LEARNING MODULE FOR PERIPHERAL I.V. THERAPY INITIATION AND MAINTENANCE CC 80-019 Developed by: Jackie Jayasinghe, Nurse Educator Medicine/Ambulatory Care Nursing Date: April, 1998 Krista Newlands, Nurse Educator Medicine/Ambulatory Care Nursing Revised by: Sally MacLean, Clinical Nurse Educator Debbie White, Clinical Nurse Educator Lisa Covey, Clinical Nurse Educator Date: February 2015 Peripheral I.V. Therapy Initiation CC 80-019 1 & Maintenance Learning Module
Peripheral I.V. Therapy Initiation& Maintenance Learning Module CC 80-019 2 TABLE OF CONTENTS Page Purpose 3 Learning Objectives 3 Method 3 Theory/ Required Readings 3 References 4 Test 6 Answers 8 Proficiency Standard Skills Checklist(s) 9
Peripheral I.V. Therapy Initiation& Maintenance Learning Module CC 80-019 3 PURPOSE: IV therapy initiation and maintenance is a basic entry level competency for RNs and LPNs. This Learning Module for Peripheral IV Therapy Initiation and Maintenance provides the Registered Nurse/Licensed Practical Nurse with the theory and practice to further assist them in performing this skill, given that they have received initial education in their nursing program. If the RN/LPN has not had IV therapy initiation education in their training, they may require additional education as determined through a needs assessment in collaboration with the nurse, educator and manager. Further educational resources can also be found on the HITS NS e-learning site. LEARNING OBJECTIVES: Upon completion of this Learning Module, the RN/LPN will be able to complete the following: 1. Identify the purpose for IV therapy initiation and maintenance. 2. Identify important factors for consideration during vein site selection. 3. Describe possible complications of IV therapy initiation and maintenance, and populations at risk. 4. Explain the procedure for initiation of peripheral IV therapy 5. Demonstrate initiation of at least ONE successful insertion on a patient and complete the proficiency skills checklist with an educator/delegate. METHOD: Review Nursing Care Policy and Procedure CC 80-019 (Peripheral IV Therapy and Maintenance) Review Self Directed Learning Module and complete the self-test. Complete Proficiency Standard Skills Checklist with demonstration of skill. THEORY/ REQUIRED READINGS: Intravenous and Vascular Access Therapy Perry, A.G. & Potter, P.A. (2010) Clinical Nursing Skills and Techniques, 7th Ed. St.Louis: Mosby- Elsevier, pp 740-756 Potter, P.A. & Perry, A.G. (2012) Canadian Fundamentals of Nursing, 4 th Ed. St. Louis Mosby-Elsevier, pp 955-986.
Peripheral I.V. Therapy Initiation& Maintenance Learning Module CC 80-019 4 Positive Pressure Technique: To maintain patency for intermittent IV access, it is necessary to flush the needle free adaptor (Micro-Clave Clear) using positive pressure technique every 24 hours. This procedure allows for the IV catheter to completely fill with saline and prevent back flow of blood. Two types of needle free systems for intermittent use exist: 1. The Micro-CLAVE clear, connected directly to the IV catheter- in this case, the saline is injected using a syringe at the same time as the syringe is removed from the connector. 2. The Micro-CLAVE clear with extension tubing connected to the IV catheter- in this case the syringe of flush solution is again pushed in through the adaptor, but during the last 0.5 mls of flush, the clamp on the extension tubing is closed and the syringe removed. Vein Selection Select the vein for venous insertion. Veins found on the dorsal and ventral surfaces of the upper extremities ( e.g., cephalic, basilic and median veins) are preferred in adults. This ensures adequate veins that are easier to puncture with needle and are less likely to rupture. Essential Clinical Procedures. Harbert, Kenneth R. Published January 1, 2013. Pages 37-47. 2013. Superficial veins. A-Inner aspect of forearm. B-Dorsal aspect of hand and wrist.
Peripheral I.V. Therapy Initiation& Maintenance Learning Module CC 80-019 5 The Cephalic, Basilic, and Median Cubital Veins are best for IV placement in adults. Use the most distal site in the non dominant arm, if possible. Moving in the direction of distal to proximal increases the availability of other sites for future IV therapy. Clip arm hair with scissors if necessary as hair impedes venipuncture or adherence of a dressing. Do not shave with a razor. Shaving may cause microabrasions and predispose a client to infection. Indications/Contraindications : 1. Avoid areas that are painful to palpation 2. Select a vein that is large enough for catheter placement 3. Choose a site that will not interfere with a clients activities of daily living or planned procedures. 4. Use fingertips to palpate the vein by pressing downward and noting the resilient, soft, bouncy feeling as the pressure is released. Fingertips are more sensitive and are better to assess vein condition. 5. Promote venous distention by instructing the client to open and close the fist several times, lowering the client s arm in a dependent position, applying dry heat to the arm from distal to proximal below the proposed site. 6. Avoid sites distal to previous venipuncture sites, sclerosed or hardened cordlike veins, infiltrated sites or phlebotic vessels, bruised areas and areas of venous valves or bifurcation. Avoid veins in the antecubital fossa and ventral surface of the wrist. Veins in the antecubital fossa are used for blood draws, and placement in this area limits mobility. Inner wrists contain numerous tendons that could be damaged. 7. Avoid fragile dorsal veins in older adults and vessels in an extremity with compromised circulation ( e.g.) in cases of mastectomy, dialysis graft or paralysis. Venous alterations can increase risk of complications ( e.g., infiltration and decreased catheter dwelling time). REFERENCES: Hadaway, L.C. (2003) Infusing Without Infecting. Nursing 2003, October, 33(10). Health Canada. (1997) Preventing Infections Associated with Indwelling Intravascular Access Devices. Pp.12, 16. Infusion Nurses Society (INS) (2012). Recommendations for frequency of assessment of the short peripheral catheter site [position paper online]. [cited 2013 Jan 16]. INS (2011) Infusion nursing - standards of practice. Lippincott Williams and Wilkins: Hagerstown, MD. Pg S55-56 IWK Health Centre Policy and Procedure Topical Anesthetics (2008).
Peripheral I.V. Therapy Initiation& Maintenance Learning Module CC 80-019 6 Perry, A.G. & Potter, P.A. (2010) Clinical Nursing Skills and Techniques, 7th Ed. St.Louis: Mosby- Elsevier, pp 740-756 Potter, P.A. & Perry, A.G. (2012) Canadian Fundamentals of Nursing, 4 th Ed. St. Louis Mosby-Elsevier, pp 955-986.
Peripheral I.V. Therapy Initiation& Maintenance Learning Module CC 80-019 7 TEST 1. If a patient is to receive long term I.V. therapy, where should the I.V. be started? 2. How many times should a nurse attempt to initiate a peripheral I.V. on one patient before requesting assistance? 3. Which are common I.V. puncture sites in adults? a. Hand b. Arm c. Foot d. Antecubital fossa 1) a,c,d 2)a,b,d 3)a,b,c 4)a,b 4. Which of the above I.V. sites is more common with pediatric clients but is usually avoided in the adult? 5. Which I.V. puncture site should be used only as a last resort? 6. Why is it important to allow the antiseptic agent to dry thoroughly? 7. What are two common sized over-needle-cannulas (ONC) used for peripheral I.V. insertion? 8. Name three patient characteristics where it may be difficult for a nurse to insert a peripheral I.V.? 9. What is to be avoided on mastectomy patients and patients with A-V fistulas when initiating peripheral I.V. insertion? TRUE OR FALSE 10. Insert the peripheral catheter in the direction of venous return. 11. Remove the tourniquet after I.V. solution has started to infuse. 12. Full blood return in the flashback chamber of the ONC plastic catheter indicates that the needle has entered the vein. 13. I.V. sites are to be changed every 48 hours.
Peripheral I.V. Therapy Initiation& Maintenance Learning Module CC 80-019 8 14. I.V. tubing is to be changed every 72-96 hours unless the patient is receiving blood products or lipids. 15. Sterile gloves are to be worn when performing venipuncture for peripheral I.V. insertion 16. An intermittent lock is flushed q12hrs or before and after each medication with 1-3mLs of sterile normal saline.
Peripheral I.V. Therapy Initiation& Maintenance Learning Module CC 80-019 9 ANSWERS 1. Distal sites first (ex. Hand) and then proximal sites (forearm) 2. Two 3. 4 4. Foot 5. Antecubital Fossa 6. It must be dry to be effective. 7. 20g, 22g 8. 1) Clients who have had many venipunctures because their veins may be sclerosed with scar tissue. 2) Obese clients 3) Thin and emaciated clients as their veins are thin and fragile 9. The client's affected arm. 10. True 11. False 12. True 13. False 14. True 15. False 16. False
Peripheral I.V. Therapy Initiation& Maintenance Learning Module CC 80-019 10 Capital Health Nursing Division Proficiency Standard Skills Checklist TITLE Initiating Peripheral I.V. Access NAME: When initiating peripheral I.V. access the RN/LPN.: YES NO Checks the prescriber s order and reviews health history. Confirms patient identification. Checks if patient has had a mastectomy or has a fistula or shunt. Explains to the patient the purpose and procedure for initiating a peripheral IV Determines the over-needle-cannula (ONC) size according to assessment of individual's arm veins and reason for initiating peripheral IV Performs hand hygiene Assembles equipment. If for intermittent use: Prepares saline flush If for continuous infusion: Prepares infusion set up with appropriate solution and infusion device if applicable. Performs hand hygiene and applies non-sterile disposable gloves Chooses appropriate site. Applies tourniquet 4-6 inches above site and checks pulse. Cleanses the area and allows antiseptic to dry thoroughly. Inserts peripheral IV catheter obtaining flash back Advances catheter carefully. Releases tourniquet and removes stylet (needle)
Peripheral I.V. Therapy Initiation& Maintenance Learning Module CC 80-019 11 Proficiency Standard Skills Checklist Initiating Peripheral IV Access cont'd When initiating peripheral IV access the RN/LPN: YES NO If intermittent infusion: Applies needle free access system and flushes with 1-3 mls of normal saline using positive pressure technique. (LPN only infuses non- If continuous infusion: Attaches IV tubing and infuses IV fluid by gravity medicated solutions) Adjusts IV flow rate Secures IV catheter. Secures IV tubing, if applicable Disposes of sharps and soiled equipment appropriately. Removes gloves and performs hand hygiene Documents procedure in patient's chart and kardex. Intermittent flushes should be documented on the patient MAR.