Course:  Venipuncture Standards and Practices Review

2 Contact Hours
Written By: B. Moore, HCRM RN
Prepared Especially For: InfusionCEUs.com

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PROGRAM DESCRIPTION

This program is intended for the medical healthcare professional involved with process of infusion therapy. It is intended as a basic introduction into the basic principles of phlebotomy and intravenous administration. The program content reviews the basic anatomy and physiology of the venous system and focuses on the principles of site selection, skin preparation, the insertion procedure, and documentation. Specific types of equipment will be described. Issues related to medication administration are explored, as well as nursing assessment and management of the patient receiving infusion therapy are reviewed.


PROGRAM OBJECTIVES

At the conclusion of this program the learner will be able to:

Identify the peripheral veins used in intravenous therapy

List anatomical characteristics of veins and arteries

Describe the procedure for skin preparation and venipuncture

Describe the insertion process

Identify elements of proper IV documentation

Review various venipuncture methods

Describe safety measures to minimize the problems that exist infusion therapy

Recognize the signs and symptoms of an extravasation or infiltration to patient receiving infusion therapy

 

PROGRAM REQUIREMENTS

The successful completion of this program requires that the participant complete entire course thoroughly. Participant must pass a post test examination with a minimum score of 80% and complete a program evaluation form. Satisfactory completion of these requirements will earn the participant two (2) contact hours towards continuing education.


 

ANATOMY AND PHYSIOLOGY OF THE VASCULAR SYSTEM

Knowledge of the anatomy and physiology of the vascular system (veins and arteries) is essential to the success and proficiency of the healthcare provider performing either phlebotomy or intravenous therapy. The patient's welfare is always the primary focus and prudent judgment is of utmost importance. The act of insertion of any invasive object into the body, especially a sharp object such as a needle is generally the patient’s primary concern. An understanding the vascular system and the influential factors affecting it enable the therapist to use discriminating judgment in venous selection for any intravenous procedure.

For any cells and tissue to exist they must continuously receive oxygen and nutrients to survive. The pathway for the delivery of these nourishments is the circulatory system. This system is a continual pathway throughout the body which provides blood flow to every living cell within the body. From the time the blood leaves the left ventricle of the heart via the Aorta (the largest artery in the body), blood is pumped throughout the entire body going from smaller arteries to smaller arterioles to even smaller capillaries. At this level cellular respiration occurs and a passive exchange of carbon dioxide (CO2) and oxygen occurs. Other nourishments are absorbed during circulation as well. Blood is then transported back towards the heart through the venous system. These tiny venules again become larger and even larger turning into larger veins.

Finally these veins empty into the Superior and Inferior Vena Cava which lead to the central veins which include the Jugular and Subclavian veins. Blood is pumped back to the heart and the process starts all over again. In fact it never stops and if it did there would obviously be a serious problem.

The primary access for phlebotomy of blood and infusion of any fluid or medication is through the venous system. Veins are structures consisting of three layers. The Tunica Intima forms the inner lining of both arteries and veins. This layer is composed of a single layer of endothelium which forms a smooth lining on the inside of the vein. This smooth surface helps to decreases friction as blood flows through the vessel. In veins, this layer is where the delicate valves are located.

The middle layer is known as the Tunica Media. This layer is composed of both smooth muscle and elastic tissue. This middle layer of the veins and arteries is controlled by the sympathetic nervous system, and this is the layer in which vasodilatation and vasoconstriction occurs. This layer controls for example blood pressure. This middle layer is much thicker in arteries, however, little muscle is noted within this layer of the veins. The Tunica Adventitia - also called Tunica Externa, is the outermost layer of the veins and arteries. Composed primarily of connective tissue, it's function is to support and protect the vessel. This layer is also stronger and thicker in arteries.

Several other differences are noted between arteries and veins. The healthcare provider must know the differences to be assured the vein is a vein rather than an artery. One of the most pronounced differences is the fact that arteries have a pulse and veins do not. Since arteries have a pulse, they also have a blood pressure (systolic and diastolic) whereas veins don’t really have much pressure until they get into the central veins and even then a pressure of only 8 - 12mmHg. One major difference are the valves. Valves are located only in the veins and occur approximately every 2 inches. Obviously, the healthcare provider must be aware of the valves and what they look like in order to avoid damaging them.

Another important difference is the fact that arteries do not collapse whereas veins can and frequently do constrict and contract. For this reason arteries are most often found deep and therefore well protected. Veins on the other hand are generally much more superficial and therefore more easily accessible. Once blood is withdrawn, the color can often indicate whether it was venous or arterial. The color is an easy giveaway. Arterial blood is a generally much brighter red color due the oxygenated effect on the hemoglobin of the red blood cell. Venous blood is usually a much darker sanguineous color or frequently referred to as "blue" blood. The more unoxygenated blood is the darker the color. Also of note is the fact that the hemo-concentration, hemo-dilution, and blood counts can all effect the color of the blood.

The superficial veins of the upper extremities are the most frequently used for most intravenous therapies. Veins in the lower extremities are only used in extreme emergencies under the general direction of a physician. Upper extremities (fingers and hands) include the digital dorsal veins. These small vessels are located on the lateral surface of the fingers and are generally not used as a first choice. They can accommodate small gauge needles in the 22 - 28 gauge size, and generally will require immobilization of the finger.

The Metacarpal veins are formed by the union of the digital veins. They are located on the dorsal surface of the hand, and are usually easily visible. The bones of the hand form a natural splint. These veins are a common site of venipuncture in the adult patient, however, they may not be suitable in the elderly population where skin and muscle may be thin and allow extravasation to occur.

The primary vein of the arm is the Cephalic vein. This vein commences at the dorsal venous arch, and travels upward along the radial border of the forearm. Size and position make this vein an excellent choice both accessibility and for accommodating larger cannulas.

The Accessory Cephalic vein originates from just above the wrist and travels up the back of the forearm or the dorsal venous arch. The Cephalic vein just below the elbow is an excellent selection for larger cannulas.

The Basilic vein commences at the ulnar part of the dorsal venous network. It ascends along the ulnar portion of the forearm and meets with the Median Cubital vein on the interior surface of the arm just below the elbow. The Median Antebrachial vein commences in the venous plexus on the palm of the hand, ascends along the ulnar side of the front of the forearm and empties into the Basilic or Medial Cubital Vein. This vein frequently does not always present itself well.

Manual manipulation and repositioning of the patient’s hands or arms will often help to promote distention of a vein that may either be buried or does not present itself well. This is the time to be as comfortable as possible with the patient, as this procedure helps to identify veins in arms and hands. Once a position offering the best venous presentation has been identified, an attempt to maintain that position is stressed. It is important to also note that if a patient is nervous, cold, or receiving any type of respiratory treatment, the actions of the smooth muscle will cause a vasoconstriction to occur and thus poor venous presentation.

 

INSERTION PROCEDURE

The procedure to insert a needle into one’s person for whatever reason requires some psychological preparation of the patient. Determine if this is a new experience for the patient, discuss the fears or misconceptions he / she may have about venipuncture. Approach the patient in a calm confident manner and help them to relax as much as possible. Answer all of their questions and ask for their cooperation. Remember a patient has the right to refuse an IV. Ask the patient his name and if the patient is not able to identify themselves, check the patient’s personal armband for their true identification.

Explain the venipuncture procedure to the patient and explain why the therapy is required. Be honest and straight forward when discussing pain. Be sure to explain that the pain will subside quickly, and if the pain does persists it may be a warning of a possible complication. Discuss the effect on mobility this may have for the patient. Reassure the patient that you will advise him prior to the actual venipuncture. Reassure the patient through each step.

Explain each procedure to the patient prior to beginning any procedure. Explain the patient’s responsibilities and ask them to notify the nurse should any of the following symptoms occur: pain or discomfort, redness, swelling, leakage of fluids, and loose dressing or taping. If the solution in the bag stops dripping or if blood begins to back up in the tubing, this should be reported to the nurse immediately as well.

Physical preparation of the patient requires some advance consideration. The environmental setting should be calm with quiet surroundings. The assurance of privacy will make this a much better experience for the patient. Position the patient correctly. Preferably, the patient should be supine and comfortable. The therapist should have the ability to examine both arms. If the patient is in bed, the therapist may wish to adjust the height of the bed, sit on the bed or in a chair to assure proper body mechanics. The arm should be in a comfortable position across the bed for easy access. Do not forget to reposition the bed and the patient after the procedure.

All equipment should be collected and set up prior to the venipuncture procedure. Inspect all equipment for any imperfections and check the expiration dates as well. The selection of equipment will be determined by the specific venipuncture procedure being performed. For example, a different set of equipment is necessary if doing only phlebotomy rather than doing a venipuncture infusion. Other miscellaneous items should include: various types and sizes of needles and syringes, filters, specific tubing, arm board, tapes, blood specimen tubes, saline, etc.

A tourniquet is used to promote venous distention. It should be applied to impede venous flow but not so tight as to restrict the arterial blood flow. Generally, tourniquets are available as soft rubber Penrose types, velcro or latex types and blood pressure cuffs can even be used in a pinch. When using a blood pressure cuff, inflate the cuff to a point just above the systolic pressure of the patient. Do not leave the tourniquet on the patient for any length of time (over a few minutes). Remember tourniquets are potential sources of infection and requires the provider to replace the tourniquet regularly or cleanse and disinfect it per facility policy. Most tourniquets from insertion kits are disposed of regularly after each use.

Various antiseptic prep agents are a necessity. These agents are used to prepare the insertion site. The agents used should reflect facility’s infection control policy. The agents should adequately cleanse the area of most microorganisms. Remember, the success of venipuncture is determined by the insertion technique. Never shave the insertion area, (especially patients on certain medications such as Heparin, Coumadin or Aspirin). Clip the hair, if needed, but never use a depilatory agents which may cause irritation.

The type of cleansing antiseptic agent most frequently used is 70% Isupryl alcohol. Alcohol is used in skin preparation as a defatting agent to remove the natural skin oils. Remember to use friction when cleansing the skin with alcohol, and do not to fan or pat dry the site, but allow the site to air dry. Starting from center to outer, the provider wipes away from the direction of insertion site. This process then allows proper disinfection of the skin.

Tincture of Iodine 1% - 2% is another popular agent that adds much more of a bacterialcidal effect. The most popular brand on the market is Povodine Iodine / Iodophors (Betadine Solution). Used full strength, this solution should not be removed with alcohol as alcohol negates the effects of iodophor. The solution requires thirty seconds of contact with the skin and then allowed to air dry completely. Be sure to check the patient allergies (Iodine) prior to any use. Should the patient be allergic to an Iodine solution, Hibiclens is an effective alternative cleanser. This solution however, requires a minimal 3 minute scrub. An important note to remember when using any type of cleansing agent, is to use a circular motion, always moving from clean to dirty, in an area 2 - 3 inches in diameter from the actual insertion site

Collect the necessary venipuncture equipment, personal protective equipment, and prime any tubings being used for the infusion. Wash hands and palpate the veins first with and without a tourniquet in place. If there is excessive hair, clip the hair, do not shave the area. Use a light touch in examining the veins. Feel for a soft, full, spongy sensation in the vein. Assess the surrounding areas for any abnormalities. Avoid selecting a vein that feels hard, crooked, inflamed, or irritated as well as any areas of vein bifurcations, or any sudden little bulges (valves). Position the insertion site so as to be in a convenient location for the patient and an area that will provide easy access for the provider. Prepare the dressing and tape to be used.

Reapply the tourniquet with a single half tie so as to be able to easily untie tourniquet with one hand. Never tie the tourniquet in a knot. The tourniquet should be applied 4 - 6 inches above intended insertion site. Select the vein with the easiest accessibility and place it in a dependent position for a few minutes. Instruct the patient to open and close his fist several times as this helps to ‘pump’ the blood and distend the vein. A gentle patting above selected insertion site can also help. Tap the insertion site gently until the vein distends. Remember, tapping too hard can cause venous spasm. An alternative procedure, should the above technique not work, is to wrap extremity in warm, moist towel for 10 - 20 minutes. The warmth will help the vein to distend; re-apply the tourniquet and check the distention of the vein again.

Prepare the site according to the facility policy. Remove the selected catheter from package, keeping it sterile. Grasp the catheter hub with thumb and forefinger of dominant hand and the cover with the other hand. Pull the cover off the needle and examine the needle for any imperfections or flaws. Position the catheter in the direction of blood flow with the bevel of the needle up.

Stabilize the distended vein by pulling the skin taut either in an upward or downward direction. The thumb should be far enough away so as not to encumber the insertion process. Hold catheter hub steady with dominant hand with bevel pointing upwards. Puncture patient's skin and insert the catheter / needle into the vein. Utilize a 30 - 45 degree angle when inserting the needle and lower the catheter to a 10 degree angle once inside the vein. A popping sensation can be felt when the needle enters vein. Once the needle is advanced through the vein, a blood flashback should be noted. If no flash of blood occurs, continue to advance the catheter until a blood return is noted, (remove the needle immediately, if unsuccessful).

If using a ‘catheter over the needle’ type, hold the needle and advance only the soft catheter by pushing or sliding the catheter off the needle into the vein. This is called threading the catheter. Do not force the catheter into the vein as this may traumatize the vein. Once the catheter is in the vein, release the tourniquet and then withdraw the needle. Never reinsert the needle into the catheters this may cause shearing of the catheter.

As the needle is withdrawn, apply a gentle pressure just above the catheter directly on the vein to impede the flow of blood return. Quickly apply an infusion administration set or appliance (saline lock) to the hub end. A gentle saline or fluid flush is required to remove the blood from within the appliance.

If there is difficulty encountered while attempting to thread the catheter some troubleshooting techniques may be helpful. Remove the needle and attach either a 3 cc syringe of normal saline or a primed administration set with solution. Attempt to float the catheter into the vein by gently administering a small amount of fluid while advancing the catheter. If any signs of infiltration (swelling or a bubble) occur, stop immediately and remove the catheter completely. Never try more than twice to start an IV. Ask for the assistance of an experienced person to attempt any further insertions.

Once the catheter is in place, a piece of tape should be placed at the connection of the hub and/or appliance immediately to help anchor the catheter to the skin. This will free your hands to gather the dressing needed and place it over the insertion site. If you are using a transparent semi-permeable membrane dressing, place the dressing so as to cover the insertion site as well as up to and including the end of hub of the catheter but not to include any portion of the catheter. No tape or other dressings should be placed over this type of dressing, as it impedes the permeability properties.

If not using the transparent dressing, a sterile 2x2 or 4x4 gauze may be used (less preferred method). Be sure the dressing remains dry and changed as per facility protocol. A gauze dressing is frequently changed daily so that the site can be visualized. Label the dressing with your name, date, time, and size of catheter. Remember to ask the patient to report to the nurse any problems involving the infusion or insertion site. Caution: always check the patient’s allergies prior to the application of any tape or antimicrobial agent.

 

DRESSING AND SITE CARE

As a national organization, the Intravenous Nurse Society (INS) sets the standards for care, throughout the intravenous community. The following protocols are from the "Standards" set forth by the INS and may not reflect actual facility policy. These standards are recognized throughout the health care community and are used as a basis on which each facility formulates it's own policies and procedures.

The purpose of dressing and site care is to allow for the inspection of the insertion site. By frequent inspection, the healthcare worker can limit and thus decrease the chances on any sudden microbial infections. When removing an old dressing take care not to dislodge catheter. It is good practice to always remove the dressing in the direction of the catheter so as not to disturb the placement of the catheter. Always check the site for any signs of inflammation, redness, or drainage. Changes at the site should be reported immediately.

If sterile gauze dressings are used, these dressings must cover the entire insertion site. This type of dressing although still frequently used prevents the site from being easily visualized. This type of dressing also allows for easy soiling and contamination. Therefore, it is a general standard within the community to change this types of dressings every 24 hours, (check your facility policy regarding your specific dressing requirements).

If a transparent semipermeable membrane dressings is used, these dressings generally have up to a seven day change standard, however many facilities still require they be changed every 48 - 72 hours. The use of any tape over these dressings is contraindicated, as covering the membrane itself reduces the permeability and air flow to the site. Transparent dressings (also called Op-site or Tegraderm) are the major dressings used today in peripheral intravenous therapy. The loss of the occlusiveness, excessive drainage, or excessive perspiration can all be reasons to change a dressing prior to the actual due date.


 

EQUIPMENT

Personal protective equipment is a general term describing all the equipment available to the healthcare provider in the prevention of a possible exposure incident. It is it is the health care facility’s responsibility to provide all necessary PPE to perform the venipuncture. The most common form of personal protective equipment is gloves, generally of the latex type. Gloves come in various sizes, powdered and un-powdered, and of various qualities and thicknesses. Gloves should always be worn when there is any chance of coming into contact with a patient's body fluids, (and always disposed of in biomedical waste near the procedure area).

Goggles, especially three sided type goggles should be available and provided by the employer. The healthcare worker should wear goggles to prevent the splattering of any bodily fluids. Do not rely on regular glasses to be 100% effective against splashes as fluids can be sprayed into eyes from around the rims.

A variety of venipuncture devices are available to the healthcare provider. Steel needles with wings, scalp needles, or butterfly needles are generally used for infants and small children, small or torturous veins as in the elderly, and short term intravenous therapy (24 hours). The primary advantage to this type of needle is that they are simple and easy to use with relatively minimal pain on insertion. Due to the size of the steel needles, the incidence of mechanical phlebitis is dramatically reduced.

Several other disadvantages arise when using the steel needle, however. Due to the needle being made of steel. The steel needle can easily puncture the vein wall and cause infiltration. Therefore, this type of needle is unsuitable for long term intravenous therapy. Generally, the steel needles are much smaller in gauge (22,23,24 and smaller) and thus, not suitable for larger volumes of fluid to be infused.

Probably the most common of all the needle types is the ‘over the needle catheter’. Usually, this type of needle is used more often for longer term intravenous therapy. Usually this type of catheter’s gauge is a much larger gauge needle (16,18,20,21,22) and thus allowing for greater and greater volumes to be delivered to the patient faster. A primary advantage of ‘over the needle catheter’ includes the complete removal of the needle or stylet with only the catheter remaining. The flexibility of the remaining catheter (generally latex) is much more comfortable allowing more patient mobility. This catheter decreases the chances of vein wall injury during infusion. Frequently, a ‘Heparin or Saline’ lock is attached to this type of catheter for intermittent infusion use and easy venous access.

One disadvantages of the ‘over the catheter’ needle includes an increased incidence of touch contamination.

By touching the plastic or latex material of the cannula, it increases the chances of infection and can cause Phlebitis.

The incidence of catheter emboli also increases with improper ‘over the catheter’ insertion. This problem can cause clots to be formed and possible occlusions to occur. Maintaining a vigorous flushing technique helps prevent the catheter from developing occlusion.

‘Inside the needle’ catheters require insertion by a physician or a specially trained medical professional. These needle types are generally used for the insertion of central lines and long term peripherally inserted central lines (PICC). These types of needles are used for long term intravenous therapy.

By accessing central venous access, this allows for monitoring of the central venous pressures. Other advantages include delivery of viscous or irritating parenteral fluids. This type of catheter permits the insertion into a large central vein via a peripheral route. The distal tip of the PICC catheter lays in the large Subclavian vein near the right atrium. The length of therapy will determine generally what size needle and /or catheter should be used and where the distal tip of that catheter should eventually lay.

A physician’s order is always required for any infusion service. The specific orders will indicate which infusion solution to be used, the rate of administration, and the method of infusion delivery. Selection of any venipuncture site requires several considerations. The patient’s age, skin condition, their mental competence and general compliance are all important issues to be considered. .

When receiving short term therapy, the preferred site should be into the non-dominant hand or arm, if possible, and as far distal in the arm as comfortably possible. Smaller gauge catheters (20 gauge - 23 gauge) are generally recommended. Smaller size catheter / needles (20 gauge- 24 gauge) are used for smaller veins when hydrating solutions and antibiotics are infused. Always attempt to choose the smallest possible catheter / needle as possible.

Larger volume amounts can be delivered by a smaller gauge catheter / needle however, a longer infusion period is required. The rate of infusion often times determines the location of the infusion site. It is recommended the rate be slower when infusing medications with irritating effects such as potassium and chemotherapy agents. If concentrated fluids such as total parenteral nutrition (TPN) or Dextrose 20% or any irritating antibiotics, a central line infusion is generally encouraged and ordered.

If long term therapy is considered, the insertion site should begin low (distal) on the extremity and be routinely alternated from arm to arm. Depending on the solution ordered, larger veins should be considered when irritating solutions such as highly acidic, alkaline, or hypertonic solutions are used. Large lumen catheters (16 gauge - 18 gauge) should be used when thick or viscous solutions, such as blood or albumen are infused. A large albumen catheter will accommodate more viscous solutions than a smaller size. Viscous solutions will accommodate a larger lumen catheter / needle than a smaller size and thus present fewer problems.

Another consideration for the patient is an IV pole. If the patient is allowed to be ambulatory, an IV pole must be made available for the patient with an IV. The pole should be strong enough to be able to have the patient comfortably hold onto it while walking. The wheels should move freely in a 360 degree radius. Generally the poles have the ability to hold more than one infusion bag at a time. And again remember to clean the pole between patients to prevent patient cross contamination or other nosocomial problems.

SPLINTS AND RESTRAINTS

The purpose of splinting and restraining is to protect the site from possible injury or any other complication that the patient may be exposed to. A splint is always used at a venipuncture site where a joint or area of flexion is involved. Select the appropriate size arm board. A short arm-board is used for below the elbow or wrist immobilization. A long board is used for the anticubital area and for total arm immobilization. If the patient is restless, combative or confused an arm board is recommended.

Arm boards are used for stabilization when the cannula is placed near an area of flexion. Constant movement of the cannula can lead to infiltration, phlebitis or infection. Care must be taken to assure adequate circulation and the placement should not deflect the visualization of the insertion area. Arm boards should be removed at intervals to verify circulation and comfort. These too can be a potential source of infection, therefore they will need to be disinfected between patients if they are not disposable. Arm boards are available in various lengths and types.

Explain to the patient the purpose of the splint. Pad the splint so as to be comfortable for the patient. Position the arm with palm down and adjust the splint so that the hand is fully supported

Finger splints are available for digital immobilization. Secure the splint by using velcro straps or two long pieces of adhesive tape. Wrap the tape around arm so as not to impede the patient’s circulation. Important note: Be sure to check the facility’s policy regarding the application and use of any restraints; most require an M.D. order.

Restraints may be applied to the combative patient to ensure successful venipuncture. They are removed immediately after the procedure; or depending on the patients level of combativeness and their confusion, left on, with a physician’s order they may be left on as per facility order. Restraints should be removed from the patient frequently to check for and document circulation, color, motion, and sensation. Generally, the restraints should be fastened to the bed frame or chair of the patient.

If the insertion site is in danger from the patient's free hand, then that hand too must be restrained.

Other types of protection for the IV site are available for the non- combative type of patient. A type of netted stockinette may be used. This elastic stockinette provides easy access to view the insertion site and helps to protect any sudden mishaps to the site or the tubing. Restraints can also be made with rolled gauze or a sheepskin type, so check with your facility’s distributors.

 

DOCUMENTATION OF INTRAVENOUS THERAPY

Documentation provides a legal recording of the information regarding the venipuncture insertion and maintenance process. Several items of information are required to be documented for each infusion process. It is very important to document the size and the type of catheter used. The date and time of venipuncture and the number of attempted sticks and their location to initiate the successful IV process must be documented as well. The name and title of person initiating the venipuncture should be written both on the IV site dressing as well in the medical record.

The type and the amount of solution being infused is required to be documented, as well as the flow rate of the ordered solution. Any and all unusual symptoms or reactions should be immediately reported and documented, including the type of dressing site care, the frequency of site care and site’s general condition must frequently be recorded.

Any additives to the infusion solution must be labeled both on the bag and again in the medical record.

Label the solution container with patient’s name, identification number, and room number (should pharmacy add the medication, this should already be on the pharmacy label). Include all additives on the label including the drug, dose amount, and the actual base solution. Be sure to sign or initial the solution bag if you perform the addition to the container, and date and time the addition. The date and time the IV was hung. The nurse hanging solution must document the drip rate, flow rate and container number. As with any intravenous set, be sure to date and time the administration tubing set. Follow the policy procedure of your facility for the frequency of documentation, however minimal documentation should be done every shift and with any changes.

 

MONITORING INTRAVENOUS THERAPY

The purpose of frequent intermittent monitoring of the site is to minimize the risk of potential complications. Always follow the facility’s policy. Monitoring is based on the type of solution, method of delivery, the age and compliance of the patient, and the patient’s condition and their diagnosis.

Assess patient's response to the infusion therapy. Document all pertinent information. Palpate the insertion site area to determine position and presence of the catheter. Report any adverse findings immediately such as redness, swelling, warmth, pain or infiltration. Should the site look good but the patient continue to complain, slow the infusion rate to a KVO rate (keep vein open @10cc/min) and check the patient more thoroughly. Determine if it is a solution problem or a patient site condition that must be addressed.

Maintain an accurate intake and output. This knowledge greatly assists the physician in determining the patient’s fluid volume status. Label the number of the infusion bag and if the infusion therapy is on either gravity method such as a "Dial a Flow" type or a mechanical pump, the bag should dated and timed so as to indicate how much fluid volume actually has infused over what period of time. Do not rely only on the integrity of the mechanical flow volume alone to assure accurate infusion volumes!

TERMINATION OF INTRAVENOUS THERAPY

When the infusion therapy is ordered by the physician to be discontinued orders must be written.

Assemble the supplies needed to include: gloves, other personal protective equipment if needed, 2x2's, a dressing or band-aid, and possibly an antimicrobial agent per facility policy.

Wash hands and apply gloves prior to discontinuing the insertion site. Again, explain procedure to the patient. Turn the infusion solution off (if applicable) and carefully remove all tape and dressings from site. Hold a sterile gauze (2x2) in the non-dominant hand and slowly withdraw IV device. Apply the 2x2 directly over the site and hold firm direct pressure with the patient's arm held up for a few minutes. Apply a dressing or band-aid once the bleeding, (if any) has stopped. Dispose of the needle / catheter in appropriate non - permeable tamper proof biohazard sharps container. Remember! To minimize the risk of exposure to the health care worker, they should never recap any needles and ensure all the needles are accounted for after any procedure. Remove the gloves and again wash your hands.

Document the time of the termination of the IV and the appearance of the site. Follow-up a short time later to assure site remains intact without further problems.

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BIBLIOGRAPHY

American Association of Blood Banks, Technical Manual, 12th Edition, Bethesda, MD: AABB, 1996.

Boyle D., Engelking C., Vesicant Extravasation: Myths and Realities. Oncology Nursing Forum, 1995; 22(1): 57-65.

Fisher D.S., Knobf M.T., Duravage H.J., The Cancer Chemotherapy Handbook, 4th Edition, St. Louis, MO.: Mosby, 1993.

Illustrated Manual of Nursing Practice. Spring house, Pa. Spring house Corp. 1991.

Intravenous Nurses Certification Corporation, Candidate Handbook for CRNI Certification, Boston, MA.: INCC, 1997.

IV Therapy. Clinical Skillbuilders Series. Spring house, Pa. 1991.

Jensen B.L., Types of Intravenous Equipment, Intravenous Therapy: Clinical Principles and Practices, Philadelphia PA.: Saunders, 1995: 321-323.

Nurse’s Photo Library Series. Spring house Pa, Spring house, Corp. 1993.

Perucca R., Obtaining Vascular Access in Intravenous Therapy: Clinical Principles and Practices, Philadelphia PA, Sanders, 1995: 390.

Phillips L.D., Manual of IV Therapeutics, 2nd Edition Philadelphia, PA.:FA Davis, 1996.

Terry J., Baronowski L., Lonsway R.A., and Hedrick C., editors., Intravenous Therapy: Clinical Principles and Practices, Philadelphia, PA.: Saunders, 1995.

Weinstein S.M., Plumer’s Principles of Infusion Therapy, 6th Edition, Philadelphia PA.: Lippincott - Raven, 1997.

US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention. Guidelines for prevention of Intravascular Device-Related Infections, American Journal of Infection Control 1996; 24(4):262-293.

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