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Reference
1271
Date approved
July 2013
Approving Body
Matrons Forum
Supporting Policy/ Working in Working in New Ways Package for
New Ways (WINW) Package Venepuncture and cannulation
Implementation date
July 2013
Supersedes
Version 1
Consultation undertaken
Nursing Practice Guidelines Group, Ward
Sisters/Charge Nurses, Practice
Development Matrons (PDMs), Clinical
Leads, Matrons.
Target audience
Document derivation /
evidence base:
Review Date
Lead Executive
Author/Lead Manager
Further Guidance/Information
Distribution:
July 2018
Director of Nursing
Diane Ryan, Stuart Thompson-Mchale
Ward Sisters/Charge Nurses, PDMs, Clinical
Leads, Matrons, Nursing Practice Guidelines
Group (includes University of Nottingham
representative), Clinical Quality, Risk and
Safety Manager, Trust Intranet.
This guideline has been registered with the Trust. However, clinical
guidelines are guidelines only. The interpretation and application of
clinical guidelines will remain the responsibility of the individual
clinician. If in doubt contact a senior colleague or expert. Caution is
advised when using the guidelines after the review date.
CONTENTS
Page
SUMMARY OF APPLICATION
INTRODUCTION
3
4
INFECTION CONTROL
INDICATIONS
CONTRAINDICATIONS
4
5
5
OTHER COMPLICATIONS
7
9
9
10
14
15
INTRODUCTION
Peripheral venous cannulation is the insertion of a Vascular Access Device
(VAD) into a peripheral vein (RCN, 2010).
A cannula is a flexible tube containing an introducer which may be inserted
into a blood vessel (Anderson & Anderson 1995; Phillips 2005) and are
usually placed in the peripheral veins of the lower arms. There are occasions
when they may be inserted into the veins of the foot, but they should not be
used routinely due to the increased risk of thrombophlebitis (RCN, 2010;
Weinstein 2007). If veins of the feet are used, the cannula should be re-sited
as soon as possible (Phillips, Collins and Dougherty 2011). It is thought that
approximately 70% of all patients will have a cannula inserted during their
admission (Rivera, Strauss, Van Zundert et.al., 2007).
Although there is a wide range of VADs available to allow for the type of
therapy being given, and for the patients quality of life needs, the principles of
care for the device remain the same:
To prevent infection
To maintain a closed intravenous system with few connections to
reduce the risk of contamination
To maintain a patent device
To prevent damage to the device & associated intravenous equipment
(Dougherty & Lister, 2011)
The cannulation procedure may be performed by a practitioner who can
demonstrate relevant theoretical knowledge & who has been assessed as
competent using a cannulation package as part of the Working in New Ways
initiative (Nottingham University Hospitals NHS Trust, 2011a). In addition, the
practitioner must be satisfied that the cannula needs to be inserted and that
the patient consents to the procedure (NUH, 2010).
INFECTION CONTROL
Insertion of a cannula must be performed using an aseptic non-touch
technique (Department of Health, 2003). Thorough hand cleaning according
to the Hand Hygiene Policy (NUH 2011b) must be performed to reduce the
risk of cross-infection to the patient. Gloves should be worn in line with
standard precautions and the NUH Glove selection Guideline (2011c).
All disposable equipment must be sterile and single use only, and should be
disposed of in accordance with local policy. (RCN 2010; NUH 2011d)
Visibly dirty skin should be washed with soap & water (Perucca, 2001). The
following procedure is then applied: Clean and prepare the skin with 2%
chlorhexidine gluconate in 70%alcohol solution using a swab, cloth or other
applicator. Apply ensuring the skin is wet for 30-60 seconds (rub for 5-10
seconds and then lay swab over the skin for the rest of the time). This should
be allowed to air dry for up to 1 minute (Weinstein, 2007). Following
cleaning, the skin should not be touched or re-palpated, as the cleaning
regimen will have to be repeated (Dougherty and Lister, 2011). The need to
remove hair by shaving has not been substantiated (Weinstein 2007).
Shaving the skin prior to cannulation is not recommended as it can cause
micro abrasions which can become a focus for infection. If excessive hair
needs to be removed it should be clipped (RCN, 2010d).
The cannula should be secured & covered with a sterile dressing which
should be transparent, easy to apply and remove, waterproof, semipermeable and comfortable for the patient (McGovern 2010; Dougherty and
Lister 2011).
INDICATIONS
The main indications for the insertion of a peripheral venous cannula are:
CONTRA-INDICATIONS
The advantages of using a peripheral cannula are that they are usually easy
to insert and have few associated complications. However, they are known to
increase phlebitis and when necessary need re-siting (Dougherty and Lister,
2011). In addition, some patients may not be able to tolerate the presence of
a cannula. In such cases an alternative may be required such as a
peripherally inserted central venous catheters (PiCC), or a central line.
The selection of a site for cannulation may be contra-indicated by:
The presence of injury or damage (e.g. fracture, cerebrovascular
accident, oedema, lymphadenopathy, thrombosis caused by multiple
attempts of cannulation or venepuncture).
The presence of infection as suggested by inflammation, phlebitis,
cellulitis.
Veins which are mobile or tortuous, or sited near a bony prominence.
If intravenous therapy is predicted to be long-term.
Continuous infusions or therapies which are vesicant or have a pH of
<5 or >9 (Hadaway, 2010).
OTHER COMPLICATIONS
Accidental Damage
A nerve, tendon or artery may be inadvertently punctured causing pain,
damage or haemorrhage as well as loss of confidence for the nurse.
The nurse may also lose confidence in undertaking the procedure
Phlebitis
This is characterised by pain and discomfort resulting from inflammation of the
intima of the vein.
The three main types are:
Mechanical - damage/irritation by a cannula that is too large for the vein, or
inadequate securement of the cannula which allows for movement.
Chemical drugs which cause irritation (ph <5 or >9 or extreme osmolarity or
vesicant. Vesicant drugs can cause blistering and necrosis if they leak into the
surrounding tissues (Scales, 2008).
Bacterial - poor hygiene or aseptic techniques leading to infection (Dougherty
and Lister, 2011).
Haematoma
Haematoma may form if the cannula pierces the front and/or back wall of a
vein. This can occur during insertion or removal of the cannula and may
render the vein unsuitable for further cannulation (Perucca, 2010). In the
event of a haematoma occurring, firm pressure should be applied for 3-5
minutes. The risk of this occurring can be reduced through good vein and
device selection and competent technique.
Extravasation
This is the leakage of vesicant fluids or drugs into surrounding tissues which
can cause local necrosis (East Midlands Cancer Network, 2012).
Prolonged Bleeding Time
This may be due to a medical condition or drug therapy. It increases the risk
of bruising/haematoma formation, and worsens the consequences of
inadvertent arterial puncture.
Blood Spillage
See local infection control guidelines (NUH, 2010d)
Needle or Blood Phobia
Patients may experience mild to severe needle/blood phobias due to past
experiences (Dougherty and Lister, 2011). It is advisable to establish if the
patient is known to have any concerns or anxieties before commencing
cannulation as this may adversely affect the practitioners success and further
compound the patients fears (Weinstein, 2007).
Anxiety can cause constriction of peripheral veins thereby making the
procedure more difficult (Dougherty and Lister, 2011). A careful explanation
and a confident manner is essential.
Vasovagal Faint/Syncope
This is due to enervation of the autonomic nervous system. It is important to
ensure that the patient is sitting/lying in a chair/bed whilst undertaking the
procedure (Phillips, Collins and Dougherty 2011). However, if the patient
begins to feel faint or appears pale and sweaty, the procedure should be
stopped immediately.
patient anxiety.
patient temperature.
mechanical or chemical irritants e.g. introduction of needle into vein,
drugs.
clinical state of patient e.g. dehydrated, vasoconstricted (Mallett and
Bailey, 1996).
There are many factors that influence choice of site but if the patient is able to
carry out normal activities while a cannula is in situ, and it is secured and
dressed appropriately then the patient will receive their intravenous therapy
with few interruptions avoiding unnecessary delays (Doherty and Lister,
2011). The use of the patients dominant arm should be avoided, whenever
possible.
Best Practice
When inserting a cannula, the introducer should never be reinserted as this may cause the distal part of the sheath of the
cannula to shear off and enter the circulation system.
In addition, a cannula, following an abortive attempt, should
never be re-inserted as this increases the risk of sepsis.
(Philips, Collins and Doherty, 2011.)
Best Practice
The smallest, shortest gauge cannula should be used in any given
situation (RCN, 2010)
EQUIPMENT LIST
Sharps container
Procedure tray
Cannulation Pack which includes;
1 small drape
1 Clinell wipe
2 dry Swabs
1 IV cannula dressing
1 Customised cannulation label
1 needle free extension set
Gloves in accordance with risk assessment and local policies
Appropriate cannula for the purpose and length of infusion
5mls sterile saline and syringe
Disposable tourniquet
Prepared infusion or needle free bung
Alcohol hand rub
VIPS chart (NUH01290S)
RATIONALE
To ensure the patient understands
the procedure and gives their
informed consent. Document consent.
Where doubt exists over the patients
ability to consent to the procedure
follow the guidance in Consent to
Examination or Treatment Policy
(NUH, 2012).
Where possible involve patient in To reduce anxiety, understand
selection of cannulation site, taking patients previous IV History, and
into account factors discussed in the obtain consent.
previous introduction, indications,
contraindications
and
hazards Avoid using unsuitable limbs with
sections.
limited venous return or access.
Also ensure that, if the patient is
seated on a bed/chair, he/she has To reduce the risk if injury from falling
back support.
backwards if the patient has a
vasovagal
attack
during
the
procedure.
The use of a local anaesthetic To reduce patient discomfort
injection (which needs to be
administered a few minutes before
cannulation) or anaesthetic cream
(e.g.Emla
Cream/Ametrop
gel,
cryogesic
spray)
should
be
considered. Cream needs to be
applied according to manufacturers
instructions (i.e. between 15-60
minutes prior to procedure) in order to
take effect. Cryogesic spray if used
acts immediately
CONSIDERATIONS
Clean hands as per Hand Hygiene
policy ( NUH, 2011b)
Collect equipment identified in
equipment list.
Where possible, establish if the
patient is known to be at risk, due to
prolonged bleeding time.
Ascertain if the patient has any
known allergies to the dressing which
is to be used.
Use an alternative dressing if
necessary.
RATIONALE
10
To maintain asepsis.
To increase accessibility and patient
comfort.
To cause venous dilation and aid
cannula insertion.
Allows the limb to be restrained whilst
also having more flexibility and
control on the amount of pressure
applied
11
Release tourniquet
12
Best Practice
Attempts at cannulation
13
References
Anderson KN & Anderson LE (Eds) (1995) Mosbys Pocket Dictionary of
Nursing, Medicine and Professionals Allied to Medicine. London:Mosby.
Department of Health (2007a) Saving Lives: reducing infection, delivering clean safe
care (revised edition), London, Crown Copyright
Department of Health (2007b) Saving Lives High Impact Interventions:
Peripheral intravenous cannula care bundle. London: HMSO.
Department of Health (2003) Winning Ways: Working together to reduce
healthcare associated infection in England. London: HMSO.
Dougherty, L. and Lister, S. (Eds.) (2011) The Royal Marsden Hospital
Manual of Clinical Nursing Procedures. 8th ed. Oxford: Blackwell
Publishing.
East Midlands Cancer Network (2011) Guidelines on the Management of
Extravasation
Hadaway, L. (2000) Peripheral IV therapy in adults Self-study Workbook.
Georgia, USA: Hadaway Associates
Mallett J and Bailey C (1996) Manual of Clinical Nursing Procedures 4th ed.
Oxford: Blackwell Science
McGovern, D. (2010). Peripheral IV cannulation in chemotherapy
administration. British journal of Nursing 9(14):pp 878
Nottingham University Hospitals NHS Trust (2012a) Consent to examination
or treatment policy.
Nottingham University Hospitals NHS Trust (2012b) Aseptic non touch
technique (ANTT) policy.
Nottingham University Hospitals NHS Trust (2011a) Working In New Ways
Expanding the Scope of Professional Practice.
Nottingham University Hospitals NHS Trust (2011b) Hand Hygiene Policy.
Nottingham University Hospitals NHS Trust (2011c) Glove Selection
Guideline: Examination and Surgical Gloves.
Nottingham University Hospitals NHS Trust (2011d) Infection Prevention and
Control Cleaning and Decontamination Policy
Nottingham University Hospitals NHS Trust (2010) Guide to intravenous
Therapy
14
Bibliography
Hudek K (1986) Compliance in Intravenous Therapy CINA 2(3): pp 7-8
Infection Nurses Society (INS) (2000) Standards for Infusion Therapy
Massachusetts, USA: INS
Infection Control Nurses Association (ICNA) (2001) Guidelines for Preventing
Intravascular Catheter Related Infection London: ICNA
Nottingham Acute Trusts (2009) Venepuncture and Cannulation: An
Educational Self-Directed Package Nottingham: NAT
Authors:
NPGG Link:
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