Transcript Day 3 Power Point

Chapter 7
Intravenous Access and Medication
Administration
Part 2
Intravenous Access, Blood Sampling, and
Intraosseous Infusion
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
•
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Types of Intravenous Access
Equipment for Intravenous Access
IV Drug Administration
Venous Blood Sampling
Intraosseous Infusion
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Intravenous (IV)
Access Indications
• Fluid and blood replacement
• Drug administration
• Obtaining venous blood specimens for lab analysis
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Types of IV Access
• Peripheral venous access
• Central venous access
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Peripheral IV Access Sites
In adults - arms, hands, external jugular, and feet as a last
resort.
In infants – you can use veins in feet and ankle, plus scalp
veins. **
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Central Venous Access
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Veins located deep in the body
Internal jugular, subclavian, femoral
Peripherally inserted central catheter (PICC lines)
Larger veins that will not collapse in shock
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
IV Solution
Containers
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Do not use any IV fluids after their expiration date;
any fluids that appear cloudy, discolored, or laced
with particulate; or any fluid whose sealed
packaging has been opened or tampered with.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
IV Administration Sets (1 of 2)
• Macrodrip
• 10 gtts = 1 mL, for giving large amounts of fluid
• Microdrip
• 60 gtts = 1 mL, for restricting amounts of fluid
• Blood tubing
• Has a filter to prevent clots from blood products
from entering the body
• Measured volume
• Delivers specific volumes of fluids
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
IV Administration Sets (2 of 2)
 I V extension tubing
- extends original tubing
 Electromechanical pump tubing
- specific for each pump
 Miscellaneous
- some sets have a dial that can set the flow rates (Dial-aFlow)
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Primary Tubing
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Secondary Tubing
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Macrodrip vs. Microdrip Tubing
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Measured Volume Admin. Set
aka Burette or Buretrol
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Extension Tubing
aka J-Loop
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pump Tubing
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Dial-a-Flow
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Y-Tubing for Blood
Administration
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
In-Line Intravenous Fluid Heaters
• IV fluids can be heated to near body temperature with heating
devices. Applies to both IV fluids and blood.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Intravenous Cannulas
• Over-the-needle catheter
• Hollow-needle catheter
• Plastic catheter inserted through a hollow needle
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Over-the-Needle Catheter
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hollow-Needle Catheter (Butterfly)
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Catheter Inserted Through the Needle
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Peripheral IV Access
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Place the constricting band.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cleanse the venipuncture site.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert the intravenous cannula into the vein.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Withdraw any blood samples needed.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Connect the IV tubing.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Turn on the IV and check the flow.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Secure the site.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Label the IV solution bag.
© Scott Metcalfe
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Intravenous Access
With a Measured Volume
Administration Set
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Prepare the
tubing.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Open the uppermost
clamp and fill the burette
chamber with
approximately
20 mL of fluid.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Close the uppermost
clamp and open the flow
regulator.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Intravenous Access
with Blood Tubing
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert the flanged spike into the spike port
of the blood and/or normal saline solution.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Squeeze the drip chamber until it is
one-third full and blood covers the filter.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Attach blood tubing to the intravenous
cannula or into a previously established IV line.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Open the clamp(s) and/or flow
regulator(s) and adjust the flow rate.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Factors Affecting IV Flow Rates **
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Constricting band
Cannula diameter
Edema at puncture site
Cannula abutting the vein wall or valve
Administration set control valves
IV bag height
Completely filled drip chamber
Catheter patency
Venting of the fluid container
Position of extremity
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
IV Access Complications
• Pain
• Local infection
• Pyrogenic reaction
• Allergic reaction
• Catheter shear
• Inadvertent arterial
puncture
• Circulatory overload
• Thrombophlebitis
• Thrombus formation
• Air embolism
• Necrosis
• Anticoagulants
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Changing an IV Bag or Bottle
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Prepare the new bag or bottle.
Occlude the flow from depleted bag or bottle.
Remove spike from depleted bag or bottle.
Insert spike into the new IV bag or bottle.
Open the clamp to appropriate flow rate.
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Complications of Intravenous
Therapy
Learning Outcomes:
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Differentiate between local and systemic
complications.
Describe the signs and symptoms of local
complications.
Identify prompt treatment for local and systemic
complications.
Identify International Standards of practice rating
infiltration.
List three risk factors for phlebitis.
Identify organisms responsible for septicemia relate
to infusion therapy.
Identify prevention techniques for the systemic
complications.
I.V. Catheter Complications
Phlebitis
 Thrombophlebitis
 Infection
 Infiltration
 Hematoma
 Hypothermia
 Extravasation
 Venous Spasm


https://youtu.be/XH3IK4hV3Qg
I. Local
complications
1. Hematoma:
Formations resulting from the infiltration of
blood into the tissues at the Venipuncture site.
Causes:
 Rupture the vein during an unsuccessful
Venipuncture attempt.
 Discontinuing the I.V. cannula or needle
without
pressure.
 Applying a tourniquet too tightly above a
previously attempted venipuncture site.
1. Hematoma (cont.)
Signs/symptoms:
 Discoloration of the skin.
 Site swelling and discomfort.
 Inability to advance the cannula all the
way into the vein during insertion.
 Resistance to positive pressure during
the lick flushing procedure.
Document:
 The observable ecchymotic areas.
2.Thrombosis
Catheter-related obstructions can be
categorized as mechanical or non-thrombotic ( 42%
of all obstructions)
or thrombotic (58% of all obstructions),
Signs/symptoms:
 Fever and malaise.
 Slowed or stopped infusion rate.
 Inability to flush licking device.

2.Thrombosis (cont.)
If you can’t flush the catheter, do not
forcibly try to flush it. You can dislodge the
thrombus and send it travelling through the
circulatory system. Instead, d/c the catheter,
start another one, preferably in the other
arm and document.
2.Thrombosis (cont.)
Documentation:
 Document the change of infusion rate.
 The steps taken to solve the problem,
and the end result.
 Chart new IV sites.
 It’ s patency, and the size of the
catheter used.
3. Phlebitis
An inflammation of the vein.
Signs/symptoms:
 Redness at site.
 Site warm to touch and local swelling.
 Palpable cord along the vein.
 Sluggish infusion rate.
 Increase in basal temperature of 1 °C or
more.
Types of Phlebitis

Bacterial Phlebitis – is usually an indication of
an infection at the insertion site.

Chemical Phlebitis – is most commonly seen
with peripheral IV devices when medications or
solutions irritate the endothelial lining of the small
peripheral vessel wall, for example:
◦ Erythromycin
◦ Tetracycline
◦ Vancomycin
◦ Large doses of Potassium Chloride
(K+)
◦ multivitamins
Types of Phlebitis

Mechanical Phlebitis – occurs when the
size of the cannula is too big for the
selected vein causing unnecessary friction
on the internal lining of the vein, leading
to inflammation.
Fighting Phlebitis
1.
2.
Phlebitis is most common after
continuous infusions, developing 2 – 3
days after the vein is exposed to the
drug solution.
Phlebitis is more common in distal veins
than in veins close to the heart.
Steps to Prevent Phlebitis
 Use
proper venipuncture technique.
 Dilute drugs correctly.
 Monitor administration rates.
 Observe the I.V. site frequently.
 Change the infusion site regularly
according to policy.
3. Phlebitis (cont.)
Nursing Interventions:

Remove IV device.

Apply warm soaks.

Notify primary care provider.
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
Restart IV infusion in a different
extremity.
Document your actions.
4.Thrombophlebitis
Thrombosis and inflammation.
Signs/symptoms:
 Sluggish flow rate, edema in the limbs.
 Tender and cordlike vein, site warm to
touch.
 Visible red line above Venipuncture site.
 Diminished arterial pulses.
 Mottling and Cyanosis of the
extremities.
5. Infiltration
Accidental administration
of a non vesicant solution
into surrounding tissue.
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Signs/symptoms:
Coolness of skin around site, and tight skin.
Dependent edema and absence of blood
backflow.
A pinkish blood return.
Infusion rate slows but the fluid continues to
infuse.
Edema at the site and above.
Treatment of Infiltration
Discontinue the infusion.
 Apply warm, moist heat to
↓edema.
 Elevate the extremity.
 Restart the infusion at another
site, preferable the other arm.

Prevention of Infiltration
Select site over long bone to act
as a splint.
 Avoid sites over joints.
 Use arm board to stabilize (as a
last resort!).

5. Infiltration (cont.)
Documentation:
 assessment findings.
 any written and verbal communications.
 nursing and medical interventions.
 client response patterns.
6. Extravasations
The accidental administration of a vesicant
solution into surrounding tissue.
Signs/symptoms:
 Complaints of pain or burning; swelling
proximal or distal to the IV site.
 puffiness of the dependent part of the limb;
skin tightness at the Venipuncture site; and
coolness of the skin.
 Slow or stopped infusion; damp or wet
dressing.
Extravasations Interventions
Stop the infusion, and elevate
extremity.
 Remove the cannula.
 Call physician.
 Administer antidote (if appropriate)
intradermaly into infiltrated tissue.
 Apply warm moist compresses for 20
minutes every 4 hours (see hospital
policy).

6. Extravasations (cont.)
Documentation:
 Document assessment and interventions.
Include the vascular access device type,
insertion site, name of medication or
solution, and how it was infused.
7. Local
infection
Microbial contamination of the cannula or
infusate
Signs/symptoms:
 Redness and swelling at the site; possible
exudates of purulent material.
 Increased quantity of white blood cells;
and elevated temperature.
7. Local infection (cont.)
Documentation:
 Assessment of site.
 culture technique & sources of culture.
 physician notification and any treatment
initiated.
8.Venous spasm
A sudden involuntary contraction of a vein
or an artery resulting in temporary
cessation of blood flow through a vessel.
Signs/symptoms:
 sharp pain at the IV site that travels up
the arm, which is caused by acute flow of
fluid that irritates the vein wall; slowing of
the infusion
8.Venous spasms (cont.)
Documentation:
 client complaints, duration of complaints,
treatment, and length of time to resolve
the problem.
II. Systemic Complication
1. Septicemia: (sepsis)
A febrile disease process that results
from the presence of pathogenic
microorganisms or their toxic products in
the circulatory system.
Signs and Symptoms:
Fluctuating fever, tremors, little cold sweat,
nausea and vomiting, diarrhea, abdominal pain.
 Tachycardia, increased respirations or
hyperventilation, altered mental status, and
hypotension
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Septicemia Interventions
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Notify physician immediately.
Symptomatic care.
Identify other sources of
infection.
Remove IV device.
Culture the IV cannula,
tubing, or solution if it is
suspect.
Return fluid to pharmacy.
Establish a new IV site for
medication or fluid
administration.
1. Septicemia (cont.)
Documentation:
 Document S/S assessed; physician
notification, all treatments instituted.
2. Fluid overload & Pulmonary
edema
 Caused
by infusing excessive amounts
of isotonic or hypertonic crystalloid
solutions to rapidly, failure to monitor
the IV infusion or too-rapid infusion
of any fluid in a patient compromised
by cardiopulmonary or renal disease.
2. Fluid overload & Pulmonary
edema (cont;)
S/S:
Restlessness, headache, tachycardia,
weight gain over a short period of
time, cough, and presence of edema.
 Hypertension, wide variance
between intake and output,
distended neck veins.

2. Fluid overload & Pulmonary edema
(cont.)
Documentation:
 client assessment, notification of
physician, and treatments instituted by
physician order.
3. Air embolism
Air entering the central vein, which
is quickly trapped in the blood as it
flows forward. Prevention is the key.
3. Air embolism(cont.)
S/S:
complaints of palpitations, and weakness.
Pulmonary findings: dyspnea, cyanosis,
tachypnea, expiratory, wheezes, cough,
and pulmonary edema.
 Cardiovascular: murmur; weak, thready
pulse; tachycardia; substernal chest pain;
hypotension; and jugular venous
distention.
 Neurologic findings: change in mental
status, confusion, coma, anxiousness, and
seizures.
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3. Air embolism (cont.)

Nursing Interventions:
◦ Immediately clamp the tubing.
◦ Turn client to left, head down (to
allow air to enter right atrium and be
dispersed via pulmonary artery)
◦ Monitor vital signs.
◦ Administer O2.
◦ Notify physician.
◦ Document actions.
Documentation:
◦ Client assessment, nursing interventions,
physician notification, and treatment.
4. Speed shock
Occurs when a foreign substance usually a
medication is rapidly introduced into the
circulation
 S/S: dizziness, facial flushing, headache,
tightness in the chest, hypotension,
irregular pulse, progression of shock.
4. Speed shock (cont.)

Documentation: medication or fluid
administered and the signs and symptoms
the pt reported, physician notification,
treatment initiated and the client
response.
5. Catheter embolism
A piece of the catheter breaks off and
travels through the vascular system.

S/S: sharp sudden pain at the IV site,
minimal blood return, rough and uneven
catheter noted on removal, cyanosis,
chest pain, tachycardia, hypotension.
Intravenous Bolus
Administration
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Prepare the equipment.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Prepare the medication.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Check the label.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Select and clean an administration port.
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Pinch the line.
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Administer the medication.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Adjust the IV
flow rate.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Monitor the patient.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Intravenous Infusion
Administration
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Select the drug.
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Draw up the drug.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Select IV fluid for dilution.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Clean the medication addition port.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Inject the drug into the fluid.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Mix the solution.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert an administration set and connect to the
main IV line with needle.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Heparin/Saline Lock
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Venous Access Device
• Surgically implanted device that permits repeated access to
the central venous circulation
• Generally located on anterior chest near the third or fourth rib
lateral to the sternum
• Accessed with a special needle specific to the device
• Requires special training
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Electromechanical
Infusion Devices
• Infusion controllers
• Infusion pumps
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Infusion Pump
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Syringe-Type Infusion Pump
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Drawing Blood
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Blood Tubes
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Vacutainer and Leur Lock
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Obtaining a blood sample
with a 20 mL syringe
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Leur Sampling Needle
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Remove any IV that will not flow or has fulfilled its need.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Intraosseous Infusion
• A rigid needle is inserted into the cavity of a long bone.
• Used for critical situations when a peripheral IV is unable to be
obtained.
• Initiate after 90 seconds or three unsuccessful IV attempts.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anterior tibia
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Pediatric and adult intraosseous
needle placement sites.
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Manual intraosseous needle
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Bone injection gun (B.I.G.)
WAISMed., Ltd.
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FAST1 – Sternal IO
• Employs an introducer
to insert an infusion
tube into the top bone
of the sternum
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
EZ-IO
Battery-powered IO driver
and needle set
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
E Z IO EDUCATION
http://www.teleflex.com/en/usa/ezioeducation/index.html
Intraosseous Medication
Administration
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Select the medication and
prepare equipment.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Palpate the puncture site and prep
with an antiseptic solution.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Make the puncture.
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Aspirate to confirm proper placement.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Connect the IV fluid tubing.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Secure the needle appropriately.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Administer the medication.
Monitor the patient for effects.
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© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Intraosseous Access
Complications
• Fracture
• Infiltration
• Growth plate damage
• Complete insertion
• Pulmonary embolism
• Infection
• Thrombophlebitis
• Air embolism
• Circulatory overload
• Allergic reaction
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Contraindications to
Intraosseous Placement
• Fracture to tibia or femur on side of access
• Osteogenesis imperfecta—
congenital bone disease resulting in fragile bones
• Osteoporosis
• Establishment of a peripheral IV line
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
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Types of Intravenous Access
Equipment for Intravenous Access
IV Drug Administration
Venous Blood Sampling
Intraosseous Infusion
Bledsoe et al., Essentials of Paramedic Care: Division 1
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ