Intravenous cannulization

Introduction

 Venipuncture, or the ability to gain access to the venous system for administering fluids
and medications.
 This responsibility includes
 Selecting the appropriate venipuncture site
 Type of cannula
 Being proficient in the technique of vein entry.
CHOOSING AN IV SITE

 The metacarpal, cephalic, basilic, and median veins as well as their branches are
recommended most commonly used sites because of their size and ease of access.
 More distal sites should be used first, with more proximal sites used subsequently.
 The antecubital fossa is avoided, except as a last option because if punctured it affects
mobililty of significant hand.
 The most distal site of the arm or hand is generally used first so that subsequent IV access
sites can be moved progressively upward
Cont..

 Central veins commonly used include the subclavian and internal jugular veins.
 It is possible to gain access to (or cannulate) these larger vessels even when peripheral sites
have collapsed.
 Hazards are much greater, however, and may include inadvertent entry into an artery or the
pleural space.
Iv sites to avoid

 Leg veins should rarely be used because of the high risk of thromboembolism.
 Veins distal to a previous IV infiltration or phlebitic area.
 Sclerosed or thrombosed veins.
 An arm with an arteriovenous shunt or fistula.
 An arm affected by edema, infection, blood clot, or skin breakdown.
 The arm on the side of a mastectomy is avoided because of impaired lymphatic flow.
Cont..

The following are factors to consider when selecting a site for venipuncture:
• Condition of the vein
• Type of fluid or medication to be infused
• Duration of therapy
• Patient’s age and size
• Whether the patient is right- or left-handed
• Patient’s medical history and current health status
• Skill of the person performing the venipuncture
Cont..

 The vein should feel firm, elastic, engorged, and round, not hard, flat, or bumpy.
 Because arteries lie close to veins in the antecubital fossa, the vessel should be
palpated for arterial pulsation (even with a tourniquet on), and cannulation of
pulsating vessels should be avoided.
General guidelines for selecting a cannula
include:
 Length: 3⁄4 to 1.25 inches long
 Diameter: narrow diameter of the cannula to occupy minimal space within the vein
 Gauge: 20 to 22 gauge for most IV fluids; a larger gauge for caustic or viscous solutions;
14 to 18 gauge for blood administration and for trauma patients and those undergoing
surgery.
 Hand veins are easiest to cannulate. Cannula tips should not rest in a flexion area (eg, the
antecubital fossa) as this could inhibit the IV flow
Venipuncture devices

Equipment used to gain access to the vasculature includes

 Cannulas
 needleless IV delivery systems
 peripherally inserted central catheter
 midline catheter access lines.
Cannulas
Most peripheral access devices are cannulas.

Scalp vein or butterfly needles are short steel

needles with plastic wing handles.
These are easy to insert, but because they are
small and nonpliable, infiltration occurs
easily.
The use of these needles should be limited to :
 Obtaining blood specimens
 Administering bolus injections
 Infusions lasting only a few hours
Cont..

 Plastic cannulas inserted through a hollow needle are usually called intracatheters.
 They are available in long lengths and are well suited for placement in central locations.
 Because insertion requires threading the cannula through the vein for a relatively long
distance, these can be difficult to insert.
Cont..

 The most commonly used infusion device is the over-the-needle catheter.

 A hollow metal stylet is preinserted into the catheter and extends through the distal tip of
the catheter to allow puncture of the vessel, in an effort to guide the catheter as the
venipuncture is performed.
 The vein is punctured and a flashback of blood appears in the closed chamber behind the
catheter hub.
The catheter is threaded through the stylet into
the vein and the stylet is then removed.
There are many safety over-the-needle catheter
designs available with retracting stylets to
protect health care workers from needlestick
injuries.
Cont..

 Most standard peripheral catheters are composed of some form of plastic. Teflon
(polytetrafluoroethylene)–coated catheters have less thrombogenic properties and are less
inflammatory than polyurethane or PVC.
 Catheter size for steel needles can range from 3⁄8 to 1.5 inches in length and 27 to 13
gauge.
 Plastic catheters range in length from 5⁄8 to 2 inches or as long as 12 inches. The size of
the catheter ranges from 27 to 12 gauge.
Needleless IV Delivery Systems.

 These systems have built-in protection against needlestick injuries and provide a
safe means of using and disposing of an IV administration set (which consists of
tubing, an area for inserting the tubing into the container of IV fluid, and an
adapter for connecting the tubing to the needle).
 IV line connectors allow the simultaneous infusion of IV medications and other
intermittent medications (known as a piggyback delivery) without the use of
needles
Peripherally Inserted Central Catheter or
Midline Catheter
 Patients who need moderate- to long-term parenteral therapy often
receive a peripherally inserted central catheter or a midline catheter.
 These catheters are also used for patients with limited peripheral
access (eg, obese or emaciated patients, IV/injection drug users)
who require IV antibiotics, blood, and parenteral nutrition.
 For these devices to be used, the median cephalic, basilic, and
cephalic veins must be pliable (not sclerosed or hardened) and not
subject to repeated puncture.
Contd..

 If these veins are damaged, then central venous access via the subclavian or
internal jugular vein, or surgical placement of an implanted port or a vascular
access device, must be considered as an alternative.
 CVC and PICC are used for rapid infusions, long-term medication administration
(antibiotics, chemotherapy), total parenteral nutrition and frequent blood draws.
Both can be seen in the inpatient and outpatient setting.
 CVC and PICC deliver medications and sample blood from large veins near the
heart. These lines end in either the superior vena cava or the right atrium of the
heart.
PREPARING THE IV SITE

 Before preparing the skin, the nurse should ask the patient if he or she is allergic
to latex or iodine, products commonly used in preparing for IV therapy.
 Excessive hair at the selected site may be removed by clipping to increase the
visibility of the veins and to facilitate insertion of the cannula and adherence of
dressings to the IV insertion site.
 Because infection can be a major complication of IV therapy, the IV device, the
fluid, the container, and the tubing must be sterile.
Cont..

 The insertion site is scrubbed with a sterile pad soaked in 10% povidone–iodine
(Betadine) or chlorhexidine gluconate solution for 2 to 3 minutes, working
from the center of the area to the periphery and allowing the area to air dry.
 The nurse must perform hand hygiene and put on gloves. Nonsterile disposable
gloves must be worn
PERFORMING VENIPUNCTURE
Preparation

1.Verify prescription for IV therapy, check solution label, and identify

patient to avoid Serious errors
2. Explain procedure to patient as knowledge increases patient comfort
and cooperation.
3. Carry out hand hygiene and put on disposable non latex gloves.
Asepsis is essential to prevent infection.
4. Apply a tourniquet 4–6 inches above the site and identify a suitable
vein. This will distend the veins and allow them to be visualized.
Cont..

5. Choose site. Using distal sites first preserves sites proximal to the
previously cannulated site for subsequent venipunctures.
Veins of feet and lower extremity Should be avoided due to risk of
thrombophlebitis.
6. Choose IV cannula or catheter. The shortest gauge and length needed to
deliver prescribed therapy should be used.
7. Connect infusion bag and tubing, and run solution through tubing to
displace air; cover end of tubing to Prevents delay.
Cont..

8. Raise bed to comfortable working height and position for patient

9. Adjust lighting.
10. Position patient’s arm below heart level to encourage capillary filling.
11. Place protective pad on bed under patient’s arm.
Procedure

1. Apply a new tourniquet for each patient or a blood pressure cuff

15 to 20 cm (6–8 in) above injection site.
2. The tourniquet distends the vein and makes it easier to enter; it
should never be tight enough to occlude arterial flow.
3. If a radial pulse cannot be palpated distal to the tourniquet, it is too
tight.
Contd..

4.Ask patient to open and close fist several times as it encourages the
vein to become round and turgid.

5. Position patient’s arm in a dependent position to distend a vein and.

Warm packs can promote vasodilation as well.

6. Prepare site by scrubbing with chlorhexidine gluconate or

povidone–iodine swabs for 2–3 min in circular motion to avoid
infection, moving outward from injection site. Allow to dry.
Cont..
6. With hand not holding the venous access device, steady patient’s arm
and use finger or thumb to pull skin taut over vessel. Applying traction
to the vein helps to stabilize it.

7. Hold needle in bevel up position and at 5°–25° angle to minimize

trauma , depending on the depth of the vein, pierce skin to reach but
not penetrate vein.

8. Decrease angle of needle further until nearly parallel with skin, then
enter vein either directly above or from the side in one quick motion.
 Cont..
8.If backflow of blood is visible, straighten angle and advance needle as it
decreases chance of puncturing posterior wall of vein. . Additional steps for
catheter inserted over needle:

a. Advance needle 0.6 cm (1⁄4–1⁄2 in) after successful venipuncture.

b. Hold needle hub, and slide catheter over the needle into the vein. Never reinsert
needle into a plastic catheter or pull the catheter back into the needle. Doing it
can cause catheter embolism
c. Remove needle while pressing lightly on the skin over the catheter tip; hold
catheter hub in place.
Cont..
9.Release tourniquet and attach infusion tubing; open clamp enough to
allow drip.
10. Slip a sterile 2-in × 2-in gauze pad under the catheter hub.
11. Anchor needle firmly in place with tape.
12. Cover the insertion site with a transparent dressing, bandage, or
sterile gauze; tape in place with no allergenic tape but do not encircle
extremity.
13. Tape a small loop of IV tubing onto dressing to decrease the chance
of inadvertent cannula removal if the tubing is pulled.
Cont..

14. Label dressing with type and length of cannula, date, time, and
initials.
15. A padded, appropriate-length arm board may be applied to an area
of flexion (neurovascular checks should be performed frequently).

16. Calculate infusion rate and regulate flow of infusion.

17. Document site, cannula size and type, the number of attempts at
insertion, time, solution, IV rate, and patient response to procedure.
IV ADMINISTRATION EQUIPMENT

 Intravenous fluids are administered through thin, flexible plastic tubing called
an infusion set or primary infusion tubing/administration set. The infusion
tubing/administration set connects to the bag of IV solution.
 Primary IV tubing is either a macro-drip solution administration set that delivers
10, 15, or 20 gtts/ml, or a micro-drip set that delivers 60 drops/ml.
 Macro-drip sets are used for routine primary infusions. Micro-drip IV tubing is
used mostly in pediatric or neonatal care, when small amounts of fluids are to be
administered over a long period of time. The drop factor can be located on the
packaging of the IV tubing.
Cont..
Primary IV tubing is used to infuse continuous or intermittent fluids or medication. It
consists of the following parts:
 Backcheck valve: Prevents fluid or medication from travelling up the IV
 Access ports: Used to infuse secondary medications and give IV push
medications
 Roller clamp: Used to regulate the speed of, or to stop or start, a gravity infusion
 Secondary IV tubing: Shorter in length than primary tubing, with no access ports
or backcheck valve; when connected to a primary line via an access port, used to
infuse intermittent medications or fluids. A secondary tubing administration
set is used for secondary IV medication.
 Contd..
IV solution bags should have the date, time, and initials of the health care provider
marked on them to be valid.
Add-on devices (e.g., extension tubing or dead-enders) should be changed every
96 hours, if contaminated when administration set is replaced. Intravenous solution
and IV tubing should be changed if:
 IV tubing is disconnected or becomes contaminated by touching a non-sterile
surface
 Less than 100 ml is left in the IV solution bag
 Cloudiness or precipitate is found in the IV solution
 Equipment (date and time) is outdated
 IV solution is outdated (24 hours since opened)
MANAGING SYSTEMIC
COMPLICATIONS
 FACTORS AFFECTING FLOW
 Flow is directly proportional to the height of the liquid column. The IV tubing drip
chamber should be approximately 3 feet above IV insertion site.
 Flow is directly proportional to the diameter of the tubing.
 The clamp on IV tubing regulates the flow by changing the tubing diameter. In addition,
the flow is faster through large-gauge rather than small-gauge cannulas.
 Flow is inversely proportional to the length of the tubing. Adding extension tubing to an
IV line will decrease the flow.
 Flow is inversely proportional to the viscosity of a fluid. Viscous IV solutions, such as
blood, require a larger cannula than do water or saline solutions.
Monitoring flow

Infusion rate (ml/hr) × IV drop factor (gtts/min) = drops per

minute
60 (Administration time is always in minutes)
 Fluid Overload

 Signs and symptoms include moist crackles on  The treatment for circulatory overload
auscultation of the lungs, edema, weight gain, is decreasing the IV rate, monitoring
dyspnea, and respirations that are shallow and vital signs frequently, assessing breath
have an increased rate. sounds, and placing the patient in a high
 Fowler’s position.
Possible causes include rapid infusion of an IV
solution or hepatic, cardiac, or renal disease. The  This complication can be avoided by
risk for fluid overload and subsequent pulmonary using an infusion pump for infusions
edema is especially increased in elderly patients and by carefully monitoring all
with cardiac disease. infusions. Complications of circulatory
overload include heart failure and
pulmonary edema
Air Embolism

 It is most often associated with  Treatment calls for immediately

cannulation of central veins. clamping the cannula, placing the
Manifestations of air embolism include patient on the left side in the
dyspnea and cyanosis; hypotension; Trendelenburg position, assessing vital
weak, rapid pulse; loss of consciousness; signs and breath sounds, and
and chest, shoulder, and low back pain. administering oxygen.
 Complications of air embolism include  Air embolism can be prevented by using
shock and death. a Luer-Lok adapter on all lines, filling
all tubing completely with solution, and
using an air detection alarm on an IV
pump.
Septicemia and Other Infection.

 Pyrogenic substances in either the infusion solution or the IV administration set

can induce a febrile reaction and septicemia.
 Signs and symptoms include an abrupt temperature elevation shortly after the
infusion is started, backache, headache, increased pulse and respiratory rate,
nausea and vomiting, diarrhea, chills and shaking, and general malaise.
 In severe septicemia, vascular collapse and septic shock may occur.
 Cont..
Culturing of the IV cannula, tubing, or solution if suspect
establish a new IV site
Prevention includes:
• Careful hand hygiene before every contact
• Examining the IV containers for cracks, leaks, or cloudiness
• Firmly anchoring the IV cannula to prevent to-and-fro motion
 Cont..

• Inspecting the IV site daily and replacing a soiled or wet dressing with a dry sterile dressing. (Antimicrobial
agents that should be used for site care include 2% tincture of iodine, 10% povidone–iodine, alcohol, or
chlorhexidine, used alone or in combination.)
 Removing the IV cannula at the first sign of local inflammation, contamination, or complication
• Replacing the peripheral IV cannula every 48 to 72 hours, or as indicated
• Replacing the IV cannula inserted during emergency conditions (with questionable asepsis) as soon as
possible
MANAGING LOCAL COMPLICATIONS

Infiltration
 Infiltration is the unintentional administration of a nonvesicant solution or medication into
surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall
of the vein.
Infiltration is characterized by
 Edema around the insertion site
 leakage of IV fluid from the insertion site
 Discomfort and coolness in the area of infiltration, and a significant decrease in the flow
rate.
 When the solution is particularly irritating, sloughing of tissue may result.
Cont..

 If the catheter tip has pierced the wall of the vessel, however, IV fluid will seep
into tissues as well as flow into the vein.
 Although blood return occurs, infiltration has occurred as well.
 A more reliable means of confirming infiltration is to apply a tourniquet above (or
proximal to) the infusion site and tighten it enough to restrict venous flow. If the
infusion continues to drip despite the venous obstruction, infiltration is present.
Cont..

 As soon as the nurse notes infiltration, the infusion should be stopped, the IV
discontinued, and a sterile dressing applied to the site after careful inspection to
determine the extent of infiltration.
 The infiltration of any amount of blood product, irritant, or vesicant is considered
the most severe
Cont..

 The IV infusion should be started in a new site or proximal to the infiltration if

the same extremity is used.
 A warm compress may be applied to the site if small volumes of noncaustic
solutions have infiltrated over a long time.
 Affected extremity should be elevated to promote the absorption of fluid.
 If the infiltration is recent, a cold compress may be applied to the area.
Infiltration can be detected and treated early by inspecting the site every hour for
redness, pain, edema, blood return, coolness at the site.
Cont..
Using the appropriate size and type of cannula for the vein prevents this complication.
A standardized infiltration scale should be used to document the infiltration(Alexander, 2000):
 0 = No symptoms
 1 = Skin blanched, edema less than 1 inch in any direction, cool to touch, with or without
pain
 2 = Skin blanched, edema 1 to 6 inches in any direction, cool to touch, with or without
pain
 3 = Skin blanched, translucent, gross edema greater than 6 inches in any direction, cool to
touch, mild to moderate pain, possible numbness
 4 = Skin blanched, translucent, skin tight, leaking, skin discolored, bruised, swollen, gross
edema greater than 6 inches in any direction, deep pitting tissue edema, circulatory
impairment, moderate to severe pain, infiltration of any amount of blood products, irritant,
or vesicant
 Extravasation
 Extravasation is similar to infiltration, with an inadvertent administration of
vesicant or irritant solution or medication into the surrounding tissue.
 Medications such as dopamine, calcium preparations, and chemotherapeutic
agents can cause pain, burning, and redness at the site.
 Blistering, inflammation, and necrosis of tissues can occur.
 Cont..
 Specific treatments, including antidotes specific to the medication
that extravagated, and may indicate whether the IV line should
remain in place or be removed before treatment.
 Application of warm or cold compresses, depending on the
medication infusing.
 This extremity should not be used for further cannula placement.
Thorough neurovascular assessments of the affected extremity must
be performed frequently.
Phlebitis.

 Phlebitis is defined as inflammation of a vein related to a chemical or mechanical

irritation, or both.
 It is characterized by a reddened, warm area around the insertion site or along the path of
the vein, pain or tenderness at the site or along the vein, and swelling.
 The incidence of phlebitis increases with the length of time the IV line is in place, the
composition of the fluid or medication infused (especially its pH and tonicity), the size and
site of the cannula inserted, ineffective filtration, improper anchoring of the line, and the
introduction of microorganisms at the time of insertion.
Cont..
Phlebitis should be graded according to the most severe presenting indication
Grade Clinical Criteria
0 = No clinical symptoms
1 = Erythema at access site with or without pain
2 = Pain at access site Erythema, edema, or both
3 = Pain at access site Erythema, edema, or both
 Streak formation
 Palpable venous cord (1 in. or shorter)
4 = Pain at access site with erythema
 Streak formation
 Palpable venous cord (longer than 1 in.)
 Purulent drainage
Cont..

Treatment consists of discontinuing the IV and restarting it in another site, and applying a
warm, moist compress to the affected site.
Phlebitis can be prevented by ;
 Using aseptic technique during insertion
 Using the appropriate-size cannula or needle for the vein
 Considering the composition of fluids and medications when selecting a site
 Observing the site hourly for any complications
 Anchoring the cannula or needle well
 And changing the IV site.
Thrombophlebitis.

Thrombophlebitis refers to the presence of a clot plus inflammation in the vein.

It is evidenced by localized pain, redness, warmth, and swelling around the insertion site or
along the path of the vein, immobility of the extremity because of discomfort and swelling,
sluggish flow rate, fever, malaise, and leukocytosis
Cont..

Treatment includes
 Discontinuing the IV infusion
 Applying a cold compress first to decrease the flow of blood and increase platelet
aggregation followed by a warm compress
 Elevating the extremity, and restarting the line in the opposite extremity.
 If the patient has signs and symptoms of thrombophlebitis, the iv line should not be flushed
(although flushing may be indicated in the absence of phlebitis to ensure cannula patency
and to prevent mixing incompatible medications and solutions).
Hematoma.

 Hematoma results when blood leaks into tissues surrounding the IV insertion site.
 Leakage can result from perforation of the opposite vein wall during venipuncture, the
needle slipping out of the vein, and insufficient pressure applied to the site after removing
the needle or cannula.
 The signs of a hematoma include ecchymosis, immediate swelling at the site, and leakage
of blood at the site.
Cont..

 Treatment includes removing the needle or cannula and applying pressure with a sterile
dressing;
 applying ice for 24 hours to the site to avoid extension of the hematoma and then a warm
compress to increase absorption of blood;
 assessing the site; and restarting the line in the other extremity if indicated.
 A hematoma can be prevented by carefully inserting the needle and using diligent care
when a patient has a bleeding disorder, takes anticoagulant medication, or has advanced
liver disease.
Clotting and Obstruction.

 Blood clots may form in the IV line as a result of kinked IV tubing, a very slow infusion
rate, an empty IV bag, or failure to flush the IV line after intermittent medication or
solution administrations. The signs are decreased flow rate and blood backflow into the IV
tubing.
Cont..

 If blood clots in the IV line, the infusion must be discontinued and restarted in another site
with a new cannula and administration set.
 The tubing should not be irrigated or milked. Neither the infusion rate nor the solution
container should be raised, and the clot should not be aspirated from the tubing.
 Clotting of the needle or cannula may be prevented by not permitting the IV solution bag
to run dry, taping the tubing to prevent kinking and maintain patency, maintaining an
adequate flow rate, and flushing the line after intermittent medication or other solution
administration.
 In some cases, a specially trained nurse or physician may inject a thrombolytic agent into
the catheter to clear an occlusion resulting from fibrin or clotted blood.