Basic IV Therapy and
review of Phlebotomy
Megan Kennedy
Cochise County
Jail Medical
Agenda for the day…….
•
•
•
•
•
•
•
•
•
•
•
•
•
Discuss purpose and uses of class
Anatomy & physiology
Identifying the purposes of IV infusions
IV solutions
Setting up an IV
IV catheters
Selecting the IV site
Starting the IV
Complications
Trouble-shooting
Removing the IV line
Drip calculations
Phlebotomy side of things
This course is designed to develop the following course competencies:
Identify the need for fluid resuscitation in pediatric and adult victims
Identify and describe the vascular anatomy and venous access for the
pediatric or adult victims
Identify and differentiate isotonic, hypotonic, and hypertonic solutions;
Select fluids, set up and manage equipment
Identify and demonstrate aseptic and safety techniques
Identify and describe indications and contraindications for intravenous site
selection
Perform all peripheral intravenous cannulation techniques, monitor infusion
Demonstrate 100% accuracy in intravenous techniques in selected scenarios
Demonstrate 85% proficiency on a written examination.
Discuss how fluid resuscitation pertains to phlebotomy.
Continue or begin your education in intravenous access.
Anatomy
Introduction
• Knowing the anatomy will aid you in
performing your skills, even when
you cannot see the veins.
• After this block of instruction you
should be able to differentiate
between veins and arteries, and show
where these items can be found.
Any questions before we
get started?
Skin
• Covers the entire body and acts as a protective layer
between the body and the environment.
• The main functions of the skin are:
– Protection from harmful influences
– Control of body temperature
– Conveyance of sensory impressions
• Some areas of the bodies skin are highly sensitive and
the insertion of a needle in one area may cause a great
deal of pain, while another area may be practically
painless.
•Besides epithelial
cells and connective
tissue cells, the skin
also contains
delicately entwined
nerves and blood
vessels.
Blood Vessels
• With the exception of capillaries, the
walls of the blood vessels consist of
three layers, though the thickness or
construction of the individual layers
can vary according to the vessel
type.
Blood Vessels
• The outer layer consists of connective tissue and
facilitates the fitting of the vessel into its
environment.
• The middle layer is composed of smooth muscle
containing elastic fibers.
• The inner layer consists of thin connective tissue.
It is covered by a layer of single-layered
endothelial cells.
Arteries
• The arteries are blood vessels which
transports blood away from the heart.
• They are different in construction from the
veins in that they have an additional layer
of an elastic membrane situated between
the inner and middle wall layers.
Arteries
•Depending on the
task and the location
of the artery, its
middle layer may be
dominated by
smooth muscle or
elastic fibers.
Arteries
• When the heart pumps blood into the
arteries during the expulsion phase
(systole), their high proportion of elastic
fibers permits them to distend.
• During the relaxation phase (diastole) of
the heart, they contract again, transporting
blood on further.
• Arteries with muscle predominating are
able to widen (vasodilation) or narrow
(vasoconstriction) their diameter through
contraction, thus enabling the amount of
blood contained within them to increase or
decrease with the demands of the body.
• Arterioles are the smallest arteries.
Veins
•The veins are the blood
vessels which transport
blood towards the heart.
•The wall layers of the
veins are thinner than
those of the arteries, yet
contain more connective
tissue.
•The muscle layer is less
marked.
•The diameter of veins
are larger than that of
arteries.
Veins
• As a result of the thin layer of muscle the veins are not
able to move blood themselves. They are aided by the
surrounding musculature around them.
• In order to prevent the blood from flowing back, some
of the veins, especially those within the extremities,
are equipped with venous valves.
• When the blood is flowing towards the heart, the
venous valves lie flat against the venous wall. If the
blood congests or starts to flow back, the valves
close.
Capillaries
• Capillaries are the smallest blood
vessels in the body
• They are connected to the arterioles
and into the venules, thus
representing the link between arteries
and veins.
Capillaries
•
In contrast to arteries and veins, capillaries have neither a middle
or outer wall layer. They only have an inner layer, constructed of
connective tissue and endothelial cells.
•
The diameter of capillaries is very small because of they are so
small they circulate in single file. This fact, and the thinness of
their wall layer promote their ability to
exchange material and Water with their
environment.
•
The oxygen and nutrients contained within the blood are pressed
out of them as a result of the blood pressure and passed off to the
intercellular cavities.
•
Carbon dioxide and metabolic products are absorbed by the blood
in the exchange
Blood
• 4-5x thicker than water
• Liquid connective tissue
– Adults = 7% of patients weight
• 4-6 Liters of blood
– Children = 9% of patients
weight
Physical Characteristics of Blood
• Color range
– Oxygen-rich blood is scarlet red
– Oxygen-poor blood is dull red
• pH must remain between 7.35–7.45
• Blood temperature is slightly higher than body
temperature (100.4)
Functions of Blood
 Transportation – oxygen, nutrients, hormones,
heat, electrolytes.
 Carries away from the body tissues
- Waste matter
- CO2
 Protection – Vital role in our immune system;
clotting mechanisms that prevent blood loss
 Regulation – pH, body temperature, water
content
Components of Blood
 PLASMA – is the yellowish fluid of the blood
and consists primarily of water (92%) and
plasma proteins (7%)
 Proteins – albumin and fibrinogen
 FORMED ELEMENTS – solid component of
the blood consisting of red blood cells, white
blood cells, and platelets
 BLOOD = 55% plasma
Blood Plasma
• Composed of approximately 92 percent
water
• Contains:
– Nutrients, salt solution
– Respiratory gases
– Hormones
– Proteins, Waste products
Plasma Proteins
• Albumin – regulates osmotic pressure
• Clotting proteins – help to stem blood
loss when a blood vessel is injured
• Antibodies – help protect the body from
antigens
Formed Elements
“Types of Cells”
• Erythrocytes = Red Blood Cells
• Leukocytes = White Blood Cells
• Thrombocytes = Platelets
Erythrocytes
“Red Blood Cells”
• The main function is to carry oxygen
• Anatomy of circulating erythrocytes
– Cells without a nucleus
– Produced continuously in the bone marrow
from stem cells at a rate of 2-3
million cells per second.
─ Hemoglobin 95% of a red cell
– Approximately 120 days life span
• Outnumber white blood cells 1000:1
Leukocytes
“White Blood Cells”
• These are complete cells, with a nucleus
• Crucial in the body’s defense against
disease. Ingest pathogens & destroy
• Produce antibodies
• Can respond to chemicals released by
damaged tissues
Thrombocytes
“Platelets”
• Cell fragments without nuclei that
release blood clotting chemicals
• Life span of 5-9 days
• Needed for the clotting process
• Platelets and clotting proteins work
together.
Purpose of starting IV’s
• To deliver fluids
• To deliver medications
Cellular Physiology
• Body Fluid
– 1. Total body water = 60% of body
weight
– 2. Electrolytes
–
–
–
–
–
–
Sodium
Potassium
Magnesium
Calcium
Bicarbonate
Chloride
• 3. Protein
– Albumin
– Plasma
– Other
• FLUID LOSS:
– Blood loss
– Plasma loss
– Nausea/vomiting/diarrhea
– Sweating
Isotonic, Hypotonic and
Hypertonic IV fluids
Isotonic – IV fluids that approximate the osmolaity of blood plasma. I.e.:
0.9% Normal Saline (note the biconcave shape of the cells as they circulate
in blood.)
Hypotonic – IV solutions that have a lower osmolarity than blood plasma
thus drawing fluids into the cell. I.e.: D5W. (note the cells are visibly swollen
and have lost their biconcave shape, and at 100 mOs, most have swollen so
much that they have ruptured, leaving what are called red blood cell ghosts.
In a hypotonic solution, water rushes into cells.)
Hypertonic – IV fluids that have a higher osmolality than normal blood
plasma thus drawing fluids out of the cells and they get irritated when
infused.I.e.: D50 (note water has flowed out of the cells, causing them to
collapse and assume the spiky appearance you see.)
Types of IV Solutions
• 0.9% Sodium Chloride
• Lactated Ringers
• D5W
0.9% Sodium Chloride
• Also called normal saline
• Isotonic solution of sodium chloride in
water
• 9 grams of sodium chloride per liter
• Indications
– Restore loss of water and sodium chloride
•
•
•
•
•
Fractures
Trauma
Dehydration
Hypoglycemia
Non-traumatic hypoperfusion
• Contraindications
– Use with caution in CHF and pulmonary edema
Lactated Ringers
• Source of water, electrolytes, and
calories
• Indications
– To replenish fluid and calories, and
restore loss of electrolytes
•
•
•
•
•
Trauma
Burns
OB
Non-traumatic hypotension
dehydration
• Contraindications
– Use with caution in CHF, pulmonary
edema, and liver disease
D5W
• Hypotonic solution of dextrose in
water (50 grams of dextrose per liter)
• Indications
– Directed by MD
• Contraindications
– Head injury
– Children
Combinations of Normal Saline,
Lactated Ringers, and D5W are
often common.
All fluids come in 250cc, 500cc, and
1000cc bags.
Setting Up An IV
Assemble and prepare the
necessary equipment
You will need:
The correct IV solution
The correct administration set
An IV catheter
An IV start pack
Tourniquet
Alcohol prep
Opsite or equivalent
Tape
Inspect the container
and solution
• Check the label and the expiration date
• Look for tears in the bag
• Assess the clarity of the solution; if it is
not clear – DO NOT USE IT!
• Look at the pull-tab and make sure that
it is intact
Types of administration sets
• IV administration sets differ
mainly in the drop factor
(the rate of flow they produce)
Minidrip/Microdrip/Pediatric Drip
• Delivers 60 gtts (drops) per cc (ml).
Used on all patients that fluids need
to be restricted on. I.e.: heart failure
patients, dialysis patients, and
pediatric patients.
Standard/Macrodrip
• Delivers 10-20 gtts (drops) per cc
(ml). Used on patients that require
a large amount of IV fluid. i.e.:
trauma, overdoses, burns, heat
related emergencies.
Blood tubing
• “Y” shaped tubing is also 10 gtts per
cc set, but is used with NS for blood
administration.
Preparing the IV bag
• Remove the protective tab from the insertion port
• Close the flow clamp on the administration set
• Remove the protective cap from the
administration set
• Holding the port carefully and firmly with one
hand, insert the spike with the other hand
• Hang the bag and squeeze the drip chamber until
it is half full (if there is too much fluid in the
chamber, you can turn the IV bag upside down
and squeeze the chamber again to return
the fluid back into the bag)
Priming the IV tubing
• Open the flow clamp. Hold the end of
the tubing over a collection container.
Be sure to maintain the sterility of the
tubing!
• Leave the clamp open until the IV
solution flows through the entire
length of the tubing, forcing out all
air.
• After priming the tubing, close the
clamp.
IV Catheters
Selecting the IV catheter
• Two types of needles and catheters
are commonly used in peripheral
lines:
– Over-the-needle catheters
– Winged-tip or scalp-vein needles
IV catheters
• The higher the number, the smaller
the gauge
• The larger the gauge, the more fluid
that can be delivered
• The shorter the catheter the more
fluid that can be delivered
General rule of thumb for
selection of size:
• Medical patient’s
– Use at least a 20 gauge catheter
– A 22 gauge can be used if the patient
has small, fragile veins
• Pediatric patient’s (NOT USED on
ages SIX and UNDER)
– Use 20-22 gauge
• Trauma patient’s
– Use at least an 18 gauge catheter
Selecting the site
• Peripheral veins – usually for shortterm use (less than 3 weeks)
– When choosing a peripheral vein both
arms should be assessed.
– Large veins are best suited for
emergency infusions
– Avoid arms with injuries, burns, open
sores. Call for medical direction if
intravenous access is only possible on
mastectomy side.
– Start with a vein at the most distal site
so you can move upward as needed for
additional insertion sites.
• EXCEPTION:
In a code arrest use the antecubital
vein as it is closer to the central
circulation. Fluids and medications do
not have as far to travel to reach the
central circulation.
The most favorable venipuncture sites
are:
- veins in the dorsum of the hand
- antecubital vein
- basilic vein
- cephalic vein
Be sure the vein can accommodate the
catheter used.
Factors affecting site selection
•
•
•
•
•
•
•
•
Type of solution
Condition of vein
Duration of therapy
Cannula size
Patient age
Patient preference
Patient activity
Presence of disease or prior surgery,
i.e.: mastectomy or shunt (Call for
medical direction)
Patient preparation
• TALK TO YOUR PATIENT. Explain
what you are going to do
• Prepare equipment
• Check solution for correct type, valid
expiration date, and clarity
• Place patient in supine position to
decrease vasovagal reaction
• Select site and catheter
• Apply tourniquet
• Cleanse site
• Hold skin taut, by placing thumb on
non-dominant hand 1-2 inches below
intended insertion site and gently pull
skin
• Insert needle through the
subcutaneous tissue at a 20-30
degree angle beside or directly into
the vein, bevel up
• Assess for blood return
• When blood return is obtained
decrease the angle of the catheter
and very carefully advance the
needle and the catheter
approximately ¼ inch to assure the
catheter is in the vein
• A steady backflow of blood indicates
a successful venipuncture
• Pull needle back into but not out of
the catheter. Advance the catheter
into the vein while continuing to hold
the skin taut
• Release the tourniquet
• Gently place pressure over the vein
above the catheter tip to prevent
bleeding while removing the needle.
Do not compress catheter!
• Attach fluid source
• Regulate flow rate
If IV is unsuccessful
• If you are unsuccessful at gaining
intravenous access after three
attempts STRONGLY consider
recontacting medical direction,
finding an equally or more qualified
person to attempt IV access, or not
continuing with an IV.
Arm boards
• Arm boards should be used to support areas of
joint flexion or to restrain IV sites in extremely
active patients or children
• Arm boards should be padded to maintain
comfort and prevent nerve or tissue damage
• Normal joint configuration should be maintained
by supplemental padding
• Tape should NOT be wrapped completely around
the patient’s arm, nor should it be applied too
tightly because it will act as a tourniquet,
decreasing peripheral circulation distal to the IV
site
Complications of IV therapy
• The potential hazards of IV therapy
range from minor to life threatening
• They may be associated with the
venipuncture or with the infusion
• Lack of aseptic technique is a major
cause of complications as it induces
pathogens into the circulatory
system
• Complications may be local or
systemic
Local Complications
Site infections (Local
contamination of insertion site)
• Signs and symptoms
– Redness, warmth, tenderness, and swelling at
site
– Possible purulent material
• Possible causes
– Failure to maintain aseptic technique during
starting or removing IV catheter
• Actions
– Remove IV and restart in unaffected arm
• Prevention measures
– Maintain strict aseptic technique of IV insertion
Clotting (Blockage at the end of
the device in the patient’s vein)
• Signs and symptoms
– Tenderness at IV site
– Sluggish flow rate
• Possible causes
– IV rate too slow to maintain patency of catheter
– Activity of patient causes increase back-flow of
blood
• Actions
– Remove IV and restart in another area
• Prevention measures
– Maintain constant flow rate
– Tightly secure all connections
Hematoma (Raised, discolored
area caused by leakage of blood
at puncture site)
• Signs and symptoms
– Tenderness at venipuncture site
– Area around site appears “bruised”
– Inability to advance IV
• Possible causes
– Vein “blown” or punctured through other wall at time of
venipuncture
– Leakage of blood from needle displacement
• Actions
– Remove IV catheter
– Apply pressure to area
• Prevention measures
– Do not advance needle further if resistance is met on
venipuncture
– Choose a vein that can accommodate size of IV catheter
Infiltration (Leakage of IV fluids
into surrounding tissues)
• Signs and symptoms
– Swelling, tenderness above the IV site that may extend along
the entire arm
– Decreased skin temperature around the site
– Fluid continues to infuse even when vein is occluded
– Back-flow of blood is absent
– Flow rate is slower or stopped
• Possible causes
– Catheter is dislodged from vein or vein is perforated
• Actions
–
–
–
–
Remove IV catheter
Apply ice (early) or warm (later) to aid absorption
Elevate extremity
Restart IV infusion above infiltration or in another limb
• Prevention measures
– Check IV site frequently
– Do not obscure area above site with tape
– Restrict movement of limb by placing on arm board
Phlebitis (Irritation along vein)
• Signs and symptoms
– Area along vein is red, tender, and warm
– Vein is hard and cord-like when palpated
– Irritation increases with infusion
• Possible causes
–
–
–
–
–
Hypertonic solutions
Repeated use of same vein for therapy
Movement of catheter in vein
Catheter is too large or flow rate too rapid for size of vein
Clotting at tip of catheter
• Actions
– Remove IV catheter
– Apply warm packs
– Restart IV infusion is a different limb
• Prevention measures
– Use large veins for hypertonic solution infusion
– Choose smallest IV needle for situation and size of vein
– Stabilize the catheter to decrease movement in vein
Systemic Complications
Catheter embolism
• Signs and symptoms
– Related to specific location of embolus:
discomfort, decreased BP, cyanosis, weak
pulse, respiratory distress, altered LOC
• Possible causes
– Rethreading stylet into catheter
• Actions
– Apply tourniquet above IV site to discourage
further traveling of device into venous system
• Prevention measures
– Withdraw catheter and stylet together is
venipuncture is unsuccessful
Air Embolism
• Signs and symptoms
–
–
–
–
–
Respiratory distress
Unequal breath sounds
Weak pulse
Decreased BP
Loss of consciousness
• Possible causes
– Disconnect between catheter and tubing thus allowing
air to be sucked in
– IV tubing that runs dry or is not purged of air properly
– Solution container empty
• Actions
– Discontinue IV infusion
– Turn patient to left side, head down
– Administer oxygen
• Prevention measures
– Purge tubing completely of air before infusion starts
Circulatory overload
• Signs and symptoms
–
–
–
–
Patient discomfort
Neck vein engorgement
Increased blood pressure
Fluid in lungs; rales, shortness of breath
• Possible causes
– Roller clamp loosened to allow “run-away” IV
– Miscalculation of fluid requirements
• Actions
– Slow or stop infusion rate
– Raise head of patient’s bed
• Prevention measures
– Double check IV rate ordered for size and
condition of patient
– Administer oxygen
Systemic infection
• Signs and symptoms
– Fever, chills without apparent reason
– Nausea, vomiting
– malaise
• Possible causes
– Contaminated IV devices or solution
– Failure to maintain aseptic technique during insertion
• Actions
– Remove IV catheter
– Restart in another area
• Prevention measures
–
–
–
–
Examine fluid and container
Monitor vital signs
Maintain aseptic technique
Secure all connections
What to do when infusion stops
• Check IV site for infiltration
• Check IV catheter (position of patients
extremity, the tip of catheter may be
against the wall of vein, tape may be too
tight)
• Check the flow clamp
• Check the tubing
• Check the air vent
– If one is required (i.e.: glass bottles)
– Check to be sure the spike is pushed in far
enough into bag
– Try flushing the line with 5-10cc of saline.
** If the IV still does not run after all the above
have been checked, then it should be
discontinued and restarted! **
Changing the solution
• Turn the flow clamp off
• Quickly remove the spike from the
bag and insert it into the new bag
(assure sterility!)
• Turn the flow clamp back on and
regulate the rate
Removing a peripheral IV line
• An IV should be removed if it infiltrates, fails to
run or the site becomes infected
• Gather necessary supplies
– Band-aid or tape
– Sterile gauze (2x2)
• Turn the flow clamp off
• Gently remove all the tape from the catheter and
skin
• Hold the sterile gauze over the insertion site and
withdraw the catheter with a gentle, brisk
movement keeping it parallel to the skin
• Cover the site with a band-aid or tape
• Document:
– Reason for removal
– Time
– Catheter integrity
DOCUMENTATION &
GUIDELINES
Patient Care Report
documentation should include:
•
•
•
•
•
•
•
•
Time
Site/Location of IV
# of attempts
Gauge of catheter
Solution type
Rate of IV
Absence of problems
Total volume infused at transfer of care
– 1310 IV 0.9% NS started Left posterior hand 1st
attempt with 18g @ TKO rate. No
signs/symptoms of infiltration. IV infusing
without difficulty. 50cc infused upon transfer of
care to…….
A few key points to
review for
Phlebotomy.
Factors affecting sample
quality:
• Poor vein selection
• Incorrect order of draw
• Insufficient blood draw
volume
• Insufficient mixing
Phlebotomy:
Things to remember
• The tourniquet should be on the arm
no longer than ONE minute.
• Release the tourniquet before
removing the needle.
• Searching for an appropriate vein
correctly first, means less pokes for
the patient later.
• If using alcohol wipes, allow the area
to dry completely before
venipuncture.
Phlebotomy cont.
• Make sure that the blood collection
tubes are drawn in the correct order
that is indicated by the lab that you
will be utilizing.
• If tubes are drawn in incorrect order
contamination can occur. This can
also cause false results.
• Fill collection tubes to the correct
volume (indicated by a black mark at
the appropriate fill level) If the tube is
not filled to the correct volume it can
also cause false results.
Phlebotomy cont.
• Proper mixing is essential. Gently mix the
tubes by rocking back and forth at least 810 times IMMEDIATELY after filling the
tube. (DO NOT shake vigorously!)
• Store unused tubes at room temperature.
Never leave supplies inside a vehicle
where temperatures can get very high (this
may cause decrease in vacuum)
• As always, check the expiration dates prior
to use! (using expired tubes may also
cause decrease in vacuum)
Any Questions?????
Let’s do some drip
calculations
IV drip rate:
Volume to be infused (ml) X drip factor of tubing
gtts/min =
Time (min) to be infused
i.e.:
1000ml X 10
= 166 gtts/min
60min
Do IV flow rate calculation
sheet now