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iv-skills

9 min read

References:

  1. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition, ISBN 978-0-13-542873-3, by Audrey Berman, Shirlee J. Snyder, and Geralyn Frandsen
  2. Lecturer (KBAP)

Insertion of an Intravenous Catheter

An intravenous infusion is performed to supply fluid when clients are unable to take in an adequate volume of fluids by mouth, to provide salts and other electrolytes needed to maintain electrolyte balance, to provide glucose (dextrose), the main fuel for metabolism, to provide water-soluble vitamins and medications, and to establish a lifeline for rapidly needed medications.

  1. Verify the order for venipuncture. Explain the procedure and its indications to the client, and how long it will need to be in place. Perform scheduled care if the IV therapy is non-urgent, as moving the patient after establishing the infusion can disturb its integrity.
  2. Confirm patient identity. Commonly, at least two identification methods are used. In order of reliability, the nurse: (1) checks the identification bracelet/band, (2) instructs the patient to state their name and birthdate, and (3) verifies identity with the staff member.
  3. Assess for contraindications, e.g., allergies, arteriovenous fistula (preserved for hemodialysis access), 1mastectomy site (risk for lymphedema), hemiplegia, infection, phlebitis, and areas below previous infiltrations or extravasations.
  4. Perform hand hygiene and observe other appropriate infection prevention procedures.
  5. Position the client appropriately. Use a comfortable position, either upright or sitting.
  6. Prepare equipment and paraphernalia.
    • Open and prepare the infusion set. Close the clamp.
    • Spike the solution container. Remove the protective cover of the bag or bottle, remove the cap from the spike, and insert he spike into the insertion site of the bag or bottle.
    • Hang the solution container on the pole. It should be suspended about 1 meter above the client’s head. Label the solution container if any medications have been added.
    • Partially fill the drip chamber with solution. Squeeze the chamber gently until it is half full of solution.
    • Prime the tubing: release the clamp and let the fluid run through the tubing until all bubbles are removed. Reclamp the tubing and replace the tubing cap, maintaining sterile technique.
  7. Perform hand hygiene again before initiating client contact.
  8. Select the venipuncture site:
    • Use the nondominant arm unless contraindicated. Identify possible venipuncture sites by looking for relatively straight veins. They may be palpable, but may not be visible especially in clients with dark skin.
    • Consider the catheter length; look for a site sufficiently distal to the wrist or elbow such that the tip of the catheter will not be at a point of flexion.

Principles

In adults, the dorsal aspect of the hands at the arteriovenous arch is the preferred site of insertion. Site selection for infants is preferably the feet or scalp.

  • If using the hand, use the non-dominant hand.
  • Distal sites are preferred over proximal sites.
  • Avoid mastectomy sites and other contraindications such as comprised circulation and injury.
  • Insert on areas naturally splinted by bone; avoid mobile areas—areas of flexion. The underlying bone prevents joint movement, keeping the IV more stable and less prone to dislodgement.
  • Easily palpable veins are better than highly visible veins.
  1. Dilate the vein.
    • Place the extremity in a dependent position.
    • Apply a tourniquet 15 to 20 cm (6 to 8 in.) above the venipuncture site. It should be tight enough to obstruct venous flow, but not too tight as to obstruct arterial flow. Palpate for a radial pulse to assess the adequacy of arterial flow. Tourniquet use may not be appropriate for clients with fragile skin (e.g., older adults).
    • If the vein is not sufficiently dilated, (a) massage or stroke the vein distal to the site and in the direction of venous flow toward the heart; (b) encourage the client to clench and unclench the fist; (c) lightly tap the vein with your fingertips.
    • If the vein remains unpalpable, remove the tourniquet and wrap the extremity in a warm towel for 10 to 15 minutes. This dilates superficial blood vessels, causing them to fill.
    • If no veins are visible or easily palpated, use vein visualization technology to improve insertion success.
    • Remove the tourniquet once a site has been selected for preparation of the site.
  2. Minimizing pain is usually overlooked, but is possible with transdermal analgesic creams, intradermal lidocaine, or according to agency policy.
  3. Apply gloves and clean the venipuncture site.
    • If visible soiled, soap and water is used. Excess hair may be removed, if necessary, using scissor or surgical clippers.
    • Clean the skin at the site of entry using a topical single-use antiseptic swab (preferably chlorhexidine gluconate-alcohol solution) applied in a back-and-forth motion for a minimum of 30 seconds to scrub the insertion site and surrounding area, then air-dry.
    • Re-application of the tourniquet above the intended venipuncture site or vein visualization technology may be used if needed. If palpation is necessary, apply sterile gloves.
  4. Insert the catheter and initiate the infusion.
    • Remove the catheter assembly from its sterile packaging and remove the cover of the needle (stylet).
    • Use the nondominant hand to pull the skin taut below the entry site. This stabilizes the vein and makes the skin taut for needle entry.
    • Insertion is done with a 15° to 30° angle along the selected vein. The bevel is pointed up. A sudden lack of resistance is felt as the needle (stylet) enters the vein. Use a slow, steady insertion technique and avoid jabbing or stabbing motions.
    • Once blood appears in the lumen or clear “flashback” chamber of the needle, lower the angle of the catheter until it is almost parallel with the skin, and advance the needle (stylet) and catheter approximately 0.5 to 1 cm (~1/4”) farther into the vein. Holding the needle assembly steady, advance the catheter forward off the stylet until the hub is at the venipuncture site. The exact technique depends on the type of device used.
    • If there is no blood return, try redirecting the catheter assembly again toward the vein. If the stylet has been withdrawn from the catheter, or the catheter tip withdrawn even a small distance, it is considered contaminated and cannot be reused. Reinsertion of the stylet can also damage the catheter.
    • If blood begins to flow out of the vein into the tissues, creating a hematoma, insertion has not been successful. This is sometimes referred to as a blown vein. Immediately release the tourniquet and remove the catheter, applying pressure over the insertion site with dry gauze. Attempt the venipuncture in another site, in the opposite arm if possible. Reusing the same arm above the unsuccessful site could result in infusing fluid into the already punctured vein, causing it to leak.
    • Release the tourniquet.
    • Put pressure on the vein proximal to the catheter to eliminate to reduce blood oozing out of the catheter. Stabilize the hub with thumb and index finger of the nondominant hand.
    • Remove the protective cap from the distal end of the tubing and hold it ready to attach to the catheter, maintaining sterility of the end.
    • Stabilize the catheter hub and apply pressure distal to the catheter with your finger. This prevents excessive blood flow through the catheter.
    • Carefully remove the stylet, and attach the end of the infusion tubing to the catheter hub.
    • Initiate the infusion or flush the catheter with sterile normal saline. This removes blood from the tubing and prevents clotting. Watch closely for infiltration (discussed later).
  5. Stabilize the catheter and apply a dressing.
    • Secure the catheter according to instructions and policy. If tape is used, it must be sterile and placed on the catheter adapter and directly on the catheter-skin junction site.
    • Apply a transparent semipermeable membrane (TSM) over the insertion site. Transparency allows for continuous assessment of the site. No ointments of any kind is placed under the dressing. No tape should be placed directly on the TSM dressing.
    • Label the dressing with the date and time of insertion, gauge, and initials.
    • Apply an IV site protection device, if available. These prevent dislodgement of the IV catheter and still provide easy assessment of the site.
    • Loop the tubing and secure it with tape. Looping the tubing will redirect the weight of the tubing, preventing its weight or movement from pulling on the needle or catheter
  6. Discard the tourniquet. Each tourniquet is only used for one patient to reduce cross-contamination. Remove and discard and gloves. Perform hand hygiene.
  7. Ensure appropriate infusion flow. An arm board may be used to splint the joint if needed. Adjust the infusion rate of flow according to the order.

Other Parenteral Routes

An angle of 5 to 15° is used for intradermal needle insertion. An angle of 45° is used for subcutaneous needle insertion while pinching the skin of an normal weight individual, and spreading out the skin of an obese individual. An angle of 90° is used for intramuscular needle insertion without any pinching necessary.

In all of these routes, routine aspiration is no longer performed. Aspiration has shown to be minimally beneficial. However, it may still be performed if the site of insertion is close to large blood vessels (e.g., dorsogluteal site) and if medications are high-risk if given via IV.

Aspiration is performed in IV insertions to determine patency.

  1. Label the tubing, and bag with the date and time of insertion as basis for dressing (labeled earlier), tubing, and bag changes at regular intervals, i.e., according to agency policy. Tubing and bag changes may be done every 1 to 2 days and dressing changes done every 3 to 4 days.
  2. Perform client teaching: limitations on movement and activity, protection of the site, signs and symptoms of complications, and alarms if an electronic infusion device is being used. Importantly, emphasize infection prevention precautions, including hand hygiene by all healthcare providers who provide care.
  3. Document all assessments and interventions: date and time; type, length, gauge of needle or catheter; venipuncture site and how many attempts were made; amount and type of solution used, including any additives; flow rate; type of dressing; general response of the client; and client education.
  4. Regularly check the client for intended and adverse effects of the infusion. Check skin status at IV site, status of the dressing, the client’s ability to perform self-care activities, and client’s understanding of any mobility limitations at least every 4 hours. Follow-up on deviated findings. Report significant deviations from normal to the primary care provider.

Footnotes

  1. In a patient with a double (bilateral) mastectomy, the distal portion of the non-dominant hand is used. ↩

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