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VENIPUNCTURE The Integumentary System Integumentary System is an anatomical barrier from pathogens and damage between the internal

l and external environment in bodily defense. Two main layers: 1. Epidermis outer layer composed of squamous cells. Normally 5-7 cells thick but thins with age. 2. Dermis inner, thicker layer consisting of blood vessels, hair follicles, sweat glands, small muscles, and nerves.

Dermis reacts quickly to painful stimuli, temperature changes and pressure sensation. Also because sensory receptors are located in dermis. Mechanoreceptors skin tactile perceptions (vein palpation). Thermoreceptors process cold, warmth, and pain (application of heat and cold). Nociceptors process pain (insertion of catheter). The Vascular System Vascular System - is concerned with the transport of blood and lymph through the body. Variations: 1. Arteries carries oxygenated blood from the heart to the body (aorta). 2. Veins carries unoxygenated blood from the capillaries towards the heart (superior and inferior vena cava). 3. Capillaries resembles a hair follicle due to its elongated structure.


Layers of the Blood Vessel: 1. Tunica Adventitia outermost layer; which consist mainly of connective tissue fibers; blends with the connective tissue surrounding the vessel; supports and surrounds a vessel. 2. Tunica Media middle layer; is formed by a layer of circumferential smooth muscle and variable amounts of connective tissue; collapses or distends as pressure changes. 3. Tunica Intima innermost layer; delimits the vessel wall towards the lumen of the vessel and comprises of endothelial lining and connective tissue.

The macrocirculation comprises all vessels that would be visible to the eye. The vessels supply and drain a network of fine vessels interposed between them, the capillaries, also called the capillary bed. Water and other components of the blood plasma from the blood vessels form the interstitial fluid, which is returned to the circulation by the lymph vascular system. Peripheral Vascular vascular system that runs across the periphery. Major Types of Veins: 1. Digital lateral and dorsal portions of fingers 2. Metacarpal dorsum of hand 3. Cephalic along radial bone of forearm 4. Basilic runs up to the ulnar bone Key Points Prior to IV Initiation 1. Physicians order 2. Patient assessment 205

3. IV set and equipment preparation 4. Medications Physicians Order 1. Initiation is based upon the written order of a licensed physician. 2. The order must indicate: a. Patients name b. Type and amount of solution c. Flow rate d. Type, dose, and frequency of medications to be incorporated/pushed. e. Orders affecting the procedure Patient Assessment a. Clinical status of the patient b. Patients diagnosis c. Patients age d. Dominant arm e. Condition of the vein/skin f. Cannula size g. Type of solution h. Duration of therapy Pointers in Choosing a Vein

Let the 10 Rs guide you

Do I have the right patient? Do I have the right solution? Do I have the right drug? Do I have the right route? Do I have the right allergy?

Assess! Assess! Assess!

Consider skin turgor Consider age Consider patients level of activity Consider dominant arm Consider type of solution and duration of therapy

Prioritize the ideal veins for venipuncture. 206

Begin with distal veins. Watch out for bifurcated or branched veins.

Do not perform venipuncture at the palm side of the wrist and cephalic veins of the wrist. Palpate for arterial pulse in order to avoid puncturing the arteries if the site chosen is cephalic or the inner aspect of the arm. Other sites to avoid include:

Veins below a previous IV infiltration. Veins below a phlebitic area. Sclerosed or thrombosed veins. Areas of skin inflammation, disease, bruising, or breakdown. An arm affected by a radical mastectomy, edema, blood clot, or infection. An arm with an arteriovenous shunt or fistula.

IV Set and Equipment Preparation a. Check for expiration date. b. Check for clarity. c. Check label against physicians written prescription. d. Label any medications added. e. Functionality of infusion pumps, PCA. Medications a. Nurses should have a knowledge on all medications administered including: b. Dosages c. Drug interactions d. Possible clinical effects Venipuncture Techniques 1. Vein dilatation 2. Site preparation 3. Catheter insertion 4. Securing the catheter Vein Dilatation 1. Tourniquet place 6-8 inches above the venipuncture site. 2. Gravity position the extremity below the heart. 3. Fist clenching open and close his fist. 4. Warm compress maximum of 10 minutes. 5. Multiple tourniquet technique use of 2-3 tourniquets. Site Preparation 207

1. Do not shave site. Remove hair with clippers only. 2. Depilatories are not recommended. 3. Cleanse with one of the following solutions: a. 2% Chlorhexidine gluconate b. Povidone-iodine c. 70% Isoprophyl alcohol 4. Work from the center outward in a circular motion. Catheter Insertion 1. Hold skin taut. 2. Adjust angle of insertion. 3. Puncture vein and observe flashback. 4. Release tourniquet. 5. Upon flashback visualization, lower catheter parallel to skin. 6. Advance needle and catheter together 1/8 inch. 7. Thread catheter into vein. 8. Place middle finger over vein distal to catheter tip 9. Stabilize catheter hub with index finger 10. Withdraw needle with a swift, continuous motion parallel to the skin 11. Dispose of needle immediately into sharps container Securing the Catheter Basic Methods: 1. Chevron method 2. U method 3. H method Chevron Method 1. Cut a strip of tape then place under the cannula, parallel to the hub. 2. Cross the end of the tape over the cannula. U Method 1. Cut a strip of tape and place it under the hub of the cannula. 2. Bring each side of the tape up, folding it over the wings of the cannula in a U shape. H Method 1. Cut three strips of tape and place one strip over each wing of the cannula. 2. Place the third strip over the wings perpendicular to the first two. Reminder for all methods: Always apply a label after securing the catheter. On the label, write the following: Date of insertion Time of insertion Type of catheter used Gauge used 208

Your initials

Maintaining Peripheral IV Therapy: 1. Changing the dressing 2. Changing the IV solution 3. Changing the administration set 4. Changing the IV site Changing the Dressing: 1. The insertion site should be inspected and palpated for tenderness daily, through intact dressing. 2. Gauze dressing should be changed routinely every 48 hours. 3. A semipermeable dressing should be changed whenever its integrity is compromised. Changing the IV solution: 1. Do not allow an IV container to hang for more than 24 hours. 2. Before changing the IV container, check the new one for cracks, leaks, and other damages. 3. Check the solution for discoloration, turbidity, and particulates. 4. Note date and time the solution was mixed and the expiration date. Changing the Administration Set: 1. Change the administration set every 72 hours and whenever you note or suspect contamination. 2. As much as possible, change the administration set when you start a new venous access device during routine site rotation. Changing the IV Site: 1. As a standard of care, rotate the site every 48-72 hours. 2. If limited venous access will prevent you from changing sites, notify the doctor of the situation. 3. Be prepared to change the entire system when you detect signs of thrombophlebitis, cellulitis, or IV therapy related bacteremia. Discontinuing Peripheral IV: 1. Be careful to avoid manipulating the device in the skin to prevent skin organisms from entering the bloodstream. 2. Never use an alcohol pad to clean the site when discontinuing an infusion. 3. If the patient feels lingering tenderness at the IV site, apply warm, moist packs. Record the Following: Date, time, and venipuncture site. Equipments used. Rates of solution. Patients tolerance to the procedure. Health teachings given. Update your records as often as needed. 209

Must be clear, concise and consistent.

References: 1. Nursing Standards on Intravenous Practice. Philippines: Association of Nursing Service Administrators of the Philippines, 2006. 2. I.V. Therapy Made Incredibly Easy. Philadelphia: Lippincott Williams & Wilkins, 2006. 3. Just the Facts: I.V. Therapy. Lippincott Williams & Wilkins, 2005. 4. RA 7164. 5. RA 9173. 6. PRC-BON Resolution No. 08. 7. PRC-BON Protocol Governing Special Training on the Administration of Intravenous Injection for Registered Nurses. 8. DOH Department Circular No. 100 Series of 1995. 9. ANSAP Code of Ethics. 10. PRC-BON Resolution No. 220. 11. Standards of Safe Nursing Practice. 12. Philippine Nursing Law, Jurisprudence and Ethics. 13. RA 7719. 14. RA 9165. 15. RA 9502.