Chapter 6 Venous Access. Chapter Goal Understand basic principles of venous access & IV therapy, as well as relate importance of employing appropriate.
Post on 01-Apr-2015
215 Views
Preview:
Transcript
Chapter 6
Venous Access
Chapter Goal
Understand basic principles of venous access & IV therapy, as well as relate importance of employing appropriate BSI precautions when employing these precautions
Learning Objectives
Describe indications, equipment needed, techniques used, precautions, & general principles of: Peripheral venous cannulation Obtaining blood sample External jugular cannulation Disposal of contaminated items & “sharps”
Introduction
Intravenous (IV) cannulation Placement of catheter into vein Used to administer:
• Blood• Fluids• Medications
Used to obtain blood samples Medical direction or standing orders typically
required
Introduction
Indications: Cardiac disease Hypoglycemia Seizures Shock
• Hypovolemic shock—to counter blood loss • Medical emergencies—to establish route for medication
administration • Administer drugs in prehospital setting• Precautionary measure
Introduction
Precautions: Bleeding Infiltration Infection
Contraindications: Sclerotic veins Burned extremities Do not delay transport to start IV
Introduction
Body substance isolation precautions Substances potentially infected with
• Hepatitis B virus (HBV)• Human immunodeficiency virus (HIV)
Wash hands:• Before & after• Immediately on contact
Wear gloves, gown, mask, eye protection HBV vaccine
Introduction
Needle stick injuries 600,000 to 800,000 per year
• Hepatitis C & AIDS Devices to help reduce risk
• Needleless systems—no needle • Needle safety systems—built-in physical attribute
Passive & active devices• Active device requires activation• Passive device does not
Introduction
Rules for avoiding injuries: Use alternatives Assist in selecting & evaluating devices Use safety devices provided Proper handling, disposal, use of barriers Avoid recapping, bending, breaking, recapping needles Avoid separating from syringe, manipulating by hand Safe handling & disposal Dispose of used needles promptly Report injuries Tell employer about hazards Attend training
Introduction
IV supplies & equipment IV solution Administration set Extension set Needles, catheters Gloves, gown, goggles Tourniquet Tape, dressing Antibiotic swabs, ointment Gauze dressings Syringes Vacutainer Blood tubes Armboards
Introduction
IV Solutions Solutions & osmotic pressure
• Described by tonicity • Isotonic solution• Hypotonic solution• Hypertonic solution
Crystalloids • Normal saline • Lactated Ringer’s
Introduction
Crystalloids Dissolved ions cross cell
membrane Sodium chloride 0.9%
solution/lactated Ringer’s solution
5% dextrose in water (D5W)
Copyright line.
Intravenous Solutions
Intravenous solutions come in four different types. Crystalloids Colloids Blood Oxygen carrying fluids
Intravenous Solutions
Crystalloid solutions move quickly across cell membranes. Colloid solutions do not, and therefore remain in the intravascular space for longer periods.
Intravenous Solutions
Solutions and osmotic pressure Isotonic solution: a solution that has an osmotic
pressure equal to the osmotic pressure of normal body fluid
Hypotonic solution: a solution that has an osmotic pressure less than that of normal body fluid
Hypertonic solution: a solution that has an osmotic pressure greater than that of normal body fluid
Copyright line.
Intravenous Solutions—Solutions and Osmotic Pressure Crystalloids
Dissolving crystals such as salts and sugars in water creates crystalloid solutions.
They contain no proteins or other high-molecular-weight solutes.
When introduced into the circulatory system, the dissolved ions cross the cell membrane quickly, followed by the IV solution water. • Crystalloid solutions remain in the intravascular
space for only a short time before diffusing across the capillary walls into the tissues.
• It is necessary to administer 3 L of IV crystalloid solution for every 1 L of blood lost (3:1 ratio) when treating patients who have experienced hypovolemic shock.
Intravenous Solutions—Solutions and Osmotic Pressure
Crystalloids Normal saline and lactated Ringer's solution are
examples of crystalloids One L of lactated Ringer's solution contains:
• 130 mEq of sodium (Na+)• 4 mEq of potassium (K+) • 3 mEq of calcium (Ca2+) • 109 mEq of chloride ions (Cl–) • 28 mEq of lactate
Intravenous Solutions—Solutions and Osmotic Pressure
Crystalloids One L of normal saline contains:
• 154 mEq of sodium ions (Na+) • 154 mEq of chloride ions (Cl–)
Copyright line.
Intravenous Solutions—Solutions and Osmotic Pressure
5% dextrose in water (D5W)
It is a glucose solution that is isotonic in the
container but hypotonic after it enters the
circulatory system.
In the past, D5W was a mainstay in the
management of medical emergencies.
The AHA Advanced Cardiac Life Support
Guidelines for cardiac arrest no longer list D5W as
the preferred solution.
Patients who survive are reported to have poor
neurological outcomes when they have increased
glucose levels.
Intravenous Solutions—Solutions and Osmotic Pressure
Numerous other crystalloid solutions are also available. Hypertonic solutions
• 5% dextrose in 0.9% saline • 5% dextrose in 0.45% saline (half-normal saline)• 5% dextrose in lactated Ringer's solution• 3% sodium chloride• 7.5% sodium chloride• 10% dextrose in water
Intravenous Solutions—Solutions and Osmotic Pressure
Hypotonic solutions 0.45% saline (half-normal saline) 0.33% sodium chloride 2.5% dextrose in water
Intravenous Solutions—Solutions and Osmotic Pressure
Colloids Colloids contain large molecules such as protein
that do not readily pass through the capillary membrane. They remain in the intravascular space for extended periods.
The presence of the large molecules in colloids results in an osmotic pressure that is greater than the osmotic pressure of interstitial and intracellular fluids.
This difference in pressure pulls fluid from the interstitial and intracellular spaces into the intravascular space.
Colloids are often referred to as volume expanders.
Intravenous Solutions—Solutions and Osmotic Pressure
Colloids Because colloids are expensive, have short half-
lives, and often require refrigeration, they are not commonly used in the prehospital setting
Common colloids include:• Blood derivatives
Plasma protein fraction (plasmanate) Salt poor albumin
• Artificial colloids Dextran Hetastarch (Hespan)
Copyright line.
IV Solution Containers IV bags Solutions used in the prehospital
setting are typically contained in a
clear plastic or vinyl bag that
collapses as it empties. The size of the IV bag varies
depending on its use. Smaller bags (100 to 250 mL) are
used in the management of medical
emergencies and drug
administration. Larger bags (1000 mL) are used in
the management of trauma
emergencies or when the patient has
experienced volume loss.
Introduction
Sodium Chloride 0.9% solution & Lactated Ringer’s solution Recommended IV use in prehospital setting Used to:
• Expand intravascular volume • Replace extracellular fluid losses • Administer with blood productsonly solution
5% dextrose in water (D5W) Was mainstay in management of medical emergencies
• In cardiac arrestno longer considered preferred • Slightly aciditic • Local EMS protocols will dictate
Copyright © 2007, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fluid Contents
Sodium Chloride 0.9% Solution Sodium and Chloride
Lactated Ringer’s Solution Lactate, Potassium, Sodium, Chloride, Calcium
5% dextrose in water (D5W) Dextrose and Water
Introduction
IV solution containers Size of bag varies
Introduction
IV solution containers 2 ports at bottom of bag Labeled with:
• Contents• Expiration date
Introduction
Administration set Clear plastic tubing Range from 60–110 inches
Introduction
Piercing spike
IntroductionMicrodrip Macrodrip
Introduction
Rates for administering IV fluids Medical emergencies—TKO rate (8-15 gtts/min.) Trauma—based on patient’s response
Introduction
Changing philosophy for hypovolemic shock —no clear rule Shock, external bleeding uncontrolled—only
enough to maintain BP Uncontrolled internal bleeding—surgical
intervention Regardless of flow rate—limited to 2–3 L
Introduction
Injection port
Introduction
Connector ends
Introduction
Blood tubing Some EMS systems use in patients with hypovolemia EMTs who work in critical care areas 2 types of blood tubing
• Y-tubing • Straight tubing
Introduction
Volume control Volutrol chamber
• For specific amount of fluid to be administered
• Pediatrics• Renal failure• Administer precise
medications
Equipment
Needle/Catheter
Equipment
Protected Needles Shielding/Retracting Self-blunting
IV Catheter Size Outside diameter is “gauge” Larger gauge number—
smaller diameter Large diameter—greater
fluid flow Color-coded system
Equipment
Choosing best size over-the-needle catheter Smaller-sized devices are better
• Except for volume replacement• Causes less injury• Allows greater blood flow
Large-bore catheters• Shock• Cardiac arrest• Viscous medications• Life-threatening emergencies—rapid fluid replacement• Minimum 18-gauge catheter—patients requiring blood
Catheter’s length—longer catheter = slower rate
Equipment
Other supplies & materials Latex, rubber or nonlatex gloves Tourniquet Alcohol preparations Sterile dressings Adhesive tape Commercial transparent dressings Armboards 10 or 35-mL syringe or Vacutainer Assorted blood collection tubes
Equipment
Intermittent infusion device Eliminates need for IV bag & administration Keeps access device sterile Self-sealing Constant venous access—not continuous infusion
Equipment
IV solution warming devices Temperature of IV fluids vary Infusion < normal body temperature Appliances designed to:
• Maintain IV fluid at normal body temperature • Prevent overheating
Hot sack
Peripheral Venous Cannulation
Veins have 3 layers—Tunica intima, Tunica media, Tunica adventitia
Peripheral Venous Cannulation
Skin has 2 layers Epidermis
• Outermost layer • Protective covering • Varies in thickness
Dermis • Highly vascular &
sensitive• Many capillaries • Thousands of nerve
fibers
Peripheral Venous Cannulation
Noncritical patients Distal veins on dorsum of
hands and arms In Indiana, a jugular vein
is considered to a peripheral vein
Peripheral Venous Cannulation
Noncritical patients Use vein with these
characteristics:• Fairly straight• Easily accessible• Well-fixed—not rolling• Feels springy
Peripheral Venous Cannulation
Sites to be avoided:
Sclerotic veins Veins near joints Areas where arterial pulse is palpable Veins near injured areas Veins near edematous extremities
Peripheral Venous Cannulation
Sites used in cardiac arrest: Peripheral veins of antecubital fossa
• Largest• Most visible• Most accessible
Distal veins are least desirable• Blood flow markedly diminished • Difficult or impossible to cannulate
Peripheral Venous Cannulation
Other sites External jugular vein Peripheral leg veins Intraosseous
Performing IV Cannulation
Insert spiked piercing end of administration set into tubing of IV bag
Squeeze drip chamber to fill halfway
Performing IV Cannulation
Place tourniquet 6 inches above venipuncture site
Make slip knot with tourniquet
Performing IV Cannulation
Complete band placement
Use povidone-iodine (use protocol) or alcohol wipe to cleanse site
Performing IV Cannulation
Pull skin taut; bevel of needle should be facing up
Penetrate vein either from top or side
Performing IV Cannulation
Watch for blood in flashback chamber
Advance needle until tip of catheter is sufficiently within vein
Slide catheter into vein until hub rests against skin
Performing IV Cannulation
Remove needle from vein & catheter
Properly dispose of used needle
Copyright © 2007, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Performing IV Cannulation
Draw sample of blood
Release tourniquet
Performing IV Cannulation
Open IV control valve; ensure IV fluid is flowing properly
Secure catheter & tubing with tape/commercial device
Performing IV Cannulation
After venipuncture is performed: Confirm needle placement Blood may not flow back If infiltration occurs
• Remove & discard catheter • Place dressing on venipuncture site • Attempt venipuncture at another site
Other methods of determining proper placement of catheter• Lower IV bag below IV site • Palpating vein above IV site• Palpating tip of catheter in vein• Aspirating blood with 10-mL syringe
Peripheral IV Access
Copyright © 2007, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Performing IV Cannulation
Using an armboard Can be avoided—choose site away from flexion areas May be necessary when:
• Venipuncture device inserted near joint • Venipuncture device inserted in dorsum of hand• Used along with restraints
Performing IV Cannulation
Regulating fluid flow rates Primary aspect Too fast or too slow—cause complications Adjust according to protocol Formula Flow rate established—check on ongoing basis
Procedures for Regulating Flow Rates
Regulating fluid flow rates (cont.) The formula below can be used to calculate IV solution drip
rates per minute.
volume to be infused (in milliliters) × drip factor (in drops per milliliter) = flow rate (in drops per minute)
time of infusion (in minutes)
Procedures for Regulating Flow Rates
volume to be infused (in milliliters) × drip factor (in drops per milliliter) = flow rate (in drops per minute)
time of infusion (in minutes)
Infuse 150ml of NS using a Marco over 1 hr.
(150ml x 15gtts)/60 min. = 2250/60 = 37.5 gtts/min
Performing IV Cannulation
Regulating fluid flow rates Factors that can cause flow rate to vary
• Vein spasm• Vein pressure changes• Patient movement• Manipulations of clamp • Bent, kinked tubing• IV fluid viscosity• Height of infusion bag• Type of administration set• Size & position of venous access device
Performing IV Cannulation
Regulating fluid flow rates Assess flow rate more frequently
• Critically ill patients• Condition can be exacerbated by fluid overload• Pediatric patients• Elderly patients• Patients receiving drug that can cause tissue damage if
infiltration occurs
Performing IV Cannulation
Document Date/time Type/amount of solution Type of device used Venipuncture site Number of attempts &
location for each IV flow rate Adverse reactions &
actions taken Name/identification
number of person initiating infusion
When IV Fluid Does Not Flow
Copyright © 2007, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Performing IV Cannulation
Complications Pain Catheter shear Circulatory overload Cannulation of artery Hematoma or infiltration Local infection Air embolism Pyrogenic reaction
Intermittent Infusion Device
Prime device with dilute heparin/saline solution
Cannulate vein
Intermittent Infusion Device
Connect intermittent device to hub of IV catheter
Connect saline/heparin-filled syringe to access port Slowly aspirate until
blood is seen Inject 3–5mL dilute
heparin/saline
Changing IV Bag
Typically occurs when directed to continue IV after bag is empty
Steps Remove cover from IV tubing port Occlude flow Remove spike Insert spike into new IV bag Open roller clamp to appropriate flow rate
Discontinuing IV Line
Close flow control valve completely
Do not disturb catheter—remove dressing
Hold 2 × 2 dressing above site to stabilize tissue while withdrawing catheter
Remove catheter by pulling straight back
To prevent blood loss Cover site with 2 × 2 dressing Hold against puncture site until bleeding stopped Tape dressing in place
Using IV Protective Devices
Penetrate skin, vein with over-the-needle device
Slide catheter forward into vein while withdrawing needle
Using IV Protective Devices
Clicks into place once plastic guard reaches end
Separate plastic guard from catheter hub
Needle is retracted fully within protective sheath
External Jugular Vein Cannulation
Benefits Fairly easy to cannulate Fluids & meds quickly reach central circulation & heart
Disadvantages Hard to access when managing patient’s airway Vein can “roll” Vein can be positional Extremely painful
Complications Same as with other veins Risk of puncturing thoracic cavity Structures can be damaged by accidental misplacement
External Jugular Vein Cannulation
Anatomy of surrounding area Proper IV cannulation
Elderly Patients
Prominent veins—less resistant skin
Difficult to stabilize vein
Veins fragile
Remove tourniquet quickly
Smaller, shorter venipuncture devices work best
Seizing or Moving Patients or Patients in Transport
Steady extremity
Look for biggest vein
Penetrate during period of less movement.
Hold little & ring fingers against patient’s extremity
Once in—slide catheter in quickly
Seizing or Moving Patients or Patients in Transport
Once in place—do not let go
Use extra tape to secure cannula
Use armboard or splint
Wrap tubing & extremity proximal to site
Summary
IV cannulation—placement of catheter into vein for purpose of administering blood, fluids, or medications &/or obtaining venous blood specimens
Placement of IV line should not significantly delay transporting critically ill or injured patients to hospital
Recommended IV solutions for use in prehospital setting— normal saline (0.9%) & lactated Ringer’s solution
Crystalloid solutions quickly diffuse out of circulatory system
2 most common types of administration sets—microdrip, macrodrip
Summary
Most commonly, plastic over-the-needle catheters are used in prehospital setting
Noncritical patients—distal veins of dorsal aspect of hand & arms preferred
Cardiac arrest—veins of antecubital fossa
Patients in whom cannulating vein is difficult Obese persons Patients in shock or cardiac arrest Chronic mainline drug users Elderly patients Small children
Summary
When equipment selected—IV fluid checked Right fluid Not outdated Clear Bag has no leaks
Continually employ infection control procedures
Release tourniquet once IV tubing is connected
Continually monitor patient for signs of improvement & signs of circulatory overload
All IV techniques share number of complications Oh Yea . .
Questions?
top related