Preform Intravenous Therapy/Maintain Access Devices and Infusions (LO8 & 9)

Question 1

Intravenous Access Sites

Answer 1

start as distal as possible and work your way up

This allows for subsequent cannulation attempts on the same extremity if there is a failed cannulation

If you attempt an IV distal to a previous attempted site, you risk leaking of fluid into the surrounding tissue at the previous site and resulting damage

Question 2

When choosing a site, it is important to keep the following criteria in mind:

Answer 2

Find a section of vein that is straight and will accommodate the full length of the cathlon.

Look for a vein that is full and round in appearance and that does not “roll.”

Avoid valves if possible as a cannula will not pass through easily and if you push through with the needle you may cause damage to the valve.

Avoid starting near joints.

Avoid any injuries, edema, fistulas, or same side as a previous mastectomy.

Question 3

Peripheral Intravenous Access Sites

-Upper Extremity

Answer 3

-The three main veins of the antecubital fossa (the cephalic, basilic, and median cubital) are frequently used

Question 4

when are the three main veins of the antecubital fossa ideal sites

Answer 4

when large amounts of fluid must be administered

Question 5

the most commonly used vein

Answer 5

The accessory cephalic vein

Question 6

when may the veins in the dorsal hand be utilized

Answer 6

if large bore access (18 gauge or larger) is not required

Question 7

Peripheral Intravenous Access Site

-Lower Extremity

Answer 7

• Insertion can be quite painful, and the catheter may cause more discomfort than if it were started in the hand or forearm
• IV catheters placed in the feet are more likely to become infected, not flow properly, and produce phlebitis
• The great saphenous vein

Question 8

which lower extremity veins can be used

Answer 8

• The lesser saphenous vein
• The great saphenous vein
• Any vein in the foot large enough to accept the IV catheter may be used, if necessary

Question 9

Alternate Intravenous Route

Answer 9

when an IV in an extremity cannot be established, is an external jugular vein cannulization.

In Saskatchewan, this skill is only to be performed by licensed Advanced Care Paramedics.

Question 10

external jugular vein cannulization

-indications

Answer 10

For the administration of fluids or medications in patients where other peripheral IV (intravenous) attempts have been unsuccessful.

Question 11

external jugular vein cannulization

-location

Answer 11

The external jugular vein

It is a painful site, reserved for patients with decreased or a total loss of consciousness.

Question 12

external jugular vein cannulization

-The external jugular vein

Answer 12

it can accommodate up to a 12g needle

formed below the ear and behind the angle of the mandible where it passes downward and obliquely backward, across the surface of the sternomastoid muscle.

It then pierces the deep fascia of the neck just above the middle of the clavicle.

Question 13

external jugular vein cannulization

-contraindications

Answer 13

• Infection over the insertion site
• Lack of anatomic landmarks due to neck size, shape, or deformities
• Patients unable to tolerate a Trendelenberg position
• Unsuccessful contralateral attempt at insertion with resultant hematoma
• Coagulopathies: In these cases, other more easily compressible sites should be considered.

Question 14

external jugular vein cannulization

-precautions

Answer 14

• Puncture the vein as close to the angle of the jaw as possible, to avoid injuring the lung and causing a pneumothorax.
• Ensure IV set is clear of all air and connections are tight.

Question 15

Local hematoma jugular vein

• prevention
• management

Answer 15

prevention
• Going too deep might lacerate the deep wall of the vein or too superficially the superficial wall of the vein

• To prevent this, take care to strictly follow the axis of the vein during insertion

management
-Local pressure (but never circumferentially applied)

Question 16

Laceration of the deeper internal jugular vein

• prevention
• management

Answer 16

-prevention
Do not insert the needle deeply for this procedure.

-management
Local pressure (but never circumferentially applied)

Question 17

Infection jugular vein

• prevention
• management

Answer 17

-prevention
Aseptic procedure
Never insert through infected skin

-management
Appropriate antibiotics

Question 18

Air embolism jugular vein

• prevention
• management

Answer 18

prevention
• Maintain a Trendelenberg position
• Have the patient exhale while advancing the catheter if conscious
• Maintain a “closed” system

management
-Place the patient in a left lateral recumbent, head down position to minimize the chances of an air embolism to the brain.

Question 19

Preparing an Infusion Site

Answer 19

• 6 rights of medication
• Check color and clarity of solution
• Check expiration date
• Insert spike into port
• Hang bag on pole
• Compress drip chamber until it is ½ full
• Prime
• Select the vein
• Apply tourniquet 4-6 inches above IV site
• Check for presence of radial pulse
• Use most distal site in non dominant arm
• Palpate vein and note resilient, soft bouncy feeling
• Cleanse area for 30 secs

Question 20

how to select vein

Answer 20

o Cephalic, basilic and median are preferred in adults
o Dorsal hand veins are fragile and should be avoided in older pts
o Avoid: areas of tenderness, redness, rash, pain or infection; interferes with daily activities; use of assisted devices; extremity affected by CVA, paralysis, dialysis shunt or mastectomy; sites distal to previous venipunctures; sclerosed, hardened or phlebitis veins; areas with infiltration or venous valves

Question 21

Initiating an IV

Answer 21

• Cleanse area for 30 secs
• Using thumb of non dominant hand stretch the skin below the site
• Holding needle bevel up firmly insert the needle in vein in one smooth motion at a 45 degree angle and then immediately drop angle to 15 degrees
• Check flashback chamber for blood return
• Advance the device 2-3mm
• Remove the tourniquet
• Remove needle while advancing the catheter up to the hub or until you meet resistance
• Attach the IV tubing to the IV catheter
• Secure

Question 22

Performing Venipuncture

Answer 22

same as initiating IV
but also:
- Advance the catheter off the needle
- Stablizie catheter and remove tourniquet
- Apply firm gentle pressure to vein 1 inch from insertion site
- Connect saline lock or primary administration set
- Slowly flush

Question 23

Dressing the Infusion Site

Answer 23

• use transparent dressing
• apply 1 edge of dressing and smooth over
• leave the area between iv tubing and catheter hub uncovered
• place 1 inch piece of tape over administration set or extension tubing
• do not apply tape to transparent dressing
• label dressing

Question 24

to secure the catheter using gauze

Answer 24

• place a piece of tape over the catherter hub
• do not apply tape over insertion site
• tape 2x2 sterile gauze over insertion site and catheter site do not cover connection between tubing and catherter hub
• fold 2x2 gauze in half and cover it with tape slide this between the tubing and catheter hub
• once secured open line clamp

Question 25

Troubleshooting Intravenous Infusions

Answer 25

• Check flow rate
• If the infusion rate is set properly but alrm is sounding check for kinks in tubing
• Assess IV device; look for bleeding at iv sight
• Check insertion site for color changes, swelling and drainage
• Palpate around site
• Check for phlebitis; if found stop infusion

Question 26

To document and IV insertion you need to include the following:

Answer 26

1. The gauge of the needle
2. The IV attempts versus successes
3. The site example left forearm
4. The type of fluid you are administering
5. The rate at which the fluid is running

Question 27

when to Change an IV bag

Answer 27

• Change the bag with approximately 50 mL of fluid is left

Question 28

The steps for changing an IV bag are as follows

Answer 28

1. Stop the flow of fluid from depleted bag by closing the roller clamp
2. Prepare the new IV bag by removing the pigtail from the piercing spike port
   - inspect the new bag of IV fluid for clarity and discolouration and to ensure that expiry date has not passed
3. Remove the piercing spike from the depleted bag and inserted into the port on the new bag
4. Ensure the drip chamber is appropriately filled and then open the roller clamp and adjust the fluid rate accordingly

Question 29

Discontinuing the IV line

Answer 29

1. Shut off the flow from the IV line with a roller clamp
2. Gently peel the tape back to where the IV site and stabilize a catheter while you loosen the remaining tape
3. Do not remove the IV tubing from the hub of the catheter
4. For the 10 x 10 piece of gauze and place it over the site holding it down while you pull back on the hub of the catheter
5. Gently pull the catheter in the IV line from the patient’s pain while applying pressure to control bleeding

Question 30

following components are necessary for IV therapy:

Answer 30

• Solution containers
• Administration sets
• Needles and cannulas
• IV fluids

Question 31

IV fluids are packaged in two types of containers and are labeled indicating…

Answer 31

glass bottles and plastic bags

labeled indicating the solution and strength, and they have a graduated scale and an expiry date

Question 32

Administration Sets

Answer 32

The administration set is in a sterile package consisting of:

• the tubing,
• a drip chamber,
• a flow adjustment valve
• piercing pin
• an injection site

Question 33

Tubing

Answer 33

• The tubing is made of a clear pliable plastic which facilitates visualization of the solution in order to check for air bubbles and foreign particles
• The pliability of the tubing allows for movement
• The top of the tube has a piercing pin for insertion into the solution bag or bottle
• At the bottom end of the tube is an adapter that fits into the IV catheter placed in one of the patient’s extremities.

Question 34

Drip chamber

Answer 34

• The drip chamber is located beneath the piercing pin
• controls the rate of fluid administration which is monitored by counting the drops falling into the chamber
• The drop size varies according to the type of set used

Question 35

There are two basic types of infusion sets:

Answer 35

macrodrip (standard) infusion set

microdrip infusion set

Question 36

macrodrip (standard) infusion set

Answer 36

is designed for rapid fluid replacement

designed to deliver a total of 10, 15, or 20 gtts (drops) /mL

Question 37

The microdrip infusion set

Answer 37

is not designed to replace lost fluid; rather, to maintain a to keep open (TKO) rate and/or to provide a route for drug administration

The microdrip set is designed to deliver 60 gtts (drops) /mL.

Question 38

the injection site

Answer 38

Near the bottom end of the tube is a junction

A syringe can be attached at this site for administration of drugs

Question 39

The most commonly used sizes in the field

Answer 39

18 and 20 gauge

Question 40

There are two types of IV needles available

Answer 40

Steel, and Over-the-Needle

Question 41

the steel needle

Answer 41

(also called the Butterfly), has been around a long time but has become less popular since the introduction of the plastic catheter over the needle system

Question 42

Over-the-Needle

Answer 42

• the catheter over the needle which allows a steel needle to puncture the skin and gain access to the vein
  o Once the placement is confirmed in the vein, the plastic catheter is slid over top of the steel needle and secured in the vein
  o The steel needle is then withdrawn from the vein and the plastic catheter remains in place

Question 43

Steel (Butterfly)

-advantages

Answer 43

• Easiest to insert
• Useful for scalp veins in infants and in small, difficult veins in geriatric patients
• Small guage short needles

Question 44

Steel (Butterfly)

-disadvantages

Answer 44

• May easily cause infiltration
• Possible blood cell damage when drawing blood
• Small gauge needles limit fluid flow

Question 45

over the needle

-advantages

Answer 45

• Less likely to puncture the vein
• More comfortable for patient once in position
• Radiopaque for easy identification during x-ray

Question 46

over the needle

-disadvantages

Answer 46

• More difficult to insert
• Risk of sticking paramedic with contaminated needle as it is withdrawn
• Possibility of catheter shear

Question 47

The most common solutions utilized in the field are

Answer 47

5% dextrose in water (D5W), Ringers lactate and normal saline

Question 48

5% Dextrose in Water (D5W)/10% Dextrose in Water

Answer 48

• This hypotonic solution contains 5 grams or 10 grams of glucose for each 100 mL of water.
• Because it is absorbed from the circulatory system into the body tissues quite rapidly, it is not used for fluid replacement but is used commonly for diabetics and maintaining a lifeline.

Question 49

Ringers Lactate

Answer 49

• This isotonic solution contains sodium chloride, lactate, potassium, and calcium.
• It is used for fluid replacement because it remains in the vascular space.
• It is commonly referred to as a volume expander and is the fluid of choice for trauma patients.

Question 50

Normal Saline

Answer 50

• This is an isotonic solution of 0.9% sodium chloride.
• It most closely resembles body fluids in density and osmotic pressure.
• It is an adequate temporary solution for fluid replacement during hemorrhage or fluid loss due to burns, peritonitis, or excessive diarrhea.
• It is also referred to as a volume expander.

Question 51

Phlebitis

• description
• signs and symptoms
• treatment

Answer 51

Description
- Inflammation of the vein. It is caused by mechanical trauma or chemical irritation to the vein.

Signs and Symptoms
- Burning pain along the vein; edema; redness; increased skin temperature over the course of the vein.

Treatment

1. Discontinue the IV.
2. Apply warm packs to provide some relief.
3. Notify emergency physician.
4. Record procedure and reasons.

Question 52

Thrombophlebitis

• description/prevention
• causes
• signs and symptoms
• treatment

Answer 52

Description
- Caused by local damage to the venous wall, and resultant inflammation and thrombus formation. This can be prevented by checking the site daily for signs, changing the IV (intravenous) site every 72 hours, ensuring all connections are tight, and using an aseptic technique.

causes
o The IV needle passes completely through the van and out the other side
o The patient moves excessively
o The tape used to secure the IV line becomes looser dislodged
o Catheter is inserted to shallow and angle and enters only the fascia surrounding the vein

Signs and Symptoms
- Pain; erythema; swelling; a palpable cord along the course of the cannulated vein.

Treatment

1. Discontinue the IV.
2. Apply warm packs to provide some relief.
3. Notify emergency physician.
4. Record procedure and reasons.

Question 53

Infiltration (Interstitial)

• description
• signs and symptoms
• treatment

Answer 53

Description
- Infiltration is the escape of fluid into the subcutaneous tissue due to dislodgement of the needle.

Signs and Symptoms
- Reduced rate of flow (an early sign); pain at the site; swelling of the subcutaneous tissues; skin becomes cold.

Treatment

1. Discontinue the infusion.
2. Apply cold packs (early) or warm packs (later) to aid absorption.
3. Re-establish an IV at another site.
4. Notify emergency physician.
5. Record procedure and reasons.

Question 54

Circulatory Overload

• description/causes
• signs and symptoms
• treatment

Answer 54

Description
- Circulatory Overload occurs when the intravascular fluid compartment contains more fluid than normal.

This is usually due to infusion rates being too rapid, resulting in cardiac failure and pulmonary edema. Monitoring flow rate is essential in preventing circulatory overload.

Flow rates must not be increased for an infusion that is behind schedule.

Signs and Symptoms
- Patient discomfort; rapid pulse; venous distention; increased B/P; coughing; shortness of breath; increased respiration; syncope, shock; pulmonary edema - dyspnea, cough, cyanosis, frothy sputum, gurgling sounds on respiration.

Treatment

1. Slow the IV to a “keep open” rate.
2. Administer oxygen.
3. Raise the patient to a sitting position.
4. Notify the emergency physician for further instructions.
5. Record procedure and reasons.

Question 55

Air Embolism & Catheter Embolus

• descriptions/causes
• signs and symptoms
• treatment

Answer 55

Description
- Air embolism occurs when air enters the circulatory system.
Causes include: patient movement, occur with the insertion of an IV catheter, during manipulation of the catheter or catheter site when the device is removed, or when IV lines associated with the catheter are disconnected.

-Catheter embolism is when the tip of the catheter is sheared off; it may potentially embolize and travel proximal in the circulation.
This is always caused by poor technique during the insertion of the IV, when the needle is withdrawn from the catheter and then reinserted.

Signs and Symptoms
- Shock; chest pain, cyanosis; tachycardia; respiratory distress, rapid loss of consciousness.

Treatment

1. Immediately close adjustment valve.
2. Clamp off tubing, with a hemostat or other clamp, as close to the infusion site as possible. Ensure the catheter is firmly attached to the tubing.
3. Place patient on the left side with the head down. This will allow the air embolus to fill the right atrium and let the blood still pass to the right ventricle, so that the heart will keep pumping.
4. Administer oxygen.
5. Initiate a second IV.
6. Contact the emergency physician for further instructions.
7. Record procedure.

Question 56

Pyrogenic Reaction

• description
• signs and symptoms
• treatment

Answer 56

Description
- An infection or bacteria (pyrogens) in the solution.
Signs and Symptoms
- Usually occur about 1/2 hour after IV is started or container is changed. Chills and fever; - malaise; headache; nausea and vomiting; backache; shock – with a possibility of circulatory collapse.
Treatment
1. Stop the infusion by closing the flow adjustment valve.
2. Discontinue the IV.
3. Treat for shock.
4. Contact the physician for further instructions.
5. Record procedure and reasons.

Question 57

Speed Shock

Answer 57

Description
- A sudden adverse physiologic reaction to IV medications or drugs that are administered too quickly.

Signs and Symptoms
- Flushed face; headache; a tight feeling in the chest; irregular pulse; loss of consciousness; cardiac arrest.

Treatment

1. Slow infusion.
2. Administer oxygen.
3. Watch for the development of cardiac arrest.
4. Contact the physician for further instructions.
5. Record procedure and reasons.

Question 58

Hypersensitivity

Answer 58

Description
- An immediate or delayed adverse response which may occur following medication administration. Always confirm the patient’s allergies prior to administering any medications.

Signs and Symptoms
- Vary. Mild rash or anaphylactic shock; urticaria; laryngeal and glottis swelling; upper respiratory obstruction; hypotension; shock.

Treatment

1. Stop the medication administration immediately.
2. Administer oxygen.
3. Administer epinephrine if indicated.

Question 59

Blood tubing

Answer 59

is a macro drip administration set that is designed to facilitate rapid fluid replacement by manual infusion of multiple IV bags or IV and blood replacement combinations

o The central drip chamber has a special filter design to filter the blood during transfusions

Question 60

Volutrol

Answer 60

: a macro Dripset that allows you to fill a 100 or 200 mL calibrated drip chamber with a specific amount of fluid and administer only that amount to avoid fluid overload

Question 61

what gauge catheter is a good size for adults who do not need fluid replacement

Answer 61

an 18 or 20 gauge catheter is usually a good size for adults who do not need fluid replacement metacarpal veins of the hand can usually accommodate 18 or 20 gauge catheters

Question 62

what gauge catheter is a good size for when the patient requires fluid replacement or may receive blood products

Answer 62

• A 14 or 16 gauge catheter should be used when the patient requires fluid replacement and certainly should be used in any patient who may receive blood products or undergo a surgery in the hospital

o You should be able to insert a 14 or 16 gauge catheter into an anti-cubital vein an average adult

Question 63

Occlusion

• description
• signs
• treatment/reestablishment of line

Answer 63

description
- The physical blockage of a vein or catheter

signs

• The first sign of occlusion is decreasing drip rate her presence of blood and IV tubing
• Occlusion may develop if the IV bag nearest empty in the patient’s blood pressure overcomes the flow causing fluid back up in the line

reestablishment of line

• follow these steps to determine whether the IV line should be reestablished
  1. Select and assemble a sterile 10 mL syringe and large gauge needle
  2. Suction injection port closest to the IV site and swab with alcohol
  3. Insert the needle into injection port
  4. Pinch the line between the injection port and IV bag
  5. Gently pull back on the plunger to disrupt the occlusion and reestablish flow never push the inclusion into the patient
  6. If the flow is reestablish ensure that the rate is sufficient
  7. If you are unable to reestablish flow discontinue the IV line and reestablish on opposite

Question 64

Hematoma

• description
• signs
• treatment

Answer 64

description
- A haematoma is an accumulation of blood in the tissue surrounding an IV site often results from the vein perforation or improper catheter removal

signs
- Blood can be seen rapidly pooling around the IV site leading to tenderness and pain

Treatment
o If a haematoma develops while you were attempting to insert a catheter stop and apply direct pressure
o If a haematoma develops after successful catheter insertion evaluate the IV flow in the haematoma
o if it appears to be controlled and the flow is not affected monitor and leave it
o if the haematoma develops as a result of discontinuing the IV line apply direct pressure with gauze

Question 65

Vasovagal

• description
• treatment

Answer 65

description
- Some patients have anxiety concerning needles with a side of blood which may cause vasculature dilation leading to a drop in blood pressure and fainting

Treatment
o Treat them for shock
1. Place patient in shock position
2. Apply high flow oxygen if necessary and indicated
3. Monitor vitals
4. Establish an IV line in case fluid resuscitation is needed

Question 66

It is important that you perform a check of the following items after every intravenous initiation and when a flow rate issue is encountered:

Answer 66

• Is the tourniquet on?
• Is the tubing clamped or kinked?
• Is the intravenous now interstitial?
• What is the cathlon size? The larger the cathlon the faster the flow.
• Is the bag too low?
• What is the administration set? Micro versus macro
• What is the fluid? Thicker and colder fluids will run slower.

Question 67

If any of these occur, the following procedure should be followed:

Answer 67

1. Shut off the IV flow by closing the flow adjustment valve.
2. Remove tape and dressing (if any) from the infusion site.
3. Hold a cotton swab or sterile 4 × 4 above the entry site. Apply pressure as soon as needle is withdrawn. Do not apply pressure while the catheter is being withdrawn as the vein can be traumatized.
4. Remove the catheter by pulling straight out in line with the vein. Immediately check the needle or catheter to ensure intactness. If the catheter is not intact or it appears that a section or piece has broken off, immediately apply a tourniquet at the most proximal location on the limb, position the patient on the left side with head lower than feet, administer oxygen, and transport to the nearest hospital.
5. Immediately apply pressure to the site for about 1 minute.
6. Apply a band-aid over the site.
7. Record procedure. Including any sign and symptoms noted, treatment done and time procedure performed.

Question 68

drip rate calculation equation:

Answer 68

Volume × Set = Time × Rate

*Remember with drip rate calculations we always round up!

Question 69

Monitor an Existing IV

Answer 69

1. Check fluid level —
   the solution container should not run dry.

The container is changed when 50 mL of the solution is left.

Reading fluid levels must be done at eye level.

If a plastic bag is in use, milk the bag by pulling the sides taut and then releasing before you read the fluid.

2. Check for total infusion to see if it is on schedule.

If too much or not enough solution is left in the bag for the amount of time expired, recalculate the drip rate.

3. Check the drip chamber. Is there flow and is the rate correct?
4. Check tubing for patency, kinking, or obstructions.
5. Check the IV site. Visualization of the infusion site is important in order to detect signs of complications.
   • Skin—colour and temperature should be normal
   • Pain—should be pain free
   • Swelling—should be free of swelling
6. Check patient’s arm.
   • Is the IV still properly affixed?
   • Is there good circulation?
7. Assess the patient’s comfort. The patient should not experience pain or discomfort in association with the IV.
8. Take vital signs at regular intervals.
   • This will help detect signs of complication early
   • Take blood pressure on the opposite arm
9. Record all observations as well as the time they were observed.

Question 70

If you cannot stabilize the flow rate, the following checks should be made in the order listed.

Answer 70

1. Check the bag for adequate fluid.
2. Check the infusion site for complications.
3. Check the tubing for kinks.
4. Reposition the patient’s arm. A bent arm may cause an obstruction of the flow.
5. Adjust the height of the bag.
6. Make sure the flow adjustment valve is working.

Question 71

Changing an Existing IV Solution Container

Answer 71

• The IV solution container must be changed when 25 mL of the solution is left in the bag.
• It is important to change the container before the solution is completely used to prevent air from entering the vein.
• If air enters the vein, an air embolus could occur

Question 72

Changing an Existing IV Solution Container procedure

Answer 72

1. Carefully inspect the new solution container prior to changing the IV container
2. Stop the flow of the existing IV.
3. Remove the tubing from the old container without touching the spike and keep fingers behind the flange.
4. Insert the spike into the port of the new container while holding the neck of the port tightly to prevent slipping and possible contamination.
5. Invert the new container and hang it on the IV pole.
6. Ensure the drip chamber is half full by squeezing the drip chamber and releasing if necessary.
7. Release clamp or open flow adjustment valve.
8. Re-establish the correct drip rate.
9. Record the procedure including the time the bag was changed.

Question 73

. The following criteria should be assessed: when assessing new solution container

Answer 73

• Compare the label on the bag to the physician’s order to ensure the correct solution has been selected. The name of the solution should be read aloud.
• Ensure the outer wrapper is intact — the bag is considered unsterile if it is out of the wrapper more than 24 hours.
• Inspect the solution. The solution must be clear, colourless, and particle free. When inspecting, hold the container up to the light. Select a different container if there is doubt.
• Check for leaks by squeezing the bag — leaks in the bag will cause the fluid to become contaminated.
• Check the expiry date.