LPN IV Series: Venipuncture and Maintenance

The skin acts as a barrier between the outside environment and internal organs. When the barrier is broken, the risk for infection increases. An infusion access device perforates the skin, interrupts the integrity of the barrier, and increases the risk of infection. Any infection in this tissue can spread throughout the body. A strict aseptic technique for venipuncture care and site maintenance is necessary.

• The vascular system is made up of blood vessels, including arteries, arterioles, capillaries, and veins. These vessels vary in size and function.
• Arteries carry oxygenated blood away from the heart. The aorta is the largest artery emanating from the heart. Arteries branch off the aorta. As they branch off the aorta, they decrease in size and become arterioles. Arterioles subdivide into capillaries.
• Capillaries provide nutrients to the tissue and take waste away. Capillaries connect with venules, which are the smallest veins. The venules connect with larger veins, eventually leading to the vena cava, which is the largest vein and connects directly to the heart.
• Veins carry deoxygenated blood back to the heart. The deoxygenated venous blood is carried to the right atrium through the superior vena cava (SVC) and the inferior vena cava (IVC). The blood enters the right ventricle, exiting through the pulmonary artery to the lungs, where it is oxygenated and carried to the left atrium through the pulmonary veins.
• The pulmonary artery carries deoxygenated blood, and the pulmonary veins carry oxygenated blood; these are the only exceptions to the rule that an artery contains oxygenated and a vein deoxygenated blood.

Intravenous Therapy is an invasive procedure. Only veins are used for venipuncture. If blood pulses out of the catheter, you have hit an artery. Discontinue the catheter and hold pressure for 10 minutes.

Before you begin the venipuncture, consider the following:

• The purpose
• Duration of use
• Condition of veins
• Type of infusion
• Patients medical condition

When selecting a vein to perform venipuncture, consider the following factors:

• Catheter size - Select a catheter with the shortest length and diameter that accommodates the provided therapy. A 20 gauge catheter can be used for blood transfusions if the patient cannot tolerate an 18. Smaller catheters lyse the RBCs during infusion, defeating the purpose.
• Type of solution - Hypertonic solutions and various medications can irritate the vein. Consult with the pharmacy regarding the properties of the medications or solutions being delivered.
• Alert: Do not administer continuous vesicant chemotherapy and parenteral nutrition exceeding 10% dextrose or 5% albumin in a peripheral line. A 20-gauge or larger catheter is needed in the forearm or above for IV contrast.
• The vein condition - If the vein has recently been used or is bruised/red/swollen/red, then do not use.
• Duration of therapy - Long-term therapy will require frequent venipunctures. When possible, alternate arms and always start distally.
• Patient age –
  • Infants have fewer accessible sites than older children and adults.
  • In toddlers, the feet and hands are the most accessible sites.
  • The hands and the antecubital region offer the best sites for children, adolescents, teens, and adults.
  • The elderly may have very fragile veins, fragile valves, and a lack of connective tissue to stabilize the veins (rolling veins).
• Patient preference - Use the non-dominant side whenever possible. Ask the patient if they have ever had an IV before and which site they prefer.
• Patient activity - As much as possible, allow hands-free, especially if the patient uses a walker, crutches, or wheelchair.

Veins for Venipuncture

Central lines should be used (Nettina, 2019):

• When infusions are:
  • Hypertonic
  • Highly irritating (chemotherapy, parenteral nutrition)
  • Required rapid or high-volume
• When peripheral blood flow is diminished (shock, dehydration)
• When peripheral veins are not accessible (obese, frequent venipuncture)
• When hemodynamic monitoring is desired
• When long term IV therapy is expected

Central lines will be discussed in another course.

IV Catheters

Butterfly (winged) metal needles are for short-term drug administration and should not be left in place. The needles easily cut the vein and lead to infiltration with the slightest movement.

Use only catheters the have a safety protection feature to guard against needlesticks.

1. Apply a tourniquet at least 2-6 inches above the planned insertion site. Fasten the tourniquet with a slipknot or hemostat. A blood pressure cuff can be used as a tourniquet. The goal is to impede venous flow while allowing arterial flow. A looser tourniquet is effective in patients with fragile veins.
2. Apply manual compression above the site by placing fingers on the vein. This procedure usually takes two people to do. The method is particularly effective in the elderly, diabetic, or chronically ill whose veins are fragile.
3. Position the arm lower than the heart level while the patient opens and closes their fist, and you lightly stroke the vein downward.
4. Lightly tap the vein. Be gentle, so the vein is not damaged.
5. Apply warmth to the site using a dry, warm towel or heat pack.

Ultrasound-guided venipuncture improves efficiency and effectiveness (Nettina, 2019).

To reduce pain during venipuncture, penetrate these layers quickly.

Local anesthetic agents can be used to minimize pain. This include:

• Topical vapor coolant sprays
• Topical transdermal agents
• Intradermal lidocaine
• Pressure-accelerated lidocaine

The anesthetic decreases pain but may cause the vein to collapse (disappear) or cause an allergic reaction. A warm compress may decrease the vasoconstrictive effect of the local anesthetics.

The IV catheter and tubing should be secured to prevent dislodging and irritation at the catheter site. The facility usually determines the IV site dressing and stabilization device. A transparent semipermeable dressing and tape are often used. More reliable devices are made but may not be used by your facility. Be sure to tape the tubing to the skin several inches above the insertion site to prevent dislodging when manipulating the fluid bags or pumps.

Use an aseptic technique when changing tubing and bags or bottles. The tubing systems have a spike on one end. Remove the protective cover from the bag or bottle and do not contaminate the insertion site. Remove the protective cover from the spiked end of the tubing and insert it into the bag or bottle. Setting up the system can be done in the medication room or at the patient's bedside. Most medication rooms have enough room to layout the equipment and control the sterile ends of the bags, bottles, and tubes.

Use only bags or bottles that are sealed and within the expiration date. If the contents of the bag or bottle of IV fluid are cloudy or not the color it is supposed to be, do not use it. The addition of medication or parenteral nutrition may change the color. These additions should be noted on the bag by the pharmacy or by the nurse who added the substance.

Microdrip systems deliver 60 drops/mL. It is used when infusing small volumes. It is commonly used with infants and pediatrics. Microdrips reduce the risk of clotting in the line because of the slow infusion rate. It also provides fluid overload safety by restricting the maximum amount infused. Microdrip systems may have a drip chamber that contains up to 100 mL and is clamped off from the liter bag of fluids. This restriction is an additional safety to prevent fluid overload in at-risk patients.

Macrodrip systems deliver 10, 15, or 20 drops/mL. 20 drops/mL is the most common type. Most facilities use a standard macrodrop size to prevent potential errors. Macrodrips are used in most adults for large quantity infusion and rapid infusion. Most IV bags and glass bottles have a built-in air vent to prevent a vacuum. If a glass bottle does not have a vent built-in, vented tubing can be used. Most facilities standardize their bags or bottles to avoid problems. Most facilities use bags.

Filters are usually built-in lines used for blood or parenteral nutrition. Some filters can be added between the tubing and the IV bag. Most facilities standardize to avoid problems. If you need a special filter for blood infusion, the blood bank will provide that add-in filter or special tubing with a built-in filter.

Most infusion pumps require special tubing. The facility will standardize this tubing.

Secondary administration tubing is used to piggyback IV medication bags to infusion tubing. The medication bag should always be hung higher than the IV liter bag.

There is specially coated tubing that prevents the leaching of polyvinyl chlorine from the tubing. This coated tubing should be used to infusion nitroglycerin, paclitaxel, and cyclosporine.

Tubing add-in devices are available. They include:

• Single and multi-lumen extension sets
• Extension loops
• Needleless connectors
• Inline filters
• Manual flow-control devices
• Stopcocks

Minimize tubing manipulation and multiple components in the tubing to reduce the chances of contamination.

The frequency of changing the IV administration sets is specific to facilities. The following are evidence-based recommendations for changing schedules.1 Primary and secondary continuous tubing should be changed no more frequently than every 96 hours and at least every 7 days. Tubing used for parenteral nutrition should be changed every 24 hours. Tubing used for blood must be changed every 4 hours. Tubing for fat emulsion infusion must be changed every 12 hours.

The tubing system must be labeled when it is hung with the date, the time it was opened, and the person's initials applying the tubing. This labeling allows everyone to identify when the tubing needs to be changed.

The provider orders the flow rate (doctor, physician assistant, or nurse practitioner). The nurse and the pharmacist's role is to evaluate the order's appropriateness based on the patient's condition. The nurse's role is also to regulate and maintain the flow and monitor the total input.

The nurse should notify the provider if the rate does not seem to be the correct rate for the patient. Considerations include age, patient condition, patient tolerance of the infusion and the prescribed infusions.

The very young and elderly are easily fluid overloaded. The flow rate should be slower, or the patient must be carefully monitored.

The patient's condition will often determine the flow rate. Someone in hypovolemic shock requires a large amount of fluid. Someone with heart or renal failure requires restricted fluids.

Some medications cause vascular irritation (KCL, Phenergan) or have a potential allergic response (antibiotics). These medications should be more diluted or infused slowly.

Some medications' efficacy is based on the administration time and infusion speed (antibiotics). Some medications need to be titrated based on the patient's response (dopamine, nitroprusside, heparin).

The flow rate is controlled more easily and accurately with an infusion pump. A pump is the best practice. However, pumps are expensive; therefore, they may be a limited resource. Infusions not on a pump require more frequent monitoring of the flow rate. Flow control dials or clamps and occlusive clamps can slip or be dislodged. Another potential flow problem is stretching and distorting the tubing due to patient movement. Cold or viscous solutions can also cause flow fluctuations.

• Flush the catheter with NS and aspirate blood prior to each infusion to assess catheter patency.
• Flush the catheter with NS to clear the catheter lumen and prevent mixing with incompatible medicine.
• Flushing with NS is as effective as flushing with heparin to maintain catheter patency.
• Flush 10 mL NS to remove fibrin deposits, drug precipitate or other debris to ensure patency.
• Locked catheters must be flushed before and after medication administration or solution.
• Prefilled syringes are preferred for flushing rather than a nurse-filled syringe.
• Use a push-pause method to inject the medication. Check the catheter for patency if resistance is met. Do not force.

Heparin is no longer routinely used to flush and maintain catheters. However, you may still hear the term hep lock. This term refers to a catheter with a short tube connected but not connected to a fluid bag or bottle. This hep lock allows the patient freedom when the IV infusions are intermittent.

Aseptic technique is used to access a hep-lock or IV tubing. Clean the hub of the hep-lock or tubing hub with alcohol. Do not contaminate the cleaned hub. Remove the protective cover from the injection device or tubing and connect it to the hub. Most systems have needless connecting injection devices and tubing. If not, tubing connected by a metal needle should be taped to the tubing to prevent accidental removal.

Assess the IV catheter at least daily for signs of infiltration, infection, phlebitis, or other complications. The IV should be removed as soon as possible after treatment is completed. Also, remove if there are any signs of complications.

Infiltration is caused by dislodgement of the catheter from the vein with an unintentional infusion into the surrounding tissue.

Extravasation is the infiltration of vesicant solutions into the surrounding tissue. Vesicants include chemotherapy, hyperosmolar solutions, parenteral nutrition, and KCL.

Phlebitis is caused by:

• Injury to the vein during venipuncture or prolonged catheter use
• Catheter to large for the vein
• Poor aseptic technique
• Irritation to the vein because of rapid infusion or irritating solutions (smaller veins are more susceptible)
• Clot formation at the end of the catheter due to slow infusion rates or inadequate hemodilution of infused medication or solutions
• More commonly seen with synthetic polyurethane catheters than silicone catheters

Catheter-associated bloodstream infection is caused by:

• Underlying thrombophlebitis
• Contaminated equipment or solutions
• Prolonged placement of the IV catheter, tubing or solution container
• Lack of aseptic technique in insertion or dressing changes
• Cross-contamination from other infected areas of the body
• Critically ill or immunosuppressed

The infusion of excessive IV fluids causes fluid overload. The elderly, infants and patients with cardiac or renal failure are at greater risk.

Air emboli are caused by:

• When air enters the catheter during tubing change or catheter removal of a central venous line (negative intrathoracic pressure sucks in the air during inspiration)
• Air in tubing delivers by IV push or infusion

Occlusion or slow flow is caused by:

• Malposition of the catheter against the side of a vein or valve
• Clot at the end of the catheter
• External mechanical causes (kinking of tubing, clogged filter, needless connector)

Hemorrhage is caused by:

• Loose connections of tubing or injection port
• Inadvertent removal of the catheter
• Anticoagulation therapy

Venous Thrombosis is caused by:

• Infusion of irritating solutions
• Infection along catheter
• Fibrin sheath formation around the catheter with eventual clot formation
• Patient factors
  • Hypercoagulable state (cancer diabetes, end state renal failure)
  • History of deep vein thrombosis
  • surgical or trauma patients
  • Critical care patients
  • Extreme age

The peripheral IV catheter is removed when treatment is complete, or a complication requires removal. To remove a catheter:

• Stop all fluids
• While stabilizing the access device, lift the tape securing the device
• Place a folded gauze over the insertion site
• Apply pressure to the insertion site as you pull out the catheter
• Hold pressure until the site stops bleeding
• Apply a dressing per facility policy
• Educate the patient to watch for bleeding and refrain from using that arm to lift heavy items for 30 minutes
• Dispose of tubing and catheter per facility policy

Documentation of IV therapy should include:

• Date and time of insertion
• Site and preparation of insertion
• Number of attempts to start IV
• Size and type of catheter inserted
• Medications and solutions hung
• Total intake of IV fluids
• Date and time of removal
• Management of complications

Patient Education

• Plan of care and goal of treatment
• Purpose of IV
• Care of the IV devices and insertion site
• Potential complications

• Nettina, Sandra M., “The Lippincott Manual of Nursing Practice” 11th Ed. Wolter Kluwer, Philadelphia, 2019.