Intravenous therapy handbook

Nursing, Oct 1996 by Thomas-Masoorli, Susan

Learn how to choose the best I.V. site, document procedures, deal with complications, and more.

Tips for a perfect puncture

* If you can't palpate a radial pulse, the tourniquet's too tight. You want to occlude the superficial veins, not the deeper arteries.

* Have the patient open and close her fist. The large muscles of the arm will massage the vein, increasing venous dilation. (Don't have her make and hold a fistthis can cause the vein to spasm, which makes catheter insertion difficult and painful.)

* Palpate with your index and middle fingers, which are the most sensitive for vein identification.

* Rub the intravenous (I.V.) site vigorously with alcohol to kill Staphylococcus epidermidis and S. aureus, the main culprits in I.V. site infection.

* Push blood in the vein up toward the tourniquet. This aids in vein dilation.

* Hold the catheter insertion device at a 0- to 5-degree angle for insertion into a superficial vein and at a 5- to 15-degree angle for a deeper vein (one that's palpable but not visible). Never use an insertion angle greater than 15 degrees.

Quick check for correct vein access

To tell that you've correctly accessed a vein, look for blood return in the flashback chamber. This means that the stylet and tip of the catheter have passed into the vein's inner lumen.

You won't see blood in the flashback chamber if the catheter's tip remains in the vein wall and the stylet is withdrawn prematurely. In this case, the catheter can't be advanced into the vein's lumen. Remove the device and try again in a new location.

If you see a hematoma, you probably used too much pressure on the device during insertion, This pushed the stylet and catheter through the vein lumen and out the vein's back wall. Remove the device and try again in a new location.

Dealing with phlebitis

Phlebitis is the top risk of shortterm I.V. therapy. If you notice mechanical or chemical phlebitis in a patient, remove the catheter and record the degree of phlebitis in the patient's medical record, using this system established by the Intravenous Nursing Standards of Practice:

1+-pain at site, erythema or edema, no streak, no palpable cord

2+-pain at site, erythema or edema, streak formation, no palpable cord

3+pain at site, erythema or edema, streak formation, palpable cord.

Fixing the flow

Too fast? Too slow? Here's how to get an infusion back on track.

* If the I fluid is running more slowly than prescribed:

1. check the I.V. site; if it's red, painful to touch, edematous, or warm, remove the catheter

2. ask the patient to reposition her arm; if the fluid flows at the proper rate, you'll know you were dealing with a positional problem

3. check along the tubing for kinks or clamps that may have stopped the infusion

4. check the height of the bag-the ideal is 1 meter (3.3 feet) from the I.V. site. Raising the bag will increase the flow rate.

5. at the catheter site, lift the I.V. tubing at the hub; if the fluid flows freely, the catheter may be against a vein wall or venous valve. Place a 2x2 sterile gauze pad under the hub and re-dress the site, adjusting the catheter for better flow before applying the dressing.

6. remove the I.V. tubing from the catheter hub; if fluid flows freely through the I.V. tubing, the problem is with the catheter. Remove the catheter rather than flushing it, which could release clots. If the fluid doesn't flow freely, the problem is in the I.V. line.

* If the I.V. fluid is running faster than prescribed, adjust the clamp to regulate the flow.

* If the I fluid runs quickly and then slowly:

1. have the patient reposition her arm

2. monitor the flow rate over several minutes

3. use an arm board, if necessary, to keep the patient's arm in the needed position

4. remove the dressing and adjust the catheter

5. check the I.V. infusion more frequently over the first couple of hours to make sure the administration rate is correct.

Through thick and thin

Do you know which catheter gauge to use when? Here are general guidelines:

14-plasmapheresis patients

16-trauma patients, preoperative open-heart surgery patients, and people giving blood donations

18-general surgical patients, patients receiving multiple blood transfusions, emergency department patients

20-patients receiving blood transfusions, I.V. fluids, partial parenteral nutrition, or radiologic dyes

22-medical patients receiving blood transfusions or I.V. fluids, geriatric patients

24-pediatric patients and adults with small veins.

Material for this handbook was provided by Susan Thomas-Masoorli, RN, president and chief executive officer, Perivascular Nurse Consultants, Inc., Rockledge, Pa., except "Through Thick and Thin," "Fixing the Flow," and "Dealing with Phlebitis," which were provided by Rhonda J. Peterson, RN, Baltimore.