Basic Intravenous

Therapy
90-95% of patients in the
hospital receive some type
of intravenous therapy.

This presentation will enhance your

knowledge of how to care for them.
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 Vein Anatomy and Physiology

Veins are unlike arteries in

that they are 1)superficial,
2) display dark red blood at
skin surface and 3) have no
pulsation

Vein Anatomy
- Tunica Adventitia
- Tunica Media
- Tunica Intima
- Valves

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 Tunica Adventitia
the outer layer of the vessel

Connective tissue

Contains the
arteries and veins
supplying blood to
vessel wall

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 Tunica Media
the middle layer of the vessel

Contains nerve
endings and muscle
fibers

The vasoconstrictive
response occurs at
this layer

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 Tunica Intima
the inner layer of the vessel

One layer of endothelials

No nerve endings

Surface for platelet aggregation

w/trauma and recognition of
foreign object at this level

PHLEBITIS begins here

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 Valves
present in MOST veins

Prevent backflow and

pooling

More in lower extremities

and longer vessels

Vein dilates at valve

attachment

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 Veins of the Upper Extremities

Digital Vessels
-Along lateral aspects fingers, infiltrate
easily, painful, difficult to immobilize and
should be your LAST RESORT

Metacarpal Vessels
-Located between joints and Digital
metacarpal bones (act as natural splint)
-Formed by union of digital veins
-Geriatric patients often lack enough
connective / adipose tissue and skin
turgor to use this area successfully

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 Veins of the Upper Extremities

Cephalic (Interns Vein)

-Starts at radial aspect of wrist
-Access anywhere along entire length
(BEWARE of radial artery/nerve)

Medial Cephalic (On ramp to

Cephalic Vein)
-Joins the Cephalic below the elbow
bend
-Accepts larger gauge catheters, but
may be a difficult angle to hit and
maintain

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 Veins of the Upper Extremities
Basilic
- Originates from the ulner side of
the metacarpal veins and runs
along the medial aspect of the arm.
It is often overlooked becauses of
its location on the back of the
arm, but flexing the elbow/bending
the arm brings this vein into view

Medial Basilic
- Empties into the Basilic vein
running parallel to tendons, so it is
not always well defined. Accepts
larger gauge catheters.
- BEWARE of Brachial Artery/Nerve
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 Purposes of IV Therapy
To provide parenteral nutrition
To provide avenue for dialysis/apheresis
To transfuse blood products
To provide avenue for hemodynamic monitoring
To provide avenue for diagnostic testing
To administer fluids and medications with the ability to rapidly/accurately
change blood concentration levels by either continuous, intermittent or IV
push method.
Types of Peripheral Venous Access Devices
Butterfly(winged) or Scalp vein needles (SVN) not recommended for non compliant
patient as it can easily penetrate the vein wall causing extravasation. We use these
frequently for phlebotomy
Safety Over the needle catheters (ONC)
- PROTECTIV -ACUVANCE

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 Starting a Peripheral IV
Finding a vein can be challenging
- Go by feel, not by sight. Good veins are bouncy to the touch, but are
not always visible.
- Use warm compresses and allow the arm to hang dependently to fill
veins.
- A BP cuff inflated to 10mmHg below the known systolic pressure creates
the perfect tourniquet. Arterial flow continues with maximum venous
constriction.
- If the patient is NOT allergic to latex, using a latex tourniquet may
provide better venous congestion
- Avoid areas of joint flexion
- Start distally and use the shortest length/smallest gauge access device
that will properly administer the prescribed therapy

(BE AWARE: Blood flow in the lower forearm and hand is 95ml/min)
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 IV Start Pain Management
One of the most frequent contributors to patient dissatisfaction is
painful phlebotomy and IV starts

Use 25-27g insulin syringe to create a wheal similar to a TB skin test on top
of or just to side of vein with 0.1 -0.2 ml normal saline or 1% xylocaine
without epinephrine

Topical anesthesia cream (ie EMLA) may be applied to children>37 weeks

gestation 1 hr. prior to stick. It might be a good idea to anesthetize a couple
of sites

Have the patient close their fist (NO PUMPING) prior to stick

Make sure the skin surface cleansing agent (alcohol/chlorhexidine) is dry

prior to stick. Drawing this into the vein may stimulate the vasoconstrictive
action of the tunica media layer

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 Flushing Peripheral IVs
Use prefilled saline and heparin flush syringes located in PYXIS
Heparin flush concentrations available:
-100u/ml (5ml in a 10ml syringe)
-10u/ml (2ml in a 3ml syringe)

Flushing intervals and amounts

- Peds: q 6hrs.
<22ga 1ml 0.9%NS followed by 1ml heparinized
(10units/ml) saline

- Adults: q 8hrs
w/1ml. 0.9%NS [3ml heparinized saline for OB]
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 Dressing/Bag Changes
Physician orders are
required if a peripheral
catheter is left in the same
site for more than 3 days.

It is best to have the

pharmacy add medications
to the infusion bags under
laminare flow to reduce
contamination

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 Central Venous Catheters
Percutaneous Tunneled PICCs Implanted Ports Dialysis
Insertion MD @ bedside w/x- MD in OR under MD/trained RN @bedside MD in OR under fluoroscopy MD in OR under
ray confirmation fluoroscopy w/x-ray confirmation fluoroscopy
Location Visible externally. Visible ext. usually Visible externally around Completely internal. Titanium or plastc Visible externally.
Enters subclavian, midway bet. clavicle antecubital fossa, upper port is implanted in a surgically created Arm or leg
ext. juglar,or int. and nipple. Tunneled arm or neck pocket and catheter is threaded into placement
juglar vein near under skin & subclavian or int. juglar vein. Access is
clavicular area threaded through through skin into self sealing port using
subclavian or IJ special non coring needle
Material/Cost Polyurethane Silicone Silicone / polyurethane Silicone catheter. Port is titanium or Various materials
$200-$400 $3500-$5000 $350-$500 plastic w/self sealing diaphragm
$3500-$5000
Lumen 2-3 2-3 1-2 1-2 2-3
Sutured Yes/entire life Yes, until internal No Yes Yes
Dacron cuff healed
Duration Short term 4-10 Long term Long term Long term Mid term
days
Flushes 5-10ml NaCl after 5-10ml NaCl after 5-10ml NaCl after use and 10ml NaCl followed by 4.5ml Done ONLY by IV
use and daily use and daily daily heparinized saline (adults-100units/ml; team or dialysis
peds-10units/ml) after ea. use or nurses
monthly if not accessed

Brands/ Arrow Howe, Triple Hickman, Broviac PICC, PIC, EDPC, Arrow Bard, Accces Port-A-Cath Bard, Tesio,
Names Lumen, Subclavian, Howe, Gesco, PASV Vescath, Quinton
IJ
Discontinue MD or speically MD in OR Specially trained RN @ MD in OR MD in OR
trained RN @ bedside
bedside

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 Central Venous Catheter Sites

Percutaneous(Subclavian)
PICC (Peripherally inserted
Central Catheter)

Implanted Port
(single or double
lumen)

Percutaneous (IJ-Int. Jugular)

Tunnelled (Hickman)
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 CVC Care/Maintenance

Percutaneous Tunneled

Flush after each access or daily for

catheters>21ga, q 6 hrs <21 ga
-adults: 10ml saline
- peds/neonates: 5ml saline
(preservative free for infants <1yr)
PICC

Transparent dressing change q 7 days & prn

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 CVC Care/Maintenance

Flush after each use and weekly while accessed;

monthly when not acessed
Implanted Port
- 10ml saline (preservative free for pts. <1yr)
- followed by 4.5ml-5ml heparinized saline
100units/ml for adults
10units/ml for peds

Transparent dressing/ access needle change q 7days

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 Monitor and Site Care
document site
condition:
Hourly for peds
Q 2 hr for adult
* Indicates
complication:
Infiltration
Phlebitis
Thrombosis
Cellulitis
Septicemia

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 Infiltration/Extravasation
The most common cause is damage to the
wall during insertion or angle of placement.

STOP INFUSION and treat

as indicated by Pharmacy,
Medication package insert
or drug reference book.

Notify MD and document

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 Phlebitis/Thrombophlebitis
Chemical
- Infusate chemically erodes
internal layers. Warm compresses may
help while the infusate is
stopped/changed. Anti-inflammatory
and analgesic medications are often
used no matter what the cause
Mechanical Bacterial
- Caused by irritation to - Caused by introduction of
internal lumen of vein during insertion bacteria into the vein. Remove the
of vascular access device and usually device immediately and treat
appears shortly after insertion. The w/antibiotics. The arm will be
device may need to be removed and painful, red and warm; edema may
warm compresses applied accompany

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 Cellulitis

Inflammation of loose connective

tissue around insertion site.
- Caused by poor insertion technique
- Red swollen area spreads from
insertion site outwardly in a diffuse circular
pattern
- Treated w/antibiotics

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 Septicemia/Pulmonary Edema/
Embolism
Septicemia
- Severe infection that occurs to a system or entire body
- Most often caused by poor insertion technique or poor site care
- Discontinue device immediately, culture and treat appropriately

Pulmonary edema- caused by rapid infusion

Pulmonary embolism - Caused by any free floating substances that
require thrombolytic therapy for several months. Increased risk w/lower ext.

Air embolism- caused by air injected into IV system. Keep insertion site
below level of heart

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 Troubleshooting

Vascular access device will not flush/cant draw blood

- Evaluate for kink in tubing or catheter tip against vein wall.
Vascular access device (VAD) leaking when flushed
- Verify that hub access cap is connected correctly
Patient complains of pain while VAD being flushed
- Assess for infiltration
VAD broken
- PICCs may be repaired. All other devices must be replaced

Call IV therapy team member for any concerns or

questions.

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 Policy notes
KVO rate:
RNs and LPNs can start Adults - 10 ml/hr Only until rate

peripheral IVs after initial Pediatrics - 2-3 ml/hr

Neonates - 0.5-1 ml/hr
order received

training and observation by Verification required for:

preceptor Insulin
Heparin
Potassium
Digoxin
LPNs CANNOT infuse blood Chemotherapy
products or high risk IV
medications. LPNs cannot push IV
medications

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 IV Medication Administration
Many medications require patient
monitoring that cannot be done on
units where the nurse/patient
ratios are greater than 1:2
A patient can be moved to a unit
where the ratio is appropriate for
invasive/frequent monitoring or
another nurse can be brought to
care for the patient during the med
administration
www.mc.vanderbilt.edu/pharmacy/ivroom/IV
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All Medications Cannot Be
Administered on All Units
General Care Units: Can give meds
requiring only basic physical
assessment data
Stepdown Units: Can give meds
that require more invasive or
frequent monitoring than is available
on general care units
Intensive Care Units: Can give
meds that require more invasive or
frequent monitoring than is available
on the Stepdown units.
VANDERBILT URL LINK FOR IV
MEDICATIONS:
MedAdm061003.pdf
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 IV Medication Administration
Sample page
from the
Pharmacy med
administration
web site

See APPROVED
FOR section.
You will find if
the medication
can be
administered on
your unit.
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 www.ins1.org
Infusion Nurses Society (INS)

Professional Organization that sets the standards of care

for clinicians practicing in the field of infusion therapy.

Standards set by INS are reflected in our policies and

procedures related to infusion therapy for health care
providers.

In a court of law, the standards set by the INS are used

to assess the infusion clinicians performance.

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