LOS ANGELES HARBOR COLLEGE



LOS ANGELES HARBOR COLLEGE

Associate Degree Registered Nursing Program

NURSING 339

Nursing Process and Practice in the care of

the Gerontologic Patient

UNIT II

Intravenous Instructional Unit

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E. Moore

LOS ANGELES HARBOR COLLEGE

Associate Degree Registered Nursing Program

NURSING 339: NURSING PROCESS AND PRACTICE IN THE CARE OF THE GERONTOLOGIC PATIENT

UNIT II – Intravenous Instructional Unit

Description : In this instructional unit the student will be achieving objectives related to the basic concepts and principles of venipuncture and building upon the basic intravenous therapy concepts already learned. It includes techniques of peripheral venipuncture, complications, principles of equipment selection and clinical application. It offers additional considerations for the gerontolocal patient. There is absolutely to be no food or drink in the IV simulation lab – if any student is found to have food or drink it shall be ground for immediate exit from the nursing program.

Estimated Time of Achievement : 8 hours

Objectives Course Content Learning Activities

|After appropriate study of assigned resources, |An overview will be given that |Resources: |

|participation in lecture/discussion and appropriate |includes but is not limited to: | |

|observation and practice the nursing student will be able |Initiating IV therapy |Readings: |

|to: |Care and maintenance of a peripherally|Perry & Potter, (2010). Clinical Nursing Skills & Techniques, 7th ed., |

|Relate the anatomy and physiology of venipuncture sites. |inserted central catheter |Elsevier Mosby: PA. |

|Analyze factors to be considered in choosing a site for |Regulating Intravenous Flow Rate |Chapter 28. |

|venipuncture. |Changing a peripheral intravenous | |

|Demonstrate the selection of appropriate needle gauge and |dressing |OR |

|length to use in venipuncture. |Changing IV solutions – composition | |

|Discriminate techniques that ensure a comfortable |and use of commonly prescribed |Perry & Potter, (2006). Clinical Nursing Skills & Techniques, 6th ed., |

|venipuncture. |crystalloid solutions |Elsevier Mosby: PA. |

|Examine hazards of venipuncture (e.g. nerve and tissue |Changing infusion tubing |Chapter 27. |

|damage, inadvertent IV administration, and abscess). |Discontinuing peripheral Intravenous | |

|Demonstrate the use of aseptic principles and standard |access |Recommended: |

|precautions essential for venipuncture. |Caring for Central Vascular Access |Josephson, Diane, Principles and Practice of Intravenous Therapy for |

|Demonstrate special techniques used in venipuncture in the |Devices |Nurses, (2004), 2nd ed., Delmar Learning. |

|older adult patient. |Discussion of conditions requiring IV | |

|Demonstrate venipuncture by inserting an intravenous needle|therapy |Phillips, Lynn Dianne, Manual of IV Therapeutics, (2005), 4th ed., FA |

|or cannula using aseptic techniques and standard |An explanation of how to prepare the |Davis. |

|precautions. |patient, family, and/or significant |Journal of Infusion Therapy |

|Demonstrate a venipuncture to obtain a blood specimen or |other for IV therapy | |

|give intravenous therapy, intravenous medications and |Factors that increase the risk of |Media resources: |

|saline locks. |complications from IV therapy |Audiovisual: |

|Demonstrate a preliminary assessment of a patient prior to |Individualized outcomes for patients |#3060 IV Therapy |

|venipuncture [sclerosed veins, bruises, hematomas, |requiring IV therapy |Internet: |

|diagnosis and activity orders, purpose of venipuncture, |Techniques used to prevent | |

|handedness (right or left), solutions, blood transfusions, |transmission of infection for a |Weblinks |

|and so forth]. |patient receiving IV therapy |Video clips |

|Demonstrate post-venipuncture procedures, i.e. securing | |Mosby’s Nursing Skills Video Exercises |

|I.V., dressing, removal of equipment, chart, appearance of |IV therapy: | |

|site, antibiotic used, date, time, and signature, MAR. |Initiating IV therapy – MD orders, |Instructional Methods: |

|Organize the care of patients with a venipuncture, |choosing a site, choosing equipment, |Lecture |

|including patient, family, and significant others by using |veins that are most commonly used, |Skill demonstration |

|the nursing process. |considerations that must be taken into|Audio/visual devices |

|Demonstrate correct labeling of a blood specimen and |account |IV Arms |

|venipuncture site with patient’s name, patient number, |Specific considerations for the |IV Cath Simulation |

|date, nurse’s name, and so forth. |geriatric population, home care | |

|Demonstrate peripheral IV insertion techniques using the |population, and long term care |Learning Support Services: |

|CathSim Computerized Intravenous Training system or |population |Campus library |

|equivalent. |Insertion technique |Learning Resource Center |

|First level assessment: |Regulation of IV flow rate |Nursing Learning Lab |

|Demonstrate an assessment of an actual or simulated patient|Changing of IV solutions |Internet |

|using basic Health History and Assessment form. |Changing of IV tubing |Simulation |

|Coordinate assessment methods interviewing, observation, |Changing of IV dressings | |

|and palpation for performing venipuncture. |Discontinuing a peripheral IV |Handouts: |

|Differentiate ineffective behaviors indicative of decreased| |IV Insertion Guidelines |

|physiological and psychological integrity. |Common types of vascular access |Intravenous Insertion Competencies – checklist |

|Categorize effective and ineffective behaviors according to|devices (VADs) and their care and | |

|the four modes. |maintenance. |Evaluation: |

|Second level assessment: | |The student will be evaluated and graded in the following ways, for this|

|Evaluate stimuli that may cause or be related to |Complications of VAD’s. |learning experience: |

|ineffective behaviors in performing venipuncture. |Educational needs of patients with |1. Psychomotor skills will be |

|Differentiate stimuli that can be manipulated by the nurse |VADs. |evaluated through Peer |

|either as an independent or dependent function. | |Evaluation using a mannequin |

|Nursing Diagnosis: |Evidenced based practice trends. |(IV arm) and CathSims |

|Categorize relevant assessment findings and list an | |Intravenous Training System or |

|acceptable nursing diagnosis, identify and state | |Equivalent with 3 successful sticks = pass rate of 75% or above to |

|appropriate diagnoses to patient’s situation. | |successfully pass this course. |

|Examine identified ineffective behaviors of correct nursing| | |

|diagnosis. | |The peer evaluation mastery |

|Analyze all components and state nursing diagnoses | |process will be conducted using the checklist of IV Insertion |

|correctly. | |competencies developed from the instruction unit IV Insertion |

|Goal Setting: | |Guidelines. The evaluation process includes selecting appropriate |

|Organize and correctly state goals for the selected nursing| |equipment, assessing a need for venipuncture, choosing an appropriate |

|diagnosis. | |site, inserting and securing the IV catheter. |

|Examine goal setting components and state outcome criteria,| | |

|measurable, observable outcome behaviors and critical time | |2. A written 20-point multiple choice and / or fill-in test at the end|

|to obtain goals. | |of the instructional unit will be used to evaluate cognitive knowledge. |

|Interventions: | |The test will consist of theoretical concepts from lecture, self |

|Differentiate two or more specific interventions to each | |practice / tutorial activities, viewing of video #3060 and reading from |

|diagnosis. | |the list of resources. |

|Relate the interventions to the identified stimuli. | | |

|Examine whether the intervention(s) will change the | | |

|stimulus or change the perception of the stimuli. | | |

|Evaluation: | | |

|Analyze the patient’s responses to determine if the goals | | |

|were achieved/attained. | | |

|Examine the patient behaviors. | | |

|Discriminate between effective and ineffective | | |

|interventions | | |

|Maintain or initiate curricular process: revise plan, | | |

|examine stimuli, state diagnoses, and goals and state | | |

|follow-up behaviors and alternative interventions. | | |

|Institute a revised care plan. | | |

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Nursing 339 – IV INSERTION GUIDELINES

1. EQUIPMENT

• Tourniquet

• Gloves

• Prepping agent (2% chlorhexidine, 70% alcohol, providone-iodine) according to agency policy

• IV fluid per physician order or saline lock

• Appropriate IV tubing, pump, pole

• Transparent dressing

• 1” tape

• Sterile 2 x 2

• Appropriate IV catheter (gauge appropriate to type of infusion used). Use smallest gauge possible. Use:

□ 18-20 gauge for hypertonic or isotonic solutions with additives

□ 18-20 gauge for blood administration

□ 22-24 gauge for pediatrics

□ 22 gauge fro fragile veins of the elderly

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2. CHOOSING AN APPROPRIATE SITE

• A suitable vein should feel relatively smooth and pliable. Don’t insert over a valve or at the y-junction of a vein.

• Start with distal veins and work proximally.

• Try to use non-dominant hand/arm.

• Position hand lower than the heart for several minutes.

• Ask the client to open and close the fist. Tap or flick the vein to release histamine, which will cause vessel dilation.

• If veins are not prominent, apply warm towels to extremity for ten minutes.

• Stay away from the joints (such as the wrist and elbow).

• Avoid red, bruised, or swollen veins. Avoid veins near previously infected areas and near sites of recently discontinued sites.

• Choose the best lowest (distal) vein. Perform venipuncture distally with each subsequent puncture proximal to previous puncture and alternate arms.

• Avoid veins too small for cannula size.

• Consider client preference for catheter placement (activity level and condition).

3. INSERTION OF CATHETER

• Explain procedure to client before start of procedure.

• Assess for allergies.

• Wash hands.

• Apply tourniquet 6-8 inches above venipuncture site

• Apply gloves

• Cleanse site with prepping solution from the center outward. Air dry.

• Pull the skin firmly below the insertion site to stabilize the vein and prevent “rolling” of the vein.

• Position the tip of the over the needle catheter, bevel up, over the selected vein at a 20-40 degree angle.

• Tell the client that they will feel a sharp, quick stick. Puncture the skin and vein using a direct or indirect approach.

• Observe for a “flashback” of blood in the catheter’s stylet, lower the catheter until almost flush with the skin, and slowly advance another 1/8 to 1/4 inch.

• Release the tourniquet.

• Push the catheter off the stylet and into the vein. The needle should not be advanced any further, only the catheter is advanced.

• Once the catheter is fully advanced, apply pressure with the index finger of the non-dominant hand, 3 cm above the insertion site to compress the vein (this will prevent blood flowing out). Remove the stylet.

• Using sterile technique, connect primed IV tubing or saline lock adapter.

• Only 2 attempts at venipuncture are recommended.

4. SECURING THE IV CATHETER

Prepare tape and dressing according to hospital policy. Tape should never be placed directly over insertion site. Dressing and taping should allow easy visual inspection and early recognition of infiltration and phlebitis.

5. GERONTOLOGIC PRINCIPLES

• Use the smallest gauge catheter or needle possible.

• Avoid the back of the hand on dominant arm (interferes with performance of ADL’s).

• Use minimal or no tourniquet pressure.

• Apply firm traction below insertion site for vein stability.

• Use 5-15 degree angle of insertion (veins are superficial).

• Use minimal tape to secure site (to prevent tissue tears).

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