A guide to starting
IV Therapy
Barbara Gibbs RN, BSN
Southeastern Louisiana University
NURS 634
May 3, 2009
For clinical lab this week, we will be initiating
IV therapy. Please read the selection in the
Nurses’Guide to Clinical Procedures on
p. 181-194. Also read Manual of IV Therapeutics
p. 281-344. You may also want to go to
the lab and spend some time with the
simulator prior to class. Please call the lab
coordinator to arrange that. We asked that
you don’t use your poor family members
and friends for practice!
In this lesson, I will use the Adult Education Theory. According to our textbook on p. 207, most adults like being involved in
the learning process. They take on the responsibility of learning (Billings & Halstead, 2009).
I chose IV therapy because I am constantly teaching other nurses at work how to start IVs. Most are still intimidated by
them, but style and technique comes with practice. Many student nurses enjoy getting to do “hands-on” skills.
Pre-Lab Survey
In this lesson, I will use a Course-Related Self-Confidence Survey (Angelo & Cross, 1993,
CAT 32). My teaching goal is to help the nursing student gain knowledge, self-confidence, and
self-esteem (Angelo & Cross, TGI Goal 45)
1. Rate your self-confidence – how you feel about starting IVs – by
circling the appropriate number below:
1. Extremely Low
2. Low
3. Average for me
4. High
5. Extremely High
2. Briefly explain why you gave yourself the
the rating above.
3. Overall, for the semester, how would you rate your selfconfidence?
1. Extremely low
2. Low
3. Average for me
4. High
5. Extremely High
4. An instructor could raise (or has raised) my self-confidence by:
Answer the following questions:
Please post your answers on discussion
board linked with this assignment
1.
By posting their answers, the student will also utilize the internet
along with the textbook readings. I have used two different
CATs with the lesson to help initiate the learning process. It is
up to the adult learner to complete assignments prior to class.
What is the very first step in the initiation of IV therapy?
a. Gather all the necessary equipment
b. Wash hands
c. Explain the procedure to the patient
d. Check the physician’s order
2.
Why is the antecubital vein not the best vein for IV
therapy even though it is usually easy to cannulate?
3.
Do you know the policy for accidental needle sticks?
4.
Where would this policy be found or how can you find it?
History of Infusion Therapeutics
(Phillips, 2001, p. 1,2)
1616 Sir William Harvey discovered the circulation of blood
1660 Sir Christopher Wren produced the first hypodermic needle
1662 Johann Majors used the needle to inject compounds into humans (resulted in
death)
1667 Jean Baptiste Denis infused from animal to human (resulted in death)
1687 Animal to human transfusions prohibited in Europe – 150 years go by
1832 Dr. Thomas Latta infuses saline to treat diarrhea from cholera (banned in the
US)
1867 Lister’s work on sterility and Louis Pasteur’s Germ Theory accepted
1889 William Halsted and Goodyear Rubber Co. introduce rubber gloves
1925 Dextrose used, but only in the critically ill
Massachusetts General Hospital has the first designated IV nurses
1950 Rochester needle introduced
1957 McGaw Lab introduced small vein sets with foldable wings as grips
1958 Intracath, a plastic catheter within the lumen of a needle in sterile packaging
1960s Momentum for change with a variety of solutions
Indications for IV Therapy
• Provides venous route
for administration of
fluids, medications,
blood, or nutrients
• Urgency in which
medication is needed
• Oral route is not
available
• Patient must have drugs
that would be destroyed
by digestion
(Smith-Temple & Johnson, 2002, p.181)
Vascular Access Devices VADs
• Peripheral IV access (which we will practice)
• Midline catheters
• Central venous access device CVAD
*non-tunneled
*tunneled
*implantable ports
• Peripherally inserted central catheter
PICC
(Scales, 2008, p.S4)
Sensory
Receptors of the
Venous System
Mechanoreceptors process skin
tactile sensations and deep tissue sensation
(palpation of veins)
Thermoreceptors process
temperature and pain (application of heat or
cold)
To decrease pain, keep
the skin taut by applying
traction to it. Move
quickly past the pain
receptors.
Four of the five types of
sensory receptors affect
parenteral therapy. These
receptors transmit along
afferent fibers.
Nociceptors process pain (puncture
or insertion of the cannula)
Chemoreceptors process osmotic
changes in blood and decreased arterial
pressure (decreased circulating blood
volume)
(Phillips, p.286-287)
Steps to Success
• Check the physician’s orders
• Educate the patient
• Gather and prepare the necessary
supplies
• Meticulous handwashing
• Site selection
• Needle selection
• Gloving
• Site preparation
• Vein entry
• Catheter stabilization
• Dressing application
• Equipment disposal
• Documentation
(Phillips, p.293)
Check the
physician’s
orders
A doctor’s order is needed to initiate
IV therapy. The orders should be dated
and timed. If it is a verbal order, then it
must be signed within the specified
time period. Remember to look for the
name of the fluid, the route of
administration, the dosage, volume,
and rate. Check the patient’s allergies.
Educate the Patient
• Explain the purpose
and procedure to the
patient
• Listen to his
suggestions or fears
and attempt to
decrease any anxiety
• Provide comfort and
privacy for the
patient
Why I need
IV Therapy!
Gather and prepare
the necessary
supplies
Some facilities have IV start kits,
others, such as ours, have
individual supplies. You will
need:
• a tourniquet (most are now
Latex free, but check your
patient’s chart for allergies)
•Alcohol wipes or Chlorhexidine
wipes
•Jelcos (I usually take a 20 and 22
gauge)
•2 x 2 gauge
•Tape
•Occlusive dressing
•IV pigtail or extension
•Saline flush
Handwashing
Handwashing is the first
line of defense against
cross contamination.
Hands should be
washed for 20 seconds
with an antibacterial
soap, rinsed, and dried
with a disposable paper
towel. Turn the faucet
off with the paper towel
and dispose.
(CDC, 2007)
Site Selection
• Veins of the hands and
arms are the most
commonly used.
• Carefully choose the site
by considering ease of
insertion and access, size
or type of catheter,
comfort and safety for the
patient, and most effective
site for the patient’s
situation
(Phillips, 2001, p. 290)
Image from
http://www.nda.ox.ac.uk/wfsa/html/ulz/u1213t03
.gif Retrieved 4/16/09.
Site Selection & Needle Selection
Factors to consider:
• Type of solution: Hypertonic solutions such as antibiotics (Vancomycin) and
potassium chloride are irritating. Choose a large vein and start at the lowest, best
vein.
• Condition of vein: Palpate the vein. It should feel elastic like a rubber band. Older
patients or hypovolemic patients’ veins collapse more easily. You should stay
away from the dorsal metacarpal veins and search for a larger vein. Avoid sites
that are bruised, red, swollen, near previously infected areas or near a previously
discontinued site. DO NOT start an IV on an extremity with a dialysis access or on
a patient’s side of an old mastectomy.
• Duration of therapy: IVs are good for 72 hours in most facilities. Alternate arms
with each subsequent venipuncture and go distally proximal to the previous IV.
Avoid joint flexion as patient’s usually bend arms during sleep or movement.
• Cannula size: The gauge should be as small as possible unless the patient will be
receiving blood. An 18-20 gauge is preferred to prevent hemolysis of the cells.
• Patient age: For the purpose of this lesson, we are cannulating adult patients 18
and older. Remember that veins in the elder are fragile. Fragile veins sometimes
work better if no tourniquet is used.
(Phillips, p. 295-297)
Gloving and Site Preparation
Prior to procedure, and after handwashing,
don clean gloves.
1.
Gravity: Place extremity lower than heart
level.
2.
Fist Clenching: Patient may open and
close fist.
3.
Tapping: Tapping the vein causes it to
release histamines beneath the skin and to
dilate.
4.
Warm compresses: Applying warm
compresses also will also cause the vein to
dilate.
5.
Blood pressure cuff: This can also
cause dilation by pumping the cuff up to
about 30mmHg.
(Phillips, p. 298)
Cleanse the area with 70% alcohol or Chlorhexidine to
reduce the potential for infection.
Vein Entry
• With the nondominant hand, pull
the skin taut for stabilization.
• Using dominant hand, insert the
needle bevel up at about 15-30°.
• Maintain parallel alignment and
advance through the subcutaneous
tissue. You should start to see a
flash of blood in the chamber.
• Release the tourniquet with the
nondominant hand and “allow the
vein to get used to the idea”.
Slowly advance the cannula while
retracting the needle. You will
hear a click when it is locked in
place. (Phillips, p. 303)
Forward the catheter while
withdrawing the needle until you hear
a click. You should see blood in the
flash chamber.
Remove the catheter at the hub and attach
the IV pigtail or extension. You can keep
this bloodless by applying pressure at the
distal end of the catheter. You may also
place a 2x2 gauze at the connection to
prevent a mess.
Flush the catheter with normal saline.
Check for any swelling to make sure
the vein has not infiltrated and that the
site is good.
Stabilize the catheter using the Chevron
Method
Dressing Application
• Catheters must be stabilized and
an occlusive dressing applied in a
manner that does not interfere
with assessment and monitoring
of the site. (Phillips, p.305)
• After placing an occlusive
dressing, usually a tegaderm, label
the site with your initials, type of
catheter, and the date.
•
We gratefully appreciate our victim here, who is also my
father, Mr. Grant. At the time of this photo, I did not
have a tegaderm. So, in this case, it is a do as I say, not
as I do.
Equipment Disposal
• Needles, syringes, and
any bloody items should
go in a biohazard
container to prevent
needlestick injuries and
the spread of bloodborne
pathogens.
• Dispose all other paper
and plastic supplies in the
trash bin.
• Check the patient’s bed
and linens for lose
supplies.
Documentation
• We all know the drill, “Not
documented, Not done”
• Example documentation might be:
20 gauge heplock started x 1
attempt to R FA. Flushes well
with + blood return. Dressing
applied to site. No signs of
infiltration. L FA heplock d/c’d
with catheter intact, pressure
drsg applied. Pt tolerated
well…Bgibbs RN.
Grading and Competency Criteria
Clinical Skill
1. Checks the physician’s orders
2. Educates the patient
3. Gathers the necessary supplies
4. Performs proper handwashing
5. Site Selection, can name basic veins and anatomy
6. Needle Selection, can give rationale for size
7. Gloving, can verbalize rationale for precautions
8. Performs Site Preparation
9. Attempts entry of vein using proper technique
10. Applies good catheter stabilization
11. Applies dressing properly and labels
12. Disposes all equipment per protocol
13. Documents well
14. Can verbalize needlestick policy for facility
The student must be able to perform at 85% or
better. The student does not have to cannulate
the vein, but must make an attempt.
Shows Skill Shows Need
Post Clinical Skills Lab
1.
2.
3.
Identify techniques
that you have observed
in clinical that may
help you in the future.
Why is it necessary to
check for patency
during the shift?
Label the veins on p.
329, Copy them and
turn it in next week.
References
Angelo, T. & Cross, P. (1993) Classroom Assessment Techniques:
A Handbook for College Teachers. San Francisco: Jossey
Bass, 87-88
Billings, D. & Halstead, J. (2009) Teaching in Nursing: A Guide for
Faculty. 3rd ed. St. Louis: Saunders Elsevier, 207
CDC recommendations and Reports (2007) Retrieved April 15, 2009
from
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5605a4.htm
Phillips, L. (2001) Manual of I.V. Therapeutics. 3rd ed. Philadelphia:
F.A. Davis, 281-344
Scales, K. (2008) Intravenous therapy: A guide to good practice.
British Journal of Nursing. 17(19), S4-S12. Retrieved from
CINAHL full text database.
Smith-Temple, J. & Johnson, J. (2002) Nurses’ Guide to
Clinical Procedures. 4th ed. Philadelphia: Lippincott,
181-194
Images obtained from Microsoft Clip
Art and from www.images.google.com
A special thank you to Mr. Grant
who served as our model vein for
the photography used in this
powerpoint