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This presentation will enhance your knowledge of how to care for them.
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Veins are unlike arteries in that they are 1)superficial, 2) display dark red blood at skin surface and 3) have no pulsation
Vein Anatomy
Tunica Adventitia
the outer layer of the vessel
Connective tissue Contains the arteries and veins supplying blood to vessel wall
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Tunica Media
Contains nerve endings and muscle fibers The vasoconstrictive response occurs at this layer
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Tunica Intima
the inner layer of the vessel
One No
layer of endothelials
nerve endings
Surface
for platelet aggregation w/trauma and recognition of foreign object at this level begins here
PHLEBITIS
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Valves
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Metacarpal Vessels
-Located between joints and metacarpal bones (act as natural splint) -Formed by union of digital veins
Digital
-Geriatric patients often lack enough connective / adipose tissue and skin turgor to use this area successfully
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the metacarpal veins and runs along the medial aspect of the arm. It is often overlooked becauses of its location on the back of the arm, but flexing the elbow/bending the arm brings this vein into view
Medial Basilic - Empties into the Basilic vein running parallel to tendons, so it is not always well defined. Accepts larger gauge catheters. - BEWARE of Brachial Artery/Nerve
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Purposes of IV Therapy
To provide parenteral nutrition To provide avenue for dialysis/apheresis To transfuse blood products To provide avenue for hemodynamic monitoring To provide avenue for diagnostic testing To administer fluids and medications with the ability to rapidly/accurately change blood concentration levels by either continuous, intermittent or IV push method.
Types of Peripheral Venous Access Devices
Butterfly
(winged) or Scalp vein needles (SVN) not recommended for non compliant patient as it can easily penetrate the vein wall causing extravasation. We use these
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Starting a Peripheral IV
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Use 25-27g insulin syringe to create a wheal similar to a TB skin test on top of or just to side of vein with 0.1 -0.2 ml normal saline or 1% xylocaine without epinephrine
Topical anesthesia cream (ie EMLA) may be applied to children>37 weeks gestation 1 hr. prior to stick. It might be a good idea to anesthetize a couple of sites
Have the patient close their fist (NO PUMPING) prior to stick Make sure the skin surface cleansing agent (alcohol/chlorhexidine) is dry prior to stick. Drawing this into the vein may stimulate the vasoconstrictive action of the tunica media layer
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- Adults: q 8hrs
Dressing/Bag Changes
Physician orders are required if a peripheral catheter is left in the same site for more than 3 days. It is best to have the pharmacy add medications to the infusion bags under laminare flow to reduce contamination
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Material/Cost
Various materials
Lumen
2-3
Sutured
Duration Flushes
Yes/entire life
Short term 4-10 days 5-10ml NaCl after use and daily
No
Long term 5-10ml NaCl after use and daily
Yes
Long term 10ml NaCl followed by 4.5ml heparinized saline (adults-100units/ml; peds-10units/ml) after ea. use or monthly if not accessed Bard, Accces Port-A-Cath
Yes
Mid term Done ONLY by IV team or dialysis nurses
Hickman, Broviac
PICC, PIC, EDPC, Arrow Howe, Gesco, PASV Specially trained RN @ bedside
MD in OR
MD in OR
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Percutaneous(Subclavian)
CVC Care/Maintenance
Percutaneous Flush after each access or daily for catheters>21ga, q 6 hrs <21 ga -adults: 10ml saline - peds/neonates: 5ml saline (preservative free for infants <1yr) Transparent dressing change q 7 days & prn
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Tunneled
PICC
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CVC Care/Maintenance
Implanted Port
Site Care
Q 2 hr for adult
* Indicates complication: Infiltration Phlebitis Thrombosis Cellulitis Septicemia
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Infiltration/Extravasation
The most common cause is damage to the wall during insertion or angle of placement.
STOP INFUSION and treat as indicated by Pharmacy, Medication package insert or drug reference book.
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Phlebitis/Thrombophlebitis
Chemical
- Infusate chemically erodes internal layers. Warm compresses may help while the infusate is stopped/changed. Anti-inflammatory and analgesic medications are often used no matter what the cause
Mechanical
- Caused by irritation to internal lumen of vein during insertion of vascular access device and usually appears shortly after insertion. The device may need to be removed and warm compresses applied
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Bacterial
- Caused by introduction of bacteria into the vein. Remove the device immediately and treat w/antibiotics. The arm will be painful, red and warm; edema may accompany
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Cellulitis
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Troubleshooting
VAD broken
- PICCs may be repaired. All other devices must be replaced
Policy notes
KVO ra te :
RNs and LPNs can start peripheral IVs after initial training and observation by preceptor LPNs CANNOT infuse blood products or high risk IV medications.
On ly u n til ra te o rd e r re c e iv e d
LP Ns ca n n ot pu sh IV m edica t ion s
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IV Medication Administration
Many medications require patient monitoring that cannot be done on units where the nurse/patient ratios are greater than 1:2 A patient can be moved to a unit where the ratio is appropriate for invasive/frequent monitoring or another nurse can be brought to care for the patient during the med administration
All Med ica t ion s Ca n n ot Be Ad m in is t er ed on All U n it s
Ge n e r a l Ca r e U n i t s : Ca n give m ed s r equ ir in g on ly ba s ic p h ys ica l a s s es s m en t d a t a S t e p d o w n U n i t s : Ca n give m ed s t h a t r equ ir e m or e in va s ive or fr equ en t m on it or in g t h a n is a va ila ble on gen er a l ca r e u n it s In t e n s i v e Ca r e U n i t s : Ca n give m ed s t h a t r equ ir e m or e in va s ive or fr equ en t m on it or in g t h a n is a va ila ble on t h e St ep d own u n it s .
www.mc.vanderbilt.edu/pharmacy/ivroom/IV MedAdm061003.pdf
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IV Medication Administration
Sample page from the Pharmacy med administration web site
See APPROVED FOR section. You will find if the medication can be administered on your unit.
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www.ins1.org
Professional Organization that sets the standards of care for clinicians practicing in the field of infusion therapy. Standards set by INS are reflected in our policies and procedures related to infusion therapy for health care providers. In a court of law, the standards set by the INS are used to assess the infusion clinicians performance.
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