Intravenous Therapy: IV Insertion

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What is intravenous insertion?

Intravenous (IV) insertion is a procedure wherein a vein is punctured through the skin by a cannula to provide venous access.

IV insertion site using a Gauge 20 IV Catheter
IV insertion site using a Gauge 20 IV Catheter

To whom is IV insertion done?

IV Insertion is done to clients:

  • with fluid and electrolyte disturbances
  • who are critically ill
  • who have nothing per orem (NPO) after surgery or for any other reason

Initiating IV Therapy through IV Insertion

Steps

Rationale

1. Check doctor’s order, identify client and secure consent.

IV insertion can’t be performed without doctor’s order.

Proper identification ensures that procedure is done to the right client.

Initiating IV therapy through IV insertion is an invasive procedure that needs client’s consent.

2. Wash hands and prepare all equipment at bedside. Ensures asepsis and a smooth flow of procedure.
3. Explain procedure and answer client’s questions and worries. Decreases fears and anxiety.
4. Select IV site.

Choose distal veins so that once damaged, the proximal part of the vein can still be used.

Avoid areas that bends (hands and wrist) to prevent infiltration.

Use non-dominant hand for freedom of movement.

Avoid extremity with low sensation or poor integrity.

5. Ask client to rest arm of selected vein. Makes the veins more visible.
6. Put on gloves. Maintains asepsis.
7. Cleanse insertion site from starting in the middle of the site going outward.

Reduces transmission of microorganism.

Be sure to leave the area dry before insertion.

8. Apply tourniquet 5-6 inches above selected site. Engorges the vein for easier IV insertion.
9. Anchor vein by placing thumb over vein and stretching the skin against the direction of insertion. Stabilizes the vein and aids in IV insertion.
10. Insert the stylet-catheter, with bevel up, at a 20 to 30 degree angle. Prevent damage to the posterior wall of the vein.
11. Check for blood backflow. Pressure from tourniquet causes quick backflow of blood into the catheter.
12. Loosen stylet and advance catheter into the vein until hub rests on the IV site.

Ensures proper placement of catheter.

Note: Do not reinsert stylet after loosening to prevent puncture to the catheter.

13. Hold thumb over the vein above the catheter tip and release tourniquet. Prevents blood leaking and reestablishes venous blood flow.
14. Quickly release pressure over the vein and connect needle adapter of the IV set to the hub of the catheter. Prompt connection reduces blood loss.
15. Begin infusion at a slow rate (per institution policy). Keeps vein open and ensures patency of IV.
16. Tape over the hub of the catheter. Place transparent dressing over the site. Secure catheter in place and controls bleeding and infection.
17. Secure tubing in loop fashion. Prevents tubing dislodgment.
18. Remove gloves and do aftercare. Prevents transmission of microorganisms.
19. Label the site with date and time of insertion and the size and gauge of catheter. Serves as guide for next dressing change.

What to document?

Make sure to document the following after procedure:

  • date and time of IV insertion
  • size and gauge of catheter
  • client’s untoward reaction to the procedure
  • type of fluid infused and prescribed rate
  • additives, i.e. contrast amount and type

Key Considerations:

  • During IV insertion on elderly clients, use a 5 to 15 degree angle because their veins are more superficial.
  • It is recommended to change IV site every 3 days to avoid infection and other IV complications. Refer to the institution’s policy.
  • Always insert IV in the direction of venous return (toward the heart) to prevent venous valve damage.

Intravenous Therapy: IV Insertion Sites, Equipment and Safety Guidelines

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Initiating IV therapy through IV insertion is a specialized and complex technique. Nurses are required to have basic knowledge of the anatomy and physiology of the different venipuncture sites to ensure client’s safety.

What are the different IV insertion sites?

The most accessible routes for IV insertion are the veins of the forearm because of its location and number.

    • Metacarpal Veins. Formed by the union of the digital veins on the back of the hand. They are ideal for IV insertion because they are easily visible and they lie flat.
    • Cephalic Vein. Located along the radial border of the forearm, the cephalic vein is ideal when using large bore cannulas or catheters. WARNING: When using this vein, avoid inserting IV near the watch-strap area because of the risk of radial nerve injury.
    • Basilic Vein. Runs along the ulnar border of the forearm and is prominent among male clients.

What materials must be prepared to initiate IV therapy?

Drip intravenous system
Adapted from DepositPhotos.com
  • Peripheral IV catheter. Use the smallest gauge and length possible to administer prescribed therapy but a large bore catheter for emergency therapy like blood transfusion.
  • IV start kit. Many healthcare institutions have these. It contains: 1) sterile drape, 2) tourniquet, 3) tape, 4) transparent dressing, 5) cleansing solution (70% alcohol or povidone-iodine), 6) 2×2 inch gauze pads 7) scissors
  • Clean gloves
  • Extension set. This can either be a saline lock, heparin lock, IV plug or adapter.
  • Prefilled 5-mL syringe with flush agent. The flush agent is a 0.9% saline solution.
  • Alcohol pads
  • Stabilizing device. This is optional but necessary for pediatric and geriatric clients.
  • Intravenous solution as prescribed by physician
  • Administration set. Choose between macrodrip or microdrip depending on prescribed rate.
  • Protective equipment. Involves the use of mask and goggles as per agency policy.
  • IV hanger. It can either be a pole or a mount on the wall or ceiling.
  • Watch. Use a watch with a second hand to accurately calculate drip rate.
  • Special patient gown. If available, have the client wear a gown with snaps at shoulder seam to make IV tubing removal  much easier.
  • Biohazard disposal container. To safely dispose sharps.

Nursing Safety Guidelines

Patient Education

  1. Educate client about the procedure in clear and concise terms. Allow client to ask questions and answer them to clarify any doubts and fears about the procedure.
  2. Instruct the client about the rationale for initiating IV therapy as well as the medications and solutions that will be used.
  3. Tell client what signs to report: inflammation, clotting, leaking or breaking.
  4. Give client instructions on how to bathe without getting the dressing wet.
  5. Discuss client’s activities and find out which activities can be continued to ensure safety during IV therapy.

Nurse Preparation

  1. Before starting IV therapy, check if you have all the needed information, physician’s order and equipment.
  2. Identify client properly using any two identifiers per agency policy: name and birthday OR name and account number
  3. Review and report any incompatibilities between prescribed medications and infusion solutions.
  4. Assess the appropriate route and rate of infusion. Ideally, use the client’s non-dominant hand if possible. NOTE: Never shave the chosen venipuncture site to avoid cuts and nicks.
  5. Assess for client’s allergies to latex or povidone-iodine.
  6. Do a mental review of the entire procedure from start to end and consider modifications, if needed.
  7. Maintain strict sterile techniques when required to prevent infections.
  8. If an equipment gets contaminated during the procedure, change it with a new one.
  9. Use standard precautions when dealing with body fluids and sharp items.

Key Points:

  • When choosing venipuncture sites, prioritize the veins on the non-dominant hand, if possible.
  • Give client as much as instruction needed about the procedure to prevent anxiety, clarify doubts and reduce fears.

Intravenous Therapy: Introduction and Legal Considerations

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What is the goal of IV therapy?

The goals of IV Therapy are to:

  • maintain and prevent fluid and electrolyte imbalances
  • administer parenteral medications or solutions
  • replenish blood volume
Regulating an IV drip
Adapted from DepositPhotos.com

Can IV therapy be delegated?

Starting IV therapy through IV insertion is an invasive procedure that cannot be delegated by the nurse unless other licensed personnel has been certified and trained to perform the procedure.

In case of delegation, the nurse must instruct the delegated personnel to report the following:

  • IV site related complications: pain, redness, swelling, bleeding
  • IV dressing becomes wet
  • low fluid in the IV bag or the electronic infusion device (EID) alarms

What are the legal considerations prior to IV therapy?

Consent is required before a nurse can start IV therapy.

The consent can either be oral and written.

What are the situations when the client is incapacitated to give a consent?

Client is incapacitated to give a consent when he or she is:

  • a minor
  • unconscious
  • mentally incompetent

From whom can the nurse obtain a consent when the client is incapacitated?

If the client is unable to give consent, the nurse may obtain consent from any of the following:

  • guardian appointed and authorized by court to make healthcare decisions
  • a person with a “power of attorney for personal care”
  • an appointed representative by the Consent and Capacity Board
  • legal spouse
  • parent
  • brother or sister of legal age
  • a relative of legal age

In what situations can IV therapy be initiated without consent?

IV insertion can be initiated without consent from client or representative during life threatening or emergency situations.

In such cases, it is considered an implied consent.

What happens when the client revokes consent?

Any time during the procedure, the client can revoke his or her consent. The healthcare provider or nurse must then stop the procedure immediately.

When is consent valid?

Consent is considered valid when it meets minimum standards required by law. Client must understand:

  • facts of the procedure
  • its implications
  • future consequences and complications

Key Points:

  • Consent is needed before a nurse can start IV therapy.
  • Initiating IV therapy is an invasive procedure that can be delegated by the nurse only to trained and certified personnel.
  • The goals of initiating IV therapy are to: 1) maintain and prevent fluid and electrolyte imbalances; 2) administer parenteral medications or solutions and 3) replenish blood volume.