tunnelled beneath the skin
to a subcutaneous pocket created on the upperto a subcutaneous pocket created on the upper
chest wall.chest wall.
• The chamber is placed on a bony prominence toThe chamber is placed on a bony prominence to
provide stability during useprovide stability during use
47. Port AccessPort Access
• Only Huber point needles must be used toOnly Huber point needles must be used to
access an implanted portaccess an implanted port
• These have a deflected point and sideThese have a deflected point and side
opening to prevent coring of the septum.opening to prevent coring of the septum.
• This preserves the port for long term useThis preserves the port for long term use
• On removal of the needle the septumOn removal of the needle the septum
reseals itselfreseals itself
48. Huber needlesHuber needles
• When the needle is inserted the siliconeWhen the needle is inserted the silicone
septum is traversed until the needle stopseptum is traversed until the needle stop
is felt. Blood return indicates correctis felt. Blood return indicates correct
needle engagement.needle engagement.
49. 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
50. That’s all folks !That’s all folks !
• Take a look at the PICC and Port modelsTake a look at the PICC and Port models
• And if interested in extending your scopeAnd if interested in extending your scope
of practice you could train up to beof practice you could train up to be
certificated to this level.certificated to this level.
Kind regards and thanks for listening!Kind regards and thanks for listening!
Carolyn DobsonCarolyn Dobson
