Nursing Interventions for IV Therapy Anxiety & Discomfort

1. LPN-C Unit Five Peripheral Intravenous Therapy

2. Nursing Interventions R/T Anxiety & Discomfort with IV Infusion • Individuals typically experience anxiety related to intravenous therapy • Illness • Unfamiliar environment • Need for complex services and procedures • Extreme anxiety can have physiological effects • Spasm or constriction of veins due to the sympathetic response • Blood shunted from peripheral circulation to vital organs • Inhibits venous access • Syncope related to the vasovagal response

3. Anxiety & Discomfort (cont’d) • Psychological preparation increases coping ability • Relaxes the client • Facilitates initiation of IV therapy for the nurse • Client teaching • Time • Building rapport and relaying caring • Allowing time for questions • Explanations • Overcoming communication barriers • Honesty • How long the IV may be in place • Why IV access is needed • Acknowledge associated pain and discomfort

4. Anxiety & Discomfort (cont’d) • Pain reduction • Advise patient of measures that may decrease distress • Assure patient that you will be as efficient as possible • Employ appropriate physical, pharmacological, and psychological measures to minimize discomfort • Professionalism • Express confidence and expertise • Reinforce positive aspects of the procedure

5. Latex Allergy Precautions • Patients at risk for latex-related reactions – • Women constitute 75% of all reported cases • Asthma • Allergy history • Occupational exposure to latex • Fruit and vegetable allergies • Avocados • Bananas • Chestnuts • Kiwis and other tropical fruits • Intermittent catheterization • Chronic genitourinary or abdominal conditions requiring multiple surgeries

6. Latex Allergy Precautions (cont’d) • Report incidents of adverse reactions to latex or other materials used in medical devices to the FDA • FDA recommendations to health professionals -- • Assess latex sensitivity while obtaining history for all patients • Use devices made with alternative materials • Be alert for an allergic reaction whenever latex-containing devices are used, especially when in contact with mucus membranes • Alert clients with suspected allergic reaction to latex to possible latex sensitivity, and advise them to consider immunologic evaluation

7. Latex Allergy Precautions (cont’d) • FDA recommendations to health professionals (cont’d) -- • Advise clients to tell health professionals and emergency personnel about latex sensitivity • Consider advising clients with a latex allergy to wear a medical identification bracelet • Other allergies • Must assess for allergies to foods, animals and insect matter, and environmental substances • Iodine • Often used in skin antisepsis • Client may only recognize this as a shellfish allergy • Adhesive • Used in dressing tape

8. Caring for an IV at Home • Many clients receive IV therapy at home • Limitations by 3rd party payers • Personal preference • Several types of IV therapy can be maintained outside of the hospital • Antibiotics • Chemotherapy • Hydration and hyperalimentation • Pain control • HIV-related therapies • Growth hormone and immunoglobulins • Dobutamine (for severe CHF) • Tocolytic therapy (to ↓ premature contractions)

9. Caring for an IV at Home (cont’d) • Arm/hand movement may be limited, so client may need to relearn ADLs • Ambulation with infusion equipment • Instruct client against tampering with IV tubing, clamp, or dressing • Advise client to keep the IV dry to minimize risk of infection • Staphylococcus epidermis • Staphylococcus aureus • Teach client how to assess IV site for signs and symptoms of infection • Provide list of symptoms or conditions for which client would need to call the doctor

10. IV Preparation *Physical preparation of the client for initiation of intravenous therapy includes safety, comfort, and positioning • Safety • Verify IV order • Verify correct patient identification • Validate that the ordered infusion is appropriate for the patient • Confirm that the patient is not allergic to anything that is to be administered • Review documentation of significant laboratory and diagnostic reports • Maintain strict asepsis when preparing all products to be used for venipuncture/infusion

11. IV Preparation (cont’d) • Safety (cont’d) -- • Ensure that all supplies and equipment for venipuncture are sterile • Check expiration dates • Provide a safe environment for the patient during infusion therapy • Bedrails • Restraints • Movement • Ambulation • Assess/select the vessel that is appropriate for the type of infusion ordered • Instruct the client about what to report in terms of activity, discomfort, or signs/symptoms associated with a reaction

12. IV Preparation (cont’d) • Comfort • Restrictions in mobility and sustaining ADLs • Prevent dislodgement of the cannula • Avoid disconnection of any part of the infusion setup • If any portion of the closed IV system were disrupted, contamination and infection could occur • Use nondominant hand for IV access • Avoid using veins in areas of flexion unless immobilized • Allow completion of ADLs prior to IV insertion • Provide loose-fitting clothing/hospital gown • Allows for less restricted movement • Does not impede fluid flow • Easily removed for changing • Provide for privacy

13. IV Preparation (cont’d) • Correct positioning • Fowler’s position • Maintain intended venipuncture site below heart level to promote venous filling • Follow institutional protocol with regards to armboards, restraints, or stabilization devices • Can cause nerve and muscle damage • Must be removed at frequent intervals to assess circulatory status • Protect insertion site from moisture and contamination • Hair may need to be removed prior to initiating IV therapy if it impedes vessel visualization, site disinfection, cannula insertion, or dressing adherence

14. IV Preparation (cont’d) • Correct positioning (cont’d) – • Hair removal (cont’d) – • Hair is to be removed by gently clipping it close to the skin • Do not scratch the skin • Do not shave the hair because of the potential for microabrasion and the introduction of contaminants • Do not apply depilatories due to the possibility for skin irritation or allergic reactions • An electric shaver may be used • Check your institutional policy • If the shaver does not belong to the patient, the shaving heads would need to be changed or disinfected between patient use

15. IV Preparation (cont’d) *IV preparation involves using the correct site preparation/maintenance materials • Obtain the appropriate dressing materials • Sterile gauze • Sterile transparent, semipermeable dressing • Cleanse the skin • Use an antimicrobial barrier • 2% chlorhexidine or per institutional policy • Available in the form of swab sticks, prep pads, or plastic, cotton-tipped squeezable vials • These are one-time use only! • Allow barrier to air dry

16. Vein Selection *Intravascular access refers to entrance into arteries, veins, or capillaries • The selected access site should provide the most appropriate access to the vessel • Needs to be appropriate for intended therapy • Must accommodate administration of the prescribed infusion • Endeavor to minimize associated risks or complications • Factors to consider with vein/site selection • Patient’s age, health status, and diagnosis • Condition of the site to be accessed • Purpose, duration, and possible side effects of therapy

17. Vein Selection (cont’d) *Peripheral intravenous routes should be achieved in an upper extremity • Venous cannulation should begin at the distal-most area of the upper extremity and proceed proximally • Examine the upper extremities • Predict the ease or difficulty of venous access • Predetermine measures to facilitate successful venipuncture • Inspect the patient’s skin • Assess for damaged areas • Apply a tourniquet • Use a flashlight for enhanced visualization

18. Vein Selection (cont’d) *Peripheral intravenous routes (cont’d) – • Palpate the patient’s veins • Determine condition of the vessel • Locate deeper, larger veins that are stronger and more suitable for initiation of IV therapy *The nurse needs to know which veins to avoid when preparing to perform venipuncture for purposes of peripheral intravenous therapy • Do not use veins in an area with a recent infiltration • Do not use veins in an area that has sustained 3rd degree burns

19. Vein Selection (cont’d) *Veins to avoid (cont’d) – • Avoid veins in the antecubital fossa • Do not use veins that are irritated or sclerosed from previous use • For a vein to be viable, it must be able to be blanched • To check for blanching, apply downward pressure over, or on each side of, a vein • If the vein disappears with the pressure, then reappears when the pressure is removed, the vein is viable • A sclerotic vein will not blanch • Avoid veins in an extremity that is partially amputated

20. Vein Selection (cont’d) *Veins to avoid (cont’d) – • Do not use veins in the lower extremities in ambulatory adults and children • Use lower extremity sites only in an emergency • Must have a written order • Ensure agency has policy in place that upholds this procedure • Never access an arteriovenous fistula, graft, or shunt that has been surgically placed for hemodialysis • Do not use the affected arm itself for IV therapy • Do not use veins in an extremity that is impaired as a result of a CVA

21. Vein Selection (cont’d) *Veins to avoid (cont’d) – • Do not use veins on the side of the body where a radical mastectomy with lymph node dissection/stripping has been performed • Bypass veins in an extremity that has undergone reconstructive or orthopedic surgery • Avoid edematous extremities

27. Cannula Selection *Types of peripheral venous devices • Steel needles • Winged needles • Catheters *Steel needles are very rarely used anymore *Winged needles, referred to as butterflies, have one or two “wings” • Connect with a needle on one side and a segment of infusion tubing that ends in a hub and protective cap on the other • Tubing varies in length from 3½ to 12 inches • Tubing is primed with NS prior to insertion to prevent entry of air into the circulation

28. Cannula Selection (cont’d) *Butterflies (cont’d) – • Wings are held upright during insertion to facilitate movement into the vein • Once the needle is in the vein, the wings are taped to the skin to secure the device • If secured properly, winged needles stay in the vein well • Good means of venous access under certain circumstances • Short-term infusions (24 hours or less) • Seldom used for adult infusion therapy • Can be used for one-time IV push medications • May be used to draw blood

29. Cannula Selection (cont’d) *Peripheral venous access catheters are the most commonly used IV device • Used to enter superficial or deep veins • Extremity • Neck • Head • Two-part flexible cannula in tandem with a rigid needle or stylet • Stylet is used to puncture and insert the catheter into the vein • Connects with a clear chamber • Allows for visualization of blood return • Indicates successful venipuncture • Facilitates removal of the needle

30. Cannula Selection (cont’d) *Catheters (cont’d) -- • Color-coded plastic cannula hub • Indicates length and gauge of catheter • Length ranges from ¼ inches to 12 inches • Catheter is radiopaque • Easily detected by radiology in case of embolus *Types of catheters include the over-the-needle peripheral catheter (ONC) and the through-the-needle peripheral catheter (TNC) • The ONC is a flexible cannula that encases a steel needle or stylet device • Most commonly used peripheral IV device

31. Cannula Selection (cont’d) *Types of catheters (cont’d) -- • ONC (cont’d) – • Once the vein is accessed, the catheter is threaded into the vessel and the stylet is withdrawn • The TNC is the opposite of the ONC, as the flexible cannula is encircled by the steel needle • Infrequently used • The needle is withdrawn once venous access is achieved • Secured in a protective shield outside the body on the skin

32. Cannula Selection (cont’d) *Factors to consider when selecting a cannula – • Use the smallest cannula that will deliver the prescribed infusate • Adequate blood flow and hemodilution • Causes minimal discomfort • Delivery rate • 24 gauge cannula → approx 15-25mL/min • 22 gauge cannula → approx 26-36mL/min • 20 gauge cannula → approx 50-65mL/min • 18 gauge cannula → approx 85-105mL/min

35. Achieving Venous Distention • Apply a tourniquet • A tourniquet is an encircling device consisting of a segment of rubber tubing that temporarily arrests blood flow to or from a distal vessel • Apply tightly enough that venous blood flow is suppressed, but not so tight that it obstructs arterial flow • Should be able to palpate pulse distal to the tourniquet • Do not leave a tourniquet in place longer than four to six minutes • Tourniquet paralysis from injury to a nerve can occur if the tourniquet is applied too tightly or left for too long a period • Apply warm compresses for 10-15 minutes

36. Achieving Venous Distention (cont’d) • Place the extremity intended for venipuncture below the level of the patient’s heart for several minutes • Have the patient open and close his or her fist, or squeeze and release the lowered bedrail • Use an alcohol pad to gently rub the skin over the vein intended for venipuncture • Alcohol and friction creates heat • Enhances venous distention • Pat the area of skin over the intended vein using light to moderate force to engorge the vein with blood

37. IV Equipment and Supplies *Infusate containers and IV administration sets • Infusate containers – • Flexible plastic • Semirigid plastic • Glass • IV administration set = tubing that delivers fluid/medication from the infusate container to the patient *All administration sets have a spike insert that fits into the administration set port of the infusate container, as well as a drip chamber, clamps, and an adapter

38. IV Administration Sets • On an administration set, the drip chamber is where the solution flows after leaving the infusate container and before entering the tubing • A screw and roller clamp allows for flow regulation • A slide clamp functions as an on-off clasp • A cannula hub can be attached to the sterile adapter at the end of the tubing • The adapter can be straight, fitting directly into the cannula hub with a push ~OR~ • The adapter can be screwed on to the cannula hub, providing a firm attachment (Luer-Lok)

39. IV Administration Sets (cont’d) • The administration set determines the rate at which fluid can be delivered to the patient (i.e. the drop factor) • Specialized tubings are used in specific settings and circumstances • Extra large (macrobore) tubings • Used in emergency surgical and trauma situations • Rapid infusion of large volumes of blood or fluid • Extra small (microbore) tubings • Used for the delivery of small amounts of precisely controlled fluid or medication • Special volume restriction (neonatal care, epidural infusions)

40. IV Administration Sets (cont’d) • Types of administration sets: • Vented systems • Used for vacuum infusate containers that don’t have their own built-in mechanisms for air displacement • Glass and some semirigid bottles • Nonvented systems • Used with flexible plastic bags and other nonvacuum receptacles • Primary administration sets • Secondary administration sets *Primary administration sets are also known as basic, or standard, sets • Carries fluid directly to the patient through one tube

41. IV Administration Sets (cont’d) *Primary administration sets (cont’d) -- • Spiked into one (single line) or two (Y-type) main infusate container(s) • May terminate in straight, flashtube, or Luer-Lok male adapters • Available in macrodrip or microdrip in varying lengths • Available with or without check valves, which prevent retrograde blood flow • May contain one or several injection ports • Can accept attachments • Secondary administration tubings, extension tubings, flow control devices, filters, adapters

42. IV Administration Sets (cont’d) *Single line primary administration sets have one spike that is inserted into one infusate container; the tubing terminates with an adapter that connects to the cannula hub at the IV access site *Y-type primary administration sets have two equal-length tubings that can each access an infusate container • Access can be simultaneous or alternately • Each tubing has its own roller clamp • Each tubing may or may not have its own drip chamber • Frequently used in emergency, surgical, and critical care situations

43. IV Administration Sets (cont’d) *Y-type administration sets (cont’d) – • The solution reaches the patient via one common tubing • Necessitates compatibility between the infusates • Blood administration tubings are Y-type sets, but differ from standard Y-type primary administration sets • Should be used only with nonvacuum, flexible infusion containers where venting is unnecessary • If vented containers are used, air can be drawn into the circulatory system, resulting in an air embolism

44. IV Administration Sets (cont’d) *Secondary administration sets are referred to as piggyback sets • Used to deliver continuous or intermittent doses of fluid or medication • Widely used because they negate the need for additional venipunctures and interruption of the primary infusion • Usually connected with a needle or needleless adapter into an injection port immediately distal to the back-check valve of the primary tubing • Some primary administration sets have a closed-system connection to a second line

45. IV Administration Sets (cont’d) *Whenever an infusion line is breached, the possibility for introduction of contaminants exists • IV line should not be broken to add accessory equipment unless absolutely necessary • Refer to your institution’s policy for adding equipment such as filters, extension sets, adapters, and connectors to infusion lines *Needleless systems and needlestick safety systems are state-of-the-art in IV therapy • Used to connect IV devices, administer fluids and medications, and sample blood

46. IV Administration Sets (cont’d) *Needleless systems (cont’d) – • Eliminates up to 80% of needles • Other than the initial stick to insert the cannula into the patient’s vein, there is no need for needles during IV therapy *Blood exposure protocol – • Wash needlestick punctures with soap & water • Flush splashes to the nose, mouth, or skin with water • Irrigate splashes to the eyes with clean water, NS, or sterile ophthalmic irrigants • Report the incident to the department responsible for managing exposures • Start post-exposure treatment ASAP

47. Mechanical Gravity Control Devices *Mechanical gravity control devices are flow-regulating mechanisms that attach to the primary infusion administration set • Manually set to deliver specified volumes of fluid per hour • Available as dials or cylindrical controls • Includes approximate flow markings that must be verified (i.e. counting gtt/min) • Accuracy varies • Discrepancies can be up to ± 25% • Dependent upon patient’s condition, activity level, positioning, and venous pressure

48. Mechanical Gravity Control (cont’d) • Should generally be used for only short periods, such as transporting the patient • IV tubing kinking/obstruction can restrict fluid flow • Must be checked frequently for infusion accuracy

49. Electronic Infusion Control Devices (EID) *EIDs are state-of-the-art infusion-regulating mechanisms that deliver fluids and medications • Powered by electricity and/or battery • Safe and accurate (± 5%) • Programmable for several infusates at different rates and volumes at the same time • Sensors detect air in the line and pressure changes • Signals infusion termination • Alerts the nurse to problems via readouts, alarms, and flashing lights

50. EIDs (cont’d) • Most newer EID models have built-in safety flow mechanisms • Prevents unintended free flow of infusate into the patient if the administration set were to be removed from the machine • NOTE: No EID is a substitute for regular patient observation and evaluation