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IV

TherapyModule

IV Therapy Module Objectives:

At the completion of this module, thecaregiver will be able to discuss theindications, complications, and key steps

for initiating IV therapy.The caregiver will also be able to identifyand discuss the considerations associatedwith selecting and maintenance of IV sites. (*Revised 9-2003)

Step #1Read the attached module. The learning activities may beused as a study guide. This module has been designed tobe completed within 30-45 minutes.

Step #2The participant should complete and return the post-test.

Welcome to the IV Therapy

Module!

Follow the steps below to successfullyestablish competence.

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IV Therapy

Learning Activity

Before the caregiver can performvascular access they should have anunderstanding of the following:

IV Therapy

In the health care environment vascularaccess is performed to deliver fluid andmedication, as well as for sampling the bloodand it's components.

Children report needlesticks to be the mostdistressing aspect of a hospital or out-patientexperience. The following principles of careare integral to efforts to minimize needlerelated pain and distress in children Avoid or cluster needlesticks whenever

possible Use the IM route only if absolutely

necessary intervene early - if a child has a difficult

experience with their initial venipuncture/ IV start they will have heightenedanxiety around subsequent procedures

Be developmentally appropriateBefore the caregiver can perform vascularaccess they should have an understanding of

the following: Vascular anatomy and physiology Basic steps for performing access Complications and hazards Growth and developmental implicationsThis module is intended to be an introductionto vascular access. The caregiver should seekout additional specific information (i.e., policyand procedure) when performing vascular

access in their area.

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IV Therapy

Learning Activity

Fill-In the names of the vessels inorder as they exit the heart.

Exiting the Heart

_______________________

_______________________

_______________________

_______________________

_______________________

Back to the heart

IV Therapy

Basic Vascular Anatomy and Physiology

The circulatory system consists of a series ofblood vessels. The blood vessels in the humanbody form a network of tubes that carryblood away from the heart, transport it to thetissues of the body, and then return it to theheart.Arteries are vessels that carry blood fromthe heart to the tissues. Large, elasticarteries leave the heart and divide intomedium-sized, muscular arteries that branchout into the various regions of the body.Arterioles are smaller -sized arteries thatdivide from medium arteries. Arterioles entertissues, and branch into countless microscopicvessels.Capillaries are the microscopic vessels foundin the tissues.Through the walls of thecapillaries, substances are exchanged betweenthe blood and body tissues.Venules are the small veins that are formedfrom groups of capillaries reuniting before

leaving the tissues.Veins are the larger vessels formed from thevenules which convey blood from the tissuesback to the heart.

Due to the design of the body's circulatorysystem the arteries receive blood beingpumped directly from the heart. As a resultarteries can be classified as high pressure /pulsatile vessels. Since the veins are the last

vessels involved with returning blood to theheart they can be referred to as low pressure/ non-pulsatile vessels.

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IV Therapy

"Learning Activity"

Explain how the veins prevent thebackflow of blood in the lower limbs

due to the force of gravity._____________________________

________________________________________________________

Indications For Vascular Access mayinclude: (Fill-In)

___________________________

___________________________

___________________________

___________________________

IV Therapy

The pressure in the veins is barely enough tobalance the force of gravity pushing bloodback down to the lower limbs. For this reasonmany veins, especially those in the limbs,contain valves to prevent backflow.

Indications for Vascular Access

The indications for vascular access mayinclude the following: fluid replacement blood sampling medication delivery parenteral nutrition

Selecting A Site for Access

Site selection is one of the most importantconsiderations in preparing to start an IV orto obtain blood. The caregiver should alwaysstart from the most proximal portion of theextremity and move toward the distal. In

addition, always remember to keep the numberof attempts to a minimum (see hospital policyand procedure for the maximum number ofattempts permitted by one individual).

When selecting the site for venous access thecaregiver should consider the following:l purpose and duration of IV therapyl age of the childl condition of the veinsl skin integrityl patient preference

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IV Therapy

"Learning Activity"

Describe why the purpose and durationof an IV is important to consider?

_________________________

_________________________

Describe when and why the lowerextremities are commonly avoidedwhen selecting and initiating an IV.

_______________________________________________________________________________________

IV Therapy

Purpose and Duration

As the length of time for IV therapyincreases, the patient's comfort and level ofimmobilization required becomes moreimportant to consider.

Ideally, the patient should receive the type ofaccess appropriate for diagnosis(epidermolysis bullosa, cystic fibrosis,osteomyelitis, sickle cell anemia). For example,if a patient requires IV therapy for a longduration, they may require a more durableform of access (i.e. peripherally insertedcentral catheter or PICC).

The caregiver should also ensure that the siteselected and type of line selected will bestsupport medications / fluids that may beirritating to the veins (i.e., Vancomycin,calcium and fluids with high dextroseconcentration).

Selecting A Site For Access

Age of The Child

The caregiver should be sensitive to patientsage when selecting and initiating an IV. Forexample, if the child is walking, the lowerextremities are commonly avoided due to the

increased risk of thrombophlebitis, and thelimitations it may place on the patientsmobility. The caregiver should also avoid thepatients thumb-sucking digit.

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IV Therapy

"Learning Activity"

The ideal site for venous access is thevein that can be

__________________or_____________,__________________ and_____________ enough to acceptthe catheter. (Fill-In)

List the characteristics common todamaged and / or irritated sites.

1.___________________________

2.___________________________

3.___________________________

4.___________________________

IV Therapy

Condition of The Veins

The ideal site for venous access is the vein

that can be visualized or palpated, smooth

and straight enough to accept the catheter.

Veins that have been damaged by frequent useand / or irritated by caustic medicationsshould be avoided. These sites can beidentified upon visual inspection as well as bytransillumination.

The characteristics common to damaged and /or irritated sites include: scarring, bruising,swelling, altered skin integrity (i.e., blister).

The presence of valves in the veins may causeproblems with proper vein cannulation.

Patient Preference

Whenever possible, especially with school-aged patients, their desires and knowledgeshould be considered. Often the older child orparent may be able to tell the caregiver whichsites they prefer as well as which sites havebeen successfully cannulated upon previousattempts.

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IV Therapy

"Learning Activity"

The ______________ and the_________ veins in the forearm arethe most commonly used in the upperextremity.

Often times the ________________is attempted first.

IN the dorsum of the hand, the mostcommonly used veins include tributariesof the _________ _________ as wellas the ___________ arch.

The __________________ vein atthe ankle is probable easiest tocannulate.

The use of _____________ veins maybe more appropriate for infants.

The caregiver should always rememberto insert the IV in the direction of the

____________.

IV Therapy

Specific IV Sites

Upper Extremity

The cephalic, basilic, and median cubital veinsin the forearm are most commonly used in theupper extremity.Often, the median cubital is attempted first.This may pose a problem in the future should amidline or a peripherally inserted centralcatheter (PICC) be needed by the child.In the dorsum of the hand, the most commonlyused veins include the tributaries of thecephalic and basilic veins as well as the dorsalvenous arch.

Lower Extremity

The saphenous veins, the median marginalveins, and the veins of the dorsal arch of thelower extremity may be accessed. Of these

veins, the great saphenous vein at the ankle isprobably easiest to cannulate.

Scalp Veins

The use of scalp veins may be moreappropriate for infants. Due to the fragilityof the infants vessels, the caregiver shouldfrequently assess the site for complications.The caregiver should always remember to

insert the IV in the direction of the heart. Toavoid puncturing an artery, the caregivershould always palpate for a pulse prior to avenipuncture.

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IV Therapy

"Learning Activity"

It is our responsibility to help thechildren ____________________ tohave _________________ and to useour _____________________ whenavailable.

The caregiver should always be__________ but yet be careful not to

use terms that may ___________ thepatient and their support systems.

List some Behavioral Interventions thatcan be used to relieve anxiety and pain:

IV Therapy

Growth and Development Considerations

Children are special individuals with their ownneeds. As they enter the hospital setting,many tests and procedures are done which aredifferent to them and at times invasive. It isour responsibility to help the children feel atease, to have patience with them, and to useour resources when available (i.e., Child Life).

Prior to initiating an IV the caregiver shouldalways communicate what the procedure mayentail using appropriate terminology andsupport measures.

Preparation and Pain Management

Behavioral and pharmacologic interventionsshould be combined in an effort to relieveanxiety and pain.

Behavioral Interventions

Parental presence is comforting to childrenand should be promoted whenever possible Be honest explain in simple language whatchild will see, hear, taste, smell and feelusing words, pictures and dolls

Treatment rooms, if available, should beused for venipuncture so that a child canrest and relax in their bed

Utilize Positioning for Comfort atherapeutic approach to positioningchildren for painful procedures, which aims

to minimize a childs feelings ofhelplessness and vulnerability whilepromoting feelings of security and control.

Refer to Needle Pain Guidelines forfurther age appropriate interventions

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IV Therapy

"Learning Activity"

List some Pharmacoloic Interventionsthat can be used to relieve anxiety and

pain:

IV Therapy

Pharmacologic Interventions

Children report that EMLA helps .. use it ! If it will be less than 20 minutes before

the needlestick, utilize Fluorimethane(Cold Spray) immediately beforevenipuncture

If 30 90 minutes is available before theneedlestick, apply EMLA to potentialvenipuncture sites

Refer to Needle Pain Guidelines fordosage & administration information.

Child Life recommends that a consistent staffmember or members conduct procedures. (i.e.,blood draw, IV initiation)

If available, Child Life should always becontacted to assist in preparing the patientand in providing diversional activities duringthe procedures. The caregiver may find ithelpful to review the module Impact ofIllness on Growth and Development.

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IV Therapy

"Learning Activity"

Fill-In the missing steps forInitiating Peripheral IV Therapy

Perform _________ / __________teaching and apply

___________________ if > 30minutes to procedure

Assess the patient for ___________sensitivity, and any other

_________________.

Take patient to_____________________________.

Put on _________and any otherprotective barriers.

Select the ____________________.

Prepare the skin with________________.

Provide ____________traction______________

_________________________________________

Slowly advance the needle/catheteruntil___________.

IV Therapy

Key Steps for Initiating Peripheral IV

Therapy

1. Perform patient / family teaching andapply EMLA cream if > 30 minutes toprocedure (refer to growth anddevelopmental considerations). If patienthas undergone venipuncture before askwhat helped them in the past.

2. Assemble equipment, prepare tape, flushcatheter and tubing if desired and if notcollecting labs. Assess the patient forlatex sensitivity and any other allergies(see policy and procedure for specificequipment).

3. Take patient to treatment room (ifavailable) and initiate behavioral supportivemeasures (e.g. positioning for comfort,distraction, relaxation) as appropriate.

4. Perform hand washing.5. Put gloves on and any other protective

barriers.

6.

Select the site. The caregiver may find ithelpful to use a tourniquet to locate a site.7. Prepare the skin, wipe with alcohol, allow

to dry, then wipe with providine (allow 30seconds for skin contact).

8. Provide counter-traction on the skin, withthe other hand, insert needle/catheter ata 10 - 30 degree angle, with bevel up,either over or beside the vein.

9. Slowly advance the catheter until bloodreturns, then lower the catheter andcontinue to advance, just enough to coverthe stylet and catheter in the vein, thenhold catheter and withdraw stylet enoughto hood in side of catheter, then graspthe stylet and catheter together andcontinue to advance to the hub.

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IV Therapy

"Learning Activity"

Attach the ___________________to the catheter followed by slowlyflushing it with normal saline.

Loop the tubing and t-connector nearthe ________________________and secure with tape,

Leave the T-connector exposed topermit ____________________when required.

IV TherapyKey Steps for Initiating Peripheral IV

Therapy

Continued

10.Remove the tourniquet if in use.11. Secure catheter in place using a sterile

transparent occlusive dressing.12.Attach the T-connector to the catheter

followed by slowly flushing the system withnormal saline. Observe for signs ofinfiltration and / or hematoma.

13.You may now chevron inch tape over theocclusive dressing.

14.Loop the tubing and t-connector near thesite of entry and secure with tape, leave theT-connector exposed to permit tubingchange when required.

15.Apply armboard, pad as necessary, toprovide protection.

16.Mark the date, time, type and size ofcatheter used in appropriate place (i.e.,chart, notes) per policy and procedure.

17.Adjust rate of solution flow according toamount prescribed or flush the site lock tomaintain patency for intermittent use.

18.Observe and document patient's response /tolerance ask patient how was that for

you?, what helped, what didnt?19.Perform hand washing.When performing phlebotomy, the caregiverwill perform steps 1-8, then collect thespecimen per policy and procedure.

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IV Therapy

"Learning Activity"

IV ChecklistWhen maintaining an IV the caregivermay find it helpful to perform a quick

review of the following: (Fill-In)

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

IV TherapyWhen maintaining an IV the caregiver may findit helpful to perform a quick review of thefollowing:

Right solution?

Appropriate volume and rate of flow per

patient weight?

Circulatory overload can occur more quicklyand have more serious effects in children.

Right equipment? Aresystem alarmsfunctional?

When working with children, medications /fluids should be administered with devicesthat permit accurate delivery (i.e., pumps).

Right labeling?

Labeling should include fluid, medications (ifmedication has been added), date, and timebottle / bag was hung and date and time tobe changed per policy and procedure.

Patency of the tubing?

Check for kinks, air, blood, leaks andflattening.

Are the clamps out of the childs reach?

Is the site free from complications?

Pain / Tenderness Swelling

Warmth or coolness Blanching Redness Vein hardness Wetness Patency of overall system, including the site

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IV Therapy

"Learning Activity"

How frequently should the dressing bechanged? (Fill-In)_____________________________

_____________________________

_____________________________

How frequently should the site bechanged? (Fill-In)_____________________________

_____________________________

_____________________________

How often should the site be checked?

(Fill-In)__________________________________________________________

_____________________________

IV TherapyIs the site free from complications?

Vital signs (alterations can indicate IVcomplications).

Urine Output Visible edema Cough or frothy sputum (may indicate fluid

overload). General appearance of the child Fluid balance record (I & O) should be

current for hourly and running volumetotals.

How frequently should the dressing bechanged?

It is generally recommended that the dressingbe changed as needed when it becomes non-occlusive and / or soiled.Otherwise, the caregiver should refer to thepolicy and procedure for the specific protocolregarding the frequency of dressing changesfor IV sites.

How frequently should the site be changed?

Peripheral IV sites should be changed asneeded, such as if signs of infiltration, phlebitisor infection occur. Surgically implanted typesof access (i.e., portacaths) are generally re-accessed in as few as 7 days or as many as 30days depending upon frequency of use. Thecaregiver should refer to the policy andprocedure for specific protocol.

How frequently should the site be checked?

It is generally recommended that IV site bechecked at least every 1-2 hours.

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IV Therapy

"Learning Activity"

Children may have IVs for the purposeof

_____________________________

and / or

infusion of medications and / or fluids.(Fill-In)

When performing vascular access for

IV initiation the caregiver shouldobserve for the followingcomplications:(Fill-In)

._________________________

._________________________

._________________________

._________________________

._________________________

._________________________

._________________________

IV Therapy

Caring for An Intermittent SystemChildren may have IVs for the purpose ofcontinuous and / or intermittent infusion ofmedications and /or fluids.If the child has an IV for intermittent therapyonly, a site lock system (e.g. heparin lock) maybe used. The site lock system need only beaccessed when the medications and / or fluidsare administered.The site lock system may be a rubber chamberor device into which the IV infusion set (e.g.needless cannula) is inserted. Once the infusionis completed the caregiver should carefullyremove the infusion equipment leaving the sitelock intact. Site locks are usually flushed with aheparinized saline solution to prevent clotting inthe cannula between infusions.The caregiver should check the current policyand procedure regarding the protocol for

selecting a flush solution.

Site locks are ideal for short-term therapy, and

may allow children the opportunity to maintainsuch therapy independently at home.

Complications Associated With Performing

Vascular Access

When performing vascular access for IVinitiation the caregiver should observe for the

following complications: infiltration, phlebitis,circulatory overload, air embolism, infection,clotting at the site, and skin irritation. Ifobserved, notify physician/designee anddocument as per current charting policy. Referto appropriate policy for further treatment.

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IV Therapy

"Learning Activity"

Describe the signs and symptoms ofinfiltration.

_____________________________

_____________________________

Describe the suggested interventions

for treating infiltration.

_____________________________

_____________________________

___________________________

Describe the signs and symptoms

phlebitis

_____________________________

____________________________

Describe the suggested interventionsfor treating phlebitis.

_____________________________

_____________________________

IV Therapy

Infiltration

Infiltration may be caused by needle / catheterdisplacement and or blood leakage from thevein.

Signs and symptoms

site swelling cool skin at site poor blood return and sluggish flow.

Interventions include: stop the flow remove needle or catheter.

Phlebitis

Phlebitis may be caused by injury to the veinassociated with movement of the needle, orimproper immobilization, too slow of a flow rate,overuse of the vein, and / or use of irritatingsolutions.

Signs and symptomsinclude: sluggish flow warm-red site swelling hardness along the vein site streaking on the skin along the tract of the

catheter and / or the vein site pain and / or tenderness possible mild feverInterventions:

stop the flow, remove needle or catheter apply warm-moist compresses.

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IV Therapy

"Learning Activity"

Describe the signs and symptoms ofinfection.

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

Describe the suggested interventionsfor treating infection.___________________________

___________________________

Describe the signs and symptoms ofair embolism.

___________________________

___________________________

Describe the suggested interventionsfor treating air embolism.

___________________________

___________________________

IV Therapy

Infection

Infection may be caused by improper aseptictechnique during the initiation of an IV and / orpoor maintenance. In addition the caregiver shouldnote that the immunocompromised patient mightbe particularly susceptible to infection.

Signs and symptoms include: site pain and / or tenderness swelling foul-smelling discharge elevated temperature chills blood culture positive for pathogens

Interventions include: discontinue the IV Seek a physician/designees order for local

and /or systemic therapy

Air Embolism

Air embolism may be caused by tubing improperlycleared of air.

Signs and symptoms include: cyanosis decrease in blood pressure weak rapid pulse loss of consciousness other clinical observations indicative of shock

Interventions include: notify the physician immediately give oxygen as necessary inspect system for air leaks turn child on left side

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IV Therapy

"Learning Activity"

Describe the signs and symptoms ofcirculatory overload.

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

________________________

Describe the suggested interventionsfor treating circulatory overload.___________________________

___________________________

___________________________

___________________________

___________________________

___________________________

Describe the signs and symptoms ofclotting/occlusion.

___________________________

___________________________

_______________

IV Therapy

Circulatory Overload

Circulatory overload may be caused by a too fastflow rate and / or a too large volume infused.

Signs and symptoms include: elevated blood pressure tachycardia increased urine output possible distention of the neck veins, gallop (an

additional sound heard in the heart due toexcessive fluid filling, may sound like horsesrunning)

periorbital edema bulging fontanel dyspnea rales cough frothy sputumInterventions include: notify physician slow the infusion to "keep vein open" (KVO)

raise the child to semi or high fowlers give oxygen as needed assist respirations as needed

Clotting/Occlusion

Clotting / occlusion may be caused by: too slow a drip rate inappropriate flushing to maintain patency bleeding disorders

IV running dry kinking of the catheter preventing flow drug incompatibilities the extended duration of use of site

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IV Therapy

"Learning Activity"

Describe the suggested interventionsfor treating clotting/occlusion.

___________________________

___________________________

_______________

Describe the signs and symptoms ofskin irritation.

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

____________________

________________________

Describe the suggested interventionsfor treating skin irritation.

IV Therapy

Signs and symptoms include: no blood return upon aspiration occluded IV flow inability to flush infiltrationInterventions may include: discontinue IV restart if possible monitor drip rate more closely

Skin Irritation

Skin irritation may be caused by injury to the skindue to taping, restraints, infiltration, and / orpressure.

Sign and symptoms include: redness at site raised-irritated areas itching and burning around the tapeInterventions include:

remove irritant reapply dressing over insertion site(hypoallergenic tape is available)

Re-investigate for allergies to skin prep,dressing and / or latex to avoid futureexposure

Seek a physician/designee order fortopical therapy.

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IV Therapy Module Resources

Broadwell Jackson, Debra and Rebecca B. Saunders. Child Healt h N ur sing. Philadelphia: J.B.Lippincott, 1993.

Taylor, Carol, et. al., Fundament als of N ursing - The A r t and Science of N ur sing Care.Philadelphia: J.B. Lippincott, 1993.

Tex t book of Pediat r ic Advanced Lif e Support. American Heart Association, 1997.

Whaley, Lucille F. and Donna Wong. Clinical Manual of Pediat r ic N ursing. St. Louis: C.V.Mosby Company, 1995.

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IV Therapy Post Test

Name: Date:

Department:

1. Select from below the indications for performing vascular accessa. fluid replacementb. medication deliveryc. enteral nutritiond. IV blood samplinge. a, b, and d are correct

2. Choose the statement which best describes how to select a site for IV initiation and / orobtaining a blood sample.

a. The caregiver should always start in the proximal portion of extremity and move moredistal.

b. The caregiver should always start in the distal portion of the extremity and move moreproximal.

c. The caregiver should select only the sites that have never been used.d. The caregiver should select only the site the patient agrees upon.

3. When selecting the site for venous access the caregiver should consider the following:a. patients ability to payb. purpose and durationc. age of the childd. skin integritye. b, c, and d are correct

4. Scarring, blisters, swelling, and bruising are all characteristics common to a damaged and/orirritated site.

a. trueb. false

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5. Select the statement which best describe the technique performing venous access.a. to prepare the skin, wipe with povidine (allow 30 seconds for skin contact), followed by

alcohol.b. to prepare the skin, wipe with sterile gauze, followed by providine.c. to prepare the skin, wipe with alcohol.d. to prepare the skin, wipe with alcohol, followed by providine (allow 30 seconds for skin

contact).

6. When performing IV maintenance, the caregiver should check that he/she has the rightsolution, right labeling, right equipment, the appropriate volume and rate of flow per patientweight, and that the site is free from complications.

a. trueb. false

7. Signs and symptoms associated with infiltration include:a. site swellingb. poor blood returnc. cool skin at sited. all of the above

8. If a patient with an IV should develop cyanosis, weak rapid pulse, loss of consciousness, andother signs indicative of shock, you should suspect an air embolism.a. trueb. false

9. If an air embolism is suspected, the caregiver should turn the child to the left side, giveoxygen as needed, and notify the physician/designee immediately.

a. trueb. false

10.It is generally recommended that a peripheral IV site be changed as needed.a. trueb. false