IV Cannulation and Related Procedures
Cannulation
Cannulation involves inserting a cannula into a patient's vein or artery, retracting the needle, and leaving the cannula inside to establish vascular access.
The process involves placing a tube into the patient's body to allow for the administration of fluids, medications, or other therapeutic interventions.
Different types of cannulation exist, varying based on the site and purpose of insertion; procedures like open-heart surgery require more intricate cannulation techniques to manage blood flow.
Cannulation is applicable to various procedures, such as cross-clamping blood vessels during surgery or establishing cardiopulmonary bypass in open-heart procedures.
Key Considerations for Cannulation:
Site Selection: The choice of insertion site depends on factors such as the patient's condition, the purpose of cannulation, and the size and accessibility of veins or arteries.
Cannula Size: Selecting the appropriate cannula size is crucial to ensure adequate flow rates while minimizing the risk of vessel damage or complications.
Sterile Technique: Strict adherence to sterile technique is essential during cannulation to prevent infection and other adverse outcomes.
Patient Assessment: Prior to cannulation, a thorough patient assessment should be performed to identify any contraindications or potential challenges.
Post-Cannulation Care: Proper care and maintenance of the cannulation site are necessary to prevent complications such as infection, thrombosis, or dislodgement.
IV Gauge Sizes
IV gauge sizes vary, typically ranging from 16 gauge to 27 gauge, each suited for different clinical scenarios.
A larger gauge number indicates a smaller needle diameter, impacting flow rates and suitability for various infusions.
Pink (20 gauge) is often preferred for administering fluids, blood transfusions, or IVP dye due to its versatility and compatibility with most infusions.
Availability of specific gauge sizes may influence the choice; dehydration or compromised venous access may limit options to smaller gauges like 22 gauge or whatever is most accessible.
Common Gauges:
Pink: 20 gauge (commonly used for general infusions and blood transfusions)
Blue: 22 gauge (suitable for patients with small or fragile veins)
Green: 18 gauge (often used for rapid fluid resuscitation or blood administration)
Yellow: 24 gauge (typically used for pediatric patients or individuals with limited venous access)
27 gauge is typically reserved for pediatric patients or situations where minimal trauma to the vein is desired.
Hydration Level
Fluid volume is directly related to pressure:
Adequate fluid volume results in juicier, more visible veins that are easier to locate and access for cannulation.
Reduced fluid volume leads to flatter, less prominent veins that are more challenging to access, potentially requiring alternative techniques or sites.
Peripheral IV Placement
Avoid the back of the wrist for peripheral IV placement due to the presence of numerous nerves and arteries, increasing the risk of complications.
Arteries have a palpable pulse, while veins do not; palpation can help differentiate between the two before attempting cannulation.
IVs should be started in a direction towards the heart to promote proper circulation and minimize the risk of thrombosis or phlebitis.
Peripheral IVs are typically intended for short-term use due to the small, thin plastic cannula, which can irritate the vein over time.
Movement of the extremity can increase the risk of dysfunction or dislodgement of the peripheral IV, requiring frequent monitoring and stabilization.
Peripheral IVs are suitable for short-term needs such as fluid resuscitation, medication administration (e.g., antibiotics), or diagnostic testing.
For long-term therapy or administration of large medication quantities, consider alternative vascular access devices such as PICC lines or midlines, which offer greater stability and longevity.
Emergency situations may necessitate a central line for rapid medication delivery or hemodynamic monitoring when peripheral access is limited or inadequate.
Considerations for Peripheral IV Placement:
Vein Selection: Choose a vein that is easily accessible, adequately sized, and free from any signs of inflammation or damage.
Patient Comfort: Minimize patient discomfort by using appropriate techniques for venipuncture and providing emotional support throughout the procedure.
Securement: Properly secure the IV catheter to prevent dislodgement and minimize the risk of complications such as infiltration or extravasation.
Documentation: Document the date, time, location, gauge size, and any complications associated with the peripheral IV placement.
Infection Prevention
Hand hygiene and skin antisepsis are critical steps before placing any vascular access device to minimize the risk of healthcare-associated infections.
Chlorhexidine is the preferred cleansing agent for skin antisepsis due to its broad-spectrum antimicrobial activity and persistent effect; use iodine if there's a known alcohol allergy.
Allow the cleansing agent to dry completely for effective bacteria elimination before attempting cannulation; premature insertion can introduce contaminants into the bloodstream.
If a peripheral IV site appears red, swollen, or infected, remove it promptly if within your scope of practice to prevent further complications such as cellulitis or bloodstream infection.
Implement standard precautions, including wearing gloves and using appropriate personal protective equipment, to protect yourself and the patient from potential infection risks.
Best Practices for Infection Prevention:
Aseptic Technique: Adhere to strict aseptic technique throughout the IV insertion and maintenance process to prevent contamination.
Site Assessment: Regularly assess the IV site for signs of infection, such as redness, swelling, pain, or purulent drainage.
Dressing Changes: Replace dressings regularly according to established protocols or when they become soiled, wet, or non-occlusive.
Education: Educate patients and healthcare providers about the importance of hand hygiene and proper IV care to prevent infections.
IV Lock
Place a venous catheter (no longer than three inches) into the selected vein, followed by attaching a cap or saline lock to maintain patency when not in use.
Scrub the access port of the lock vigorously for 15 seconds with an antiseptic solution (e.g., chlorhexidine or alcohol) to reduce the risk of infection prior to each use.
Flush the IV lock with saline or heparin (as per institutional protocol) to maintain patency and prevent clot formation within the catheter lumen when not in use.
Protocols for IV Lock Maintenance:
Positive Pressure: Use a positive pressure flush technique to prevent blood reflux into the catheter lumen during flushing.
Frequency: Follow established guidelines for flushing frequency to maintain catheter patency and prevent occlusion.
Documentation: Document each flushing procedure, including the date, time, solution used, and any observed complications.
LPN Scope of Practice
LPNs can administer a range of intravenous medications, including normal saline for hydration, antibiotics to combat infection, anti-infectives to treat various infections, anti-tuberculins for tuberculosis management, and antivirals for viral infections.
LPNs typically cannot administer blood or blood components (such as albumin) due to the risk of transfusion reactions and the need for specialized training; they also cannot administer TPN (Total Parenteral Nutrition) due to the complexity of managing nutritional imbalances.
Regulations for LPN Scope of Practice:
State Regulations: LPN scope of practice is governed by state regulations, which may vary regarding specific IV medication administration privileges.
Facility Policies: Healthcare facilities may have policies that further define the scope of practice for LPNs regarding IV therapy management.
Training and Competency: LPNs must receive appropriate training and demonstrate competency in IV therapy to safely administer medications within their scope of practice.
Vein Selection
Primary veins to consider for peripheral IV placement include the basilic or cephalic veins in the arm, and metacarpal veins in the hand, offering suitable access points.
Assess whether a peripheral catheter is appropriate for the prescribed infusion therapy, considering factors such as the type of medication, duration of therapy, and patient-specific factors.
Advocate for the patient's well-being; chemotherapy should not be administered via peripheral IV due to the risk of extravasation and tissue damage; consider alternative access options.
Peripheral IVs are acceptable for administering antibiotics or limited fluid administration when the therapy is short-term and the medication is compatible with peripheral infusion.
For more complex or long-term needs, consider PICC lines, implanted ports, or central lines, offering greater stability, compatibility, and reduced risk of complications.
Choose the least invasive option that is likely to last the duration of the planned infusion therapy, balancing patient comfort, safety, and efficacy.
Considerations for Vein Selection:
Vein Size: Select a vein that is adequately sized to accommodate the catheter and allow for sufficient blood flow around the catheter.
Vein Condition: Avoid veins that are sclerosed, thrombosed, or otherwise compromised, as they may increase the risk of complications.
Patient Preference: Involve the patient in the vein selection process, when appropriate, to promote comfort and cooperation.
Catheter Duration
Short peripheral catheters are typically suitable for infusion therapy lasting four or fewer days, providing a temporary solution for medication or fluid administration.
Prolonged Infusion Considerations:
Risk of Complications: Prolonged use of peripheral catheters increases the risk of complications such as phlebitis, infiltration, and infection.
Alternative Options: Consider alternative vascular access devices such as PICC lines or central lines for therapies lasting longer than four days.
Monitoring: Monitor the insertion site regularly for signs of complications and replace the catheter as needed.
Site Selection
Avoid starting an IV at valve locations or bifurcations where blood flow is turbulent, increasing the risk of thrombosis or catheter occlusion.
Consider the patient's mental status and activity level when selecting a site; for example, avoid the antecubital fossa (AC) in alert, active patients due to increased movement and risk of dislodgement.
In confused or demented patients, place the IV on the back of the arm or forearm to minimize tampering or accidental removal of the catheter.
Palpate veins to assess their condition, even if they are not immediately visible, to identify suitable insertion sites with adequate size and stability.
Select a gauge that is compatible with the vein size to ensure adequate flow rates while minimizing the risk of vessel damage or complications.
Blood pressure cuffs can be used as tourniquets, especially in patients with fragile skin, to distend veins and facilitate cannulation.
Release the tourniquet before flushing the IV to prevent vein rupture or extravasation of fluid into surrounding tissues.
Avoid the AC area in alert and oriented patients due to increased mobility and potential for dislodgement, and avoid hands in confused patients due to the risk of self-removal.
Vein distension is aided by a tourniquet, which temporarily restricts venous blood flow, causing veins to become more prominent and easier to access.
Gravity can promote blood flow and vein distension by holding the arm down, increasing venous pressure and visibility.
Ensure the selected catheter is appropriate for the patient's vein size to prevent irritation or damage to the vessel during insertion and infusion.
Inspect the cannula before insertion to ensure it is intact and free from any defects that could compromise its integrity or increase the risk of complications.
Prepare all necessary supplies before initiating the IV procedure to streamline the process and minimize the risk of contamination or delays.
Strategies for Optimal Site Selection:
Visualization: Use techniques such as transillumination or ultrasound guidance to visualize veins that are not readily visible.
Patient Input: Involve the patient in the site selection process, when appropriate, to promote comfort and cooperation.
Assessment: Assess the patient's overall condition and medical history to identify any contraindications or potential challenges with IV placement.
Catheter Sizes
14 and 16 gauge are large sizes typically reserved for specific situations such as dialysis or trauma resuscitation, where rapid fluid or blood administration is required.
20 gauge is a preferred size for general infusions and blood transfusions, offering a balance between flow rate and vessel compatibility.
22 and 24 gauge are smaller sizes often used in patients with small or fragile veins, or when administering medications with low viscosity.
26 gauge is the smallest available size, typically used in pediatric patients or neonates where minimal trauma to the vein is desired.
A 20 gauge can be used for drawing blood, although an 18 gauge may be considered if larger volumes are needed or if the patient has difficult venous access.
Considerations for Catheter Size Selection:
Infusion Rate: Choose a catheter size that is appropriate for the required infusion rate to ensure timely and effective medication or fluid delivery.
Vessel Size: Select a catheter size that is compatible with the patient's vein size to minimize the risk of vessel damage or complications.
Patient Comfort: Consider the patient's comfort and minimize the risk of pain or irritation by selecting the smallest appropriate catheter size.
Skin Preparation
Use chlorhexidine (preferred) for skin antisepsis due to its broad-spectrum antimicrobial activity and persistent effect; use iodine if the patient is allergic to chlorhexidine.
70% alcohol wipes are also acceptable for skin cleansing, but they may be less effective than chlorhexidine or iodine in reducing bacterial load.
Maintain skin tautness during insertion to prevent needle slippage and facilitate smooth entry into the vein, minimizing patient discomfort and tissue damage.
Additional Tips for Skin Preparation:
Scrub Technique: Use a vigorous scrub technique with the antiseptic solution to ensure adequate coverage of the insertion site.
Drying Time: Allow the antiseptic solution to dry completely before attempting cannulation to maximize its antimicrobial effect.
Contamination: Avoid touching the prepared skin with non-sterile gloved hands to prevent recontamination of the insertion site.
Potential Problems
Not releasing the tourniquet promptly after successful cannulation can cause venous congestion, discomfort, and an increased risk of hematoma formation.
Puncturing the vein during insertion results in swelling and bruising (hematoma) at the insertion site, necessitating restart at a different location.
Limit attempts to two pokes per healthcare provider; if unsuccessful, seek assistance from a more experienced colleague to minimize patient discomfort and potential complications.
Strategies for Minimizing Potential Problems:
Proper Technique: Use proper venipuncture technique, including angling the needle correctly and advancing it smoothly into the vein.
Stabilization: Stabilize the vein during insertion to prevent it from rolling or moving, which can increase the risk of unsuccessful cannulation.
Documentation: Document all attempts at cannulation, including the location, size of the catheter used, and any complications encountered.
Dressing
Use a transparent semipermeable membrane (TSM) dressing to cover the insertion site, allowing for visualization of the site for signs of swelling, redness, or drainage.
Utilize a J-loop or extension tubing to access the IV without disrupting the dressing, reducing the risk of contamination or dislodgement of the catheter.
Label the dressing with the date, time, and initials of the person who inserted the IV, as well as the gauge size of the catheter used.
Document the insertion site, gauge size, patient tolerance of the procedure, number of attempts, and confirmation of aseptic technique in the patient's medical record.
Dressing Management Best Practices:
Securement: Ensure that the dressing is securely affixed to the skin to prevent catheter dislodgement or contamination.
Dressing Changes: Change the dressing according to established protocols or when it becomes soiled, wet, or non-occlusive.
Assessment: Assess the insertion site regularly for signs of complications such as infection, phlebitis, or infiltration.
Patient Education
Instruct patients to keep their arms straight, especially with AC IVs, to prevent kinking or occlusion of the catheter.
Advise them not to push buttons on the IV pump unless instructed to do so by a healthcare provider, as this could alter the infusion rate or medication delivery.
Explain signs and symptoms of infection in understandable terms (redness, swelling, pain, drainage) and instruct them to report any concerns to their healthcare team.
Reassure them that beeping alarms on the IV pump do not always indicate a serious problem and that a nurse will respond to address any issues promptly.
Caution them against touching or interfering with the IV site or dressing, as this could increase the risk of infection or dislodgement.
Key Points for Patient Education:
Purpose of IV: Explain the purpose of the IV and the medications or fluids being administered to the patient.
Potential Complications: Educate patients about potential complications such as phlebitis, infiltration, or infection and how to prevent them.
Contact Information: Provide patients with contact information for their healthcare team so they can report any concerns or questions they may have.
Charting and Documentation
Record the IV insertion site, including the specific location on the extremity (e.g., cephalic vein in the left forearm) and the size of the needle used (e.g., 20-gauge).
Note the number of attempts made before successful cannulation, as well as any difficulties encountered during the procedure.
Document how the patient tolerated the procedure, including any signs of discomfort, anxiety, or adverse reactions.
Comply with facility policy regarding documentation requirements, including any specific forms or electronic health record fields that must be completed.
Essential Elements of IV Documentation:
Date and Time: Record the date and time of IV insertion, dressing changes, and any other relevant interventions.
Solution and Rate: Document the type of solution being infused, the infusion rate, and the total volume administered.
Assessment Findings: Record any assessment findings related to the IV site, such as redness, swelling, pain, or drainage.
Family Education
Instruct family members not to adjust the pump settings or tamper with the IV equipment, as this could compromise the delivery of medications or fluids.
Educate them on the signs and symptoms of potential issues, such as infiltration, phlebitis, or infection, and encourage them to report any concerns to the healthcare team.
Be vigilant as families may attempt to steal drugs, especially controlled substances, and take appropriate measures to prevent diversion.
Document whether the IV flushed easily with normal saline and if there was any noted edema or resistance during flushing.
Document if the IV was inserted near or close to a bruise, as this could affect the accuracy of assessment findings.
Strategies for Effective Family Education:
Clear Communication: Use clear and concise language when educating family members, avoiding medical jargon when possible.
Visual Aids: Use visual aids such as diagrams or handouts to illustrate key concepts and reinforce learning.
Cultural Sensitivity: Be sensitive to cultural differences when providing education and tailor your approach to meet the specific needs of the family.
Continued Monitoring
Assess the IV site every shift (typically every 8 or 12 hours) or more frequently (every 2-4 hours) depending on facility policy and patient condition.
Verify the IV functionality before administering any medications or fluids, ensuring that the catheter is patent and the infusion is running at the correct rate.
Visualize the IV insertion site regularly (every 2-4 hours, or every 2 hours for vesicant infusions) to monitor for signs of complications such as redness, swelling, or drainage.
Key Elements of Ongoing IV Monitoring:
Flow Rate: Monitor the infusion rate to ensure that medications or fluids are being delivered at the prescribed rate.
Patient Comfort: Assess the patient's level of comfort and address any complaints of pain, burning, or irritation at the IV site.
Complications: Monitor for signs and symptoms of complications such as phlebitis, infiltration, or infection and take appropriate action as needed.
Discontinuing an IV
Remove the tape and carefully withdraw the catheter from the vein, applying gentle pressure to the insertion site to stop bleeding.
Apply pressure for 30 seconds to a minute (or longer) to minimize bruising, especially in patients on blood thinners or with bleeding disorders.
Ensure the catheter tip is intact upon removal to prevent complications such as embolism or retained foreign body.
Educate the patient on post-infusion care, such as avoiding dirty activities or heavy lifting with the affected arm for a period of time.
Best Practices for IV Discontinuation:
Proper Technique: Use proper technique to minimize the risk of complications such as hematoma or nerve injury.
Documentation: Document the date, time, and reason for IV discontinuation, as well as any assessment findings related to the site.
Patient Education: Provide patients with instructions on how to care for the insertion site and when to seek medical attention.
Patient Controlled Analgesia (PCA)
LPNs typically do not initiate or alter PCA medication syringes due to the advanced knowledge and skills required for dosage calculation and programming.
Common medications used in PCA pumps include morphine, fentanyl, hydromorphone, lorazepam, and ketamine, each with its own set of potential side effects and contraindications.
Be aware of the risk of medication diversion, where patients or healthcare providers may attempt to obtain controlled substances for non-medical purposes.
Monitor patient respiratory rate, heart rate, and blood pressure frequently due to the CNS depressant effects of opioid analgesics, which can lead to respiratory depression or hypotension.
Stop the PCA infusion if the patient shows signs of respiratory depression (e.g., decreased respiratory rate, shallow breathing, decreased oxygen saturation) and activate the emergency response system.
PCA Safety Considerations:
Dosage Limits: Ensure that PCA pumps are programmed with appropriate dosage limits to prevent accidental oversedation or respiratory depression.
Patient Monitoring: Monitor patients closely for signs of respiratory depression, sedation, or other adverse effects.
Education: Educate patients and families about the purpose of the PCA pump, how to use it safely, and when to seek assistance.
Narcan Administration
LPNs may be able to administer intranasal Narcan (naloxone) in certain situations, while RNs may give IV Narcan, depending on state regulations and facility policies.
PCAs contain controlled substances, so stringent handling procedures must be followed to prevent diversion, theft, or misuse.
Narcan Administration Protocols:
Indications: Administer Narcan to patients exhibiting signs of opioid overdose, such as respiratory depression, pinpoint pupils, or unresponsiveness.
Dosage: Follow established protocols for Narcan dosage and administration, adjusting the dose as needed based on patient response.
Monitoring: Monitor patients closely after Narcan administration for recurrence of opioid overdose symptoms.
PCA Safety Measures
Orders for PCA medications are typically entered by RNs and verified by the pharmacy to ensure accuracy and appropriateness.
Medications are hand-delivered to the nursing unit, signed for by a licensed healthcare provider, and placed in a locked box or secured medication dispensing system.
Two nurses are often required to verify and initiate the PCA pump to ensure accuracy and prevent errors.
Dosage is based on the patient's weight and programmed into the pump with set limits to prevent accidental oversedation or respiratory depression. There is also family education to avoid accidental administration.
Strategies for Enhancing PCA Safety:
Standardized Protocols: Implement standardized protocols for PCA ordering, programming, and monitoring to reduce the risk of errors.
Independent Double Checks: Use independent double checks to verify medication orders and pump settings.
Education and Training: Provide ongoing education and training to healthcare providers on PCA safety and best practices.
Correprocal Nerve Catheter/On-Q Ball
The On-Q ball can contain pain medicine (local anesthetic), chemotherapy agents, or antibiotics, depending on the specific clinical situation and patient needs.
A filled On-Q ball with antibiotics negates the need for IV antibiotics, providing a convenient and effective alternative for delivering antimicrobial therapy.
It works by negative pressure, gradually deflating as it infuses the medication over a specified period, providing continuous pain relief or medication administration.
Two tip types are available: a needleless connector for IV hookup or a catheter designed for direct insertion into a surgical site, allowing for targeted medication delivery.
Lasto metric pump is synonymous with On-Q ball, both referring to the same type of portable infusion device.
Used in home care and outpatient settings, allowing patients to receive continuous medication infusions while maintaining their independence and mobility.
Essential Considerations for On-Q Ball Management:
Site Assessment: Regularly assess the insertion site for signs of infection, bleeding, or catheter dislodgement.
Flow Rate: Monitor the flow rate to ensure that the medication is being delivered at the prescribed rate.
Patient Education: Educate patients and families about the purpose of the On-Q ball, how to care for the insertion site, and when to seek medical attention.
Final Exam Preparation
Reflect on previous exam performance to identify contributing factors such as study habits, content comprehension, or time management that may have affected your scores.
Review past exams and seek help from the instructor as needed to clarify any confusing concepts or address areas of weakness.
Utilize study guides and create your own by reviewing questions, focusing on key concepts and topics that are likely to be covered on the final exam.