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Intravenous Therapy: Assessment and Maintenance of an IV Insertion Site

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Why should the IV insertion site be regularly assessed and maintained?

Assessment and maintenance of an IV insertion site is done to ensure that the client does not suffer any untoward complications connected to IV therapy.

What indicates a normal IV insertion site?

  • Healthy Vein. A healthy vein is round, firm, elastic and engorged without hardened, bumpy or flattened areas.
  • Absence of signs and symptoms of complications. The IV insertion site must be free from redness, swelling, bleeding, warmth at the IV site, pallor, pain or discharge.

Assessment and Maintenance of an IV Insertion Site

Steps Rationale
1. Review the doctor’s order for IV therapy. Ensure accuracy of the administration of IV therapy.
2. Review for hypersensitivity to medications. Prevents risk of allergic reactions.
3. Review client’s IV site record and Intake and Output records. To check for previously noted IV site problems or fluid and electrolyte imbalances.
4. Wash hands and obtain vital signs. Decreases transmission of microorganisms and checks changes in client’s cardiovascular system.
5. Check IV fluid for the following:

  • right fluid
  • right additives
  • right rate
  • right volume at the beginning of shift
Ascertains client is receiving the appropriate IV therapy.
6. Check IV tubing connections. To avoid fluid leaks.
7. Check the gauze IV dressing and vein site for the following:

  • Dampness
  • Redness
  • Warmth
  • Swelling
  • Pain
  • Drainage
These are early signs and symptoms of IV insertion site complications: infection, infiltration or phlebitis.
8. Document according to institution policy:

  • Name of IV solution with additives
  • Rate of infusion
  • IV site condition
  • Time assessed
Provide record of significant IV site findings and proof of regular IV site observation.
9. Wash hands and do aftercare. Decreases transmission of microorganisms.

What must the nurse do with the abnormal IV site assessment findings?

IV Site Complication Nursing Intervention

Hypersensitivity

Note for:

  • fever
  • joint swelling
  • rash
  • hives
  • wheezing
  • Discontinue the infusion.
  • Notify doctor immediately.

Infiltration

Note for:

  • swelling
  • discomfort
  • burning sensation
  • cool skin
  • pallor of site
  • Stop infusion and discontinue IV.
  • Elevate affected extremity.
  • Restart new IV site above previous site or opposite extremity.
  • Document findings and intervention done.
  • Notify doctor for follow-up care.

Phlebitis

Note for:

  • redness
  • tenderness at tip of the IV catheter
  • edema over vein
  • warmth of IV site or general elevated temperature
  • Stop infusion.
  • Apply warm packs for client’s comfort.
  • If necessary, restart new IV site on the opposite arm with larger vein and smaller device.
  • Document findings and intervention done.
  • Notify doctor for follow-up care.

Extravasation

Note for:

  • burning or stinging discomfort
  • cool skin
  • redness
  • swelling 
  • Follow agency’s protocol for extravasation.
  • Stop IV flow or remove IV line.
  • Estimate amount of extravasated solution.
  • Instill appropriate antidote per agency protocol. The commonly used antidote is phentolamine [Regitine].
  • Elevate extremity.
  • Document findings and intervention done.
  • Notify doctor.

Key Considerations:

  • Elderly patients have fragile veins that are prone to infiltration. Extra careful assessment must be done.
  • Always teach client the signs and symptoms of IV insertion site complications so that they know what to report.