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Drug administration
Parenteral nutrition
Blood transfusion
Preparation
As with any medication administration, ensure the 5 Rights: Right
drug, right dose, right patient, right route, right time.
Equipment
Gather solution (medication, blood component), administration set,
inline lter (if needed), pole, pump (if needed), volume-control set
(if required), alcohol sponges, medication. and label if necessary.
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Verify equipment/medication expiration dates and inspect product
intactness (e.g., chips, cracks, leaks). Inspect uids/meds for abnormal
particles, discoloration, and cloudiness.
Priming
1. Wash hands and always use aseptic technique when preparing intra-
vascular devices. If solution or administration set is contaminated,
replace them with a new one and start over.
4. Purge tubing (invert all Y sites and backcheck valves, and tap if
necessary to prime). Follow manufacturers instructions for pump
tubing and proper priming. Attach lter if needed (usually at distal
end) and purge tubing, forcing all air out of line (remember to practice
a sterile techniquekeep the tip of the tubing in sight and above
waist level).
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Infusion set
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Special equipment
Filters: Used to decrease potential for vascular/pulmonary obstruction and
air emboli. Generally, lter should be located as close to the catheter inser-
tion site as possible (follow manufacturers instructions). For non-lipid-
containing solutions that require ltration, a 0.2-micron lter containing a
membrane that is bacteria- and particulate-retentive, and air-eliminating
shall be used. For lipid or other uids that require ltration, a 1.2-micron
lter containing a membrane that is particulate-retentive and air-eliminating
shall be used. Blood and blood components are administered through
special lters designed specically for their administration. Other size
lters are available for special circumstances (e.g., microaggregate blood
lters and leukocyte-depleting blood lters). When using lters, adhere to
the manufacturers labeled use(s), directions, and ltration requirements of
therapy. Be aware that some therapeutic agents can not be ltered.
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Common areas for peripheral placement of an IV cannula in adults
include metacarpal, cephalic, basilic, and median veins.
Use an extremity that does not have the patients ID band to avoid
circulatory impairment if complications occur. Move ID band to
another site per policy, if necessary.
Start with the most distal site available and move proximally as
needed for subsequent cannulations (if an inltration occurs,
cannulation must be performed proximal to the old site or in the
opposite extremitysee Site complications, p. 22).
Avoid using veins in the antecubital fossa (save these for midlines,
PICCs, and lab draws).
Avoid veins in the arm of a patient who has undergone surgery (e.g.,
mastectomy, axillary dissection, AV stula/graft) or has a condition
where circulation to the arm is compromised (consult institutional
policy for proper protocol/physicians approval).
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Venous access: Arm
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Venous access: Foot
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Site preparation (short-term peripheral IVs)
Excess hair may be removed to help visualize the vein and secure the
catheter/dressing. Hair is clipped with scissors/clippers; shaving is not
recommended (potential risk for infection).
Warm compress for 510 min before procedure will help dilation (use
warm water, do not microwave).
Tap skin over vein or ask patient to open and close hand to help
visualize the vein.
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its eect. Apply solution in circular motion working outward from
intended site to an area of 24 inches.
Anesthetics
Local anesthesia: Local anesthetic agents including, but not limited to,
intradermal lidocaine, iontopheresis, low-frequency ultrasonication,
pressure-accelerated lidocaine, or topical transdermal agents, should be
considered and used according to organizational policies and procedures
and manufacturers labeled use(s) and directions. As with all medications,
be aware of patients allergies and drug actions/side eects.
Venipuncture equipment
Solution and primed infusion set hanging ready on pole/pump.
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connector and maintain it aseptically; ush air out completely with
normal saline.
Remember to use the shortest length and smallest diameter catheter that
will get the job done. Also, the smaller the catheter gauge number, the
larger the diameter.
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Catheter gauge selection (cont.)
Gauge Uses Implications
16 Large fluid/volume; rapid Increased likelihood of pain on insertion
infusions (high-risk surgical (# anesthesia). Large vein needed.
procedures, trauma). ? likelihood of irritation to vein wall.
18 Surgery, viscous solutions Large vein needed to accommodate
(whole blood, packed RBCs). catheter.
Various emergent situations.
20 Routine infusions and routine Frequently selected gauge size.
IV access. Minor surgical
procedures.
22 Suitable for most infusions at Easier to insert into small, thin, fragile
slower rates. Recommended for veins but may be difficult to insert into
small and/or fragile veins. Not tough skin.
appropriate for rapid flow rates.
24, 26 Slower flow rates. Neonatal, Easier to insert into extremely small
pediatric, and elderly patients. veins; difficult to insert into tough skin.
Consult local institutional policies for specific guidelines and protocols if applicable.
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Peripheral-short devices*
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Venipuncture
Dierent products will require dierent implementation. It is important to
follow specic manufacturers instructions. Below are general guidelines.
Grasp needle/catheter with dominant hand. Hold skin taut with other
hand to stabilize vein.
Approach at 3045 angle; bevel up. Enter skin directly over vein.
Apply slight pressure with your nger on the catheter tip to prevent
bleeding (place nger right over patients skin), and remove needle.
Some catheter devices have a spring-loaded-needle-retrieval system
that is activated with the push of a button, others require a rm pull,
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and others a careful withdrawal. Ensure you are familiar with equip-
ment and follow manufacturers instructions.
Insertion of peripheral IV
Only nurses who have been certied as competent in the insertion of IV
cannula will perform this procedure. As always follow specic manufac-
turers instructions and hospital policy. Below are general steps and advice.
2. Wash hands with antiseptic soap Strict adherence to hand washing and
and wear gloves. aseptic technique remains the cornerstone of
prevention of cannula related infections.
3. Apply the tourniquet above For pediatric patient, an assistants hand used
insertion site. as both as a tourniquet and restraint is often
more acceptable to a child than a tourniquet.
4. Disinfect the selected site with skin Do not touch the skin with the fingers after
prep and allow to dry preparation solution has been applied.
5. Inspect the cannula before insertion Do not touch the shaft or tip of the cannula.
to ensure that the needle is fully
inserted into the plastic cannula and
that the cannula tip is not damaged.
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Insertion of peripheral IV (cont.)
6. Ensure the bevel of the cannula is Facilitates the piercing of the skin by
facing upwards. the bevel.
7. Insert the needle and the cannula Gentle traction on skin may stabilize the vein
into the vein. under the skin.
11. Flush the cannula with Ensures the line is patent accessible.
normal saline.
12. Cover the intravenous and Ensure that the insertion site and the
surrounding area with a sterile area proximal to the site are visible for
transparent dressing. inspection purposes.
13. If infusion ordered, prime the line Ensure that the insertion site and the
and connect the intravenous and area proximal to the site are visible for
surrounding area with a sterile inspection purposes.
transparent dressing.
14. Note the date and time of insertion Intravenous lines used for intermittent
in the patients medical record. infusions must be labeled with the
patients name, and the date and time of
commencement.
15. If the site needs to be immobilized, For infants < 12 months, a transparent tape
use a well-padded splint and must be used.
strapping if necessary.
If a bandage is used, apply it at each end
of splint so that the central area is lightly
covered for easy inspection.
16. Dispose of equipment safely.
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Securing the catheter
Great job! You got the IV in. Now you have to keep it in! Special
precautions for taping and securing an IV site should be followed
according to the clinical situation. A confused patient, an active
child, or placement on a joint will require extra attention to your
technique. Assess the situation for the need for splints, and special
taping measures.
Good catheter stabilization does not just maintain patency but it also
reduces the chances of phlebitis, inltration, sepsis, and cannula
migrationnot to mention the happy patient that wont have to get
poked again!
! When tape is used, it should be applied to cannula hub/wings and not
directly over the junction between the skin and catheter. Do not
encircle limb with tape.
Sutures are seldom used for catheter stabilization, but if they are used,
follow institutional protocols and manufacturers instructions. Replace
sutures if they become loose, or are not intact. Do not readvance a
catheter that has migrated.
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What is the best method for securing a catheter?
Healthcare workers have customarily used tape or sutures to secure
medical catheters. Typically sutures are used for central venous catheters,
arterial catheters, and chest tubes. Improved adhesive products and
securement devices may decrease or eliminate the need for sutures and
thus directly reduce the risk of needlestick to the healthcare provider.
The site at which a catheter is placed inuences the subsequent risk for
catheter-related infection and phlebitis. The inuence of site on the risk
for catheter infections is related in part to the risk for thrombophlebitis
and density of local skin ora.
Phlebitis has long been recognized as a risk for infection. For adults,
lower extremity insertion sites are associated with a higher risk for
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infection than are upper extremity sites. In addition, hand veins have a
lower risk for phlebitis than do veins on the wrist or upper arm.
Replacement of catheters:
Evaluate the catheter insertion site daily, by palpation through the dress-
ing to discern tenderness and by inspection if a transparent dressing is in
use. Gauze and opaque dressings should not be removed if the patient
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has no clinical signs of infection. If the patient has local tenderness or
other signs of possible CRBSI, an opaque dressing should be removed
and the site inspected visually.
Interventions used:
Monitoring IV site, ushing, dressing changes, blood draws,
insertion, device removal, patient education, patient compliance
cap, dressing, volume and type of ush, and tube changes, catheter
selection, patient education, drugs, allergy history.
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Reviewers
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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.