Inserting a Short-Term Peripheral Intravenous Catheter

• To provide venous access for administration of fluids, electrolytes, blood, medications, or nutrients.
• Other indications for intravenous (IV) therapy access are administration of diagnostic reagents and monitoring hemodynamic functions.
• Types of catheters used
• Scalp or butterfly vein needles.
• Over-the-needle catheters.
• Through- or inside-the-needle catheters.
• Neonates—26- to 24-gauge needles; children—24- to 22-gauge needles.
• Short peripheral catheters are not used to infuse vesicants, parenteral nutrition exceeding 10% dextrose, and/or 5% protein solutions.
• Site selection should be in accordance with diagnosis, age, condition of veins, previous venipuncture, and type and length of therapy required.
• All IV therapy should be accompanied by a physician's order.
• IV therapy requires frequent monitoring.
• Documentation should include site, type of catheter, needle gauge and length, date and time of insertion, IV fluids or flush solution, absence of signs and symptoms of complications.
• All IV sites require care at least every 48 to 72 hours.
• Tubing change is usually every 48 to 72 hours.
• Avoid drawing blood from short catheters.
• Site should be carefully inspected at least every 2 hours while therapy is in progress.

• Choose needle length and gauge appropriate for the solution.
• Choose smallest gauge that will meet the patient's specific need.
• Use lower distal veins first to avoid leakage if same vein is used later.
• Veins in the lower extremities should not be used routinely to avoid the increased risk for embolism and thrombophlebitis.
• Vein should be large enough for needle insertion and advancement.
• Avoid areas of flexion.
• Do not shave venipuncture site; clip hairy sites with scissors. Shaving increases chances of contamination.
• IV solution should be clear and outer wrap dry.
• Do not use felt tip pens to mark IV solution bag—it may migrate through plastic into solution.
• Cannulas must be maintained by flushing if IV fluids are not ordered.
• Protocol for use of local anesthetic should be in accordance with Nurse Practice Act and the institution's policies.

See Table 12.1A Catheter Sizes and Uses

Special Considerations

• Patients with mastectomies need physician's approval and written order to access veins in the extremity.

Elderly

• Elderly patients' veins are often fragile; insertion may be done without tourniquet if vein is clearly visible.

Pediatric

• Scalp vein needles, and veins in the dorsum of the hand, forearm, and foot, are usually used in infants and children or for single-dose therapy, IVP medications, or blood drawing.
• Candidates for infant peripheral IV therapy include those with diarrhea, dehydration, or serious infection.

Relevant Nursing Diagnoses

• Risk for injury and infection related to invasive venous access device
• Risk for excess fluid volume related to IV fluid therapy

• Vein is cannulated successfully
• IV insertion site is clean, dry, and free of redness, swelling, or pain
• Catheter is secured safely
• Catheter aspirates blood and flushes easily
• Cannulation and IV intake are consistent with physician's order

Clean gloves

Select catheter (over-the-needle, through-the-needle, or butterfly) that is appropriate for the patient, considering type of infusion and vein fragility

IV fluid or IV lock, injection caps, IV tubing (vented or nonvented), IV pole, IV pump 0.9% sodium chloride (normal saline) flush (at least 2–3 mL)

IV kit (if available) or

• Tourniquet
• Tape 1 or 2 inch (if patient has tape allergy, use paper tape)
• 70% alcohol wipes, 10% povidone-iodine swabs or wipes, tincture of iodine 2%, and chlorhexidine
• Dressing—2×2-inch gauze, transparent semipermeable occlusive dressing (Tegaderm, Opsite)
• Labels
• Plastic pad or towel

Prepare IV Fluids

• Verify physician's order for IV therapy.
• A physician's order is needed to initiate therapy. Order should include type of infusion, route, dosage of administration, volume to be infused, rate, and duration.
• Gather equipment: IV tubing, injection caps/needleless systems; type of IV solution.
• Enhances efficiency.
• Wash hands.
• Reduces microorganisms and chances of cross-contamination.
• Remove container from outer wrap; inspect fluid, and check expiration.
• Assess sterility of contents.
• Remove IV tubing and uncoil; do not let end become contaminated.
• Prevents contamination.
• Close roller clamp or flow regulator.
• Prevents accidental spillage of IV fluids.
• Remove protective cap from fluid container.
• Allows sterile tubing entry into container.
• Remove covering from spike of IV tubing.
• Permits entry of tubing into IV container.
• Insert spike into port of IV container with a quick twist.
• Prevents contamination from insertion.
• Hang fluid container on IV pole.
• Squeeze drip chamber once or twice.
• Creates suction effect; fluid enters drip chamber and prevents air entry.
• Open clamp or regulator slowly, allowing tubing to fill slowly.
• Starts fluid flow.
• Invert filters and medication ports/Y-sites to clear air.
• Clears air.
• Close clamp.
• Prevents loss of fluid.

Insert Peripheral Catheter

• Check physician's order.
• A physician's order is needed to initiate therapy.
• Assemble and organize equipment.
• Enhances efficiency.
• Wash hands.
• Reduces microorganisms and chances of cross-contamination.
• Explain procedure.
• Decreases anxiety and evaluates patient's psychological preparedness for the procedure.
• Tie tourniquet on arm 3 to 5 inches above projected insertion site.
• Promotes vein distention or dilation.
• Ask patient to open and close hand; use warm compress if the vein difficult to palpate, or ask the patient to let his or her arm hang down below the level of the heart.
• Increases blood flow to veins below tourniquet.
• Select vein. Use vein with few curves and largest diameter. Use nondominant hand/extremity or patient's preference, if possible.
• Selecting the best and largest vein with few curves allows more chance at successful cannulation and toleration of IV therapy.
• Release tourniquet.
• Reestablishes blood flow; allows patient comfort while preparing for venipuncture.
• Select appropriate catheter, and open IV kit or supplies.
• Selecting appropriate catheter size prevents irritation of vein lining, decreasing infiltration and phlebitis problems; opening supplies prevents interruption during insertion.
• Place patient's extremity on top of pad or towel.
• Protects linen.
• Prime IV tubing and hang on pole or prepare saline flush for IV lock.
• Enhances efficiency and avoids delay after vein is cannulated.
• Tear tape 3 strips of ½ inch tape.
• Have tape ready for immediate stabilization of cannula after insertion.
• Don gloves and prep site.
• Reduces potential for infection and cross contamination.
• Remove hair with scissors.
• Clip hair instead of shaving because of potential abrasive effect of a razor, which increases risk of infection.
• Can use prep agents as single agent or in combination; 70% alcohol wipes can be used to defat skin prior to application of other antimicrobial agents.
• Adhesive on tape sticks better if skin is defatted.
• Vigorously use circular motion at site from center outward for at least 30 seconds using povidone-iodine 10% or chlorhexidine.
• If patient is ALLERGIC to iodine or shellfish, use 70% alcohol for at least 30 seconds.
• Friction needed to remove microbes.
• Alcohol should NOT be used after povidone.
• Alcohol negates the effect of povidone.
• Allow agent to completely air-dry.
• Fanning the area may transmit microorganisms.

Venipuncture

• Pull skin taut below puncture area (continuously).

  See Fig. 12.1A Pulling Skin Taut

• Stabilizes skin and prevents vein rolling.
• With bevel up, insert needle at a 30- to 45-degree angle into skin.

  See Fig. 12.1B Insert Needle at Correct Angle

• Allows backflow of blood.
• For winged-tip (butterfly or scalp) catheter, pinch wings together to insert needle.
• Provides stabilization, and decreases pain during insertion.
• For fragile or rolling veins, puncture directly over the vein.
• Greater chance for success if catheter is inserted and directed over a rolling vein.
• For all other veins, insert alongside the vein distal to the selected puncture site.
• Allows full insertion of catheter.
• Gently insert into vein and advance tip into vein lumen (about ¼ inch). Maintain alignment with vein, relocate vein, and reduce angle, if necessary.
• Reduces risk for going through vein, which causes a hematoma and immediate swelling at site.
• Observe for blood flashback in plastic hub of catheter.
• Indicates you are in vein.
• After catheter tip is in vein, advance plastic over-the-needle catheter (not needle) forward off the needle into vein while maintaining skin taut.

  See Fig. 12.1C Advance the Catheter

• Prevents accidental puncture of both walls of vein wall causing swelling or hematoma.
• *DO NOT ATTEMPT to reinsert needle if backflow of blood subsides.
• Catheter tip may shear off, causing an embolus.
• *IF UNABLE to insert fully, DO NOT force: Attach catheter to IV fluid and open clamp.
• Fluid may facilitate insertion by dilating and straightening small curves in veins.
• When catheter is in place, carefully place one 2×2 gauze under catheter and needle.
• Absorbs blood.
• Release tourniquet.
• Prevents vein rupture from fluid flowing against closed vessel and restores circulation.
• Remove needle by holding hub with one hand and placing pressure with fingertip above tip to occlude site.

  See Fig. 12.1D Removing the Needle

• To slow blood flow.
• Connect IV fluids or injector cap. For IV lock, flush with 1 to 2 mL of normal saline.
• Prevents clot formation; clears tubing of blood.
• Open clamp on IV fluids, and observe flow at site.
• Check for patency and ease of flow.
• Clean site of moisture and blood.
• Removes medium for bacteria growth.
• Stabilize catheter by taping main hub or butterfly wings using one of the methods below. Make sure insertion site can always be visualized.
• Maintains catheter's position for long-term use. Allows site assessment for swelling, redness, or drainage.

U Method

• Place one piece of ½-inch tape below hub, adhesive side up.
• Bring tape ends over the wings of the catheter and secure to skin in a U-shape (both ends parallel to the catheter).
• Place a sterile, occlusive, transparent dressing over site and partially over hub.
• Stabilizes and secures catheter. Allows visualization of site.

See Fig. 12.1E U Method

Chevron Method

• Place one piece of ½-inch tape under the hub and criss-cross over each wing, forming an “x” over the hub, but not over insertion site.
• Place another small piece over the crossed tape at the hub to stabilize further, if necessary.
• Place a sterile, occlusive transparent, dressing over site and partially over hub.
• Stabilizes and secures catheter. Allows visualization of site.

See Fig. 12.1F Chevron Method

Transparent Film

• The transparent film may also be used alone, without the adhesive tape.
• Place film over insertion site and up to catheter hub. Pinch the film around the catheter hub to secure.

  See Fig. 12.1G Cover Site with Transparent Film

• Stabilizes and secures catheter. Allows visualization of site.
• Loop IV tubing and tape to arm or hand a short distance from site.
• *DO NOT loop so as to cause a kink in tubing.
• Keeps tubing from dangling.
• Label site with date, needle gauge, and initials on side of dressing or across hub.
• Alerts others when inserted and type of needle used.
• Label tubing according to agency policy. Label all fluids with date, time hung, medication additives, and initials.
• Alerts caregivers when tubing and fluid change is due.
• Dispose of all equipment.
• *DO NOT recap needle; dispose in needle container.
• Prevents accidental needle puncture.
• Document in nurse's notes procedure and patient response.
• Contains information to identify infusion procedures and provides patient and caregiver protection.

[Outline]

• Prepare IV Fluids
• Insert Peripheral Catheter
• Venipuncture
• U Method
• Chevron Method
• Transparent Film

Evaluation and Follow-Up Activities

• Note skin above insertion site for swelling or redness. If present, discontinue IV and remove cannula
• If fluid does not infuse, try to flush again and hang bag higher. If catheter is determined to be clotted, remove peripheral short catheters
• Follow agency's policy for site change, tubing change, and site/dressing care
• For all peripherally placed catheters, do not use blood pressure cuffs or tourniquets on the same extremity as the catheter
• If bright red blood is seen immediately in the tubing and IV bag, you may be in an artery. Stop the flow, remove the catheter, and place pressure on the site for 5 minutes
• Infusion therapy should be discontinued upon order of authorized prescriber or when complications of therapy are evident. Complications can include
• Phlebitis or infiltration
• Circulatory overload, especially in the elderly and very young
• Infection at site
• Extravasation
• Thrombosis

Key Points for Reporting and Recording

• Date and time of insertion.
• Catheter device with gauge and length.
• Location of insertion site.
• Fluid infusing and rate or if catheter is IV locked (heparin or saline lock).
• Infusion controlled by pump or gravity.
• Patient's response to procedure and therapy including what instructions were given to patient.
• Condition of site and last time assessed.
• Any specific changes in therapy owing to, for example, volume, type of fluid, or rate change.
• Time current IV container was hung and how much is left to be infused.