IV CANNULATION
POLICY
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PURPOSE
PURPOSE
““The
The aim
aim of
of intravenous
intravenous
management
management isis the the ‘Safe
‘Safe and
and
effective
effective delivery
delivery of of treatment
treatment
without
without discomfort
discomfort or or tissue
tissue
damage
damage and
and without
without
compromising
compromising venous venous access,
access,
especially
especially ifif long
long term
term therapy
therapy isis
proposed”
proposed”
Definition:
Peripheral cannulation is the
insertion of a flexible tube
containing a needle into blood
vessels, usually the peripheral
blood vessels.
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VEINS
Veins have 03 layers:
Tunica Adventitia
Tunica Intima
Tunica Media
Tunica
Tunica Intima Adventitia
Valve
Tunica Media
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TUNICA INTIMA
Is the inner layer of the vein
Consists of smooth, elastic endothelial lining
Damage to this lining or presence of foreign
material induces an inflammatory response
Resulting complications - Phlebitis, Thrombus
formation
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TUNICA MEDIA
The middle layer of the vein consists of
muscle & elastic tissue
Nerve fibres are present in this area
Stimulation of this layer by cold infusions and
irritating medications can cause Vasospasm
Patients may feel pain during venepuncture,
when the needle penetrates this layer
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TUNICA ADVENTITIA
The outer layer of the vein consists of
connective tissue
Provides support & protection to the vein
Blood vessels to the vein are also present in this
layer
A haematoma may be formed, if one of the
vessels is penetrated
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VALVES
Structures within the lumen formed by
endothelial lining of the Tunica intima
They are present as bumps along the course of
the vein & also at bifurcations
Predominantly found in large veins of the
extremities
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VEINS USED FOR
CANNULATION
Basilic veins
Cephalic veins
Metacarpal veins
Median cubital veins
Veins in the foot
Veins in the scalp
Jugular, Subclavian and Femoral veins
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Veins
Basilic
Cephalic
Metacarpal
Median
Cubital
Cephalic
Basilic
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ARTERIES
Do not have valves
Pressure within the artery keeps blood moving
in appropriate direction
Arterial flow is downward - with gravity
Are much deeper than veins & surrounded by
nerve endings
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Blood Vessels
Vein
Valve
Tunica Intima
Tunica Media
Tunica
Adventitia
Artery
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Arteries
Brachial
Artery
Radial Artery
Ulnar Artery
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Veins, Arteries &
Nerves
Cephalic
Basillic
Radial
Brachial Artery
Radial 1st Intercostal
Cephalic Vein
Artery
Veins Median Cubital
Median
Vein
Arteries
Ulnar Ulnar Artery
Nerves Basilic
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CATHETER PARTS
Luer Lock
Plug Needle
grip Injection port
cap
Cannula hub Flashback
+ wings chamber
Valve Cannula
Bevel
Trim
distance
Needle
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CATHETER
Ported
Non-Ported
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Purpose
To maintain fluid and electrolyte
balance.
To provide large volume of fluid.
To inject continuous or intermittent
medications.
To provide a ready approach to
meet emergency (circulatory failure)
To administer blood and its
components.
To provide nutrition.
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Advantages
Immediate effect
Control over the rate of fluid administration
Patients those who cannot tolerate drugs /
fluids orally
Some drugs cannot be absorbed by any
other route
Pain and irritation is avoided compared to
some substances when given SC/IM
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Selection
Selectionof
ofaa
Cannula
Cannula
1. Patient related
factors
2. Cannula Related
Factors
3. Therapy related
factors
4. Vein related
factors
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Patient related factors:
1.
Patient Assessment
Age of patient
Previous uses and condition of the veins
Clinical status of patient e.g. Dehydrated, shock,
amputee, mastectomy, oedema,
thrombocytopenia,CVA etc.
Other clinical procedures required during admission
Type and length of treatment medications:
warfarin, heparin, steroids etc.
Patient preference
Patient co-operation
Previous experiences
H/o past illnesses and hypersensitivity.
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Cannula related factors:
Minimizing discomfort
Ensuring good flow rates
Easy insertion with no tissue injury
Allergic condition-
Vein catheter ratio- ideal vein catheter
ratio is 2:1. This will reduced the vein
damage and gives
provision for good blood flow in the catheter
(* Try to use non dominant arm sites:
median antecubital veins, forearm veins,
dorsum of hands and in difficult patient’s
the dorsum of foot.
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Vein related factors
A good vein is: Avoid Veins which are:
A good vein is: Avoid Veins which are:
Bouncy Thrombosed / sclerosed /
Soft fibrosed
Refills when Inflamed / bruised
depressed Hard or Thin / Fragile
Visible Mobile / tortuous
Has a large lumen Near bony prominences,
Well supported painful
Straight Areas or sites of infection,
edema or phlebitis
In the lower extremities
(unless none else available)
Have undergone multiple
previous punctures
AV shunt or Fistula
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Vein related
factors
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veins that should be considered for peripheral
veins that should be considered for peripheral
cannulation are those found on the dorsal and
cannulation are those found on the dorsal and
ventral surfaces of upper extremities. For neonates
ventral surfaces of upper extremities. For neonates
and pediatric patients additional site can be selected.
and pediatric patients additional site can be selected.
Veins of lower extremities should not be used
Veins of lower extremities should not be used
routinely in adult population due to risk of embolism
routinely in adult population due to risk of embolism
and phlebitis. Site selection should be routinely
and phlebitis. Site selection should be routinely
initiated in the distal areas of upper extremities.
initiated in the distal areas of upper extremities.
Subsequent cannulation should be made proximal to
Subsequent cannulation should be made proximal to
the previously canulated site.
the previously canulated site.
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4. Therapy related factors:
a) Time of therapy –
When long therapy is required, the distal
portion of the vein should initially be used
The expected duration of IV therapy(5-7
days).starting with the patients hand,
preferably the non dominant hand, leaving
more proximal sites available for
subsequent venipuncture.
B]Type of solution
If the solution (Hypertonic solutions and various
medications) is chemically irritant, select the large
vein and a small cannula.
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Infection Control ….Must
DO’s……
.The main sources of microbial contamination
are:
Cross infection from practitioner to patient
Skin flora
Hand Washing…Hands should be clean, having been washed prior to the
The site
procedure, oforthe
and/ venepuncture
using should
alcohol based hand be wiped
rub applied with
to the hands
before donning a pair of gloves.
an isopropyl alcohol 70% /CHG swab and this should
be allowed to dry (for a minimum of 30 seconds) prior
to proceeding with venepuncture.
The skin must not be touched or the vein re-
palpated once the skin has been cleaned.
No needles should be recapped.
Use a NO TOUCH technique
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Caution.......5 stages at which a needle stick
injury can occur
% RISK OF NEEDLE
STAGE
STICK INJURY
Preparation 6%
In use 42%
After use, before 28%
disposal 11%
During disposal 13%
After inappropriate
disposal
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V enepunc tu re [Equi pment/Arti cles]
Tray
Alcohol swab
Tourniquet
Small adhesive dressing
Sharps Container
Gloves
CHG Hand rub solution
Vacutainer’ system needle, holder, appropriate
tubes
‘Or Sterile syringe, Sterile needle, Appropriate
evacuated tube
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Improving Venous Access
Application of a tourniquet promotes venous
distension.
Lower the extremity below the level of the
heart
Use muscle action to force blood into the
veins - e.g. open and closing of the fist
Light tapping of the vein
Apply warm compresses
Consider NTG Patch, if placed on the
hand/fore arm etc.
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Procedure
1. Assemble equipment
2. Inform patient of procedure
3. Select a suitable vein - e.g. the vein in the forearm or dorsum of
the hand
4. Palpate the vessel
5. Apply a tourniquet medial to selected site
6. Put on gloves
7. Skin Preparation
Clean visibly soiled skin with soap and water
Apply isopropyl alcohol 70% /CHG swab for 30 seconds. Clean
the site using long
strokes from inner to outer side (i.e. from puncture site
towards surroundings). One
should not repeat this process with the same swab.
Allow to dry
No touching of skin once the skin has been cleaned/disinfected
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8. Hold patient's hand with your non-dominant hand, using your thumb to
keep skin taut, and anchor vein to prevent it rolling.
9. Inspect needle tip to ensure cutting edge is smooth and intact. Place
cannula needle in line with direction of the vein and a few milimeters
below proposed entry site, with bevel pointing upwards to reduce tissue
trauma.
10. At a low angle, gripping the cannula, insert the needle through the
skin and into the vein, as
identified by the flashback of blood into the chamber at the hub of the
cannula.
11. Once inside the vein advance the needle 2-3mm in a parallel motion
to ensure the cannula is also in the vein
12. Withdraw the needle stylet (holding the cannula steady) about 5mm to
avoid piercing the posterior
vein wall, there should be a further flashback of blood along the shaft of
the cannula and now advance the cannula into the vein.
13. Release the tourniquet
14. Place a finger above the tip of the cannula over the vein to prevent
bleeding as you now remove the needle stylet.
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15. To separate the needle and the lure lock cap, hold the cap between
thumb and third finger and use
your index finger of the same hand to push on the guard, away from
you.
16. Place the cap on the cannula and safely dispose of the stylet.
17. Flush the cannula with 2-5 ml 0.9% Sodium Chloride or attach an IV
giving set and fluid
18. Cover the insertion site and immobilize the cannula by applying a
sterile non-occlusive dressing*.
19. Document the procedure including label:
a. Clinical indication for the intravenous cannula
b. Insertion method
c. Size of cannula
d. Date & time of insertion
e. Number of pricks & location
f. Identification of site
g. Type of dressing
h. Name of person placing the device/ cannula
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Different types of IV Cannula
dressing:
Occlusive sterile polyurethane Transparent semi
gauze dressing Dressing permeable
Advantages Advantages dressing
Absorb exudates
Water resistant
Keep puncture site Allow continuous Secure the device
clean inspection of the site reliably for a long
Skin could breath Can keep 3-7 days in period
Disadvantages normal condition More comfortable for
Site inspection is
the patient
difficult Disadvantages Hypo allergic
Change very 48 hours
Semipermiable but
Limited absorption Cannot absorb exudates impervious to bacteria
Poor moisture permeability Can keep the
dressing for 3-7 days
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Securing the Cannula
It is important to secure the cannula to prevent mechanical phlebitis. This
is to be done with an adhesive
dressing. Care should be taken to avoid the insertion site. The Function of
dressing is:
• To protect the site of venous access
• To stabilize the device in place
• Prevent mechanical damage
• Keep site clean
Flushing of Cannula – Pre and Post Cannulation:
As Recommended by INS 2011- (guidelines): ‘ACL’
A- Assess
- After Cannulation
- During dwell time
C – Clear
- Between two drugs
- After blood withdrawal
L – Lock
- After therapy completion to maintain potency.
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Flushing Protocol
Wash hands.
Don gloves
Scrub / clean with friction the access surface of needleless I.V.
access ports (Extension Lines) or cannula hub with isopropyl
alcohol swab and Check the patency prior to infusion of
medications (to verify catheter placement) & then irrigate the
catheter with 3 - 5 ml of 0.9% normal saline. Use a sterile
disposable syringe, for single use, 3 - 5 ml filled with 0.9%
normal saline, preferably from a single dose vial unless a pre
medicated flush is prescribed by the clinician (heparin,
gentamicin etc)
into needle less connector system / Extension Lines.
If resistance or complication occurs at any time during flushing,
discontinue & report.
Close clamping mechanism on catheter extension line or IV
tubing.
Do not use the top port of PVC unless no other access
“RUB THE HUB” pre and post use -using an alcohol wipe 44
TROUBLESHOOTING POINTS
[Link] , but unable to advance: Cannula
and needle through other side of vein.
Drawing back.
b. Flashback and hematoma
c. No flashback and unstable vein (mobile vein)
d. No flashback but able to advance.
e. Peripheral edema: Compress skin over area
where vein might be expected
f. Unable to find veins
g. If Extravasations occurs … 45
It is the infiltration of a vesicant drug from an I.V. line into
surrounding tissue-can occur with either a peripheral or a central
venous catheter.
Extravasations occurs when a peripheral catheter erodes through
the vessel wall at a second point, when
increased venous pressure causes leakage
around the original venipuncture site, or when a
needle
pulls out of the vein.
Signs and symptoms of extravasations include
edema and changes in the site's appearance and
temperature,
such as edema, blanching, and coolness. The patient
may complain of pain or a feeling of tightness around
the site. Vesicant drugs or solutions (such as certain
antineoplastic drugs, antibiotics, 46
a. Immediately stop the infusion and disconnect the
tubingAttach a syringe to the hub and attempt to
aspirate the remaining drug from the catheter.
b. Estimate the amount of extravasated solution and
notify the primary care provider.
c. Remove the catheter without placing pressure on the
site. Use a 25-gauge needle to inject the antidote into
subcutaneous tissue as ordered or per protocol.
d. Elevate the affected arm.
e. Apply either ice packs or warm compresses to the
affected area, depending on the type of vesicant. For
most extravasations, you'll apply ice for 20 minutes four
to six times a day for 24
to 48 hours. However, treat extravasations from Vinca
alkaloids to be treated with heat.
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f. Photograph the site, if possible.
g. Record the date and time
h. Include the time you notified the
patients primary care provider and the
primary care provider name. Continue
regularly assessing and documenting the
appearance of the site and associated
signs and symptoms. Some signs, such
as erythema and ulceration, may be
delayed for 48 hours or more after the
extravasations. 48
Resiting or Removal Of Cannula
Perform hand hygiene
• Wear gloves
• Use sterile gauze
• Apply pressure for approx 2-3 minutes
• Inspect the cannula to ensure it is
complete and undamaged.
• Apply appropriate dressing.
• Dispose of cannula into the red bin.
• Perform hand hygiene
• DOCUMENT in Care plan or in notes
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Golden Rule – The ‘Best Practice
Mantra’:
Preplan as much as possible
Always use aseptic technique.
Know how to use the products (cannula, dressings
etc) selected.
Understand the associated risks and know how to
deal with these risks.
Know when to seek extra help and from whom.
Always explain and communicate the procedure
to the patient / attendants/ relatives.
Evaluate patient factors.
Avoid unnecessary interference with IV lines.
Keep good documentation.
Know the protocols and understand the reason
behind them.
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Antimicrobial solutions for site preparation
70% alcohol Chlorhexidine
Most common used Excellent bactericidal
Excellent bacterial effect effect
Requires a 1 minute Most preferred
scrub Mot recommended for
Must be allowed for air children less than 2
dry months
Repeat use dries the
Agents of choice for 30 seconds Up to 6
skin
iodine hours
Allergy immediate None
10% idopore
Reduce the iodine
irritation
Mask visualization of vein
Effect are neutralized by
organic material( blood)
When dry 2-3 hours
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Complications: Local and Systemic
HEMATOMA
Extravasation
Tenderness at
The infiltration of a vesicant
venipuncture
drug from an I.V. line into
site
surrounding tissue can occur
Bruising around site
with either a peripheral or a
Inability to advance or
central venous catheter.
flush
I.V line Nerve, Tendon or Ligament
VENOUS SPASM
Damage
Pain along vein. Sluggish
flow rate when clamp is Extreme pain numbness and
completely open muscle contraction
Blanched skin over vein Delayed effects
THROMBOSIS PHLEBITIS
Painful, reddened and Severe discomfort
swollen vein sluggish or reddened, swollen and
stopped I.V flow. hardened vein.
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Complications:
Systemic
Signs & Symptoms Possible causes Nursing interventions
Circulatory Overload Roller clamp Raise the head of the
Discomfort. loosened to allow run head.
Neck vein on infusion: Flow Administer oxygen
engorgement rate too rapid and medications as
Respiratory Miscalculation of per the
distress fluid requirements order.
Increased B.P Prevention: use
Crackle pump controller or
Large positive fluid rate minder
balance. for elderly or
compromised
patients.
Recheck
calculations of fluid
requirements
Monitor infusions
frequently
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Signs & Symptoms Possible causes Nursing
interventions
Systemic infection Failure to maintain Monitor vital signs
Fever, chills and aseptic technique Notify doctor
malaise for during insertion or site Administer
no apparent reason care medications as
Contaminated I.V Severe phlebitis, prescribed
site, usually with no which can set up ideal Culture site and
visible signs of conditions for device
infection at site organism growth. Prevention: Use
Poor taping that scrupulous aseptic
permits access device technique
to move, which can when handling
introduce organisms solutions and tubing,
into blood inserting
stream venipuncture device,
Prolonged indwelling and discontinuing
time of device infusion
Immuno Secure all 54
Air Embolism
Unequal breath sounds
Respiratory distress
Weak pulse
Increased CVP
Decreased BP
Loss of consciousness
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Nursing daily assessment
Iv site Scor Nursing action
e
IV site healthy 0 No phlebitis, observe cannula
1 of the following is 1 Early stage of phlebitis (Treat for
evident phlebitis..... frequent observation, dressing
Slight pain, Slight etc.)
redness Remove cannula if required.
2 of the following are 2 Early stage of phlebitis (Treat for
evident phlebitis..... frequent observation, dressing
Pain, erythema, swelling etc.)
Remove cannula if required.
all of the following are 3 Medium phlebitis,
evident: Remove cannula,
Treatment and Observation
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All of the following are 4 Advanced phlebitis, or
evident and possible
extensive thrombophlebitis
Pain along the cannula, Remove cannula,
swelling, Treatment and
induration, palpable Observation
venous cord
All of the following are 5 Advanced
evident and thrombophlebitis,initiate
extensive treatment,
Pain along the cannula, Remove cannula
swelling, Follow up
induration, palpable
venous cord,
pyrexia
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VIP SCORE
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