Venipuncture Flashcards
What is venipuncture
-Process of obtaining intravenous access for the purpose of administering IV therapy or drawing a blood sample
What is a straight poke
Often done by lab techs
Done to draw a blood sample
Types of Vascular Access Devices
-Intraosseus
-Short Peripheral IV catheter
-Midline Catheter
-CVAD/PICC
When is Intraosseus used
-Used in emergency situations when obtaining peripheral IV access is difficult/impossible or when delay could be life threatening
-Eg. Cardiac arrest, shock, extensive burns, major trauma
IO’s and circulation
-Reach central circulation rapidly
Sites for OS insertion
-Tibia, Femur, Humerus, Sternum
-Chosen site must be an intact bone (no fracture or crush injury because fluids could leak into tissue
-Site must have no sign of compromise (infection, decreased circulation)
Duration of OS
-Short term use only (24 hours)
-After 24 hours must replace with another vascular access device
How to insert OS
-Drill which drills needle to appropriate depth
-Manual needle that is inserted by applying pressure and twisting
-Must have special training before you attempt (advanced life support course)
Short peripheral IV catheter (winged butterfly)
-Winged butterfly needle is meant for short term use like for a straight poke
-Can stay in the vein for up to 2 hours
-It has a metal needle which is rigid so there is increased trauma and discomfort if left in vein too long
Short Peripheral IV Catheter (IV Start)
-Over the needle catheter is what would be inserted for an IV start
-Plastic cannula is over a metal styler
-Cannula is flexible and softens so it can be used long term (several days)
-IV catheters can be made out of different materials such as Teflon, polyurethane, or silicon
Safety Devices Manitoba
-Due to safety legislation in Manitoba, all needles must have a safety mechanism to prevent needle stick injuries
Passive Safety Device
-You do not need to do anything to activate the safety mechanism
-Will automatically happen
-Eg. When the metal stylet is removed from the plastic cannula, the end of the needle will automatically be covered by a safety device
Active Safety Device
-You need to do something to activate the safety mechanism like push a button
Blood Control Technology
-Some IV catheters have
-After catheter is inserting into vein, when metal stylet is removed from cannula, there is a temporary one way valve that prevents blood from coming out and allows the nurse time to connect IV extension set
-Those that DONT have require digital pressure
How we chose catheter size
-Depends on the intended use of the IV and the size of the patients vessels
-Idea is to pick smallest gauge and shortest length IV catheter that will do the job
What choosing the best catheter size means
-Takes up less space in the vein
-Leads to better flow around the catheter thereby promoting hemodilution of the fluid and reducing risk of phlebitis (vein inflammation)
Yellow catheter
24g
-infants, children, elderly
Blue catheter
22g
-Children, elderly, general infusions
Pink catheter
20g
-General infusions, blood admin
Green and grey catheter
18g, 16g
-Trauma, surgery, blood admin
Midline catheter
-For therapy 1-4 weeks
-Longer than PIV catheter (7.5-20cm)
-Inserted near the antecubital area and tip located level/near the level of axilla
-Not a CVAD because tip does not sit in the central circulation
-Can be single or double lumen
-Requires special training; inserted by same nurse who insert PICCs
IV order
-Typically providers do not write an order to insert and IV catheter
-Instead they order something to be administered by the IV route
Assessment: Allergies
-Patient should be asked if they have any allergies to latex, skin antiseptic, and tape
Assessments: Hair removal
-Nurse needs to inspect the patients arms to determine if hair removal is needed
-Never use a razor to shave hair
-Shaving causes little nicks in the skin or micro abrasions which can lead to infection
-Nurse should use a clipper to clip hair instead
Assessment: Vital Signs
-Not routinely taken before starting IV catheter
-Some patients can have a vasovagal episode which will affect their vitals (bradycardia and hypotension) which can lead to syncope
-Good to ask how patient is with needles
If patient says they get lightheaded or pass out
-Get them lying down prior to the IV start so that they are not at risk for a fall
-Having baseline VS helps to know when a patient is recovered from vasovagal episode
Assessment: Bleeding tendencies
-Patient may have medical conditions such as thrombocytopenia (low platelets) or may be on anticoagulants
Assessment: Analgesic
-Not routinely done
-May be administered in certain patient populations or circumstances
-NOT referring to an oral analgesic like Tylenol
-May be a transdermal or topical analgesic cream such as Emla (applied 60 mins before insertion) of intraddtmal anaesthetic like lidocaine to freeze skin just prior to IV insertion
Peripheral Access Site Selection Depends On
-Age, duration, & rate of therapy, type of solution, condition of veins
Peripheral Access Site Selection: Adults
-Use veins in arms
-Forearm preferred over metacarpal veins in hand for rapid infusions, hypertonic, acidic, alkaline, and irritating solutions
When planning which vein to use ..
-Nurse needs to consider viscosity (thickness) of solution
-How quick a certain volume needs to be infused
-The pH or osmolarity (amount of solute or how concentrated a solution is)
Veins in hand/forearm
-Small, have slowest flow rate
-As we move up into the forearm the veins get bigger and the flow rate is faster
-Closer to the heart, the flow rates are the fastest
Flow rates: Hands and lower forearm
-10-95ml/min
Flow rates: Upper arm
-250ml/min
Flow Rates: Closer to superior vena cava
2-3L/min
When you need a vein with increased blood flow
-If nurse needs to infuse a thick solution
-If a nurse needs to administer an IV solution very quickly
-Solutions with high or low pH can be irritating to the vein
-When meds/solutions have a high osmolarity it can be irritating
-in these situations a nurse should choose a vein that has increased blood flow to allow for greater mixing and prevent vein irritation
When choosing a vein for IV insertion..
-Inspect both upper extremities for a suitable vein
-Look for a vein In The back of the hand (metacarpal veins
-Or look in the forearm (inner or outer but inner is more tender; cephalic or basilic veins)
-Only nurses who get additional special training (after becoming an RN) should insert IV catheters above the anyecubital fossa (ACF)
Ideally look for a vein that is…
-Visible, palpable, straight
-at least straight for a portion long enough to accommodate the length of the IV catheter
-Vein should be round, soft, elastic, bouncy, and full
-Should consider going distal to proximal and work our way up
-Means we should consider using a vein in the back of the hand if possible before looking for a vein in the forearm
-However more recent practice guidelines indicate that nurses should select a vein that will likely last the duration of IV therapy even if it means starting with a vein in the forearm
Non-dominate
-If possible select a vein on the non dominate arm first, choose a site that doesn’t interfere with ADLs particularly in the older adult population
Patient preference
-Lastly if possible consider patient preference in location
Vascular Visualization Technology
-Recommended for those with difficult venous access; visualization technology could be use of light (transillumination) or ultrasound
-But this technology is not available in all clinical settings and would require additional training on how to use it
What to Avoid when Selecting a Vein:Flexion
-Avoid areas of flexion like ACF and wrist (can alter rate of infusion and increase discomfort)
-If area of flexion cannot be avoided, consider using an arm board to keep the joint extended
What to avoid when selecting a vein: wrist
-Avoid laterally and ventral surfaces of the wrist
-Stay 3 finger breadths above the wrist to prevent potential nerve damage
-If during insertion a patient complains of an electric shock, burning pain, or numbness, immediately remove the IV catheter
What to Avoid when Selecting a Vein: Compromised extremities
-Examples of compromised extremities include arms with decreased circulation (mastectomy, presence of lymphedema, dialysis fistula a, area for planned procedure
-Avoid extremities with paralysis like an affected side after CVA
What to Avoid when Selecting a Vein: Compromised Vein
-Examples of compromised veins include veins that are bruised, have phlebitis (inflamed), infiltrated (IV catheter is no longer in the vein and is in the tissue surrounding the vein), sclerosed (hard or thick veins from multiple punctures, feel cord like)
Veins in lower extremities
-Avoid due to risk of embolism/thrombophlebitis
-Veins in feet in adults are only used in an emergency situation and only with a health care providers order to do so
-Veins in the lower extremities are routinely used in infants
Vein Distention: Tourniquet
-Various methods to assist
-A nurse can apply a tourniquet about 6 inches above the intended puncture site
-Tourniquet should be tight enough to occlude venous flow but not tight enough to occlude arterial flow
-Should be able to palpate the radial pulse with tourniquet on
-Should attempt to keep the tourniquet flat as a twisted/rolled tourniquet can cause discomfort
-Limit time the tourniquet is on to avoid circulatory compromise (1 minute max)
-Tourniquet should be single use only and tied in quick release manner
Vein Distention: BP Cuff
-Can be used to occlude venous flow instead of tourniquet
-Nurse should inflate the BP cuff to a level just below the diastolic blood pressure
-Using BP cuff may be gentler on fragile skin/veins than using a tourniquet
Vein Distention: Warmth
-Can be applied to the area
-Heat dilates vessels
-Nurse May wrap the patients arm in warm flannels
Vein Distention: Methods
-Arm can be dangled below the level of the heart (when an extremity is in a dependent position, venous return is slower so there will be vein Distention)
-The patient could be instructed to open and close first a few times
-The vein could be stroked distal to insertion site in the direction of venous flow towards heat
-Lastly nurse could lightly tap the vein
What angle to insert IV needle
-insert needle bevel up at 10-30 degree angle
While flushing watch for …
-swelling
-hematoma formation
-pain
What dressing should be applied to IV site
-Dressing used should be a transparent semi permeable membrane (TSM)
-Dressing that is breathable but not impermeable to liquids and bacteria
Documentation
-Document should include type/length/gauge of IV catheter/site/# of attempts/type of dressing/IV therapy initiated/Patient response/plan
-Eg: #18g IV catheter established to left forearm on second attempt. NS @ TKO infusing well. Client tolerated procedure well. Will monitor for complications.
Common Reasons For Venipuncture Failure
-Tourniquet placement
-Failure to release tourniquet
-Failure to stretch/stabilize vein
-Stopping insertion before cannula enters vein
-Angle of insertion
-# of Attempts
Failure: Tourniquet Placement
-If the tourniquet is too tight or too loose, or too close to the insertion site
Failure: Releasing Tourniquet
-Pressure builds in the vein if left distended too long, the vein will blow
Failure: To stretch/stabilize
-If not adequately stabilized, veins can roll when punctured
Failure: Angle of insertion
-It is common to insert at too high of an angle which leads to the catheter shearing through the posterior vein wall
Failure: Attempts
-Only 2 attempts allowed by a nurse, no more than 4 total attempts
Complications of Venipuncture: Vasovagal reaction
-Potential complication
-Usually short lived event
-HR and BP drop and subsequently patient becomes pale, diaphoresis, dizzy, feels hot/cold, and may faint (syncope)
-Treatment is to lie patient down (usually happens when someone is sitting up, monitor VS and possibly give IV fluids
Complications of Venipuncture: Nerve Damage
-If wrist area not avoided nerve damage can result
-The patient will experience electric shock, or a burning sensation if a nerve has been poked during IV insertion
Complications of Venipuncture: Hematoma
-Is a collection of blood outside of the vein
-Can form during insertion or after removal of an IV catheter
-Treatment for a hematoma is to apply direct pressure, elevate the extremity, and to apply ice
Complications of Venipuncture: Infiltration
-Occurs when IV fluids enter the surrounding space around the Venipuncture site
Causes of Infiltration
-Include:
-Puncture of the vein wall during insertion and cannula friction from a line not being secured and having movement/manipulation
Clinical Manifestations of Infiltration
-Swelling around IV insertion site when IV catheter is flushed with normal saline
Treatment for infiltration
-To remove the IV catheter and insert a new one elsewhere
IV Pediatric
-IV sites used include: scalp, forearm, hand, and foot
-With scalp veins, aim towards the heart (less risk of entanglement, not in their way)
-Extra help will be required for IV insertion on infants and young children (often bundle the child up in a sheet only leaving out the limb intended for insertion)
-Parents should never be asked to restrain their own children (May let go at the wrong moment and this can be psychologically traumatizing to both the parent and the child)
-Ask the parent if they wish to stay in the room or leave
-Cover IV sites with protective devices and use padded arm boards or splints to decrease mobility of extremities
IV: Geriatric
-With aging skin loses tone and elasticity and becomes more fragile and prone to bruising
-If possible avoid back of hand because loss of subcutaneous tissue and thin skin and it may interfere with their independence with ADLs
-Consider not using a tourniquet or use a BP cuff for vein Distention as it is gentler and result in less vein blowing
-Careful dressing fragile skin (minimize the use of tape to avoid irritating sensitive skin)
-Older adults less likely to complain of pain at insertion site so be sure to check frequently and do a pain assessment
IV maintenance
-Assess IV site hourly if something is infusing, q4h if nothing infusion
-Assessment includes inspection for colour, drainage, swelling, temp, and pain
-Change IV site when clinically indicated (as long as IV is healthy and patent, there is no need to change IV site at regular intervals)
-Clamp when not in use
-Reassess q shift to determine if IV access still indicated
IV removal
-If patient on anticoagulants or antiplatelets you may need to maintain pressure for a longer period of time (ie up to 5 minutes whereas normal Hemostasis is often 30 seconds)
IV removal non intact catheter
-If cannula is not intact, palpate vein, if a piece can be felt, apply a tourniquet above the site and seek help
How to document removal
-#18g IV catheter removed intact from L forearm. No swelling, redness, or bleeding noted, 2x2 pressure dressing applied. Pt stated no discomfort
