Pharm Basics, part 7: Routes of Administration: Peripheral IVs, Central Venous Catheters
This article discusses intravenous (IV) therapy, including how to insert an IV and best practices for IV care and medication administration. We'll also cover central venous catheters (CVCs) — what they are and how to use them.
This series follows along with our Pharmacology Basics and Safe Medication Administration Flashcards for Nursing Students which are intended to help RN and PN nursing students build a strong foundation going into Pharmacology and as preparation for the ATI, HESI, and NCLEX.
What is a catheter?
When you hear the term catheter, you might automatically think urinary catheter, but the medical definition of catheter is a tube for insertion into canals, vessels, passageways, or body cavities, to permit injection or withdrawal of fluids.
“IV” stands for intravenous, which means “in the vein." An IV (sometimes called a peripheral IV) is a small, short plastic catheter that is placed through the skin into a vein, usually in the hand, elbow, or foot.
IVs are usually hooked up to tubing that carries fluid, medicine, or blood to the patient. The delivery of these fluids is called IV therapy.
IV therapy works by using an injection with a syringe or via infusion, often referred to as a drip. IV therapy is the fastest way to deliver medications, blood products, and more into the bloodstream. IV therapy can be used to help with various health conditions, alleviate dehydration, and to transfuse blood.
How to insert an IV
Here are some best practices for inserting an IV.
Choose the correct catheter size
When inserting an IV, it is important to know the proper catheter size for the job. Choose as small a catheter size as possible to maintain maximum blood flow. When it comes to gauge size, the higher the number, the smaller it is. For example:
- 16 gauge for trauma patients
- 18 gauge for surgery patients
- 20 – 24 gauge for medical patients
How to choose and prepare a vein for IV insertion
When attempting to insert an IV, place the patient's arm in a dependent position, that is, hanging down or below the middle of the body. This will encourage blood flow into the arm more efficiently than if the arm is in a horizontal or raised position.
Place a tourniquet about 5 to 6 inches above the insertion site. If you have an older patient, you can use a blood pressure cuff instead of a tourniquet.
Try to choose a distal vein on the arm first. Distal means located away from the center; for example, the hand is distal to the bicep. We attempt to insert the catheter in a vein distally first because in the event of an error that "blows out" the vein (if the needle punctures the vein in a way that causes the vein to rupture), we can work our way up the arm to another point in the vein and try again. If we try to insert the catheter too high on the arm and cause the vein to rupture, we won't be able to move down the arm to try again.
Veins to avoid
Avoid placing the IV in veins in flexion areas (the joints). On the arm, the antecubital fossa is a flexion area. The antecubital fossa (or AC) is a depression on the anterior surface of the elbow joint (the crook of your elbow). Note that in an emergency situation when it is important to insert the IV as fast as possible, the AC would be appropriate as an insertion point.
Another reason to avoid the AC or any flexion area is in a stable patient. An alert, active patient will bend their arms when they eat or move about their room, which will cause the IV to become occluded. This will set off an alarm on the IV pump. Place the IV for a stable patient in another part of their body to avoid having to repeatedly enter their room to turn off the IV alarm.
Avoid using hard or sclerosed veins for an IV. Sclerosis is the hardening of the tissue, which makes it harder to insert the catheter.
With older patients, try to avoid the veins in the hand. There are many nerve endings there, which can make IV insertion painful. Also, the veins in the hand tend to be more difficult to hit with the needle.
Finally, do not place an IV on the same side as a mastectomy (a surgery to remove a whole breast) or AV fistula (a surgical connection between an artery and a vein often used in dialysis). Pick the side that is not already affected by another procedure, surgery, or catheter.
Angle of insertion
Remember always to use a new, sterile needle for each insertion attempt.
Insert the catheter at a 10- to 30-degree angle with the bevel up. If you cannot hit the vein with the needle, you cannot remove it and then reinsert it. This could cause an infection. Instead, find another kit and start again. For inexperienced nurses, consider bringing two or three kits when it is time to insert an IV.
IV Care and medication administration best practices
Here are some best practices for IV care and medication administration, including how to ensure the line is sterile and functioning properly.
Maintain IV patency
Once an IV line has been successfully inserted, it is important to maintain the patency of the line. Patency means the line is open and not blocked (like a patent airway)! A patent IV line is one that is correctly placed, allowing the treatment to flow directly into the patient's vein. If the patient is not getting continuous IV fluids through the line, flush the line every 8 to 12 hours with normal saline.
Change IV sites and tubing regularly
Change IV sites every 72 hours and IV tubing every 24 hours, or in accordance with your facility policy.
How to connect a line or syringe
When connecting a line or syringe to an IV access site, first wipe the port with an antiseptic alcohol wipe for 15 seconds before connecting the line or syringe. Use an alcohol swab to ensure the port is disinfected.
Check medication compatibility
When giving medication through an IV, always check the compatibility of that medication with the IV fluids that the patient is receiving.
Never give medications through a line delivering total parenteral nutrition (TPN) or blood products. Those are dedicated lines and need to be left on their own. Start a separate line to give the patient their IV medication.
How to administer medication
Always flush the line with normal saline before and after the administration of any IV medications. Have extra flushes handy with the medication syringe.
Attach a normal saline flush to the port, then aspirate and check the blood return to make sure the IV line is patent (there is no clotting or other issues).
When it is clear that the blood is returning, flush the line with the normal saline. Then, disconnect the saline flush and attach the medication syringe. Push the medication at the prescribed rate, disconnect the syringe, and then flush again with another normal saline syringe.
Remember, always flush the line before and after medication administration.
Central venous catheters (CVCs)
A central venous catheter (CVC) is a catheter that terminates in the superior vena cava, just above the right atrium. The vena cava is a large and robust vein, and it can accommodate harsher medications such as vancomycin or chemotherapy. While peripheral IVs are standard for short-term use, if the patient requires long-term therapy, they need a catheter that can remain in the body for a longer period of time.
CVC uses include long-term antibiotic therapy, chemotherapy, and total parenteral nutrition, as well as blood draws and CVP (central venous pressure) monitoring.
Types of CVCs
There are several types of CVC, including tunneled and nontunneled, implantable ports, and PICC lines. A pregnant woman with hyperemesis, for example, requires TPN, which, in turn, requires a central venous catheter.
A tunneled CVC is a small plastic tube placed into a major vein that can remain in place for long-term use. A tunneled path is formed away from the actual vein entrance point in order to decrease the risk of infection. Tunneled central venous catheters are used for total parenteral nutrition, fluid resuscitation, antibiotics, chemotherapy, and hemodialysis (administered in the event of renal (kidney) failure). A patient with a tunneled catheter can continue to receive intravenous therapy even after leaving the hospital.
A nontunneled catheter is designed to be temporary and may be inserted into a large vein in the neck, chest, or groin. Often a nontunneled CVC is used when urgent or emergent access is needed, for example hemodialysis in the event of renal failure, or resuscitation.
An implantable port is shaped like a disk and is connected to a flexible tube that has been placed into a vein in the chest during surgery. Implantable ports can remain in place for years, until a provider determines it is no longer needed. Ports can be used for giving IV (intravenous) medicines, fluids, food, or taking blood samples.
A PICC line (peripherally inserted central catheter) is a long, thin tube inserted through a vein in the arm and passed through to the larger veins near the heart. Sometimes (rarely) the PICC line may be placed in a person's leg. A PICC line is generally used to give medications or liquid nutrition.
Nursing care of CVCs
There are a number of protocols to follow when working with a central venous catheter. You’ll see that some are the same as when working with a peripheral IV.
When to change a CVC dressing
Change a patient's dressing 24 hours after the insertion of a CVC. Then, continue to change the dressing on a weekly basis (or as timed per facility policy). Perform a complete dressing change over the insertion site using the aseptic technique.
How to access implantable ports
Access implantable ports with a non-coring Huber needle, which provides a strict aseptic no-touch technique during vascular access procedures. This is to reduce the risk of catheter-related infection. This is a job that requires skill and experience — it is advisable to reach out to a mentor nurse or charge nurse for help showing how to do this the first time.
How to flush the line of a CVC
As with peripheral IVs, it is important to flush CVCs on a regular basis. Flush the line with normal saline, or depending on the facility, use heparin.
Always flush with a 10ml syringe or bigger. Using a smaller syringe can put too much pressure on the catheter.
Where to take a patient's BP
Do not take a patient's blood pressure in the arm with a PICC line. This is because the pressure of the cuff might cause bleeding at the insertion site. It also increases the risk of thrombus (clot) formation or can cause retrograde blood flow, which raises the risk of catheter occlusion.
How to remove a CVC
Place the patient in supine position when removing a central venous catheter. Also, instruct the patient to perform the Valsalva maneuver (bearing down as if having a bowel movement) during removal.
Hi. I'm Cathy with Level Up RN. In this video, we are going to talk about the IV route medication administration. At the end of the video, I'm going to give you guys a quiz, test your knowledge of some of the concepts I will be covering in this video. So definitely stay tuned for that.
Let's start off by talking about best practices for IV insertion.
In terms of catheter size, we're going to want to use a bigger catheter, so a smaller gauge for trauma patients. So for trauma patients, we would use a 16-gauge catheter. If we're talking about a surgery, then an 18-gauge would be appropriate.
And for medical patients, we can use a 20-, 22-, or a 24-gauge catheter.
When we are attempting insertion of an IV, we want to place the patient's arm in a dependent position to really encourage blood flow down into that arm. We would place a tourniquet about 5 to 6 inches above the insertion site, and we use a blood pressure cuff instead of a tourniquet for older patients. You want to try using veins or inserting the catheter in a vein distally on the arm first. So you don't want to start up high because if you mess up and blow out that vein, then you're not going to be able to use that vein down lower from that injury site. So you want to start lower on the patient's arm, and if you don't hit it, you can kind of work your way up.
You want to avoid any hardened veins, and we also want to avoid veins in the hand for older patients because there's a lot of nerve endings there, so it can be really painful, and also those veins tend to be kind of wiggly and difficult to hit with an IV. You want to avoid veins in flexion areas as well, such as the antecubital fossa. So those veins there in the AC are pretty easy to see and to hit and, obviously, for dealing with an emergency situation, you want to get that IV in as fast as possible, so the AC would be appropriate in that case.
But if we're talking about a stable patient who's going to be admitted to the hospital, then really it makes sense to choose a different area that is not in the AC or any flexion area because if you put the IV in there, then when the patient is eating or doing other things, they're bending their arm and that's going to cause the IV to be become occluded, and that's going to cause the IV pump to start alarming, and you're going to be in that patient's room every two minutes resetting the alarm until you really bite the bullet and move their IV to a better spot. So it's just better to start off with a better spot than to put it in the AC and then have to move it later.
You also never want to put an IV on the same side as the patient has had a mastectomy, or where a patient has an AV fistula, which they would use for dialysis. So in terms of inserting the catheter, you want to insert it at a 10- to 30-degree angle, and you need to use a new sterile needle for each insertion attempt.
So if you're trying to insert the IV and you're not hitting it, and it's not going well, and you pull it out, you can't just stick it back into another spot. You need to go get another kit.
So when I used to be a floor nurse-- I don't do a lot of IV insertions now. But when I was a floor nurse, I would always bring two or three kits with me because I wasn't the best at IVs right out of the gate. So again, you need to use a new sterile needle for each insertion attempt.
Once we've successfully inserted our IV line, we need to take measures to maintain the patency of that line.
So if the patient is not getting continuous IV fluids through that line, then we're going to want to flush that line every 8 to 12 hours with normal saline, or per facility policy, in terms of the timing. And then every 24 hours, we're going to want to change all the IV tubing out.
And any time we connect a syringe or line to that IV access site, we want to scrub the port down with an alcohol swab for 15 seconds.
And any time we're giving medication, we always want to check the compatibility of that medication with the IV fluids that the patient is receiving.
And then if the patient is getting TPN, so total parenteral nutrition, that TPN line is dedicated for just TPN. So we are not going to administer any kind of medication through that line. We need to use a separate line to give the patient their IV medication.
And then we always want to flush before and after the administration of any IV medications. So when you come in the patient's room, you want to bring a couple of flushes along with the medication syringe. You want to attach one of the normal saline flushes to the port, and you want to aspirate and check for that blood return to make sure that the IV line is patent, that there's no clotting or other issues.
Once you see that blood return, you can flush the line with the normal saline, disconnect that saline flush, attach the medication syringe, push the medication at the prescribed rate, disconnect that syringe, and then flush again with another normal saline syringe. So again, we're always flushing before and after medication administration.
So peripheral IVs are fine for short-term use. However, if your patient requires long-term antibiotic therapy or chemotherapy or total parenteral nutrition, then they really need to have a central venous catheter or a CVC.
There are several different types of CVCs out there, including tunneled and non-tunneled CVCs as well as implantable ports and PICC lines. I actually had to have a CVC when I was pregnant because I had hyperemesis which required me to get TPN which in turn required me to have a CVC.
So no matter the type of CVC that your patient has, the catheter tip will terminate in the superior vena cava right above the right atrium. And that vein there is nice and fat, and it's able to accommodate harsher medications such as vancomycin or chemotherapy, as opposed to your peripheral vein which is kind of skinny and delicate and would not hold up well to a medication such as vancomycin over the long term or chemotherapy.
So in terms of the nursing care of a CVC, 24 hours after your patient has the CVC inserted, you're going to want to do a complete dressing change over the insertion site using aseptic technique.
And then going forward, you will need to perform dressing changes weekly or per facility policy, again, using aseptic technique.
If you need to access your patient's implantable port, you need to do so using a non-coring Huber needle. And if you've never used this before, then definitely reach out to your mentor nurse or your charge nurse for help showing you how to do that the first time.
Just like with peripheral IVs, we're going to need to flush our CVCs on a regular basis. And we would flush these with normal saline. Or sometimes at certain facilities, they would flush using heparin.
And we always want to flush with a 10-milliliter syringe or bigger. So if we use a smaller syringe, it puts too much pressure on that catheter, so you always want to use a bigger syringe, at least 10 milliliters or bigger.
And then lastly, you never want to take blood pressure on a patient's arm where they have a PICC line. So you definitely want to make sure you use the other arm instead.
Okay. It's quiz time. I have three true-or-false questions for you. Question number one, IVs should not be placed on the same side as a mastectomy or AV fistula, true or false? The answer is true. Second question, a PICC line should be flushed with a syringe that is smaller than 10 milliliters, true or false? The answer is false. We want to use a 10-milliliter or larger syringe when flushing our PICC line. Question number three, you should not give any medications through a line receiving TPN, true or false? The answer is true.
Hopefully, you found this video helpful as well as that quiz. If you did, be sure to like the video. Thank you so much for watching.
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