IV

CANNULATION

LEARNING

PACKAGE

1.NAME OF COURSE

Intravenous (IV) Cannulation.

2.RATIONALE

This education package has been designed to facilitate the achievement of competency in the procedure of intravenous cannulation in an adult patient.

This procedure may be performed by a Registered Nurse (Division 1):

  • To replace fluids/administer blood transfusion
  • To administer medications
  • To provide circulatory access for emergencies

3.OBJECTIVES

Participants will demonstrate the ability to:

  • Describe and differentiate arterial and venous anatomy.
  • Identify the principles of asepsis in relation to intravenous therapy.
  • Discuss risk factors that may contribute to IV related infections
  • Outline important factors in appropriate vein selection.
  • Outline the important factors in appropriate cannula selection
  • Discuss correct documentation of IV cannula insertion
  • State complications that may occur during/following IV cannulation.
  • Discuss the implications of intravenous cannulation in relation to competency assessment and the scope of professional practice.
  • Complete three successful supervised insertions of a peripheral intravenous cannula in an adult patient.

4.COURSE OUTLINE

The course comprises a self-directed theoretical learning component, a practical component and a supervised clinical component.

  • 1 hour self-directed theoretical learning component in the form of an IV cannulation learning package, to be completed prior to practical and clinical component. Accessed via the SWH Intranet site.
  • 1 hour practical tutorial(see Appendix I) utilising model/patient conducted by one of the following:

Specialist Anaesthetist/Physician/Director of Emergency Department/Senior Registrar/Registered Nurse (Division 1) appointed by Clinical Facilitator , Clinical Facilitator (Emergency Department/Critical Care), Clinical Support Nurse or Clinical Nurse Educator. Note: above must be deemed competent in IV cannulation.

  • Supervision of Intravenous Cannulation Insertion (see Appendix II)

To achieve competency:

The procedure must be performed successfully on three (3) occasions, under the direct supervision of a Specialist Anaesthetist/Director of the Emergency Department/Physician/ Senior Registrar/Clinical Facilitator (Emergency Department / Critical Care), Clinical Support Nurse or a CNS/ above Emergency Department / Critical Care/ Chemotherapy/ Clinical Nurse Educator. Note: above must be deemed competent in IV cannulation.

5.PARTICIPANT ASSESSMENT

  • Clinical assessment of competency in performing intravenous insertion must be achieved.
  • To maintain proficiency in this technique, the participant may gain additional clinical practice in the Peri-operative or Endoscopy Unit. This must be under the supervision of an Anaesthetist / Physician / Clinical Facilitator.

6.maintenance of competency

  • The participant must take responsibility for maintaining their own competency in this procedure. If the participant has not inserted at least one (1) intravenous cannula in a six month period they must undertake thesupervised intravenous cannula component of this competency annually.

Annual competency in this procedure will be assessed by one of the following:

i)Specialist Anaesthetist

ii)Director of Emergency Department

iii)Physician

iv)Clinical Facilitator (Emergency Department/Critical Care / Appointee)

v)Senior Registrar

vi)Clinical Support Nurses/Clinical Nurse Educators

vii)CNS or above Emergency Department / Critical care / Chemotherapy

  • It is the participant’s responsibility to provide documentation of competency assessment to the Unit Manager/Education Service, to ensure maintenance of Records.

Ashley Zanker

(Education Department/Critical Care)

Updated February 2009

Updated May 2012

Shannon Graham

(Clinical Nurse Educator)

IV CANNULATION

SELF DIRECTED

LEARNING

PACKAGE

Anatomy and Physiology of Veins

Veins have three layers:

a) tunica intima (inner layer)

Anelastic, endothelial lining which also forms the valves. Valves are semilunar folds of endothelium and their function is to keep the blood flowing towards the heart. They occur more frequently at junctions and can be observed as a small bulge in the veins. Valves can interfere with the withdrawal of blood as well as the advancement of a cannula. (Dougherty, 1996)

b) tunica media (middle layer)

Muscular and elastic tissue, as well as nerve fibres. These keep the vessels in a state of tonus and stimulate the vein to contract and relax. Stimulation by a change in temperature or by mechanical or chemical irritation may produce venospasm, which impedes the flow of blood and causes pain. (Dougherty, 1996)

c) tunica adventita (outer layer).

Comprises the epidermis and the areolar connective tissue which surrounds and supports the vessel. (Dougherty, 1996)

ACTIVITY ONE

Locate and name the landmarks indicated on the following diagram:

Sites of selection for the insertion of intravenous needles for the parenteral administration of fluids, medication or for blood transfusion.

Brunner, Suddarth (1988), Textbook of Medical - Surgical Nursing. Chpt. 9, p 127, 6th Ed, JB Lippincott Co, Philadelphia.

The superficial veins of the arms should be used for the placement of intravenous cannula in adults.

  • easily accessed
  • allow patients to perform activities of daily living with minimal impairment to function. (Dougherty, 1996).
  1. Digital veins/Metacarpal veins
  • Easily visualised and palpated
  • Leaves proximal sites on the limb for cannulation
  • Use with caution in elderly people and where skin turgor and subcutaneous tissue is diminished.
  1. Cephalic vein
  • Large vein, which is easily stabilised and accessible. Its size and position make it an excellent choice for intravenous therapy
  • Good vein for large bore cannula, and useful for rapid infusions, including blood
  • More comfortable for patient, as hand is free

3. Basilic vein

  • Large easily palpable vein but may be difficult to access and stabilise due to its location.

4. Median Cephalic and Basilic veins

  • Usually used for venipuncture. Their size and superficial location make them easy to palpate and visualise and they are well supported by connecting tissue
  • Can be difficult to stabilise (in joint)
  • Risk of dislodgment , infiltration, extravasion and mechanical phlebitis
  • Median cephalic vein crosses in front of the brachial artery and care must be taken to avoid puncturing the artery. (Dougherty, 1996)

General principles when choosing a vein for cannulation
Veins to use / Veins to avoid
Distal veins first:
This enables proximal veins to be used when the catheter requires resiting / Veins in lower extremities:
Veins in the feet, for example, are only used if there is no other venous access or there is a clinical requirement e.g. Patients with a mastectomy.
Easily palpable with good capillary refill:
If the vein feels bouncy or springy to touch, this infers a healthy, full vein with good venous flow. / Points of flexion:
Cannulation near a joint may increase the risk of mechanical phlebitis because of continual movement in the vein.
Opposite limb to surgical procedures:
If the patient is to undergo a procedure on one arm, it is advisable to cannulate the opposite arm to ensure easy access during the procedure. / Obvious valves:
A vein with visible valves (notches along the vein) should be avoided as the valve may prevent smooth entrance of the catheter into the vein.
Veins with the largest diameter:
Although not always possible because of patient’s vein quality, the aim is to insert the smallest possible gauge catheter for intended use into the largest diameter vein (RCN, 2003; Dychter et al, 2012) to maximise blood flow and minimise risk of thrombus or venous stasis. / Infected sites or broken skin:
The risk of phlebitis and infection are much greater and the catheter will cause the patient discomfort if the site is infected or the skin is broken

Prevention of Intravascular Device-Related Infections

DEVICES USED FOR SHORT TERM VASCULAR ACCESS

Short peripheral venous catheters, usually inserted into the veins of the forearm or hand, remain the most commonly used intravascular device. Phlebitis, largely a physicochemical mechanical, rather than infectious, phenomenon, remains the most important complication associated with the use of peripheral venous catheters. When phlebitis does occur, the risk of local catheter-related infection may be increased.

Factors associated with infusion-related

Phlebitis among patients with peripheral venous catheters

PATHOGENESIS

The pathogenesis of catheter-related infections is multifactorial and complex, but available scientific data show that most catheter-related infections appear to result from migration of skin organisms at the insertion site into the cutaneous catheter tract with eventual colonisation of the catheter tip. There is a smaller, but growing body of data to suggest that contamination of the catheter hub also is an important contributor to intraluminal colonisation of catheters, particularly long-term catheters.

STRATEGIES FOR PREVENTION OF CATHETER-RELATED INFECTIONS

Strict adherence to hand washing and aseptic non touch techniques remain the cornerstone of prevention of catheter-related infections. Other measures may confer additional protection and must be considered when formulating preventive strategies: selection of an appropriate site of catheter insertion and type of catheter material, use of barrier precautions during catheter insertion, replacement of catheters, administration sets and IV fluids at appropriate intervals, appropriate catheter-site care, use of filters, flush solutions, prophylactic antimicrobials.

Site of Catheter Placement

Several factors should be assessed when determining the site of catheter placement, including patient-specific factors, pre-existing catheters, anatomic deformity, bleeding diathesis, relative risk of mechanical complications (eg. bleeding) and the risk of infection. The site at which a catheter is placed has been shown to influence the subsequent risk of catheter-related infection. For peripheral venous catheters, lower extremity insertions pose a greater risk of phlebitis than do those inserted in the upper extremity (Dychter et al, 2012), and upper extremity sites differ in their risk for phlebitis, in adults, hand vein insertions have a lower risk of phlebitis than do upper arm or wrist vein insertions.

Barrier Precautions During Catheter Insertion

For short peripheral catheters, good hand washing before catheter insertion or maintenance, combined with proper non touch aseptic technique during catheter manipulation provides protection against infection (Dychter et al, 2012).

Refer also Guidelines for prevention of intravascular device related infections from the Public Health Service, U.S. Department of Health and Human Services, Centres for Disease Control and Prevention, Atlanta, Georgia. (Complete guidelines can be found at

ACTIVITY TWO

INTRAVENOUS CANNULATION WORKSHEET

(Additional reading may be required –see references and SWH Intravenous insertion and infusion policy)

1. List four factors to consider when assessing the patient for intravenous cannulation.

______

2. List two groups of patients who should be approached cautiously with regards to intravenous cannulation.

______

3. List contraindications for arm choice for IV cannula placement.

______

4.List two characteristics of an ideal vein choice.

______

5.List 3 things to avoid when selecting a vein.

______

6.How far above the intended puncture site should the tourniquet be placed?

______

7.List actions to help raise a vein not dilated after tourniquet application.

______

8. What is the nursing responsibility when the procedure is complete?

______

9. What are the risk factors for developing a peripheral line infection?

______

10. List three signs/symptoms of a peripheral line infection ______

APPENDIX I

IV CANNULATION

PRACTICAL

TUTORIAL

  1. SITES
  • Hand – metacarpal vein, cephalic vein, basilic vein.
  • Arm – cephalic vein, accessory cephalic vein, median cubital vein, median antebrachial.

Factors to consider:

Location

•Sites in order of preference are lower arm, hand, and antecubital fossa (the lower extremities are undesirable because they are prone to thrombophlebitis and embolism and should be resited ASAP).

•If possible use the distal end of the vein therefore; recannulation of the same vein may be possible later.

•Generally, use distal veins first, preserving more proximal ones for future sites. To reduce the risk of phlebitis and trauma, the gauge of the cannula inserted should be appreciably smaller than the lumen of the vein. When viscous or large volumes of fluid are to be infused, a large bore cannula will need to be sited to ensure adequate flow rates.

•Ante-cubital fossa – ideal for quick access but is not recommended routinely. This area requires splinting which decreases direct viewing of the site. Cannula mobility is also increased, thus increasing the risk of vein damage. The cannula is liable to kink in this area.

•The median nerve and brachial artery lie in close proximity – special care must be taken to avoid them. Minimise striking the artery by first locating pulse before venipuncture.

•Avoid joints, (such as at the wrist or elbow) infected or injured areas.

•Registered nurses must not attempt to cannulate:

-veins in lower extremities

-veins in upper arm

-the last visible vein.

Condition

•The vein must be full, soft and unobstructed.

•Avoid crooked, hard, scarred on inflamed veins.

Reasons for selection of specific sites

•Time factor eg. emergency cannulation – antecubital route.

•Type of intravenous solution – highly acidic/alkaline or hypertonic solution can irritate a small peripheral vein, a larger vein will dilute the infusion better.

•Rapid infusions require larger veins.

  1. CANNULA SIZE

It has been shown that the incidence of vascular complications increases as the ratio of cannula external diameter to vessel lumen increases. Therefore most literature recommends the smallest, shortest gauge cannula in any given situation (Dychter et al, 2012; RCN,2003).

GUIDE ONLY:

  • 24g Medications, short term infusions, fragile veins, children
  • 22g Blood Transfusions, most medications and fluids
  • 20g Blood Transfusions, large volumes of fluids
  • 18g Blood Transfusions, parenteral nutrition, large volumes of fluid
  • 16g as per 14g
  • 14g used in theatres or emergencies for rapid transfusion of blood or viscous fluids.

(Dougherty & Lister, 2004)

  1. PROCEDURE

(To practice on IV simulation arms)

  1. Equipment

Standard precautions apply

Cleanse area appropriately

Disposable dressing tray/ IV starter pack

Chlorhexidine 2% and alcohol 70% solution prep (Solu-IV)

Clippers if required

Tourniquet

IV cannula 18 – 22g (appropriate for patient)

Primed giving set / IV bung / extension tubing with 3 way tap

Protective covering &/ Splint p.r.n.

Tegaderm & tape

I.V. labels and stand

Waste disposable bag & sharps container

Personal Protective Equipment (PPE) Gloves, Glasses

Normal saline ampoule (for flushing)

Vacutainer (when collecting blood sample)

  1. Cannula Insertion
  • Decontaminate hands with soap and water or alcoholic based hand rub
  • Clean trolley/tray/surface with soap and water (or detergent wipes) and dry with a paper towel
  • Gather equipment required, if using a trolley place on bottom shelf of trolley
  • Take trolley/tray to the patient or ensure the prepared surface is close to patient
  • Hand hygiene performed before contact with the patient
  • Assess appropriate site for insertion, apply tourniquet, palpate vein
  • Assess if hair removal is required, clippers to be used for hair removal
  • Appropriate PPE is selected and worn. Safety glasses or shield, gloves.
  • Open dressing pack/IV pack using only the corners of the paper, taking care not to touch any of the sterile equipment.
  • Decontaminate hands with alcoholic based hand rub or use clinical wash (2 minutes)
  • Prepare skin- prep with (Chlorhexidine 2%and alcohol 70%), allow to

dry – approx 45sec. (Palpation of the vein should not be performed after the skin prep is applied

  • Apply gloves, clean correct fitting. Non sterile.
  • Drape insertion site with sterile drape
  • Stabilise vein with thumb, and stretch skin gently downward and

maintain position until cannula is inserted properly

  • With bevel up, approach vein slowly at a low angle (about 45°)
  • Advance needle forward at 20-30° angle to vein’
  • ‘Pop” into vein, observe flashback, initially seen along cannula
  • Upon flashback visualisation, lower cannula almost parallel to skin
  • Advance entire unit about 2-3mm before threading cannula, to ensure cannula is located in vein (Advancing whole assembly gently up vein, without excessive force).
  • Slight twisting may assist passage.
  • Using the push off tab, thread cannula into vein while maintaining skin traction
  • For needle removal, release the tourniquet, place middle finger over vein distal to catheter tip (to interrupt blood flow) and stabilise catheter hub with index finger (“V technique), then withdraw needle (a protective shield will automatically clasp over the bevel upon removal of the needle, making the sharp safe)and put immediately into the sharps container.
  • Connect IV/bung and secure with Tegaderm. Ensure dressing is

applied appropriately to minimise movement and thus reduce irritation

on the vein. Any spillage is cleaned up and insertion site is clean and dry prior to dressing application

  • Flush with Normal Saline
  • Sharps are disposed of at point of use
  • Dispose of contaminated swabs etc in the clinical waste stream
  • Dispose of all packaging in the domestic waste stream
  • Dispose of aprons and gloves in the appropriate waste stream as per policy.
  • Decontaminate hands
  • Clean the trolley/tray/surface with soap and water or detergent wipes and dry with a paper towel
  • Document time and date of insertion on appropriate area of dressing

and on Clinical Management Plan, also document type and length of cannula and person inserting device

If cannulation is unsuccessful following 2 attempts, a more experienced person must perform the procedure.

Caution Reminders:

  • Needle should be retracted prior to disposal in a puncture resistant, leak proof sharps container.
  • Never reinsert the needle into the cannula as this could shear the cannula

RECOMMENDATIONS

  • Wash hands/ cleanse with antimicrobial gel before and after clinical procedure
  • Maintain an aseptic technique and utilise standard precautions
  • Clip hair, do not shave
  • Air-dry all preps.

APPENDIX II:

SUPERVISION OF

INTRAVENOUS (IV)

CANNULATION

SUPERVISION OF

INTRAVENOUS (IV) CANNULATION

COMPETENCY STATEMENT / INSTRUCTIONAL STRATEGIES
Demonstrates the ability to perform IV Cannulation. / 1.Policy and Procedure
2.IV Cannulation education program
Performance Criteria / Clinical Performance
The participant must achieve the following: / CompetentUnsuccessful
1.Identify four (4) indications for IV Therapy / 
2.Name possible insertion sites / 
3.Identify correct solution, additives, selects appropriate size needle, prime tubing, set administration rate and prep insertion site appropriately. / 
4.Clean trolley/tray/surface with soap and water (or detergent wipes) and dry with a paper towel. Collect equipment for IV cannulation / 
5.Safely and effectively perform cannulation using aseptic technique/standard precautions. / 
6. Cannula Insertion:-
•Explain procedure to patient and ensure privacy. / 
•Position patient appropriately and provide adequate lighting. / 
  • Ensure the trolley/tray or prepared surface is close to the patient
/ 
  • Assess appropriate site for insertion:
Non dominant hand
Avoid areas of bony prominence and flexion
The antecubital fossa veins should only be used in emergency situations
Select appropriate sized cannula / 
  • Assess if hair removal is required, clippers to be used for hair removal
/ 
  • Appropriate PPE is selected and worn. Safety shield or glasses, gloves
/ 
  • The dressing pack/IV pack is opened using only the corners, taking care not to touch any of the sterile equipment
/ 
•Apply tourniquet. / 
•Palpate vein. / 
•Decontaminate hands with alcoholic based hand rub or use clinical hand wash (2 minutes) / 
•Prepare skin with Chlorhexidine 2% and alcohol 70% prep
Allow skin to dry.
Palpation of vein should not be performed after the skin prep is applied / 
  • Apply gloves, non sterile, clean, correct fitting
/ 
•Stabilise vein with thumb, and stretch skin gently downward and maintain until cannula is in properly / 
•With bevel up, approaches skin slowly at a low angle (about 45°) / 
•Advance needle forward at 20-30° angle to vein / 
•"Pop" into vein, observe flashback along the cannula / 
Competent Unsuccessful
· Upon flashback visualisation, lower cannula almost parallel to skin /  
•Advance entire unit about 2-3mm before threading cannula, to ensure cannula is located in vein / 
•Advance whole assembly gently up vein, without excessive force.
Slight twisting may assist passage.
Take blood for Pathology if required. /  
• Releases tourniquet, applies digital pressure beyond cannula tip, gently stabilises hub (“V technique”).
  • Dispose of needle into sharps container.
/ 

•Connect IV/Bung and secure with Tegaderm
Any spillage is cleaned up and insertion site is clean and dry prior to dressing application / 
• Flush with normal saline / 
  • Gloves are removed and hand hygiene is performed
/ 
  • Dispose of waste appropriately
/ 
  • Clean the trolley/tray/surface with soap and water or detergent wipes and dry with a paper towel
/ 
7.Verbalise 4 signs and symptoms of phlebitis. / 
8.State 3 ways to decrease the risk of developing IV-related infections. / 
9.Identify 2 ways to help prevent vascular irritation. / 
10.Identify 3 complications associated with IV therapy noting with each complication: / 
•Cause / 
•Prevention / 
•Symptoms / 
•Treatment / 
11.Demonstrate correct documentation: / 
•Date and time of IV insertion / gauge & length of cannula / 
•Type and volume of solution / 
•Rate of administration / 
•RN's signature / 

EVALUATIONCompetentUnsuccessful 