OSCE: IV

Question 1

What are peripheral IV catheters used for?

Answer 1

Peripheral intravenous (IV) catheters are commonly used in hospitals to deliver fluids, medications or
nutrition directly into a vein.

Question 2

What is phlebitis?

Answer 2

It is inflammation of a vein, which may be accompanied by tenderness, warmth, erythema or palpable venous cord.

Question 3

What is infiltration? Why may it occur? What are the associated symptoms?

Answer 3

It is fluid infused into the tissues surrounding the venipuncture site.

This may occur when the tip of the catheter slips out of the vein, the catheter passes through the wall of the vein, or the blood
vessel wall allows part of the fluid to infuse into the surrounding tissue.

Symptoms may include
localised swelling, blanching, coolness of affected tissue and discomfort.

Question 4

What is extravasation? What can vesicants cause?

Answer 4

It occurs when there is accidental infiltration of a vesicant or chemotherapeutic drug into the surrounding IV site.

Vesicants can cause tissue destruction and / or blistering. Irritants can result in pain at the IV site and along the vein and may or may not cause inflammation.

Extravasation can result
in tissue sloughing, pain, loss of mobility in the extremity and infection.

Question 5

What is thrombophlebitis? What are the causes?

Answer 5

It is an inflammatory process that causes a blood clot to form and
block one or more veins, usually in your legs. The affected vein might be near the surface of your skin
(superficial thrombophlebitis) or deep within a muscle (deep vein thrombosis, or DVT).

Causes include
trauma, surgery or prolonged inactivity.

Question 6

What are tourniquets? Where should they be applied?

Answer 6

It’s for single patient use.

Tourniquets should be applied approximately 10cm above the IV
insertion site and stay on for a maximum of 2 minutes.

Question 7

Why are IV cannula’s used?

Answer 7

An intravenous (IV) cannula is inserted to establish an IV infusion or an IV lock device.

Question 8

Why are IV infusions used?

Answer 8

IV infusions are established to restore or maintain fluid and electrolyte balance, provide basic nutrition, and/or provide a vehicle to administer medications.

Question 9

Why are IV lock devices used?

Answer 9

IV lock devices are inserted to supply a direct route to a vein for intermittent administration of IV medications, or provide IV access for emergency medications.

Question 10

What should you keep in mind when selecting an insertion site for adults (4)?

Answer 10

1) Consult attending service before selecting an insertion site in extremities with contraindications
- (e.g. AV fistula, radical mastectomy, PICC line).

2) IV access in hands produces a lower incidence of infection than the wrist or upper arm.
- NOTE: Attempt all IV access as distal on limb as possible to preserve proximal sites for future
use.

3) If a lower extremity is used for cannula insertion, transfer cannula to an upper extremity site as soon as the latter is available.
4) Try to avoid veins that are at an awkward angle, thrombosed, inflamed, bruised, fragile, rolling, near bony prominences or sites of infection.

Question 11

What should you keep in mind when selecting an insertion site for paediatric pts (2)?

Answer 11

1) The scalp (in neonates or young infants), hand or foot are preferable to legs, arms or antecubital fossa sites.

2) Choose the site based on the infant’s history, physical examination and type of medication to be delivered.
- Consider the potential for scarring when selecting a scalp vein site.

Question 12

What should you keep in mind during the cannula selection (4)?

Answer 12

1) Select catheter size on the basis of the intended purpose and duration of use, known infectious and non-infectious complications (e.g. phlebitis and infiltration), vein size and experience of individual catheter operators.
2) Choose smallest size cannula possible for the type of infusion.
3) A large cannula may restrict the flow of blood through the vein.

4) A large gauge cannula (e.g. #16 or #18) should be selected for administration of blood or irritating solutions.
- NOTE: Paediatric patients –> may infuse blood with a #24 gauge cannula if it is the only
available vein.

Question 13

What should you keep in mind during the IV lock device selection?

Answer 13

1) Intravenous (IV) lock devices are established to supply a direct route to a vein for intermittent
administration of IV medication or to provide IV access in urgent situations.

2) IV lock devices are not normally used for obtaining blood samples.
- Blood cultures are never drawn from an IV lock device.
- In neonates, blood samples are never drawn from an IV lock device.
- In pediatric patients, IV lock devices are occasionally used for blood sampling with the
exception of blood cultures.

3) Flushing prevents thrombi and fibrin deposit formation, which may contribute to microbial colonisation.

Question 14

Outline the steps for establishing IV access (13).

Answer 14

1) Verify patient care order.
2) Perform hand hygiene.
3) Verify patient’s identity using two identifiers (full name & DOB).
4) Determine gauge of IV catheter required.

5) Assess extremities for appropriate placement of IV catheter.
- NOTE: Identify contraindications for insertion.

6) Prepare IV solution (if ordered).
7) Perform hand hygiene and don clean gloves.

8) Apply a tourniquet 8 to 10 cm above the selected insertion site.
- NOTE: for paediatric patients have a second person hold the limb.
- Activities to dilate veins may include: lowering extremity and applying warm compress to extremity for a maximum of 15 minutes.

9) Cleanse skin at selected vein using appropriate solution for at least 30 seconds, and allow to dry. (3 minutes in the NICU)
- Maintain aseptic technique for insertion.
- NOTE: If vein must be palpated again, cleanse site.

10) Prepare catheter system following appropriate product directions.

11) Stabilize the blood vessel and perform venipuncture following appropriate product directions.
- NOTE: Pulsations in the blood return indicate that the IV cannula is in an artery. If this occurs, release the tourniquet and remove the needle. Apply pressure over the site for a minimum of 5
minutes.

12) Release the tourniquet.
13) Apply dressing as ordered.

Question 15

Outline the steps for IV infusions (5).

Answer 15

1) Verify patient care order.
2) Perform hand hygiene.
3) Verify patient’s identity using two identifiers.
4) Cleanse access port with alcohol swab.

5) Attach primed IV administration set, infuse IV solution slowly and observe IV site.
- Discontinue IV if swelling or severe pain occurs
- Regulate IV flow rate as prescribed.
- NOTE: For paediatric patients and neonates, secure the IV access site with a skin closure
application (e.g. Steri-Strips™) and a transparent semipermeable dressing.

Question 16

Outline the steps for IV lock devices (7).

Answer 16

1) Verify patient care order.
2) Perform hand hygiene.
3) Verify patient’s identity using two identifiers.
4) Cleanse the injection site with an alcohol swab and allow site to dry for 30 seconds.
5) Insert the syringe containing the flush solution into the injection site.

6) Twist syringe one-quarter turn and gently aspirate for blood.
- EXCEPTION: In neonates, aspiration of blood is not performed to confirm patency. If the cannula is interstitial, refer to the NICU extravasation guidelines.
- If no blood appears in the syringe, gently flush the IV lock device with the prescribed flush
solution while assessing the IV lock device insertion site.
• Before initiating a chemotherapy infusion, it is usually necessary to observe blood return in peripheral sites. (On rare occasion, the site may still be deemed patent in the absence of blood
return).

7) When the IV lock device is assessed to be patent, inject the flush solution.
- Use positive pressure technique.
• The positive pressure technique ensures that blood is not drawn up into the IV lock device cannula by the negative pressure produced when the syringe is pulled out of the injection site.
- Withdraw the flush syringe from the injection site while still exerting downward pressure on the plunger and inject the last 0.5 mL of flush solution.

Question 17

Outline the steps for IV intermittent medication administration (10).

Answer 17

1) Verify patient care order.
2) Perform hand hygiene.
3) Verify patient’s identity using two identifiers.
4) Cleanse the injection site with an alcohol swab and allow site to dry for 30 seconds.
5) Insert the syringe containing the flush solution into the injection site.

6) Twist syringe one-quarter turn and gently aspirate for blood.
- EXCEPTION: In neonates, aspiration of blood is not performed to confirm patency. If the cannula is interstitial, refer to the NICU extravasation guidelines.

7) If no blood appears in the syringe, gently flush the IV lock device with the prescribed flush solution while assessing the IV lock device insertion site.
- Before initiating a chemotherapy infusion, it is usually necessary to observe blood return in
peripheral sites.
• On rare occasion, the site may still be deemed patent in the absence of blood return.

8) When the device is assessed to be patent, connect the medication line to the injection site and infuse the medication as prescribed.

9) After confirmation of specific medication administration practices in the KHSC parental therapy
manual, connect the prescribed medication line into the primary line, and infuse as ordered.
- For neonates, attach the medication to the injection site using the:
• Syringe for IV push medications; or
• IV tubing on a syringe pump for slow infusion medications.
- For pediatric patients, attach the medication to the injection site, buretrol (as required by
weight) and infusion pump.

10) When the medication has infused, disconnect the medication line and flush the IV lock device per prescriber orders

Question 18

Outline the steps for the care and maintenance of an IV site (4).

Answer 18

1) Inspect the site regularly for signs of phlebitis, infiltration and extravasation.
- NOTE: If dressing prevents palpation or visualisation of catheter insertion site, remove dressing and visually inspect site then replace with new dressing.
- NOTE: Have extravasation supplies available when irritant fluids, vesicant or vasoconstrictors are
infused.
- 1.1. If thrombophlebitis present:
• assess for alternate access
• promptly remove cannula
• apply cold or warm compresses, dependant on classification of medication infiltrate
• notify prescriber
• monitor patient’s temperature and
• avoid affected vein until phlebitis has resolved
- If infiltration present remove cannula and consider:
• elevating affected limb
• applying pressure
• splinting and/or
• application of heat or cold dependent on classification of medication infiltrate

2) Regularly monitor cannula insertion site and patient’s circulatory, neurological, and motor function in the affected limb.

3) Change IV dressing, administration set and solution per Clinical Policy T-7000 Tubing Changes: Intravascular Catheter and Device Management.
- Cleanse the area around the cannula insertion site with 2% chlorhexidine (preferred) or alcohol
during dressing changes.

Question 19

Outline the steps for the discontinuation of an IV catheter.

Answer 19

If IV cannula site is compromised and requires removal or if removal ordered:

• stop IV infusion and clamp tubing
• remove IV cannula and inspect for damage
• apply pressure until bleeding stops
• apply gauze dressing

Question 20

What should you report/record in regards to IV (4)?

Answer 20

1) Document on the Continuous Parenteral Therapy Record or unit-specific flowsheet:
- IV cannula insertion site
- gauge, length and type of cannula inserted
- IV solution, volume and rate

2) Document on the MAR or unit-specific flowsheet:
- IV solutions with medications/additives
- IV lock device flushes

3) Document in the Inter-professional Progress Notes:
- number of attempts to insert cannula
- patient’s response to the procedure
- lack of patency
- evidence of inflammation or infiltration
- assessment of the site indicating variation from the expected response

4) Communicate in the Inter-professional Patient Profile (Kardex):
- date of insertion
- site
- infusion and rate
- change due date(s)

Question 21

Go through all the steps for preparing and administering a BD Nexiva Closed IV Catheter system.

Answer 21

Preparation

• Secure vent plug and BD Q-Syte Luer Access Split Septum
• Clamp should not be engaged.
• Twist to remove the needle cover
• Pull back about 1/8 of an inch on the finger grips
• Push finger grips back to the OG position so the securement platform and finger grips are snugly together

Insertion and flashback:

• Hold the system and access the vessel
• Initial blood return is along the catheter, then up the extension tube. Look at the catheter for initial blood return.
• Lower and advance the entire catheter and needle unit slightly, to ensure the catheter tip is within the vessel

Advancement:
- Place pad of index finger behind the push-tab and push the catheter off the needle into the vessel
• Tip: don’t pull back on the needle during advancement

Needle removal:
- Stabilize the system and pull back until the push-tab component releases from the securement platform
- Discard the shielded needle into a puncture-resistant, leak-proof sharps container
• Tip: don’t hold onto the push-tab component of the device as this will prevent the release of the needle shield.

Preparation for use:

• Engage the clamp
• Remove the vent plug and attach the other BD Q-Syte device

Access and flushing:

• Disinfect the BD Q-Syte device with an appropriate antiseptic
• Insert the male luer using a straight-on approach
• Release the clamp and flush or start the infusion
• Clamp before disconnecting to minimize the reflux of blood
• Hold the BD Q-Syte device during disconnection and use a straight-off approach

Stabilization:
- Apply a transparent dressing to cover the septum, allowing maximum use of extension tubing

Question 22

What are some points to remember in regards to IV therapy? (12)

Answer 22

1) You need to be aware if your patient has intravenous access (a peripheral (ex PIV) or central (ex PICC))
2) You need to include assessment of the insertion site in your initial morning assessment
3) If your patient has an IV infusion, you need to be aware of the solution and the rate – you need to asses both of these in your initial morning assessment
4) If the solution or the rate is different from what you were expecting from your patient prep you need to follow up
5) You can check the KARDEX, discuss with your primary nurse or your clinical instructor
6) Assess when the solution bag will empty and need to be changed
7) Assess when the tubing was last changed and assess if it needs to be changed on your shift
8) Consider why your patient is receiving an IV infusion
9) You need to record your assessment of the IV site, the solution and the rate on the flowsheets
10) If your patient has a foley catheter you need to assess with your initial assessment and throughout your shift to make sure that your patient has an adequate output
11) If your patient does not have a foley catheter and is incontinent, voiding via commode/urinal or bathroom you still need to be assessing that they are voiding appropriately through the day
12) If your patient does not have adequate intake or output you need to follow up with your primary nurse and clinical instructor