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INTRAVENOUS MEDICATION Care and Complications

Dr.T.V.Rao MD

20-10-2012

Dr.T.V.Rao MD @ Hospital care

Indications for IV Medication


Indications:
Intravenous access to patients circulatory system. Administration of Meds. & Fluids, as well as blood collection

Contraindications:
IV access should be attempted as distal as possible. Avoid veins that cross over joints, local infection/injury Extremities with renal shunts or fistulas
Dr.T.V.Rao MD @ Hospital care

20-10-2012

Procedure for Insertion of Peripheral IV Catheter


1. 2. 3. 4. Obtain and review the order Ascertain allergies Gather Equipment Verify patients identity using two patient identifiers 5. Explain procedure, benefits, care management, and potential complications to patient
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Procedure for Insertion of Peripheral IV Catheter (cont)


6. Perform hand hygiene 7. Assemble equipment 8. Apply Tourniquet 9. Assess veins, keeping in mind the rational for therapy and duration of therapy 10. Apply Non sterile gloves 11. Wash intended insertion site with antiseptic soap and water. (as needed)
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Procedure for Insertion of A Peripheral IV Catheter (cont)


13. Clean intended insertion site with

antiseptic solution, working outward using back-and-forth motion 14. Allow site to dry 15. Perform venipuncture while stabilizing skin with the nondominate hand
20-10-2012 Dr.T.V.Rao MD @ Hospital care

Procedure for Insertion of A Peripheral IV Catheter (cont)


16. Enter skin at a 10- to- 30 degree angle.

Decrease angle when the skin has been penetrated. When blood is obtained in the flash back chamber, advance catheter 1/16 inch, and then slightly pull stylet back, advancing catheter gently into vessel. Continue to advance catheter into vein until the catheter hub is against the skin.
20-10-2012 Dr.T.V.Rao MD @ Hospital care 6

Procedure for Insertion of A Peripheral IV Catheter (cont)


17. Release tourniquet 18. Occlude tip of catheter by pressing finger of non dominant hand over vein to prevent blood spillage. 19. Activate needle safety device before removing stylet. Connect IV administration set or injection cap/needless device. Begin infusing solutions slowly.
20-10-2012 Dr.T.V.Rao MD @ Hospital care 7

Procedure for Insertion of A Peripheral IV Catheter (cont)


22.Discard stylet in sharps container 23. Remove gloves. Perform hand hygiene 24. Document procedure in the patients medical record.
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Choosing IV catheter Size


Age
< 1 year: 22, 24 gauge (g)

1-8 years: 18, 20, 22 gauges > 8 years: 16. 18, 20 gauges
20-10-2012 Dr.T.V.Rao MD @ Hospital care 9

IV Procedure
Use universal precautions (glove and eye protection) Allergies (beta dine or latex) Explain procedure to Pt. Prepare all material Select vein. Apply tourniquet above the elbow. Prepare site
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IV Procedure (cont.)
Warn the patient of possible pain Bevel up at 30 degree above horizontal Look for flashback of blood into catheter Upon seeing flashback, advance catheter another millimeter or two Advance the sheath completely into the vein and release tourniquet
20-10-2012 Dr.T.V.Rao MD @ Hospital care 11

IV Procedure (cont.)
Connect the IV tubing/heplock Secure catheter and tubing Dispose of needles in sharps container Document the IV site, catheter size and date on the patients chart
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Complications of IV Therapy
Classified according to their location
Local complication: at or near the insertions site or as a result of mechanical failure Systemic complications: occur within the vascular system, remote from the IV site. Can be serious and life threatening
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Dr.T.V.Rao MD @ Hospital care

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Local complications
Occur as adverse reactions or trauma to the surrounding venipuncture site Assessing and monitoring are the key components to early intervention Good venipuncture technique is the main factor related to the prevention of most local complications associated with IV Therapy. Local complications include: hematoma, thrombosis, phlebitis, post infusion phlebitis, thrombophlebitis, infiltration, extravasation, local infection, and veno spasm.
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Hematoma
Subcutaneous hematoma is the most common complication Can be a starting point for other complications: thrombophlebitis and infection Related to:
Nicking the vein Discontinuing the IV without apply adequate pressure Applying the tourniquet to tightly above a 20-10-2012 previously attempted venipuncture site. Dr.T.V.Rao MD @ Hospital care

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Hematoma
Signs and symptoms:
Discoloration of the skin Site swelling and discomfort Inability to advance the cannula all the way into the vein during insertion Resistance to positive pressure during the lock flushing procedure

Document

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Dr.T.V.Rao MD @ Hospital care

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Hematoma Prevention
Use of an indirect method Apply tourniquet just before venipuncture Use a small need in the elderly and patients on steroids, or patients with thin skin. Use blood pressure cuff to apply pressure Be gentle
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Hematoma Treatment
Apply direct, light pressure for 2-3 minutes after needle removed Have patient elevate extremity

Apply Ice
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Thrombosis
Catheter-related obstructions can be mechanical or non-thrombotic Trauma to the endothelial cells of the venous wall causes red blood cells to adhere to the vein wall, forms a clot or Thrombosis Drip rate slows, line does not flush easily, resistance is felt Never forcible flush a catheter
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Thrombosis
Signs and Symptoms
Fever and Malaise Slowed or stopped infusion rate Inability to flush

Prevention
Use pumps and controllers to manage flow rate Micro drip tubing for rate below50mL/hr Avoid areas of flexion Use filters Avoid lower extremities
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Thrombosis
Treatment
Never flush a cannula to remove an occlusion Discontinue the cannula Notify the physician and assess the site for circulatory impairment
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Phlebitis
Inflammation of the vein in which the endothelial cells of the venous wall become irritated and cells roughen, allowing platelets to adhere and predispose the vein to inflammation-induced phlebitis
Tender to touch and can be very painful
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Dr.T.V.Rao MD @ Hospital care

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Phlebitis
Mechanical:
To large a catheter for the size of the vein Manipulation of the catheter: improper stabilization

Chemical: vein becomes inflamed by irritating or


vesicant solutions or medication

20-10-2012

Irritation medication or solution Improperly mixed or diluted Too-rapid infusion Presence of particulate matter
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Phlebitis
Chemical (cont):
The more acidic the IV solution the greater the risk Additives: Potassium Type of material Length of dwell:
30% by day 2, 39-40% by day 3 (Macki and Ringer)

The slower the rate of infusion the less irritation


20-10-2012 Dr.T.V.Rao MD @ Hospital care 27

Phlebitis Bacterial
Also called Septic phlebitis: least common Inflammation of the intima of the vein Contributing factors

20-10-2012

Poor aseptic technique Failure to detect breaks in the integrity of the equipment Poor insertion technique Inadequate stabilization Failure to perform site assessment Aseptic preparation of solutions Hand washing and preparing the skin
Dr.T.V.Rao MD @ Hospital care 28

Phlebitis Post infusion


Inflammation of the vein 48-96 hr after discontinued Factors that contribute:
Insertion technique Condition of the vein used Type, compatibility, pH of solution used Gauge, size, length, and material Dwell time Infrequent dressing change Host factors: age, gender, age and presence of disease

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Dr.T.V.Rao MD @ Hospital care

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Phlebitis
Immune system causes leukocytes to gather at the inflamed site Pyrogens stimulate the hypothalamus to raise body temperature Pyrogens stimulate bone marrow to release more leukocytes Redness and tenderness increase
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Phlebitis
Signs and Symptoms
Redness at the site Site warm to touch Local swelling Palpable cord along the vein Sluggish infusion rate Increase in basal temperature of 1degree C or more

Prevention
Use larger veins for hypertonic solutions Central lines for Infusions lasting longer than 5 days
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Thrombophlebitis
Thrombophlebitis denotes a twofold injury: thrombosis and inflammation Related to:
Use of veins in the lower extremity Use of hypertonic or highly acidic infusion solutions Causes similar to those leading to phlebitis
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Thrombophlebitis
Signs and Symptoms
Sluggish flow rate Edema in the limbs Tender and cord like vein Site warm to the touch Visible red line above venipuncture site Diminished arterial pulses Mottling and cyanosis of the extremities
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Thrombophlebitis
Prevention
Use veins in the forearm rather than the hands Do not use veins in a joint Assess site q 4 hr in adults, q 2 hr in children Catheter securement Infuse at rate prescribed Use the smallest size catheter to do the job Proper dilution
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Thrombophlebitis
Septic thrombophlebitis can be prevented:
Appropriate skin preparation Aseptic technique in the maintenance of infusion Proper hand hygiene
60% from patients skin 35% from the line itself 5% from hands MD @ Hospital care Dr.T.V.Rao

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Extravasations
Signs and Symptoms
Complaints of pain or burning Swelling proximal to or distal to the IV site Puffiness of the dependent part of the limb Skin tightness at the venipuncture site Blanching and coolness of the skin Slow or stopped infusion Damp or wet dressing
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Extravasations
Prevention:
Use of skilled practitioners Knowledge of vesicants Condition of the patients veins

Drug administration technique


If continuous give in CVAD Only with brisk blood return of 3-5 cc Use of a free flow IV Do not use a pump on vesicants given peripherally Assess for blood return frequently
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Personal safety of Health Care Workers

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Steps to prevent needle sticks


Wear gloves Do Not Bend or Break Needles Never RECAP!!! If you must, use the One Handed technique Take your time Dispose of contaminated needles immediately in puncture-resistant containers
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Risks to you - if Careless


Risks after needle Sticks Exposure
Hepatitis B:
Hepatitis C: HIV:

10-30%
2% 0.4 %

Other blood borne pathogens


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POLICY ON ACCIDENTAL NEEDLE STICKS


Immediately wash injured area. Report all needle sticks immediately to your instructor or immediate supervisor. Complete an incident report and report to employee health or ED. Determine if the needle was clean or dirty. Cleansing wound with antiseptic. Request that the identified patient be tested for Hepatitis B surface antigen and HIV antibodies. Have your blood tested for Hepatitis B and HIV antibodies as soon as possible. Begin drug treatment (if necessary) & counseling.
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Programme Created by Dr.T.V.Rao MD for Medical and Paramedical Professionals in the Developing World
Email

doctortvrao@gmail.com

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