Module 2
Peripheral Intravenous
Insertion Learning Package
August 2007
Revised November 2011 &
January 2013
Table of Contents
Introduction and Competency
3
Objectives
4
Indications for IV therapy
5
Professional Practice Considerations
6
Standards of Care
7
Anatomy & Physiology
8-11
Peripheral veins appropriate for IV initiation
12-14
Equipment used for peripheral IV initiation
15-20
Special considerations before initiating peripheral I.V. therapy
21-23
Steps to initiating I.V therapy
24-42
Complications of I.V. Insertion and therapy
43-46
References
47-48
Appendix A Competency Skills Check List
49
Appendix B Algorithm for IV initiation
50
Appendix C Post test
51-53
Peripheral Intravenous (I.V.) Initiation 2
Introduction and Competency
The purpose of this module is to provide information to the Registered Practical Nurse
(RPN) and the Registered Nurse (RN) with regards to peripheral intravenous (I.V.)
initiation/insertion.
Process of Competency:
This is a self-directed learning package. To provide evidence that you have completed
this module, you must:
1. Complete Module 2 – Peripheral Intravenous (I.V.) Initiation/Insertion
2. Complete written test (80% pass) to your Clinical Nurse Educator or your Clinical
Team Manager within one month of receiving the package.
3. Attend a teaching/didactic session by the Clinical Nurse Educator or a trained I.V.
certified nurse.
4. Successfully initiate 3 - 5 intravenous (I.V) and signed off by competent nurses
certified to initiate I.Vs using the Competency Skills Check List (See Appendix F).
Nurses who were IV certified in other organizations will successful initiate 3
IVs.
You will receive a Certificate of Intravenous (I.V) Initiation/Insertion once you have
completed all of the above. See Appendix A
Please Note: The Clinical Nurse Educator may require of you additional study or
practice until 100% competence is acheived.
Continuing Competency
Competency will be maintained through:
1. On-going practice.
2. Self reflection and review of learning package if ongoing practice or opportunities
not available.
3. Two (2) successful intravenous (I.V) initiation per month as per documented
patient MRN in the Unit Based IV Competency Binder.
4. Monitoring of I.V. practices through unit-based I.V audits.
It is your professional obligation to determine if you have the knowledge, skill and ability
to continue practicing safely. Please contact your Clinical Nurse Educator or Clinical
Team Manager if you have any learning needs. Additional copies of this package may
been obtained from the Educator.
Peripheral Intravenous (I.V.) Initiation 3
Objectives
By the end of this self-directed learning module, the nurse will be able to:
1.
2.
3.
4.
5.
6.
Describe the indications for intravenous therapy
Describe standards of care and maintenance of peripheral intravenous (PIV)
therapy.
Describe basic anatomy of veins and skin.
Identify complications of intravenous therapy.
Demonstrate how to succesfully initiate IV therapy.
Describe components of documentation regarding IV initation.
Peripheral Intravenous (I.V.) Initiation 4
Indications for Intravenous Therapy
Indications for initiating intravenous therapy include:
a)
b)
c)
d)
e)
f)
maintenance of fluid & electrolyte balance
blood & blood products administration
medication administration
parenteral nutrition (short term)
to provide access for diagnostic tests and/or procedures
resuscitation
Peripheral Intravenous (I.V.) Initiation 5
Professional Practice Considerations
Nurses have a professional responsibility to ensure care and maintenance of peripheral
intravenous (PIV) therapy in their clinical setting.
These include:
1. Evidence-based theoretical and practical knowledge to enable safe practice
2. Maintaining practical competency and practice in accordance with NYGH policy
and procedures
3. Patients receive education of signs and symptoms and potential complications
related to intravenous therapy
4. Maintaining ongoing documentation of care and maintenance, initiation and
discontinuation related to intravenous therapy.
Adapted from http://www.cancernursing.org
Peripheral Intravenous (I.V.) Initiation 6
Standards of Care
Both RNs and RPNs are responsible for care & maintenance of the IV site. In the event
of complications, it is your responsibility to assess, consult when necessary, take action
and document. You are required to be knowledgeable in the care of patients with
peripheral intravenous sites and therapy.
As per the NYGH Policy and Procedures – Intravascular Care and Maintenance II-240
& Peripheral IV Initiation Competency II- 245 and as per the Medical Directive –
http://www.nygh.on.ca/nygh_test/XII_138_Initiate___Discontinue_Saline_Lock.pdf
According to the Journal of Infusion Nursing (2011), The RNAO Best Practice
Guidelines (2008), the Center for Disease Control (2011), and NYGH Policy and
Procedures, it is your responsibility to perform the following:
Hand Washing
•
•
Perform hand hygiene in accordance to NYGH Infection Prevention and Control
Policy and Procedures.
Wear personal protective equipment. Assess patient risk factors and use
personal protective equipment when needed (to either protect the patient, as in
immunosuppressed patients or to protect you, in case of contact with body
fluids).
Peripheral Intravenous (I.V.) Initiation 7
Anatomy and Physiology
Skin
The skin consists of two main layers, the epidermis and the dermis which lies over the
superficial fascia. The epidermis is the layer that acts as a defense mechanism. Its
thickness varies with age and exposure to elements such as wind and sun.
The dermis, a much thicker layer, is located directly below the epidermis. The dermis
consists of blood vessels, hair follicles, sweat glands, sebaceous glands, small muscles,
and nerves. As a result, it reacts quickly to painful stimuli, temperature changes, and
pressure sensation.
(http://health.yahoo.com/media/mayoclinic/images/image_popup/skin_type.jpg)
Peripheral Intravenous (I.V.) Initiation 8
Sensory Receptors
Phillips (2005) describes five types of sensory receptors, four of which affects parental
therapy. Sensory receptors related to parental therapy includes
a. Mechanoreceptors: which process the skin tactile sensation and deep tissue
sensation.
b. Thermoreceptors: which process cold, warmth and pain (application of heat and
cold)
c. Noiceptors: which process pain (puncture of the vein fro insertion of the cannula)
d. Chemoreceptors: which process osmotic changes in the blood and decrease
arterial pressure (decrease circulating blood volume)
(http://fig.cox.miami.edu/~cmallery/150/neuro/c7.49.3.skin.jpg)
Peripheral Intravenous (I.V.) Initiation 9
Characteristics of Veins and Artery
Tissue Layers
Tunica Intima
The Inner Layer
Tunica Media
The Middle Layer
Vein Characteristics
Elastic endothelial lining
Smooth surface allows
cells and platelets to
flow through the vessels
• Damage to this layer
encourages thrombus
formation
Artery Characteristics
• Elastic endothelial
lining
• Smooth surface allows
cells and platelets to
flow through the
vessels
• Damage to this layer
encourages thrombus
formation
•
Muscular and elastic
tissues
Contains constrictors
and vasodilators nerve
fibers
Not as strong and stiff
Allows vein to collapse
or distend with pressure
changes
Areolar connective
tissues surrounds and
supports the vessels
•
Veins have valves to
permit only
unidirectional blood flow
towards the heart.
Usually found superficial
Blood will appear dark
red
Blood will flow from
cannula
Does NOT have a
palpable pulse
•
•
•
•
•
•
Tunica Adventitia
The Outer Layer
•
Valves
•
Other differences
•
•
•
•
•
•
•
•
•
•
•
•
Muscular and elastic
tissues
Contains constrictors
and vasodilators nerve
fibers
Strong and stiff
Arteries DO NOT
collapse or distend
with pressure changes
Areolar connective
tissues surrounds and
supports the vesselsBut thicker in arteries
due to greater
pressure
No Valves
Usually found deep
and surrounded by
muscles
Blood will appear
bright red
Blood will pulsate from
the IV cannula
Has a palpable pulse
Peripheral Intravenous (I.V.) Initiation 10
(http://www.sci.sdsu.edu/class/bio590/pictures/lect5/artery-vein.jpeg)
Peripheral Intravenous (I.V.) Initiation 11
Peripheral Veins Appropriate For IV Initiation
Peripheral Intravenous (I.V.) Initiation 12
Veins of the Arms
Vein and Location
Digital
Lateral and dorsal portions of the
fingers
Metacarpal and Dorsal
Dorsal surface of the hand
Cephalic
Radial portion of the lower arm along
the radial bone of the forearm from the
wrist to the Anticubital fossa
•
•
•
•
•
Good site to begin IV therapy
Easily visualized
Avoid if infusing antibiotics,
potassium chloride or
chemotherapeutic agents
•
•
Large vein, easy to access
First use most distal section and
work upward for long term
therapy
Useful for infusing blood and
chemically irritating medications
Puncture at the wrist may cause
mechanical irritation from joint
movement
•
•
Accessory Cephalic
Branches off the cephalic along the
radial bone
•
•
•
Upper Cephalic
Radial aspect of the upper arm above
the elbow
Basilic
Ulnar aspect of the lower arm and runs
up the ulnar bone
Considerations
Use a padded tongue blade to
splint the finger
Use solutions that are Isotonic
and with out additives, to
decrease the risk of infiltration
Medium to large size, easy to
stabilize and access
Difficult to palpate in persons
with large amounts of adipose
tissue
Valves at the cephalic junction
may prohibit cannula
advancement (use a shorter
cannula, 1inch)
•
•
Difficult to visualize
Great site for confused patients,
who tend to pull at their I.V. line
•
•
Difficult area to access
Large vein, easily palpated, but
moves easily, therefore needs to
be stabilized
Often available when other sites
have been exhausted
•
Peripheral Intravenous (I.V.) Initiation 13
Median Antebrachial
Extends up ulnar side of anterior
forearm from the median Anticubital
veins
•
•
Anticubital Fossa
In the bend of the elbow
•
•
•
•
•
Vein is readily accessible
Area has many nerve endings
and should be avoided
Infiltration occurs easily
Should be reserved for blood
draws for laboratory analysis
Uncomfortable placement site,
due to unnatural positioning of
the arm
Difficult to splint with an arm
board
If used in an emergent situation
(e.g. dehydration, blood loss,
arrest) change site within 24
hours
Peripheral Intravenous (I.V.) Initiation 14
Equipment Used for I.V. Initiation
I.V. Catheters: There are various companies and types of peripheral I.V. catheters
used. A catheter is another term for tube that can be inserted into the body for the
delivery or removal of fluid. When choosing the correct size catheter, for your patient,
the following should be considered: age, level of activity, venous status, type of solution,
type of medications being administered, the length of therapy, and the
procedure/surgery to be performed when deciding. In the medicine and surgical units,
the BD NEXIVA CLOSED CATHETER SYSTEM – SINGLE PORT is used. For more
information, read pages 17-20.
Catheter
Lengths:
¾ inch-1 ¼ inch
•
24 gauge
•
22 -20 gauge
•
•
•
•
•
18 gauge
•
•
•
•
•
•
Considerations
Use the shortest length and the
smallest gauge that allows for
proper administration of
prescribed therapy
Use in infants, children, older
adults and adults with extremely
small or fragile veins
Difficult to insert in tough skin
22 gauge: For fragile veins in
elderly persons if unable to
place a 20 gauge catheter
20 gauze: Medical or surgical
patient requiring medication and
fluid replacement
Blood may be given to patients
with 22 gauge catheter on a
pump (i.e. IVAC pump)
20 gauge: preferred for cardiac
patients and for blood
administration
Immediate post-op surgical
patients
Obstetrical patients
Blood and blood product
administration
TPN and viscous solutions
CT Scan procedures
Patients requiring resuscitation
Peripheral Intravenous (I.V.) Initiation 15
Gloves: Gloves are the recommended standard precaution whenever exposure to
blood and bodily is likely. Latex and vinyl gloves protect wearers from contact with blood
and body fluids. See Policy IV-a-85 for latex awareness
Skin Cleansing Solution: A tincture of 2% chlorhexidine gluconate and 70% isopropyl
alcohol significantly reduces the chance of nosocomial infection. Recommended by the
CDC (2011) guidelines. Scrub insertion site using side to side, up and down friction.
Let it dry for 30 seconds and apply the dressing.
Dressings & Site Securing: A clear transparent dressing is the standard (i.e.
Tegaderm). When a patient is diaphoretic, sterile skin prep is available and can be
used after catheter insertion to secure the dressing to the skin.
Tapes: Tape must NOT to be used over the insertion site as it will hinder the ability to
assess and visualize the site. Use tape to anchor the tubing and hub. Paper tape is best
used on patients that are allergic to plastic tape and for patients with thin skin that are
prone to skin tares.
Tourniquet: A disposable tourniquet must be used and discarded after each patient to
decrease the transfer of infection to other patients (INS, 2000)
Needleless Connector: Hospira’s Microclave Clear Needleless Connector(“cap”) must
be primed and attached to the end of the Nexiva single port catheter. Then flush using
the stop/start and positive pressure technique before clamping the catheter.
IV Tubing: New tubing must be used after each IV initiation. See page 21 for IV tubing
changes.
Sharp Disposal: See NYGH Policy IV-a-90
Peripheral Intravenous (I.V.) Initiation 16
Peripheral Intravenous (I.V.) Initiation 17
Peripheral Intravenous (I.V.) Initiation 18
Peripheral Intravenous (I.V.) Initiation 19
Peripheral Intravenous (I.V.) Initiation 20
Special Considerations
Site selection
a. The site selection should be readily visible and roller bandages should
never be used around the catheter site (INS, 2000)
b. Select an area without flexion: movements may cause irritation, resulting
in phlebitis and or infiltration. An area of flexion may interfere with the flow
rate and it may cause irritation and pain
c. Avoid areas of skin irritation, this may increase the risk of infection and
embolus
d. Avoid the lower extremities, especially in patients who are diabetic and/or
have peripheral vascular disease (PVD). Initiating an IV will increase the
risk of ulcer formation related to poor healing
Vein selection
a. Vein selection shall include assessment of the patient’s condition, age and
diagnosis, the condition of the vein, the size and location and the duration
of therapy. The vein should be able to accommodate the gauge and length
of the cannula required by the prescribed therapy (INS, 2000)
b. A suitable vein should feel relatively smooth, pliable with valves well
spaced.
c. Start with distal veins and work proximally.
d. Veins that feels bumpy, like running your fingers over a cat’s tail, are
usually thrombosed or extremely valvular (Phillips, 2005)
Geriatric Considerations
a. Due to the decrease in subcutaneous tissue the veins loss stability and roll
away from needle. To stabilize the vein, apply traction to the skin below
the projected insertion point
b. Use the smallest gauge possible (22- 24 gauge for fluid and medication
administration, less traumatic)
c. Avoid the back of the hands – it interferes with independence
d. Sclerotic and fragile veins are common in the elderly population,
approach venipuncture gently and evaluate the need for a tourniquet
(Fabian, 1995)
Peripheral Intravenous (I.V.) Initiation 21
Overweight Considerations:
a. If you are unable to palpate or see the vein, create a visual image of the
venous anatomy and select a longer catheter
b. According to Weinstein (2001), double or triple tourniquets are
recommended.
Pediatric Considerations (see Pediatric IV SDLM)
a. Infants do no have accessible sites; this is related to an increased body
fat. Hence, veins in the hands, feet and antecubital region may be the only
accessible sites.
b. Peripheral routes for pediatric IV include scalp vein, veins in the dorsum of
the hand, forearm and foot
c. The major superficial scalp veins (frontal best access), perauricular,
supraorbital and occipital can be used fro children up to 18months of age.
Only RNs with added competencies may initiate scalp veins IV
d. The major superficial veins of the scalp are easily visualized, readily
dilates because it has no valves; hands are kept free
e. The dorsum of the hand and forearm,
f. A flashlight or transilluminator device placed beneath the extremity helps
to illuminates tissue surrounding the vein; the veins are better outlines for
better visualization (Frey, 2001)
Psychological Considerations:
a. Anxiety, stress and fear will increase stress response and causes
vasoconstriction and may inhibit cannulation
Physiological Considerations:
a. Thermoregulation: Veins distends when warm and constricts when cold
b. Hypovolemic: In severe shock, veins will collapse
c. Previous trauma: Repeated cannulation or drug therapy can result in
damage veins
Chemotherapy Considerations:
•
Veins suitable for IV administration of chemotherapeutic agents must be
smooth and non-sclerotic. When selecting veins for chemotherapeutic, it is
recommended to use the distal veins of the hands and arm first. However,
large veins of the forearm are preferable. Veins commonly used are including
Peripheral Intravenous (I.V.) Initiation 22
the basilica, cephalic and metacarpal veins. Do not use the antecubital fossa
or the wrist.
Peripheral Intravenous (I.V.) Initiation 23
Steps to IV initiation - Adapted from (Philips, 2005)
Precannulation
1. Check the physician’s orders:
a. validate the order for IV insertion or document the medical directive used
b. determine the need for venous access based on nursing judgment
2. Hand hygiene
a. Scrub hands vigorously with an antimicrobial agents for 15- 20 seconds
before and after all clinical procedures
3. Equipment preparation:
a. Prepare and prime IV tubing using aseptic technique.
b. Gather equipments and select vascular access device base on needs
4. Patient assessment and psychological preparation:
a. Provide privacy
b. Explain the procedure to minimize anxiety
c. Instruct the patient regarding the purpose, the procedure, mobility
limitation and potential complications
d. Assess the psychological preparedness for the IV procedure such as fear
of blood or needles and pain.
5. Site selection and veins dilation:
a. Based on age, diagnosis, vein conditions types and duration of therapy
b. The following list provides suggested ways to dilate the vein
i. Gravity: position the extremities below the heart
ii. Fist clenching: instruct the patients to open and close the fist
squeezing a rubber ball or rolled washcloth works well
iii. Tapping: using the thumb and the second finger; flick the vein. This
enhance the release of histamines beneath the skin and causes
dilation.
iv. Warm compress: Apply warm towel to the extremities for 10- 15
minutes will result in vasodilatation and enhance cannulation
(Walling and Lenhardt, 2003)
v. Tourniquet: Apply the tourniquet 6 to 8 inches (10 – 15cm) above
the intended insertion site. If the blood pressure is within normal
Peripheral Intravenous (I.V.) Initiation 24
l step) method
For direct (one
Indirect entry (two –steps method)
i
limits, place the tourniquet lower with hypotensive patients and
higher with hypertensive patients. Do not leave the tourniquet in
place for longer than 2-3 minutes. Patients with fragile veins do not
require tourniquets
Cannulation
6. Needle selection : (See page 15 & 20)
7. Gloves: Recommended routine standard of practice.
8. Site preparation:
a. Clip excessive hair only if necessary, shaving is not recommended
because of the potential for microabrasion. Using a tincture of 2%
chlorhexidine gluconate and 70% isopropyl alcohol significantly reduces
the chance of nosocomial infection. Prepare the site using vigorous
circular motion, working from the center outwards to a diameter 2 – 3
inches for 20 seconds. The solution should be allowed to air dry
9. Cannulation: Direct vs. Indirect
Direct: Insert the catheter directly over the vein at a 15 to 25° angle; penetrating all
layers of the vein with one motion. Not suitable for small veins due to hematoma
potential.
Indirect: Cannula is inserted “through skin below the point where vein is visible but
above the vein. This approach depresses the vein, obscuring its position. The
catheter is adjacent to the vein, but has not penetrated the vessel wall. Gently locate
the vein, decrease the catheter angle and enter the vessel.”
NOTE: In the medicine and surgical units, BD NEXIVA CLOSED
CATHETER SYSTEM – SINGLE PORT is used. For more
information, read pages 29 - 41.
Peripheral Intravenous (I.V.) Initiation 25
a) Wash hands.
a) Wash hands & stabilize vein
b) pull the skin below the puncture
b) Insert the cannula at a 15 to 25°
site to stabilize the skin and
angle to the skin along the vein;
prevent the rolling of the vein
gently insert the cannula distal to
c) Insert the needle of choice
bevel up at a 15 - 25° angle,
depending on the vein location
the point at which the needle will
enter the vein
c) After the bevel enters the vein
and catheter, while applying
and blood flashback occurs,
traction on the vein to keep skin
lower the angle of the catheter
taut. For superficial veins, a
and stylet (needle) as one unit
lower angle of 5° is
and advance into the vein.
recommended. (CINA, 1999)
a. Insert the catheter by
d) After the catheter tip and bevel
are in the vein, advance the
direct or indirect method
catheter forward of the stylet and
with a steady motion.
into the vein.
e) After the vein is entered,
cautiously advance the cannula
into the vein lumen. Hold the
catheter hub with your thumb and
middle finger and use the index
finger to advance the catheter
f) While the stylet is still partially
inside the catheter, release the
tourniquet
g) Remove the stylet
h) Connect the adapter to the
administration set to the hub of
the catheter
Peripheral Intravenous (I.V.) Initiation 26
10. Catheter stabilization and dressing management
a. The catheter should be stabilized in a manner that does not interfere with
visualization and evaluation of the site. Stabilization reduces the risk of
complications related to IV therapy.
b. Cover the insertion site and the catheter hub with a transparent dressing.
Secure the lines to prevent excessive movements
Post Cannulation
11. Attach primed needleless connector to end of single port of catheter. Then flush
using the stop/start and positive pressure technique before clamping the
catheter (See page 42).
12. Labeling
a. IV set up must be labeled in three areas: the insertion site, the tubing and
the solution container/ bag
b. The venipuncture site must be labeled on the side of the transparent
dressing or across the hub with the date, time, size of catheter and
nurse’s initials.
13. Equipment disposal
a. Sharps must be placed in the sharps container
14. Patient education
a. Inform the patient of any limitation on movement or mobility
b. Instruct the patient to call for assistance if the venipuncture site becomes
tender or sore or if redness or swelling develops
c. Advise the patient that the site will be checked by the nurse
15. Rate calculation
a. Accurately calculate the rate, the drop per minute should be calculated
based on the drop factor. (See Self directed learning Module on Care
and Maintenance of intravascular therapy )
16. Documentation
a. Monitor the patient’s response to the therapy, document procedure
performed, how the patient tolerated the venipuncture, and what
instructions were given.
b. Document the size and length of the catheter and difficulties during the
procedure, and site and vein. Including the solution and rate/ saline lock.
Peripheral Intravenous (I.V.) Initiation 27
BD Nexiva Points to Practice – Initiation
Peripheral Intravenous (I.V.) Initiation 28
BD NEXIVA CLOSED CATHETER SYSTEM – SINGLE PORT
Peripheral Intravenous (I.V.) Initiation 29
Peripheral Intravenous (I.V.) Initiation 30
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Peripheral Intravenous (I.V.) Initiation 40
Peripheral Intravenous (I.V.) Initiation 41
BD Nexiva’s IV Closed System Catheter-Single Port with Hospira’s Microclave
Clear Needleless Connector and/or Bifurcated Extension Set
Hospira’s Microclave Clear Needleless Connector(“cap”)
This new needleless connector requires no change in practice with stop/start and
positive pressure technique.
Practice change related to starting an IV:
1. Retrieve a single port Nexiva IV Closed Catheter system and a Hospira Microclave
Needleless Connector. Note: If you need to use 2 ports- bring Hospira’s bifurcated
extension set(Important- the needleless connectors on the bifurcated extension set are
bonded to the tubing-see picture below).
2. Wash hands and apply gloves(follow Infection Prevention and Control standards).
3. Scrub the Microclave needleless connector hub for 30 seconds using 70% alcohol swab
and attach prefilled 0.9% saline syringe. Prime the Microclave needleless connector
with 0.05mls 0.9%normal saline.
4. Insert the single port Nexiva IV Closed Catheter System(follow guidelines for IV
insertion)
5. Add the primed Microclave needleless connector to the end of the Nexiva single port
catheter. Flush using the stop/start and positive pressure techniques and clamp the
catheter.
6. If 2 ports are required, scrub the Microclave needleless connector hubs on the
bifurcated extension set for 30 seconds using 70% alcohol swab and attach prefilled
0.9% saline syringe. Prime the bifurcated extension set with 1.4mLs 0.9% normal
saline.
7. Scrub the Microclave needleless connector (already attached to the IV catheter) and
attach the bifurcated extension set. Flush using the stop/start and positive pressure
techniques and clamp the catheter.
Peripheral Intravenous (I.V.) Initiation 42
Complications of IV Insertion and Therapy
An important part of IV therapy is the ongoing evaluation. There can be several
complications that may occur and require immediate recognition and nursing
intervention.
Complication
Definition
Causes
Infiltration
*Leaking of
nonvesicant
solution/medication
into the surrounding
tissue
*Trauma to vein
with insertion
*Cannula is
positioned
outside vein
*Large volume
infiltrate
Extravasation
*Leaking of
vesicant
solution/medication
into the surrounding
tissue
(vesicant solution
can cause blister
formation and
possible tissue
necrosis)
*Trauma to vein
with insertion
*Cannula is
positioned
outside vein
*Large volume
infiltrate
Signs and
Symptoms
*Swelling and
pain to the area
*Alerted flow
rate
*Blanching and
coolness of the
skin area
*Leaking at the
site
*Swelling and
pain to the area
*Alerted flow
rate
*Blanching and
coolness of the
skin area
*Leaking at the
site
*Sloughing off of
tissue
Nursing
Interventions
*Stop infusion
*Remove IV
cannula
*Elevate limb
and apply warm
compresses
*Restart IV in
unaffected area
*Document
*Stop Infusion
*Contact MD for
orders
*Change tubing
at hub
*Infuse antidote
as per MD order
*Remove IV
cannula
*Cover with dry
sterile dressing
*Document
(http://pharmlabs.unc.edu/parenterals/routes/intravenous_sites.jpg)
Peripheral Intravenous (I.V.) Initiation 43
Complication
Definition
Causes
Arterial Puncture
*Accidental
puncture of artery
Phlebitis
*Inflammation of
the Intima; inner
lining of the vein
Thrombophlebitis
*Inflammation of
vessel due to
formation of
thrombus
*Inappropriate
site selection
*Inability to
distinguish
between
vein/artery
*Mechanical:
- Inflammation
causes by
trauma or IV
catheter,
manipulation of
the catheter
*Chemical:
-vein becomes
irritated by
medications or
solution
*Bacterial:
-caused by
breakage of skin
barrier
pathogens have
access
*See causes for
phlebitis
Signs and
Symptoms
*Blood pulsing
from site
*Inability to
thread IV due
to high pressure
Nursing
Interventions
*Remove IV
cannula
*Apply direct
pressure to site
*Document
*Pain at the site
*Area is warm to
touch
*Inflammation of
the vein,
erythema,
edema
*Bacterial
phlebitis may
have purulent
discharge, and
fever
*Stop infusion
*Remove IV
cannula
*Clean area with
antimicrobial
agent and apply
dry dressing
*Apply
warm/cold
compress to
area
*Document
*Contact MD if
Bacterial
phlebitis is
suspected
*Pain and
inflammation at
the site
*Hard cord like
vein
*Altered infusion
flow rate
*Limb may be
cool and
discolored
*Stop infusion
*Remove IV
cannula
*Clean area with
antimicrobial
agent and apply
dry dressing
*Apply COLD
compress to
area to
decrease flow
*Followed by
WARM
Compress and
elevate arm
*Instruct client
against rubbing
area – may
cause EMBOLI
Peripheral Intravenous (I.V.) Initiation 44
(http://www.postgradmed.com/issues/2004/11_04/slaughter.htm)
Complication
Definition
Causes
Embolism
*A thrombus is
formed and
becomes
dislodged
*Emboli can be
dislodged due
-to forced
flushing with
syringe
-manipulation of
cannula
Occlusion
*An emboli
formed within or
at the tip of the
cannula
*Prolonged
interruption of
the flow of IV
fluids
Signs and
Symptoms
*Pain in arm
*Hypotension,
cyanosis,
tachycardia
weak pulse
*Rise in venous
pressure
*Decreased
GCS
*Unable to
resume flow of
IV fluids
*Blood may
back up into
tubing
Nursing
Interventions
*Apply
tourniquet
above IV site
*Check vital
signs
*Place client in
Trendelenberg
position
*Have another
staff member
call the MD
*Do not leave
client
*Do not flush IV
(may cause
emboli)
*Remove IV
cannula
*Document
Peripheral Intravenous (I.V.) Initiation 45
Complication
Definition
Causes
Pain
*As defined by
the client
*Insertion site
may be tender
*Infusion may
be too rapid
*Infiltrate may
be too
concentrated
Speed Shock
*A systemic
reaction that
occurs due to
rapid introduction
of a medication
*Large volume
infused too fast
which permits
toxic levels of
medication in
the plasma
Fluid Overload
*Venous pressure
is increased due
to circulatory
overload
*Large volume
infused to fast
Signs and
Symptoms
*Client states
that they are in
pain and
indicate IV site
as the source
*Immediate
complaint of
headache
*May complain
of face flushing,
chest pain
*Rare cases –
loss of
consciousness,
anaphylactic
shock or cardiac
arrest
*Hypertension
*Distended
jugular veins
*SOB
*Crackles to
lung fields
*Possible
Pulmonary
Edema
Nursing
Interventions
*If pain is
extreme remove
cannula
*dilute solution if
possible
*reposition
tubing
*Slow infusion
rate
*Stop infusion
*Put client in
Trendelenberg
*Provide O2 by
non-rebreather
mask
*Notify MD
*Slow rate to
TKVO
*Position client
in Semi-fowlers
if possible
*Notify MD
*Document
Peripheral Intravenous (I.V.) Initiation 46
References
BD Nexiva Closed IV Catheter System.
College of Nurses of Ontario (2005). The Standards of Practice for Nurses.
Retrieved March 20, 2006 from www.cno.org
Center for Disease Control (2011). Guidelines for the Prevention of Intravascular
Catheter-Related Infections.
Center for Disease Control (2002). Guidelines for the Prevention of Intravascular
Catheter- Related Infections. Morbidity and Mortality Weekly Report. 51
(10)
Fabian, B. (1998). Basic I.V. skills: Adult and Pediatric. National Academy
Presentation: November 1998, Pheonix, AZ
Infusion Nurses Society, 2011. Infusion Nursing Standards of Practice. Journal
of Infusion Nursing 34(1S).
Hibbard, J.S. Mulberry, G., & Brady, A. (2002). A clinical study comparing the
Skin antisepsis and safety of chloraprep, 70 isopropyl alcohol and
aqueous chlorhexidine. Journal of Infusion Nursing, 25 (4) 244- 249
Infusion Nursing Society (2000). Revised intravenous standards of
practice. Journal of Intravenous Nursing, 21 (65)
North York General Nospital (2005) Policy and Procedure on Infection control
North York General Hospital (2005). Policy and Procedure on Latex Gloves
North York General Hospital (2006?) Self Directed Learning Module on
Chemotherapy and Biotherapy
Philips, D (2005). The Manual of I.V therapeutic. 4th Ed. F.A Davis Philadelphia
Peripheral Intravenous (I.V.) Initiation 47
Potter, & Perry (2004). Clinical Nursing Skills & Technique. 5th Ed. Mosby
Register Nurses Association of Ontario (2006). Best Practice Guideline:
Assessment and Selection of Vascular access device.
Retrieved March 20, 2006 from www.rnao.org
Weinstein, S. (2004) .Plumer’s Intravenous Therapy. 7th ED. Lippincott.
Philadelphia
Walling, A & Lenhardt, R. (2003). Local warming and insertion of peripheral
Venous cannulas: Single blinded prospective randomized controlled trial
and a single blinded randomized crossover trail. American Family
Physician 67 (2), 401
Vanek,V. (2002). the In and Outs of venous access: Part 1. Nutrition in Clinical
Practice 17(2) 85- 98
Peripheral Intravenous (I.V.) Initiation 48
Appendix A
Competency Skills Check List
Name: _________________
Unit ____________________
S= Satisfactory; U = Unsatisfactory
The RN/RPN must successfully initiate 3- 5 IVs to be competent
Number of successful starts
Criteria
1 2 3 4 5 6 7
Comments
1.
Check the physician’s order
2.
Collection of all the
necessary equipment
3.
Hand Hygiene
4.
Explain the procedure to the
patient
5.
Proper positioning of the
patient
6.
Applies Tourniquet 3-4”
above the site of insertion
7.
Proper cleansing of the site
based on aseptic technique
8.
Maintain standard
precaution (gloves)
9.
Check proper functioning of
the catheter
10.
Anchor patient’s limb/ vein
appropriately
11.
Insert the needle
12.
Observe for flash back,
withdrawal of needle,
advance the catheter
13.
Proper stabilization of the
site with tape and
transparent dressing
14.
Proper adjustment of Flow
rate
15.
Proper labeling of IV site/
Tubing
16.
Disposal of sharps
17.
Hand hygiene
18.
Appropriate documentation
on Powerchart
19.
Initials of Trainer
Most Responsible Educator______________________ Date:_______________
Peripheral Intravenous (I.V.) Initiation 49
Appendix B
ALGORITHM for IV Initiation
IV INSERTION ORDERED
↓
RN/RPN (knowledge, skills and resources available to manage outcome)
↓
RN/RPN assesses Patient & Purpose for IV
↓
No Contraindications
↓
Determine the right gauge & site selection
↓
INSERT IV Once, if unsuccessful
↓
Utilize unit resources or champions and attempt again
↓
Still unsuccessful
↓
Page Vascular Access Nurse (Write Request in Book)
↓
Ensure IV tubing is primed and labeled
Peripheral Intravenous (I.V.) Initiation 50
Appendix C
Post Test
Name: ________________________ Unit:_______ Date:_______________
1. Which of the following types of patients should have a minimum 18-gauge
intravenous initiated as per hospital guidelines
a) Multiple trauma patients, L & D patients pre- operative patients
only
b) Pediatric patients, dehydrate patients and chemotherapy patients
c) Patients receiving transfusions of blood and blood products,
multiple trauma patients, and all L & D and preoperative patients
2. Thrombophlebitis is:
a) a painful inflamed area along the length of the vein or surrounding
area around the site of the catheter
b) Swelling noted distally to the catheter insertion site
c) A large area of discoloration proximal to hand
d) Pain, numbness, or a decrease sensation of the extremities
3. Intravenous cannulation should progress from the:
a) Dorsal surface of the hand towards the antecubital space
b) Lateral surface of the hand towards the antecubital space
c) Antecubital space towards the finger
d) None of the above
4. Veins commonly used for peripheral IV therapy are:
a) The veins at the point of flexion
b) Veins in the antecubital fossa
c) Basilic, Cephalic and Metacarpals
d) Veins on the inner aspect of the forearm
5. A peripheral saline lock must be flushed:
a) after medication
b) Between medication
c) Before giving a medication
d) All of the above
6. A patient complains of pain and has redness with swelling near the site of
the I.V. The action the nurse should take is to:
a) Rub or massage the reddened area
b) Change the IV tubing
c) Stop the infusion and resite the cannula
d) Splint the site to make it more comfortable for the patient
Peripheral Intravenous (I.V.) Initiation 51
Post Test
Please Answer True (T) or False (F)
1)
If there is blood “flash back” during intravenous cannulation, advance
the stylet back into the catheter and adjust the positioning of the needle
to locate the vein
2)
Under the new RHPA guidelines, intravenous initiation is considered
an added nursing skill.
3)
When an IV is blocked, the nurse should milk the tubing a few times to
unblock it.
4)
You should turn the patient on the left to trendelenberg position if you
suspect the existence of an air embolism.
5)
If there is a lack of blood flash back during intravenous cannulation,
wiggle the needle around to center the bevel in the vein
6)
The healthcare provider must follow the hospital policies and
procedures regarding IV therapy before and after initiating an IV.
7)
Saline locks and IV sites are changed every 4 days.
Match column A to definitions found in Column B
1. Arteries
a) Free floating
2. Veins
b) Usually superficial and palpable but may
be deep
3. Infection
c) sensitivity to IV catheter
4. Allergic Reaction
d) No valves present
5. Pulmonary Embolism
e) Redness, tenderness, swelling at IV site
Symptom Identification
Place an (I) infiltration and/ or (P) phlebitis beside the symptom most commonly
associated with infiltration or phlebitis
1. Blanching
_____________
2. Cold skin
_____________
3. Hot skin
_____________
4. Palpable cord
_____________
5. Pain
_____________
6. Redness
______________
7. Sensation of heaviness
_____________
8. Swelling
_____________
9. Tenderness
_____________
10. Burning Sensation
_____________
Peripheral Intravenous (I.V.) Initiation 52
Short Answer
1. Identify FOUR purposes of IV infusion
a) ____________________________
b) ____________________________
c) ____________________________
d) _____________________________
2. The first line of defense against nosocomial infection is _______________
3. List 3 characteristic of Veins and arteries
Veins
a) _________________
b) _________________
c) _________________
Arteries
________________
________________
_________________
Post Test score: __________
PLEASE RETURN TO YOUR CLINICAL NURSE EDUCATOR – THANK YOU
Peripheral Intravenous (I.V.) Initiation 53