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IV clinical procedure: Cannulation

Statement of Intent Policy number Author Owner Approved by All competent colleagues will follow this procedure when entering a vein with a cannula for the purpose of administering Intravenous Therapy (IV). Issue number 1 Practice Educator Clinical Skills Lead Infection Prevention and Control Nurse Specialist IV therapy service Practice Educator; Date approved Infection Control November Nurse Specialist and 2011 Standards and Policy Co-ordinator Quality, Safety and Date ratified 13/12/2011 Performance Unit 01/10/2013 Expiry date 12/12/2013 All clinical colleagues who are administering Intravenous therapy within a Community setting Outcome 2 Consent to care and treatment Outcome 4 Care and welfare of people who use services Outcome 8 Cleanliness and infection control Outcome 12 Requirements relating to workers SEQOL is committed to promoting equality in all its responsibilities ­ as a provider of services, as a partner in the local economy and as an employer. This policy will contribute to ensuring that all clients, potential clients and employees are treated fairly and respectfully with regard to the protected characteristics of age, disability, gender reassignment, marriage or civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation.

Ratified by Review date Applies to Care Quality Commission Essential Standards of Quality and Safety

Equality & Diversity

SEQOL is the trading name of Care and Support Partnership Community Interest Company (company number: 7581024). Registered in England. Registered office: Civic Offices, Euclid Street, Swindon SN1 2JH

Objective ­ All community Nursing Staff will demonstrate competence in relation to the procedure of entering a vein with a cannula for the purpose of administering Intravenous Therapy. Standard statements 1. All staff performing such procedures are deemed competent and have been trained according to Trust Guidelines 2. The procedure will be carried out in accordance to Trust Guidelines and Trust polices on Infection Control and needle stick injury 3. The Nurse is responsible for ensuring that the patient understands the procedure and that the patient has given his/her valid consent 4. The Nurse is responsible for ensuring the patient is given the correct info on the care and protection of the cannula ­ of who to contact should a problem arise 5. The Nurse is responsible for ensuring the following is recorded in the client's notes. Procedure, clinical observations., date, time and reason for cannulation, cannula size and phlebitis severity scale Targets 100% 100% 100% 100% Exceptions Nil Nil Nil Nil

100%

Nil

Peripheral Intravenous Cannulation - Criteria for practice Any registered practitioner who has obtained or is obtaining the necessary knowledge and supervised practice to complete the skill of peripheral intravenous cannulation safely. Each practitioner will be able to: Ensure that a short peripheral cannula is the appropriate device for intended need. Decide the size/type of device to be used. Choose an appropriate insertion site. Prepare the appropriate equipment. Complete the procedure safely. Conclude the care episode. Equipment Disposible Tourniquet Sterile Dressing pack Well fitting Non Sterile Gloves Pillow 2% chlorhexidine in 70% Alcohol skin prep swabs Appropriate cannula device Sharps bin Moisture responsive sterile transparent cannula dressing ­ i.e. IV3000. 10ml syringe 10mls Sodium chloride 0.9% for intravenous use. Plus additional equipment as appropriate ­ i.e. prescribed medication/solution

IV therapy: Cannulation procedure

Clinical

Issue 1

Approved 13/12/2011

Expiry 01/10//2013

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Site

The veins of choice are either the cephalic or basilica veins Distal veins should be used first with subsequent venepunctures proximal to previous site. Always allow adequate time for assessment of appropriate vein. Use veins on patients less dominant side. AVOID areas of joint flexion, and veins close to arteries and deeper lying vessels. Using these areas may lead to an increased risk of mechanical Phlebitis and an infusion that will infuse intermittently due to the patient's movement. It may also be awkward for the patient and restrict his/her ability to carry out activities.

IV therapy: Cannulation procedure

Clinical

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Expiry 01/10//2013

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Principles for practice - Cannula insertion Action Explain and discuss procedure with patient Ask patient to clean hand and arm Ensure suitable environment Complete an accurate assessment Clean Hands with an alcohol hand rub or soap and water Clean trolley or tray with an appropriate cleansing wipe, whilst it dries - Gather and prepare equipment Clean Hands with alcohol hand rub or soap and water Check for good lighting, comfort of patient and practitioner and privacy is maintained Place the patients arm on a pillow Wash Hands Open the sterile pack and place sterile towel under the patient's arm/hand Prepare equipment and flush Apply disposable tourniquet, locate vein and release Use ANTT Apply tourniquet, assess and select vein. Release tourniquet. Select device Check packaging that no equipment is damaged Rationale To gain informed consent To reduce anxiety and possible infection risk Note any known allergies Past history

Apply tourniquet six to eight inches above the insertion site ­ tourniquet is used to restrict venous return (Campbell 1995)

Clean hands with alcohol hand rub or soap and water Re-tighten tourniquet Apply Gloves Cleanse skin thoroughly with an alcoholbased solution; allow 30 sec drying time (Pritchard & Mallett 1992) Use sterile gloves if key parts or keysites need touching directly 2% chlorhexidine and 70% alcohol

IV therapy: Cannulation procedure

Clinical

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Expiry 01/10//2013

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Action Do not re-palpate the cleansed area Anchor vein - use gravity if necessary, prepare and check device and stabilise the vein by applying manual traction below insertion site Insert the cannula bevel up into the patient's vein at an angle of approximately 10-45 according to the depth of the vein (note: fragile veins usually require a lower angle of insertion). Stop as blood is observed in the flashback chamber. Lower the angle of insertion to correspond to vein depth and direction Advance the device 2mm into the vein. Stop and withdraw the needle up to five millimetres from the cannula. Secondary flashback should be seen along the length of the cannula Slowly advance the cannula into the vein in short stages, after each stage gradually withdraw a section of the needle ­ never fully remove the needle from the patient until the cannula is fully inserted Once the cannula has been fully inserted into the vein, release the tourniquet. Apply digital pressure to the vein above the cannula tip Withdraw the needle and dispose of it immediately in the sharps bin ­ keeping the luer lock cap (sharps must never be resheathed or carried around the ward/department/home). Apply a luer lock cap to the cannula Release digital pressure from the vein Secure the cannula in place with an IV moisture responsive dressing Flush the cannula with 5-10mls of Sodium Chloride 0.9% for intravenous use

Rationale Use ANTT

Use ANTT

IV therapy: Cannulation procedure

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Approved 13/12/2011

Expiry 01/10//2013

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Action Conclude the care episode with the patient Dispose of equipment as per waste disposal guidance and clean hands with alcohol hand gel or soap and water Complete relevant documentation, date and time, size of device including device batch number If cannulation is unsuccessful, a fresh cannulation device should be used for a subsequent attempt. The practitioner should not have more than two attempts before requesting assistance from a more experienced colleague If unsuccessful, release tourniquet and remove cannula, apply pressure over insertion site until bleeding stops. Apply dry dressing and reassure patient Do not routinely bandage the cannula site

Rationale

Ensure good record keeping

Bandage to ensure comfort and security of device if deemed necessary as per assessment. Bandage will need to be removed every day and cannulation site inspected (use VIP score)

Replace soiled or loose dressings Flush with 5-20mls of Sodium Chloride 0.9% twice a day if not in regular use or as by medical advice Consider re-siting cannulae every 48-72 hours. Although observing the site on a regular basis and acting upon findings is more important than routine re-siting; unless the patient has a predisposition to cannula related problems.

IV therapy: Cannulation procedure

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Expiry 01/10//2013

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Principles of practice- Cannula removal In practice operators often develop their own technique. This is acceptable as long as the principles of aseptic non touch technique are adhered to. The latest edition of the Royal Marsden Manual of Clinical Procedures can be used as a source of best practice. Action Rationale Explain the procedure to the patient, Be aware of the mental capacity act if giving opportunity for questioning and acting in the patients best interests. gain verbal consent. Gather equipment in suitable clean receptacle preferably on a clean dressing trolley with a sharps bin (as per Clinical waste policy). Equipment: Non-sterile gloves Sharps bin Sterile gauze and tape or other sterile dressing. Wash hands correctly as per organisation policy. Put on non-sterile gloves and apron. Remove dressing without using scissors. Gently withdraw cannula keeping the hub parallel with the skin. When the cannula has been withdrawn apply firm direct pressure yourself on the insertion site until bleeding stops with sterile gauze. When the bleeding has stopped apply a sterile dressing. Ensure cannula integrity. If there is any doubt that the entire device has not been removed, retain the device, and obtain medical advice Dispose of the cannula in a sharps bin or send the tip to microbiology if infection is suspected. Dispose of all equipment appropriately. Remove gloves and apron Wash hands correctly as per organisation policy. Document in the care plan that the cannula has been removed with the reason for removal and sign entry. Conclude the episode of care with the patient

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Expiry 01/10//2013

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Action upon discovering extravasation: It is difficult to state, in general terms the action to be taken if an extravasation injury is suspected. This is due to the varied treatment and antidotes to the number of drugs that may cause an injury. Stop the administration of substance. Mark the boundaries of the extravasation area with a pen. Inform the person in charge of the patients care i.e. G.P/Consultant Contact drug information for advice about specific drugs Initiate other specific treatments if appropriate for the drug involved, these include: Hot and cold compresses Injecting the area with Sodium Chloride 0.9% for intravenous use Injecting the area with a drug specific antidote. Attempt to aspirate the extravasated drug from cannula Elevate the extremity Observe the site regularly for erythema, induration, blistering or necrosis Document in patient notes. Complete incident report

Phlebitis Guidelines All patients with an intravenous access device in place must have the IV site checked at least daily for signs of infusion phlebitis using the Visual Infusion Phlebitis (VIP) scoring tool (Appendix 1). The subsequent score and action(s) taken (if any) must be documented on the cannulation record. The cannula site must also be observed. When bolus injections are administered IV flow rates are checked or altered When solution containers are changed The incidence of infusion phlebitis varies. The following Good Practice Points may assist in reducing the incidence of infusion phlebitis: Aseptic technique must be followed Use the smallest gauge cannula Cannula must be inserted away from joints whenever possible Secure cannula with a proven intravenous dressing Replace loose, contaminated dressings Observe cannula site at least daily Resite the cannula at the first indication of infusion phlebitis i.e Pain at IV site Erythema Swelling Pain along path of the cannula Induration Phlebitis Re-site the cannula every 72 hours (or as indicated by Jackson score) Plan and document continuing care Seek advice from Infection Control Nurse

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Appendix 1

VISUAL INFUSION PHLEBITIS (VIP) SCORE

Policy Statement-All patients with an intravenous access device in situ must have the site checked daily for signs of infusion phlebitis. The subsequent score and action(s) taken (if any) must be documented. The cannula site must be observed: When bolus injections are administered. When short duration infusions are administered. Each time the nurse sees the patient in the home. The incidence of infusion phlebitis varies. The following `good practice points' may assist in reducing the incidence. Observe cannula site each time you see the patient Secure cannula site with approved dressing. Replace loose contaminated dressings. Cannula must be inserted away from joints where possible. Aseptic techniques must be used. Consider routinely resiting venflon every 48-72 hours. Plan and document continuing care Use smallest gauge cannula most suited to the patient and the drug(s) being given. Replace cannula at first sign of infusion phlebitis.

IV site appears healthy

0 1 2 3 4 5

No signs cannula

of

phlebitis-observe

One of the following signs is evident: Slight pain at IV site Or Slight redness near IV site Two of the following are evident: Pain at IV site Erythema Swelling All of the following signs are present: Pain along path of cannula Erythema Induration All of the following signs are evident and extensive: Pain along path of cannula Erythema Induration Palpable venous cord All of the following signs are evident and extensive: Pain along path of cannula Erythema Induration Palpable venous cord Pyrexia

Possible 1st signs observe cannula

of

phlebitis-

Early stage cannula

of

phlebitis-resite

Mid-stage of phlebitis-resite cannula and consider treatment

Advanced stage of phlebitis or start of thrombophlebitis-resite cannula and consider treatment

Advanced stage of thrombophlebitisinitiate treatment and resite cannula

Copyright-Jackson 1997 Adapted for use in the community by A. Bellot 2004.

Appendix 1 Cannulation Record Patients Name................................................................... NHS number................................................. Date Site Date of Birth ....................................

Size of cannula Phlebitis Score Comments

Signature Print name

IV therapy: Cannulation procedure

Clinical

Issue 1

Approved 13/12/2011

Expiry 01/10//2013

Page 10 of 10

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