inserting a peripheral IV in adults

preprocedure steps for inserting a peripheral IV

Check care plan, treating clinician orders, and facility protocols on inserting peripheral IV cannula using over-the-needle technique. Review patient's medical history/medical record for: Indications for inserting peripheral IV cannula using over-the-needle technique Medication use, such as anticoagulants Lab/other diagnostic test results, such as coagulations studies Allergies (use alternatives as appropriate) Note: if topical or injectable anesthetic is to be used. EMLA cream requires 1 to 1.5 hours to take effect, IV insertion must be preplanned (vs emergency treatment) in order for EMLA to be a useful analgesic for the cannulation procedure.

red flags for peripheral IV

DO NOT use peripheral IV for routine blood sampling because their small diameter can increase risk of clotting monitor for complications of peripheral IV insertion including extravasation, phlebitis, thrombosis, hematoma, and infiltration including redness, swelling, pain, and visual or palpable enlargement of the cannulated blood vessels

documentation for inserting peripheral IV site

Date/time of IV cannula insertion Description of IV cannula insertion, including catheter size, anesthesia type (if any), and catheter placement method IV solution administered, if applicable Patient assessment information Patient's tolerance of IV cannula insertion Any unexpected patient events or outcomes, interventions performed, and whether the treating clinician was notified Patient/family education, such as topics presented, response to education, plan for follow-up education, any communication barriers, and techniques that promoted successful communication

post procedure steps of inserting a peripheral IV

Evaluate IV site every 8 hours or per facility protocol to detect signs/symptoms of CLABSI or infiltration, including redness, pain, swelling, or vein enlargement. Do not delegate this duty to assistive medical staff. Replace IV cannula, IV tubing, and accessory equipment after specified period per facility protocol to reduce risk of phlebitis or infection. Remove IV cannula when IV therapy no longer is needed.

client and family education for inserting peripheral IV

Explain purpose of inserting a peripheral IV cannula with over-the-needle technique and describe what to expect during and after procedure. Explain importance of protecting insertion site, and to immediately report any leakage, bleeding, pain, or other unusual conditions. Explain importance of keeping IV patent by avoiding activities that place pressure on IV site or cause catheter to bend. Educate patients about avoiding vigorous physical activity because catheter could become dislodged or damaged. Provide information for contacting nurse or treating clinician if questions/problems arise after discharge. Provide patient education resources, if available, to reinforce verbal education.

signs and symptoms of CLABSI (central line associated bloodstream infection)

Fever Chills/rigors Hypotension Tachycardia Diaphoresis Lethargy Altered mental state Hemodynamic instability (shock)

INS/CDC/HICPAC issued recommendation timing when replacing a catheter, admin sets, dressing changes: nursing responsibilities when assessing and maintaining IV catheters in the absence of signs and symptoms of IV related complications guidelines are as follows: replacing admin sets

IV admin sets that are used for continuous infusions (excluding blood, blood products, or fat emulsions) should be changed no more frequently than at 96hr intervals but no less than frequently than every 7 days tubing and filter used to admin blood or blood products should be changed after each unit has been completed or every 4hr (more than 1 unit can be transfused if completed within 4hr) tubing used to infuse propofol (diprivan) should be changed every 6-12hr or when the medication vial is changed primary intermittent admin sets should be changed every 24hr

standard preprocedure steps for inserting a peripheral IV

Introduce yourself to patient/family. Identify patient using at least 2 unique identifiers (such as full name, date of birth, or medical ID number). Identify and address any special communication needs patient/family may have. Identify and accommodate, if possible, any specific cultural and religious beliefs that may enhance care. Be aware of any assumptions you may have to minimize bias. Ask patient if they would prefer a clinician of a certain gender if procedure involves steps that possibly compromise dignity/privacy. Provide privacy for patient. Explain procedure. Verify completion of informed consent documents, if appropriate. Verify supplies are in good working order and review manufacturer instructions for use. Perform hand hygiene. Use personal protective equipment and appropriate aseptic technique.

standard postprocedure steps for inserting a peripheral IV site

Maintain patient safety. For example, position for safety, verify alarms are audible, verify call light is in easy reach, and follow facility protocol for fall prevention. Remove and discard used personal protective equipment and other used materials in proper receptacles. Clean equipment if there has been patient contact. See specific manufacturer instructions. Perform hand hygiene.

procedure supplies for inserting a peripheral IV

Nonsterile gloves Other personal protective equipment if you anticipate exposure to bodily fluids Antiseptic agent, typically 2% chlorhexidine gluconate (CHG) in 70% alcohol (or povidone iodine, iodophor, or 70% alcohol if CHG is contraindicated) Disinfectant, facility-approved Sterile gauze or antiseptic-impregnated swabs Tourniquet (rubber band for infants or BP cuff for older adults or those with fragile skin/veins) Transparent, occlusive dressing Sterile, nonallergenic tape Vascular securement device (and skin protectant), optional Over-the-needle IV catheter with built-in safety mechanism Prefilled sterile normal saline flush syringe(s) Saline lock (short extension tubing with clamp) Supplies for IV infusion, if ordered, including IV solution, IV pole, infusion pump, and infusion tubing Splint or arm board (for pediatric patients or IVs placed at a flexion point) Local anesthetic, if prescribed, such as lidocaine solution for subcutaneous injection or topical anesthetic cream (EMLA) Ultrasound device with sterile probe cover and sterile gel packet, or near infrared light device (optional) Moist heating pad or carbon fiber warming mitt Single-use patient scissors or disposable-head surgical clippers

medication administration rights before admin in peripheral IV

Right Patient: Confirm identity using at least 2 unique identifiers. Use appropriate methods for newborns, such as mother's full name and baby's gender. Use barcode technology if available. Right Medication: Compare medication label to order and medication administration record. Triple check medication name when received, when prepared, and before administration. Verify patient is not allergic to medication. Verify expiration date has not passed. Right Dose: Check order and confirm appropriate dosage (such as for age and weight). Check label for medication concentration. Calculate dose and have second nurse confirm, if necessary. Right Route: Check route on medication label and compare to order. Confirm route is appropriate and patient can receive medication by route ordered. Right Time: Check medication frequency. Double check correct time. Confirm time of last dose. Right Documentation: Document medication name, dose, route, and time immediately after administration. Additional rights can include Right Reason, Right to Be Educated, Right to Refuse, and Right Response.

care considerations after for inserting peripheral IV

Site care, including skin antisepsis and dressing changes, should be performed per facility protocol and immediately if the dressing integrity becomes compromised. Typically, transparent semi permeable membrane dressings are changed every 7 days, and sterile gauze at least every 2 days. Peripheral IVs are removed if signs of complications are observed or if no longer needed for therapy. Peripheral IV cannulas are easier to insert and care for than central IV lines and are associated with fewer complications such as air embolism and sepsis. Sharps with built-in safety mechanisms, such as retractable needles, should be used to reduce risk of needlestick. Lower extremity cannulation has a higher risk of infection and thrombophlebitis compared with cannulation of an upper extremity. Consult with treating clinician regarding central line placement or other alternatives before inserting peripheral IV in a lower extremity. A small-gauge, shorter cannula usually causes less trauma to the vessel and is easier to insert than a larger or longer cannula. Ultrasound guidance or infrared lighting can increase success rates of IV insertion on first attempt without additional complications

patient outcome for inserting peripheral IV

The patient has peripheral IV access without complications, such as phlebitis and infection. The patient tolerates the cannulation procedure with minimal pain.

purpose of inserting an peripheral IV

a peripheral IV cannula is inserted using an over-the-needle catheter to deliver fluids, aqueous medications, blood products, and parenteral nutrition directly into a clients peripheral vein it is the fastest way to deliver fluids and medications throughout the body

skin preparation for peripheral IV insertion

access site be cleaned with a >5% chlorhexidine in alcohol solution alternatives include tincture of iodine, an iodophor, or 70% alcohol if contraindications to the chlorhexidine solution exist CHG in alcohol solution is applied using back and forth motion for a minimum of 30 seconds CHG should be used with caution in infants younger than 2 months of age povidone-iodine is applied per facility protocol and allowed to dry for 1.5-2min

procedure step 4 for inserting a peripheral IV

apply gentle pressure to skin above cannula to stabilize and prevent blood leakage release tourniquet with other hand attached primed saline lock with attached flush syringe to cannula hub flush cannula with normal saline to verify line is patent and flushes easily leave flush syringe in place until IV site is secured secure cannula hub to client skin with tape or vascular securement device (use skin protectant first) stabilize and cover IV site with sterile transparent dressing, maintaining visibility of insertion site and its proximal area close clamp on saline lock if indicated, remove syringe label dressing with date/time of insertion if an infusion is ordered attach distal end of IV tubing to Saline lock adjust infusion rate begin infusion use padded splint or arm board if IV site requires immobilization, secure at each end of splint if needed keeping central area open to allow for inspection

things you should know before inserting a peripheral IV cannula using Over the needle: how to choose an appropriate cannula

appropriate IV cannula size depends on its intended use, duration of use, and age/size of client use the smallest gauge cannula that can deliver the prescribed therapy at the desired rate use 18-20 gauge cannula for rapid infusion of IV fluids, viscous medications, or blood components use 22-24 gauge needle with a short cannula for older adults and ped clients, small gauge shorter cannula usually causes less trauma to the vessel walls and may be easier to insert be aware that obese clients with veins deep in the subcutaneous tissue may require longer peripheral IV cannula, if needed consider a peripherally inserted central catheter (PICC) as an alternative

things you should know before inserting a peripheral IV cannula using Over the needle

aseptic technique, meticulous hand hygiene should be used for all aspects of IV care to reduce the clients risk for infection, occlusion, and other complications associated with venous access device IV are inserted and maintained using general aseptic non touch technique (ANTT) the skin should not be touched after it has been prepared with antiseptic cleanser and any item introduced into the client is sterile prior to insertion confirm that sterile items and equipment are used and the sterile part of the equipment does not come into contact with anything else that is not sterile adhere to standard precautions when performing peripheral IV insertion (hand hygiene, PPE) sharps safety, use of sharp devices that are designed to prevent needlestick injuries anatomy of the vascular system, like superficial veins of the upper extremities veins suitable for cannulation are straight and resilient avoid using hard cordlike veins or veins located at a point of flexion (wrist or antecubital fossa) because client movement can cause the cannula to erode the vein wall and lead to infiltration veins in the forearm are preferred to those in the hand (exception is when inserting a small short-term winged needle catheter- ideally placed in veins in the hand that lie close to the surface of the skin and are easily accessible) in adults use long straight veins in an upper extremity in preference to sites on lower extremities

parenteral nutrition through peripheral IV insertion

can be admin if the osmolarity of the PN solution does not exceed 900mOsm/L peripherally admin PN solutions cause phlebitis if admin PN solution peripherally use multiple methods to reduce the risk of and/or prevent phlebitis

competency assessment for insertion of a vascular access device

evaluated at the outset and then at continuous regular intervals competency assessment can include multiple components including evaluating psychomotor skills, giving written tests, using self-assessment, observing skills in the work setting, and participating in professional activities

things you should know before inserting a peripheral IV cannula using Over the needle: sites to avoid

extremities with impaired circulation or injury, such as postoperative swelling, lymphedema, or recent trauma extremities where venipuncture has been performed within the last 24 hours lower extremity sites which are associated with a higher risk of infection and thrombophlebitis than are upper extremities use of an lower extremity should be based on specific clinician regarding central line placement or other alternatives before using a lower extremity vein

supplies needed to insert a peripheral IV

gloves: nonsterile gloves, additional PPE facility approved pain assessment tool facility approved antiseptic solution (>5% CHG in alcohol solution, tincture of iodine, an iodophor or 70% alcohol with sterile gauze or antisepsis-impregnated swabs) tourniquet, rubber band for use in infants, blood pressure cuff for use in older adults transparent occlusive dressing sterile non allergenic tape to secure cannula and tubing over the needle IV catheter with built in safety mechanism sterile normal saline (sodium chloride 0.09%) flush syringes saline lock (short extension tubing with clamp) supplies for IV infusion, if ordered including prescribed IV solution, IV pole, infusion pump, and infusion tubing splint or armboard for ped clients or IV placed at a point of flexion local anesthetic if prescribed like lidocaine solution or EMLA cream buffered lidocaine is preferred to decrease injection pain and tissue irritation EMLA cream can help make the insertion of IV cannula in peripheral sites or superficial scalp veins painless, because EMLA must be applied up to an hour before procedure it is usually suited for elective procedure not emergencies EMLA will be effective for up to 4 hours from the time of application and skin penetration of the medication may continue 30 minutes after removal to reduce the possibility of systemic adverse effects EMLA is not recommended for use in infants under 3 months, premature infants should be at least 52 weeks post conception before EMLA is considered

things you should know before inserting a peripheral IV cannula using Over the needle part 2

if possible avoid the veins of the dominant hand placement in antecubital veins is not recommended because of difficulty of detecting infiltration and because they are located on a flexion area use distal veins first, but choose a site proximal to previous venipuncture in ped clients insertion into the scalp (preferable in infants only), hand, or foot veins is preferable to leg, arm, or antecubital fossa site if needed use of an assistant hand as both a tourniquet and a restraint is often more acceptable to a child than use of an actual tourniquet

potential complications of peripheral IV insertion

infiltration extravasation phlebitis thrombosis hematoma embolism allergic reaction localized or systemic infection

attempts on inserting peripheral IV

no more than two attempts at cannulation be performed per nurse per patient to avoid unnecessary trauma to the client sometimes after a number of unsuccessful attempts by nursing staff it must be performed by a physician

INS/CDC/HICPAC issued recommendation timing when replacing a catheter, admin sets, dressing changes: nursing responsibilities when assessing and maintaining IV catheters in the absence of signs and symptoms of IV related complications guidelines are as follows: dressing changes

peripheral and midline catheters: the catheter insertion site should be evaluated daily-by palpitation if a gauze or opaque dressing is in use or by inspection if a transparent dressing covers the site. Gauze and opaque dressings should not be removed if there are no clinical signs of infection

procedure step 3 for inserting a peripheral IV

prepare site for IV insertion wash hands and don nonsterile gloves apply tourniquet 4-6inch above insertion site depending on clients size, do not apply tourniquet for longer than 1 minute before procedure apply warmth using moist heating pad or carbon fiber warming mitt and/or use gravity to enhance venous engorgement as needed palpate distal pulse, position guide needle with bevel facing upward palpate vein distal to insertion site apple gentle skin traction to stabilize vein beneath the skin gently stretch skin in opposite direction of insertion 1.5-2in insert peripheral IV cannula insert needle tip and cannula into vein at 1-30 degree angle watch for flash of blood return through the catheter and blood flash chamber indicating needle and cannula have entered vein partially withdraw needle after cannula has entered vein to minimize risk of piercing the opposite vein wall and causing infiltration continue advancing cannula until cannula hub is flush with skin remove needle carefully and engage safety mechanism, place needle into sharps container make no more than 2 attempts of cannulation to avoid unnecessary trauma to client

preliminary steps that should be performed before inserting a peripheral IV cannula using the over the needle technique

review facility protocol for peripheral IV catheter insertion using over the needle technique review the treating clinicians order to insert the peripheral IV cannula using over the needle technique note: if topical or injectable anesthesia is to be used review the instructions for all equipment to be used, and verify that the equipment is in good working order verify completion of facility informed consent documents general consent for treatment is by outset of admission to healthcare facility includes standard provisions that encompass placement of IV catheters review the clients medical history/medical record for any allergies gather supplies

INS/CDC/HICPAC issued recommendation timing when replacing a catheter, admin sets, dressing changes: nursing responsibilities when assessing and maintaining IV catheters in the absence of signs and symptoms of IV related complications guidelines are as follows: replacement of catheter

to reduce the risk of infection and phlebitis adults, there is no need to replace peripheral catheters more frequently than every 72-96hr only if clinically indicated with ped clients it should only be replaced when there is a clinical indication

procedure steps for inserting a peripheral IV

use standard aseptic non touch technique (ANTT) during the procedure clean off and disinfect the working surface, let surface dry before using perform hand hygiene and don nonsterile gloves assist client into seated or supine position select vein for IV placement based on amount, type, and infusion rate of IV solution try to choose a straight and resilient vein do not use hard cord-like veins or veins at flexion points such as antecubital veins or veins on dominant limb and extremities with impaired circulation or injury like lymphedema, postoperative swelling, or recent trauma use distal upper extremity site such as the forearm if infusing short term therapy consider using vein in hand in children use hand or foot veins versus leg, arm, or antecubital fossa sites in infants, use vein in the scalp as an option use vascular visualization technology such as ultrasound or near-infrared light device for clients with difficult IV access select appropriately sized IV catheter use catheter slightly smaller than chosen vein use smallest gauge catheter that can deliver the prescribed therapy at desired rate use an 18-20gauge cannula for rapid infusions of IV fluids, blood components, or vicious medications use a short (3/4inch), 22-24 gauge cannula for older adults and ped clients use a longer cannula for obese clients with veins deep in subcutaneous tissue

procedure step 2 for inserting a peripheral IV

verify rights of safe medication administration administer local anesthetic to insertion site allow time for anesthetic to take effect use distraction techniques when possible, with or without the use of local anesthetic prepare for IV insertion remove hair if needed with single-use client scissors or disposable head surgical clippers attach flush syringe to saline lock, prime saline lock, leaving syringe attached open outer packaging of catheter supply dressings, do not touch or contaminate key parts prepare skin with antiseptic solution allow to air dry for 60 seconds, do not touch skin overlying vein insertion site after application or preparation solution to maintain asepsis inspect cannula to confirm the needle is inserted completely into cannula and cannula tip is intact