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Learning Objectives ⬇

After completing this chapter, the reader will be able to:

Glossary ⬆ ⬇

Introduction ⬆ ⬇

The peripheral intravenous catheter (PIVC) is the most commonly used invasive device among hospitalized patients. As discussed and defined in the previous chapter, peripheral catheters include the short and the long PIVC and the midline peripheral catheter. Placement techniques include either a traditional over-the-needle insertion technique or an advanced placement technique such as modified or accelerated Seldinger technique, often in conjunction with ultrasound guidance. Long peripheral catheters are placed in superficial or deep veins and are required when accessing deep veins to ensure a sufficient length of catheter within the vein (Gorski et al., 2021). They may be placed in deep veins of the upper arm or, alternatively, in the forearm, where it is important that the long PIVC does not cross into the antecubital fossa, an area of flexion. The short PIVC is commonly placed by nonspecialty nurses across all health-care settings, and the risks associated with peripheral access are often underestimated. This chapter primarily focuses upon short PIVC placement. Based upon a classic review of the literature, peripheral IV catheters “fail” 35% to 50% of the time (Helm et al, 2015), with complications that lead to pain, patient dissatisfaction, depletion of venous access, and the cost of treating minor and major complications. In a 2021 analysis of 11,800 PIVCs, there was a 36% failure rate attributed to complications, including infiltration/occlusion, phlebitis, and dislodgement (Marsh et al., 2021). The incidence of such complications is decreased when attention is paid to site selection, proper skin antisepsis, adherence to aseptic technique, catheter securement, and ongoing monitoring as addressed in this chapter.

Nursing Process ⬆ ⬇

The nursing process is a six-step process for problem-solving to guide nursing action (see Chapter 1 for details on the steps of the nursing process related to vascular access). The following table focuses on nursing diagnoses, nursing outcomes classification (NOC), and nursing interventions classification (NIC) for peripheral infusion therapy in adults and pediatric patients. Nursing diagnoses should be patient-specific and outcomes and interventions individualized. The NOC and NIC presented here are suggested directions for development of specific outcomes and interventions.

Nursing Diagnoses Related to Peripheral Infusion Therapy in Adults and ChildrenNursing Outcomes Classification (NOC)Nursing Interventions Classification (NIC)
Infection risk for related to:
Invasive procedure; impaired skin integrity; environmental exposure to pathogens		Risk control: Infectious processInfection control; Infection protection
Deficient knowledge related to: Information misinterpretation; lack of exposure; unfamiliar with peripheral infusion therapyKnowledge: Treatment procedures; treatment regimenTeaching: Disease process (PIVC, reasons for infusion therapy, treatment)
Impaired physical mobility related to:
Movement limitations due to presence of PIVC/infusion administration		Ambulation; mobilityAmbulation; joint mobility; positioning
Skin integrity impaired related to:
External: Interruption in barrier protection—venipuncture		Tissue integrity: SkinSkin care, skin surveillance, incisional (venipuncture) site care
Anxiety, related to: Situational crisis (placement of PIVC, need for infusion therapy)Anxiety level, anxiety self-control, copingAnxiety-reduction; calming technique; relaxation technique
Pain, acute, related to:
Biological injury (e.g., PIVC placement)		Pain controlPain management, analgesic (anaesthetic) administration

Sources: Ackley et al., 2020; Herdman et al., 2021.

Chapter Highlights ⬆ ⬇

Thinking Critically: Case Study

A 40-year-old obese African American man is readmitted to the hospital with a wound infection and requiring IV antibiotic infusion.

Case Study Questions

    1.Which type of access devices should be used to initiate therapy and give the rationale?

    2.What should be taken into consideration during assessment of venous access sites?

    3.What equipment might help you with a successful venipuncture?

Media Link: Chapter post tests and answers are provided on FADavis.com, along with case studies and critical thinking activities. Worksheets 6-1 and 6-2 are also available on FADavis.com.

References ⬆

PROCEDURES DISPLAY 6-1
Steps for Inserting a Peripheral-Short Over-the-Needle Catheter by Direct and Indirect Methods

Equipment Needed

IV start kit (preferred) containing the following:

Delegation

This procedure can be delegated to the licensed practical or vocational nurse (LVN/LPN) depending on the state nurse practice act for initiation of infusion therapy and organizational policy.

ProcedureRationale

    1.Verify order.

    1.A written order is a legal requirement.

    2.Introduce yourself to the patient.

    2.Establishes nurse-patient relationship

    3.Verify the patient's identity using two forms of ID.

    3.Patient safety.

    4.Perform hand hygiene and put on gloves.

    4.Hand hygiene is the single most important means of infection prevention.

    5.Help patient get into a comfortable position. Place linen saver pad under arm or hand.

    5.Promotes cooperation with the procedure and facilitates your ability to perform the procedure. Protects bed linens.

    6.Assess patient (verify allergy status) and evaluate for psychological preparedness. Instruct patient on purpose of infusion or locking device. Apply tourniquet and evaluate both arms for best access site. Release tourniquet.

    6.Prepares patient for procedure. Allows for distention of veins and assessment of both extremities. Standard precautions.

    7.Cleanse skin with soap and water if visibly soiled and remove excess hair if necessary using scissors or surgical clippers.

    7.To prepare skin for application of an antiseptic. Removal of excess hair will aid in dressing securement.

    8.Select the site and dilate the vein using tourniquet; remove tourniquet after site selection.

    8.Select the site most likely to last the full length of the prescribed therapy, preferentially using the forearm (adult) to increase dwell time. Ensures preservation of veins. Reduced tourniquet time reduces discomfort until ready for PIVC insertion

    9.Select the appropriate catheter for therapy.

    9.Choose the best needle gauge considering the therapy, patient age, and condition/size of veins, most often a 20- to 24-gauge catheter.

    10.Remove gloves, perform hand hygiene again before beginning procedure and don a new pair of gloves.

    10.Reduce risk of infection.

    11.Perform skin antisepsis, preferentially with alcohol-based chlorhexidine. Use back-and-forth motion for at least 30 seconds and allow to fully dry. Do not touch site once skin antisepsis is completed.

    11.Reduce risk of infection.

    12.Reapply the tourniquet.

    12.Distends veins.

    13.Insert the catheter by a direct or indirect method at no more than a 30-degree angle with a steady motion using traction to maintain an anchor on the vein.

    13.Anchoring the vein properly is the key to successful catheter insertion.

    Quickly passes through layers of epidermis and dermis, decreasing pain, and allows for adjustment to technique based on skin thickness.

For the Direct (One-Step) Method

    A.Insert the catheter directly over the vein.

    B.Penetrate all layers of the vein with one motion.

For the Indirect (Two-Step) Method

    A.Insert the catheter alongside the vein; gently insert the catheter distal to the point at which the needle will enter the vein.

    B.Maintain parallel alignment and advance through the subcutaneous tissue.

    C.Relocate the vein and decrease the angle as the catheter enters the vein.

Flashback of blood indicates that the vein has been cannulated.
Releasing the tourniquet restores full circulation to the patient's extremity.
Note: Jabbing, stabbing, or quick thrusting should be avoided because such actions may cause rupture of delicate veins. For performing a venipuncture on difficult veins, follow these guidelines:
  • For paper-thin transparent skin or delicate veins: Use a small catheter (e.g., 24-gauge); use direct entry; consider not using a tourniquet (blood pressure cuff); decrease the angle of entry to 10 to 15 degrees; apply minimal tourniquet pressure.
  • For patients who have DIVA or if you are unable to palpate or see veins, consider visualization technology.
  • For veins that roll: Apply traction to the vein with the thumb during venipuncture, keeping skin taut.

After the bevel enters the vein and blood flashback occurs, lower the angle of the catheter and stylet (needle) as one unit and advance into the vein. After the catheter tip and bevel are in the vein, advance the catheter forward off the stylet and into the vein.
After the vein is entered, cautiously advance the catheter into the vein lumen. Hold the catheter hub with your thumb and middle finger and use your index finger to advance the catheter, maintaining skin traction. A one-handed technique is recommended to advance the catheter off the stylet so that the opposite hand can maintain proper traction on the skin and maintain vein alignment. (A two-handed technique can be used, but this increases the risk of vessel rupture during threading of a rigid catheter in a nonstabilized vein.)
While the stylet is still partially inside the catheter, release the tourniquet.
Remove the stylet and activate the safety feature of the catheter. If using a passive safety device, the safety mechanism is automatic.

    14.Connect the administration set or needleless connector using a non-touch technique to protect Key-Parts with a twisting motion.

    14.Secures the Luer-Lok and prevents leakage and contamination.

    15.Secure the catheter with a securement device or apply transparent semipermeable membrane (TSM) dressing directly over the catheter and hub.

    15.To reduce micromovement of catheter in the vein. Prevents microorganisms from entering the catheter-skin junction.

    16.Label the site with date and time, type and length of catheter, nurse's initials.

    16.To communicate key information to all clinicians.

    17.Dispose of all equipment in appropriate receptacle.

    17.Reduces risk of exposure to blood.

    18.Instruct the patient on use of an electronic infusion pump, what to report regarding site, and how often to expect the nurses to check the infusion site.

    18.Knowledge of infusion therapy treatment assists in providing a positive outcome.

    19.Calculate the infusion rate or dial appropriate rate into electronic infusion pump.

    19.Ensure correct delivery of prescribed solution or medications.

    20.Document in the medical records: Date and time of insertion; type of device; gauge and length of catheter; solution infusing and rate of flow; any additional equipment (electronic infusion pump); number of attempts; condition of extremity before access; patient education, patient's response; signature.

    20.Maintains a legal record and communication with the health-care team.

PROCEDURES DISPLAY 6-2
Flushing and Locking a PIVC or Midline Catheter After an Intermittent Infusion

Equipment Needed

Prefilled syringe of 0.9% sodium chloride

Antiseptic solution: 70% alcohol

Delegation

This procedure can be delegated to an LPN/LVN who is specially trained in IV therapy, depending on the state nurse practice act for initiation of infusion therapy and organization policy and procedure. This cannot be delegated to nursing assistive personnel.

ProcedureRationale

    1.Follow standardized protocol for the organization or confirm order.

    1.A standard protocol or order is required.

    2.Introduce yourself to the patient.

    2.Establishes the nurse-patient relationship.

    3.Perform hand hygiene.

    3.Single most important means of infection prevention.

    4.Verify the patient's identity using two forms of ID.

    4.Patient safety

    5.Identify whether the needleless connector is a negative-displacement device, a positive-displacement device, or a neutral-displacement device (see later).

    5.Locking technique varies based on category.

    6.Don clean gloves if required by organizational procedures.

    6.Whether or not clean gloves are worn, the critical steps in ANTT are recognizing Key-Parts—not touching the needleless connector after disinfection and not touching the tip of the flush syringe after the protective cover is removed.

    7.Stop intermittent infusion, disconnecting IV administration set.

    8.Disinfect the needleless connector with 70% isopropyl alcohol using a scrubbing motion and allow to dry. Many organizations require at least a 15-second scrub.

    7.Critical step in infection prevention. Disinfects and reduces risk for intraluminal introduction of microbes.

    9.Attach prefilled syringe of 0.9% sodium chloride to the needleless connector.

    10.Begin to flush and then slowly aspirate until blood is aspirated.

    10.Confirms catheter patency.

    11.Flush and lock catheter with 0.9% sodium chloride.

    11.Maintains patency of catheter and prevents occlusion.

    12a.For neutral- and negative-displacement NCs: Flush all solution into the catheter lumen, clamping catheter before disconnecting the syringe.

    12a.A “positive-pressure” flushing technique to prevent reflux of blood.

    12b.For positive-displacement NC:

    Flush all solution into the catheter lumen, disconnect the syringe, and then close the catheter clamp.

    12b.Catheter is clamped after disconnection of the syringe.

    12c.For antireflux NCs:

    Flush all solution into the catheter lumen; clamping sequence does not matter.

    12c.It does not matter whether the catheter clamp is closed before or after the flush procedure.

    13.Document the procedure on the patient record.

    13.Maintains a legal record.

Source: Gorski et al., 2021.