NMNC 2335
Student Name: _____________________________
Intravenous Therapy: Initiation
This process will be vary according to organization policy and equipment used.
Satisfactory (S), Unsatisfactory (U)
Performance Criteria
1
Review patient’s record for any pathologic
condition that may impair IV insertion.
Gather equipment. Perform hand hygiene.
Enter patient’s room.
Introduce yourself, explain what procedure is
to be done and why. Assess for allergies
(Latex, Tape, Antiseptics).
Perform hand hygiene and apply clean gloves.
(Wear eye protection and mask – check
policy, if splash or spray of blood is possible)
Prepare patient (Assist the patient to a
comfortable position, either sitting or lying
and safety for client and self, including raising
bed to appropriate height for procedure).
Expose the limb to be used but provide for
patient privacy.
Apply tourniquet around arm above 10 to 15
cm (4 – 6 inches) above proposed insertion
site to begin vein selection (the ends of the
tourniquet should point toward patient’s
head, out of way of the insertion site).
Do not apply it too tightly to avoid injury,
bruising the skin, or occluding arterial flow.
Check for presence of radial pulse.
a. You may apply tourniquet on top of
thin layer of clothing such as a gown
sleeve to protect fragile or hairy skin.
b. Use BP cuff instead of tourniquet.
Inflate it to a level just below
patient’s normal diastolic pressure
(less than 50 mmHg).
Select venipuncture site:
a. Place towel or bed protector under
extremity to protect linens.
b. Use patient’s non-dominant arm.
Identify possible venipuncture sites.
Veins on dorsal and ventral surfaces
of upper extremities (e.g., cephalic,
Peer
1
S U
Peer
2
S U
Informal Formal Comments
S
U
S
U
NMNC 2335
basilica, and median veins) are
preferred in adults. Check agency
protocol about shaving if site is very
hairy.
c. Use most distal site in non-dominant
area if possible.
Select a well dilated vein (Sometimes you
need to remove gloves to palpate vein and be
sure to re-glove prior to insertion). Methods
to foster venous distention include:
a. Place extremity in dependent
position.
b. Apply warmth to extremity for several
minutes.
With your index finger, palpate vein by
pressing downward. Note resilient, soft,
bouncy feeling while releasing pressure.
Avoid vein selection in:
- Area with tenderness, pain, infection,
or wound.
- Extremity affected by previous stroke
(CVA, paralysis, mastectomy, or
dialysis graft).
- Site distal to previous venipuncture
site, sclerosed or hardened veins,
infiltrate site or phlebotic vessels,
bruised areas, or areas of venous
valves.
- Fragile dorsal veins in older adult
patients and vessel in an extremity
with compromised circulation.
Choose a site that does not interfere with
patient’s ADLs, use of mobility aids such as a
cane, or planned procedures. Clip arm air with
scissors if necessary (explain to patient).
Release tourniquet temporarily and carefully.
Apply clean gloves if not done.
Prepare IV extension tubing
- Prime the tubing with NS 0.9%
- Ready for dual luerlock cap (loosen
the luerlock cap) so that you can
remove the dual luerlock cap easier
to connect the IV.
Use antiseptic swab or applicator
(Chlorhexidine 2% is preferred) to clean
insertion site. Allow to dry completely.
NMNC 2335
Reapply tourniquet or BP cuff above 10 – 12
cm (4- 6 inches) above anticipated insertion
site.
Evaluator ____________________________________________________________________________
Peer 1 ________________________________ Peer 2________________________________________
Student ____________________________________Date_____________________________________
Revised 01/2020