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Knezich IV therapy power point
1. IV Therapy –
tricks, tips and
best practices
By: Cynthia M. Knezich, RN, BSN
Educational Assessment
Madelyn Ball, Instructor, EDU 544-5042
October 10, 2017
2. IV Therapy
• The intravenous route is the fastest way to
deliver medications, fluid replacement and
blood product throughout the body. It is
considered the fastest route because the
circulatory system carries the product.
3. Medical indications for IV
• Fluid and electrolyte balance
• Medications
• Bolus injection
• Blood/blood products
• Anesthesia
• Nutrition/CPN/TPN
• Testing/Diagnostic reagents
4. Warm Up Scenario
Your best friend, Kira McBride, just finished running a 5K for
breast cancer at Patterson Park (weather has been 90 degrees
and hot). She feels light headed, thirsty, nauseated and has
muscle cramps. She is confused, has blurred vision and a
headache. You take her to Johns Hopkins Emergency room
where they find her blood pressure low and her heart rate to be
110 bpm. The ER nurse starts a 20 gauge IV in her right hand.
They infuse her with two liters Normal Saline and give her IV
Zofran for nausea. She is discharged home and feels much
better.
What is your assessment? Dehydration
6. Tips for best results
• Always use two patient identifiers.
• Obtain a doctor’s order for IV insertion.
• Wash hands prior to and after procedure.
• Wear protective gear (gloves, gowns, goggles).
Dispose of sharps in needle box.
• Scrub site with alcohol and Chloraprep.
• Two IV attempts are the maximum with a live
patient, always ask for assistance.
7. Pre-assessment considerations
Patient’s condition and medical history should
always be considered. These sites should be
avoided:
mastectomy sites, fistula or surgical sites,
tattoos, stroke side, or any limb with paralysis.
8. Best IV Site Selections
Photo credit: http://keepcalmparamedic.blogspot.com/2013/07/cannulation-reflective.html
9. Scrub the site for 30 seconds
Allow site to air dry
Never blow or fan site dry, as this can introduce
micro-bacteria to site.
The tourniquet allows veins to fill with blood
making it easier to access the vein.
11. INFILTRATION SIGNS AND SYMPTOMS
• Inflammation at or near the insertion site
• Swollen taut skin with pain is notable.
• Blanching and coolness of skin is present
around site.
• IV dressing is damp or wet.
• IV infusion is slowed or stopped.
• There is no blood return from iv catheter.
12. IV insertion checklist
Item Check List Item description Rationale Observed
Skill
Needs Practice
1 Verify Doctor’s order Always obtain order
2 Washes Hands Before and After Hand Hygiene
3 Identify Patient Right Patient
4 Explain purpose Care giver role
5 Don Gloves Personal Protective gear
6 Apply tourniquet Helps to visualize vein
7 Assess arm for best vein Always assess
8 Prepare equipment Be prepared, ready to start
9 Select Catheter Size matters
10 Cleanse Site Aseptic Technique
11 Tourniquet on before insertion Right before procedure
12 Vein traction Secure the vein
Prevents rolling
13 Warn Patient Communication
14 Insert correctly 1-2 attempts only
15 Observe flash of blood You are in vein
16 Lower catheter Advance into vein
17 Advance needle To make sure you are in the
vein
18 Release tourniquet Be nice to your patient
19 Compress site to prevent blood flow Stop the blood flow
20 Remove needle Pull back on the needle for
safety
21 Attach extension set Access for medication
connection
22 Disinfect connector Sterile technique
23 Assess patency Check to make sure you are
in the vessel
24 Dispose of sharp Safety
25 Dress and secure site Dressing / securement
26 Label Date/time/initials
27 Assess site Infiltration/pain?
28 Document Record size, time, date
ficiency Name: 5/27/2017
14. Accurate IV documentation
includes:
• Date and time IV is placed.
• Anatomical location (ie: forearm, hand).
• Gauge, brand name or type, and length of
catheter.
• Drug or solution the patient will receive and
the rate of flow.
• The patient’s response to the IV insertion.
• Your signature.
15. Nurses Note Example
4/19/2017 16:20 Placed 20 g 1”IV in patient’s
right hand on first attempt. Normal Saline
infusing at 150 ml/hr. with Alaris infusion pump.
No signs or symptoms of adverse effect and
patient states “that wasn’t bad at all.” Good
blood return achieved. Monitored.
C. Knezich, RN, BSN.
16. References
Alexandrou, E., Ramjan, L., Murphy, J., Hunt, L., Betihavas, V., & Frost, S. (2012). Training of
undergraduate clinicians in vascular access: an integrative review. Journal of the Association
for Vascular Access, 17, 146-160.
Major Differences (Producer). (2013). Available from
http://www.majordifferences.com/2013/02/difference-between-artery-and-
vein.html#.WVJQ0oWcGbg
My Learning (2017), Johns Hopkins Hospital. Available from http://www.myjhu.edu
Ohio University School of Nursing (Producer). (2013). Ohio University School of Nursing
Skills/IV Start [Video]. Available from https://www.youtube.com/watch?v=M2N7KjC4GbM(1)
Peripheral Veins [Picture of peripheral veins, hands, forearm]. (2013). Retrieved June 27, 2017,
from http://keepcalmparamedic.blogspot.com/2013/07/cannulation-reflective.html
Schuster, C., Stahl, B., Murray, C., Keleekai, N., & Glover, K. (2016). Development and testing of
a short peripheral intravenous catheter insertion skills checklist. Journal of the Association for
Vascular Access, 21:4, 196-204.
Notes de l'éditeur
Intravenous therapy has changed over the years. The skill of placing an intravenous catheter was once thought to be for the emergency nurse or intensive care nurse, but this is no longer the case. Today’s nurses are actively involved in steps to critically think through and actively manage the vascular access site. This presentation is to assist you with IV placement and to become familiar with critical thinking and steps to manage the intravenous site. Students will have an opportunity to place an IV using simulation t the end of class and to evaluate each other. Can I assist you in learning more about developing this skill? Teacher then pairs two or three people up to work in groups gives out tourniquets and IV check list proficiency.
Photograph taken of Tracy Green, RN, coworker at Johns Hopkins Hospital.
First, lets cover the benefits of intravenous therapy. Can anyone suggest the various ways we administer therapies with intravenous access? Intravenous therapy is one of the fastest and most effective way to administer therapies. This list documents the various ways in which IV therapy can benefit the patient.
To help you become familiar with the IV insertion, here is a list of supplies to insert an IV. Before we get started, I would like you to turn to your assigned partner and identify an area on his or her arm where you would potentially insert an IV. You may use a tourniquet, which was handed out in class. Some IV therapists can see the veins and some insert the IV by feel. Identify a vein on your assigned partner’s arm where you would potentially place an IV. Does it feel spongy or are you able to visualize the vein? Take a look at the hand out (see slide eleven). The hand out lists the appropriate steps to take when placing an IV. Feel free to help each other to identify the equipment listed here in your IV insertion kit. Can you explain to each other the purpose of each item in the IV kit?
Gloves are used for personal protection; tourniquet is used to plump up veins; J-loop is filled with normal saline (flush) and is used to flush the IV with saline. It is connected to the IV hub, then taped and tegaderm (dressing) is placed over top. Gauze is used to absorb any bleeding and the chloraprep is used to decontaminate the skin. The various needle is used to cannulate the vein.
Photograph taken by Cindy Knezich.
Always identify your patient and obtain an physician’s order when placing the IV. Can anyone tell me two ways to identify patients? Make sure there is a doctor’s order to place an IV and the person placing the IV should only attempt two sticks. Any more than two attempts and another nurse or IV therapist should start the IV. Precautions should always be used when performing venipuncture or obtaining labs. In general, procedure gloves are adequate protection but you may need additional protective barriers depending on the likelihood of splashing of bodily fluids from insertion. Protection is always a good idea during any procedure. Wash your hands with the bacteriostatic soap prior to each IV insertion. Discard and remove protective gloves and wash your hands again after procedure has ended.
How many sticks can you attempt on a patient? Answer: two Call another IV expert to help you obtain access.
Some patients are unable to use both arms for the IV site. Always ask the patient if both arms are ok for an intravenous needle. When a patient has had a mastectomy or fistula, the arm is compromised and should not be used for IV placement. Always ask the patient if there is any hardware in place in the arm you are assessing for an IV. If the patient has had a stroke, it is best to place an IV in the opposite arm of the stroke side. The blood flow has been compromised on that side, so we do not place an IV unless there is a doctor’s order to specifically do this.
Can everyone see the anatomy of their veins exactly like this picture here? (maybe funny). See if you can locate some of these veins either on yourself or the person sitting next to you. Can anyone identify (show and tell) the landmarks on their own anatomy?
The most commonly used sites for children and adults are the dorsal venous network, dorsal metacarpal and basilica veins – these are located on the back of the hand. Cephalic vein is at the wrist and may cause discomfort with wrist motion and irritation to the tunica intima from the cannula movement. Areas of flexion should be avoided as the IV can become dislodged and cause discomfort. Cephalic vein is in the inner arm and it is usually smaller than the basilica. The basilic vein is the largest vein and runs along the inner arm. The median cubital vein runs from the antecubital area to the lower inner arm and joins with the basilic vein. The median vein of the forearm is in the inner most area of the forearm, it joins with the basilica vein.
Photo credit: http://keepcalmparamedic.blogspot.com/2013/07/cannulation-reflective.html
Before placing a needle into the skin, it is very important to scrub the insertion site for 30 seconds. Chloraprep is a broad spectrum antiseptic that significantly reduces microorganisms on the skin which cause infection. When you insert a needle through the skin you can insert microorganisms which can cause infection. It is very important to scrub the area and let it dry. Do not contaminate the area by touching it with your hands or you will need to scrub the site again.
Information Credits: According to Johns Hopkins My Learning, IV Review 2017
The size and gauge of the needle matter and can influence how rapid you infuse fluids, blood, etc. This chart is a quick reference for choosing needle size and various uses for each size needle and various flow rates.
Can anyone tell me about needle sizes and identify reasons for different sizes used? Needle sizes get smaller as the gauge gets bigger, so if you have a 16 gauge needle, this would be very large. For example a 26 gauge (violet) iv can be used when inserting in pediatric patients it is very small. . A very large 16 gauge needle can be used for dialysis or is necessary in a rapid response situation.
According to Schuster et al (2016), this list of IV insertion steps will assist you when working in pairs on the simulation arm. After practicing, check your fellow student off on her technique on inserting an IV. IV needles are for use on the simulator only, please discard them in the sharps container provided. This is your hand out, please complete and turn this in at the end of class. I will be going around the room to assist with insertion technique. Please become familiar with the equipment.
Schuster, C., Stahl, B., Murray, C., Keleekai, N., & Glover, K. (2016). Development and testing of a short peripheral intravenous catheter insertion skills checklist. Journal of the Association for Vascular Access, 21:4, 196-204.
In class, practice with a partner and check each other off on the steps listed with the help of the handout to guide you. The instructor will assess your practice and check you off.
