Basic

Intravenous
Therapy
90-95% of patients in the
hospital receive some type
of intravenous therapy.

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This presentation will enhance

your knowledge of how to care

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Vein Anatomy and

Physiology

Veins are unlike arteries in

that they are 1)superficial, 2)
display dark red blood at skin
surface and 3) have no
pulsation

Vein Anatomy

- Tunica Adventitia
-

Tunica Media
Tunica Intima
Valves

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Tunica Adventitia
the outer layer of the vessel

Connective
tissue

Contains the
arteries and
veins supplying
blood to vessel
wall

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Tunica Media

the middle layer of the vessel

Contains nerve
endings and
muscle fibers

The
vasoconstrictive
response occurs at
this layer

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Tunica Intima

the inner layer of the vessel

One
No

layer of endothelials

nerve endings

Surface

for platelet
aggregation
w/trauma and recognition of
foreign object at this level
PHLEBITIS

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begins here

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Valves

present in MOST veins

Prevent backflow and

pooling

More in lower
extremities and longer
vessels

Vein dilates at valve

attachment

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Veins of the Upper Extremities

Digital Vessels
-Along lateral aspects fingers,
infiltrate easily, painful, difficult to
immobilize and should be your LAST
RESORT

Metacarpal Vessels
-Located between joints and
metacarpal bones (act
as natural splint)

Digital

-Formed by union of digital veins

-Geriatric patients often lack
enough connective / adipose tissue
and
skin turgor to use this area
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Veins of the Upper Extremities

Cephalic (Interns Vein)

-Starts at radial aspect of wrist
-Access anywhere along entire
length
(BEWARE of radial
artery/nerve)

Medial Cephalic (On ramp

to Cephalic Vein)
-Joins the Cephalic below the elbow
bend
-Accepts larger gauge catheters,
but may be a difficult angle to hit
and maintain

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Veins of the Upper Extremities

Basilic
- Originates from the ulner side of
the metacarpal veins and runs
along the medial aspect of the
arm. It is often overlooked
becauses of its location on the
back of the arm, but flexing the
elbow/bending the arm brings this
vein into view

Medial Basilic
- Empties into the Basilic vein
running parallel to tendons, so it
is not always well defined.
Accepts larger gauge catheters.
- BEWARE of Brachial Artery/Nerve

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Purposes of IV Therapy

To provide parenteral nutrition

To provide avenue for dialysis/apheresis
To transfuse blood products
To provide avenue for hemodynamic monitoring
To provide avenue for diagnostic testing
To administer fluids and medications with the ability to
rapidly/accurately change blood concentration levels by either
continuous, intermittent or IV push method.
Types of Peripheral Venous Access Devices
Butterfly

(winged) or Scalp vein needles (SVN) not recommended for non

compliant patient as it can easily penetrate the vein wall causing extravasation.
We use these frequently for phlebotomy
Safety

Over the needle catheters (ONC)

- PROTECTIV

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-ACUVANCE

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Starting a Peripheral IV

Finding a vein can be challenging

- Go by feel, not by sight. Good veins are bouncy to the touch, but
are not always visible.
- Use warm compresses and allow the arm to hang dependently to
fill veins.
- A BP cuff inflated to 10mmHg below the known systolic pressure
creates the perfect tourniquet. Arterial flow continues with
maximum venous constriction.
- If the patient is NOT allergic to latex, using a latex tourniquet may
provide better venous congestion
- Avoid areas of joint flexion
- Start distally and use the shortest length/smallest gauge access
device that will properly administer the prescribed therapy

(BE AWARE: Blood flow in the lower forearm and hand is

95ml/min)
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IV Start Pain Management

One of the most frequent contributors to patient
dissatisfaction is painful phlebotomy and IV starts

Use 25-27g insulin syringe to create a wheal similar to a TB skin

test on top of or just to side of vein with 0.1 -0.2 ml normal saline
or 1% xylocaine without epinephrine

Topical anesthesia cream (ie EMLA) may be applied to children>37

weeks gestation 1 hr. prior to stick. It might be a good idea to
anesthetize a couple of sites

Have the patient close their fist (NO PUMPING) prior to stick

Make sure the skin surface cleansing agent (alcohol/chlorhexidine)

is dry prior to stick. Drawing this into the vein may stimulate the
vasoconstrictive action of the tunica media layer

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Flushing Peripheral IVs

Use prefilled saline and heparin flush syringes located in
PYXIS
Heparin flush concentrations available:
-100u/ml (5ml in a 10ml syringe)
-10u/ml

(2ml in a 3ml syringe)

Flushing intervals and amounts

- Peds: q 6hrs.
<22ga 1ml 0.9%NS followed by 1ml
heparinized (10units/ml) saline

- Adults: q 8hrs
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w/1ml. 0.9%NS [3ml heparinized saline for

OB]

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Dressing/Bag Changes
Changing dressings

Physician orders are

required if a peripheral
catheter is left in the
same site for more
than 3 days.
It is best to have the
pharmacy add
medications to the
infusion bags under
laminare flow to reduce
contamination
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TSM q 7 d

Gauze q
2d

Changing bags and tubing

1

24
hrs

normally every 3d

If respiked or meds added

outside pharmacy

Changing Sites
1

normally every 3d

Every 7 d c MD order

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Central Venous Catheters

Percutaneous

Tunneled

PICCs

Implanted Ports

Dialysis

Insertion

MD @ bedside
w/x-ray
confirmation

MD in OR under
fluoroscopy

MD/trained RN
@bedside w/x-ray
confirmation

MD in OR under fluoroscopy

MD in OR under
fluoroscopy

Location

Visible externally.
Enters
subclavian, ext.
juglar,or int.
juglar vein near
clavicular area

Visible ext. usually

midway bet.
clavicle and
nipple. Tunneled
under skin &
threaded through
subclavian or IJ

Visible externally
around antecubital
fossa, upper arm or
neck

Completely internal. Titanium or

plastc port is implanted in a
surgically created pocket and
catheter is threaded into
subclavian or int. juglar vein.
Access is through skin into self
sealing port using special non
coring needle

Visible externally.
Arm or leg
placement

Polyurethane
$200-$400

Silicone
$3500-$5000

Silicone / polyurethane
$350-$500

Silicone catheter. Port is titanium

or plastic w/self sealing diaphragm
$3500-$5000

Various materials

2-3

2-3

1-2

1-2

2-3

Sutured

Yes/entire life

Yes, until internal

Dacron cuff
healed

No

Yes

Yes

Duration

Short term 4-10

days

Long term

Long term

Long term

Mid term

Flushes

5-10ml NaCl
after use and
daily

5-10ml NaCl after

use and daily

5-10ml NaCl after use

and daily

10ml NaCl followed by 4.5ml

heparinized saline (adults100units/ml; peds-10units/ml) after
ea. use or monthly if not accessed

Done ONLY by IV
team or dialysis
nurses

Brands/
Names

Arrow Howe,
Triple Lumen,
Subclavian, IJ

Hickman, Broviac

PICC, PIC, EDPC, Arrow

Howe, Gesco, PASV

Bard, Accces Port-A-Cath

Bard, Tesio,
Vescath, Quinton

MD or speically
trained RN @
bedside

MD in OR

Specially trained RN @
bedside

MD in OR

MD in OR

Material/Co
st
Lumen

Discontinue

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Central Venous Catheter

Sites

PICC (Peripherally
inserted
Central Catheter)

Percutaneous(Subclavia
n)

Implanted Port
(single or double
lumen)
Tunnelled (Hickman)
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Percutaneous (IJ-Int.
Jugular)

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CVC Care/Maintenance

Percutaneous

Tunneled

Flush after each access or daily for

catheters>21ga, q 6 hrs <21 ga
-adults: 10ml saline
- peds/neonates: 5ml saline
(preservative free
for infants <1yr)
Transparent dressing change q 7 days &
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prn

PICC

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CVC Care/Maintenance

Flush after each use and weekly while

accessed; monthly when not acessed

- 10ml saline (preservative free for pts.

Implanted Port

<1yr)
- followed by 4.5ml-5ml heparinized
saline
100units/ml for adults
10units/ml for peds

Transparent dressing/ access needle change q

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7days

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Monitor and
document
site
condition:

Site Care

Hourly for
peds
Q 2 hr for adult
* Indicates
complication:
Infiltration
Phlebitis
Thrombosis
Cellulitis
Septicemia
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Infiltration/Extravasation
The most common cause is damage to
the wall during insertion or angle of
placement.
STOP INFUSION and
treat as indicated by
Pharmacy, Medication
package insert or drug
reference book.

Notify MD and
document
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Phlebitis/Thrombophlebitis
Chemical
- Infusate chemically
erodes internal layers. Warm
compresses may help while the
infusate is stopped/changed. Antiinflammatory and analgesic
medications are often used no
matter what the cause

Mechanical

Bacterial

- Caused by irritation to
internal lumen of vein during
insertion of vascular access
device and usually appears
shortly after insertion. The device
may need to be removed and
warm compresses applied

- Caused by introduction
of bacteria into the vein.
Remove the device
immediately and treat
w/antibiotics. The arm will be
painful, red and warm; edema
may accompany

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Cellulitis

Inflammation of loose
connective tissue around
insertion site.
- Caused by poor insertion
technique
- Red swollen area spreads from
insertion site outwardly in a diffuse
circular pattern
- Treated w/antibiotics
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Septicemia/Pulmonary Edema/
Embolism
Septicemia
- Severe infection that occurs to a system or entire body
- Most often caused by poor insertion technique or poor site
care
- Discontinue device immediately, culture and treat
appropriately
Pulmonary edema- caused by rapid infusion

Pulmonary embolism - Caused by any free floating substances

that require thrombolytic therapy for several months. Increased risk
w/lower ext.
Air embolism- caused by air injected into IV system. Keep
insertion site below level of heart
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Troubleshooting

Vascular access device will not flush/cant draw

blood
- Evaluate for kink in tubing or catheter tip against vein wall.

Vascular access device (VAD) leaking when flushed

- Verify that hub access cap is connected correctly

Patient complains of pain while VAD being flushed

- Assess for infiltration

VAD broken
- PICCs may be repaired. All other devices must be replaced

Call IV therapy team member for any concerns or

questions.
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Policy notes
KVO rate:

RNs and LPNs can start

peripheral IVs after initial
training and observation
by preceptor

Adults - 10 ml/hr
Pediatrics - 2-3 ml/hr
Neonates - 0.5-1 ml/hr

Only until rate

order received

Verification required for:

Insulin
Heparin
Potassium

LPNs CANNOT infuse

blood products or high
risk IV medications.

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Digoxin
Chemotherapy

LPNs cannot push IV

medications

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IV Medication Administration
Many medications require
patient monitoring that cannot
be done on units where the
nurse/patient ratios are
greater than 1:2

All Medications Cannot Be

Administered on All Units
General Care Units: Can give meds
requiring only basic physical
assessment data
Stepdown Units: Can give meds
that require more invasive or
frequent monitoring than is available
on general care units
Intensive Care Units: Can give

A patient can be moved to a

meds that require more invasive or
frequent monitoring than is available
unit where the ratio is
on the Stepdown units.
appropriate for
VANDERBILT URL LINK FOR IV
invasive/frequent monitoring
MEDICATIONS:
or another nurse can be
brought to care for the patient www.mc.vanderbilt.edu/pharmacy/ivroo
m/IVMedAdm061003.pdf
during the med administration
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IV Medication
Administration
Sample page
from the
Pharmacy med
administration
web site

See
APPROVED
FOR section.
You will find if
the medication
can be
administered
on
your unit.
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www.ins1.org

Infusion Nurses Society (INS)

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Professional Organization that sets the standards of

care for clinicians practicing in the field of infusion
therapy.

Standards set by INS are reflected in our policies and

procedures related to infusion therapy for health care
providers.

In a court of law, the standards set by the INS are used

to assess the infusion clinicians performance.
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