The initiation of a PIVC and IV infusion is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, initiation of a PIVC and IV infusion may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

• IV solution, as prescribed
• Electronic MAR (eMAR) or medication administration record (MAR)
• Towel or disposable pad
• Nonallergenic tape
• IV administration set
• Label for infusion set (for next change date)
• Transparent semipermeable membrane (TSM) dressing
• Electronic infusion device (if appropriate)
• Tourniquet
• Time tape and/or label (for IV container)
• Cleansing swabs >0.5% chlorhexidine in alcohol solution is preferred; tincture of iodine, an iodophor ([povidone-iodine], or 70% alcohol may also be used) (Gorski et al., 2021; Mimoz et al., 2015; O'Grady et al., 2017)
• IV securement/stabilization device, as appropriate
• Clean gloves
• Additional PPE, as indicated
• IV pole
• Local anesthetic (based on facility policy and/or if prescribed)
• PIVC
• Short extension tubing, if not permanently attached to the PIVC
• Needleless connector or end cap for extension tubing
• Antimicrobial wipes
• Passive disinfection caps (based on facility policy)
• Skin barrier protectant wipe (e.g., Skin-Prep^®)
• Single-use clippers or scissors for hair removal (as indicated)
• Single-use, commercially prepared, prefilled syringe with sterile normal saline for injection, minimum volume equal to twice the internal volume of the catheter system (Gorski et al., 2021), according to facility policy.

Review the patient's record for baseline data, such as vital signs; intake and output balance; and pertinent laboratory values, such as serum electrolytes. Assess the appropriateness of the solution for the patient. Inspect the IV infusion solution for any particulates and check the IV label. Confirm it is the solution prescribed. Review assessment and laboratory data that may influence solution administration. Evaluate the patient's history for any allergies or sensitivity to skin antiseptics (Gorski et al., 2021). The suitability of particular veins for peripheral IV infusions varies with individual circumstances. Determine site selection after considering the accessibility of a vein, the condition of a vein, and the type of fluid to be infused. Assess the patient's arms for potential sites for initiating the PIVC and IV infusion. Keep in mind the following guidelines related to PIVCs and access sites:

• Determine the most desirable accessible vein. For a short PIVC, use the forearm to prolong dwell time, increase the likelihood of the PIVC lasting the full length of the prescribed therapy, decrease pain during dwell time, promote self-care, and prevent accidental removal and occlusions (Gorski et al., 2021). The dorsal and ventral surfaces of the upper extremities, including the metacarpal, cephalic, basilic, and median veins, are appropriate sites for infusion (Gorski et al., 2021). Avoid the cephalic vein at the radial wrist, inner aspect of the wrist, and sites at/above the antecubital fossa because of the potential risk for nerve damage (Gorski et al., 2021). For a long PIVC, use the veins on the dorsal and ventral surfaces of the upper extremities, including the cephalic, basilic, and median veins; insertion should be in the forearm without crossing into the antecubital fossa (Gorski et al., 2021). Consider use of the basilic, cephalic, or brachial veins when inserting a midline catheter (Gorski et al., 2021).Figure 1A illustrates infusion sites on the arm and hand for adult patients.
• In adults, hand veins may be considered for short-term therapy (>24 hours); catheter insertion in areas of flexion such as the hand is associated with higher failure rates over time (Gorski et al., 2021).
• In general, either arm may be used for IV therapy. Use of the nondominant arm is preferred for patient comfort and to limit movement in the impacted extremity (Gorski et al., 2021). For example, if the patient is right-handed, the IV is preferably placed on the left extremity to improve the patient's ability to complete activities of daily living. This is particularly important if the duration of infusion is expected to be prolonged.
• Determine accessibility based on the patient's condition. The use of an extremity for IV therapy may be contraindicated in some circumstances. For example, patients with a history of breast cancer with same-side surgical axillary lymph node removal; patients with burns, infections, or traumatic injury to the extremity; and patients with an upper extremity arteriovenous fistula or graft or other catheters for dialysis treatment will not be able to have an IV catheter placed on the impacted extremity.
• Avoid PIVC insertion in areas of flexion, if there is pain on palpation, in compromised skin and sites distal to these areas (such as open wounds), in extremities with infection, and in extremities with planned procedures (Gorski et al., 2021).
• Do not use the antecubital veins if another vein is available. They are not a good choice for infusion because flexion of the patient's arm can displace the IV catheter over time. By avoiding the antecubital veins for peripheral venous catheters, a PICC line may be inserted later, if needed.
• Do not use veins in the leg of an adult, unless needed for an emergent insertion; if used, remove as soon as possible, as use of the lower extremities is associated with risk of tissue damage, thrombophlebitis, and ulceration (Gorski et al., 2021). Some facilities require a prescribed intervention to insert an IV catheter in an adult patient's lower extremity.

Implementation

Action	Rationale
1. Verify the prescribed IV solution on the eMAR/MAR. Consider the appropriateness of the prescribed therapy in relation to the patient. Clarify any inconsistencies. Check the patient's health record for allergies. Know techniques for IV insertion, precautions, and the purpose of the IV solution administration, if prescribed. Check the solution for color and the container for leaking and expiration date, if prescribed. Gather the necessary supplies.	This ensures that the correct IV solution and rate of infusion and/or medication will be administered. The nurse is responsible for critically evaluating all patient orders prior to administration. Any concerns regarding the type or amount of therapy prescribed should be immediately and clearly communicated to the prescribing health care provider. This knowledge and skill are essential for safe and accurate IV and medication administration. Preparation promotes efficient time management and an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Assemble equipment on the bedside stand or overbed table or other surface within reach.	Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
5. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why. Ask the patient about allergies to medications, tape, or skin antiseptics, as appropriate. If considering using a local anesthetic, inquire about allergies for these substances as well. Consider use of nonpharmacologic interventions to reduce pain associated with PIVC insertion.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement. Possible allergies may exist related to medications, tape, or local anesthetic. Injectable anesthetic can result in allergic reactions and tissue damage. Nonpharmacologic interventions suggested for use to reduce PIVC insertion-related pain and discomfort include distraction, relaxation, breathing exercises, and virtual reality (VR) (Basak et al., 2020; Gorski et al., 2021). The choices of interventions for pediatric patients include swaddling, breastfeeding, pacifiers, rocking, blowing bubbles, reading books, use of VR, and local vibrating cold devices and should be made with consideration of growth and development level (Gorski et al., 2021).
6. If using a local anesthetic, explain the rationale and procedure to the patient. Apply the anesthetic to a few potential insertion sites. Allow sufficient time for the anesthetic to take effect.	Explanations provide reassurance and facilitate engagement. Local anesthetic agents should be used to reduce pain in all adult and pediatric populations (Gorski et al., 2021). Local anesthetic agents to reduce pain associated with PIVC insertion include vapocoolant sprays, topical transdermal agents, jet injection of pressure-accelerated lidocaine (needle-free), application of hot or cold to the site, and intradermal injection of lidocaine or bacteriostatic 0.9% sodium chloride (Gorski et al., 2021; Korkut et al., 2020; Welyczko, 2020). Some anesthetics take up to an hour to become effective.
Prepare the IV Solution and Administration Set
7. Compare the IV container label with the eMAR/MAR. Remove the IV bag from the outer wrapper, if indicated. Check expiration dates. Scan the bar code on container, if necessary. Compare the patient identification band with the eMAR/MAR. Alternatively, label the solution container with the patient's name, solution type, additives, date, and time. Complete a time strip for the infusion and apply to the IV container.	Checking the label with eMAR/MAR ensures the correct IV solution will be administered. Identifying the patient ensures the right patient receives the medications and helps prevent errors. The time strip allows for quick visual reference by the nurse to monitor infusion accuracy.
8. Maintain aseptic technique when opening sterile packages and the IV solution. Remove the administration set from the package (Figure 2). Apply the label to the tubing reflecting the day/date for the next set change, per facility guidelines.	Asepsis is essential for preventing the spread of microorganisms. Labeling the tubing ensures adherence to facility policy regarding administration set changes and reduces the risk of the spread of microorganisms. Refer to Box 16-3 in Skill 16-3 for recommended administration set change guidelines.
9. Close the roller clamp or slide the clamp on the IV administration set (Figure 3). Invert the IV solution container and remove the cap on the entry site, taking care not to touch the exposed entry site. Remove the cap from the spike on the administration set. Using a twisting and pushing motion, insert the administration set spike into the entry site of the IV container (Figure 4). Alternatively, follow the manufacturer's directions for insertion.	Clamping the IV tubing prevents air and fluid from entering the IV tubing. Inverting the container allows easy access to the entry site. Touching the opened entry site on the IV container and/or the spike on the administration set results in contamination, resulting in the need to discard the container/administration set. Inserting the spike punctures the seal in the IV container and allows access to the contents.
10. Hang the IV container on the IV pole. Squeeze the drip chamber and fill it at least halfway (Figure 5).	Suction causes fluid to move into the drip chamber. Fluid prevents air from moving down the tubing.
11. Open the IV tubing clamp and allow fluid to move through the tubing. Follow the additional manufacturer's instructions for the specific electronic infusion pump, as indicated. Allow fluid to flow until all air bubbles have disappeared, and the entire length of the tubing is primed (filled) with IV solution (Figure 6). Close the clamp. Alternatively, some brands of tubing may require removal of the cap at the end of the IV tubing to allow the fluid to flow. Maintain its sterility. After the fluid has filled the tubing, recap the end of the tubing.	This technique prepares for IV fluid administration and removes air from the tubing. Air should be purged from all administration sets to prevent air embolism (Gorski et al., 2021). Touching the open end of the tubing results in contamination, resulting in the need to discard the administration set.
12. If an electronic device is to be used, follow the manufacturer's instructions for inserting the tubing into the device (Figure 7).	This ensures proper use of equipment.
Initiate Peripheral Venous Access
13. Place the patient in the low-Fowler position in bed. Place a protective towel or pad under the patient's arm.	The supine position permits either arm to be used and allows for good body alignment. The towel protects the underlying surface from blood contamination.
14. Provide emotional support, as needed.	The patient may experience anxiety because they may, in general, fear needlestick or IV infusion.
15. Open the short extension tubing package. Attach the needleless connector or end cap, if not in place. Clean the needleless connector or end cap with an alcohol wipe. Insert a syringe with normal saline into the extension tubing. Fill the extension tubing with normal saline and place the extension tubing and syringe back on the package, within easy reach.	A needleless connector should be attached to the extension tubing to eliminate the use of needles when connecting to the VAD (Gorski et al., 2021). Priming the extension tubing removes air from the tubing and prevents administration of air when connected to venous access. Having the tubing within easy reach facilitates accomplishment of procedure.
16. Select and palpate for an appropriate vein. Refer to the guidelines in the previous Assessment section. If the intended insertion site is visibly soiled, clean the area with soap and water (Gorski et al., 2021).	The use of an appropriate vein decreases discomfort for the patient and reduces the risk for damage to body tissues.
17. Remove excess hair at the insertion site, if needed, to facilitate application of the site dressing. Use single-patient-use scissors or disposable-head surgical clippers to remove hair at the insertion site and dressing area.	Hair can inhibit adhesion of the site dressing. Shaving causes microabrasions and may increase the risk for infection (Gorski et al., 2021).
18. Put on gloves.	Gloves prevent contact with blood and body fluids.
19. Apply a single-patient-use tourniquet (Gorski et al., 2021) 3 to 4 inches above the venipuncture site to obstruct venous blood flow and distend the vein (Figure 8). Direct the ends of the tourniquet away from the entry site. Make sure the radial pulse is still present.	A single-patient-use tourniquet prevents transmission of microorganisms. Impeding venous blood flow causes the vein to distend while maintaining arterial circulation. Distended veins are easy to see, palpate, and enter. The end of the tourniquet could contaminate the area of injection if directed toward the entry site. The tourniquet may be applied too tightly, so assessment for the radial pulse is important. Checking radial pulse ensures arterial supply is not compromised.
20. Instruct the patient to hold their arm lower than their heart.	Lowering the arm below the heart level helps distend the veins by filling them.
21. Ask the patient to open and close their fist. Observe and palpate for a suitable vein. If a vein cannot be felt, consider the use of vascular visualization technology or ultrasound to assist with identification of peripheral veins (Gorski et al., 2021).	Contracting the muscles of the forearm forces blood into the veins, thereby distending them further. Vascular visualization technology can be used to assist with identification of peripheral veins, with resulting increased insertion success; reduced insertion-related complications; and minimization of the need to escalate to unnecessary, more invasive VADs (Gorski et al., 2021). Ultrasound-guided PIVC insertion is a safe, efficient intervention and should be used for placement of a short PIVC in difficult-to-access adult patients (Gorski et al., 2021; Houston, 2013), the insertion of long PIVCs (Gorski et al., 2021), and after failed venipuncture attempts (Edwards & Jones, 2018; Egan et al., 2013).
22. Use a single-use sterile applicator containing sterile antiseptic solution to cleanse the site with >5% chlorhexidine in alcohol solution or the solution identified by facility policy. Follow the manufacturer's directions for use to determine the product application process and dry times (Gorski et al., 2021). Allow the antiseptic to dry naturally; do not wipe, fan, or blow on the skin (Gorski et al., 2021).	Cleansing is necessary because organisms on the skin can be introduced into the tissues or the bloodstream with the needle. Use of >0.5% chlorhexidine in alcohol solution is preferred for skin antisepsis (Gorski et al., 2021; Sarani et al., 2018). If there is a contraindication to alcoholic chlorhexidine solution, tincture of iodine, an iodophor (povidone-iodine), or 70% alcohol may instead be used (Gorski et al., 2021; Mimoz et al., 2015; O'Grady et al., 2017).
23. Do not touch/palpate the insertion site after skin antisepsis. Use sterile gloves if repalpation of the vein is necessary after skin antisepsis.	Touching the site after skin antisepsis recontaminates the insertion site. Use of sterile gloves for palpation prevents contamination of the insertion site.
24. Using your nondominant hand placed about 1 or 2 inches below the entry site, hold the patient's skin taut against the vein. Avoid touching the prepared site. Ask the patient to remain still while performing the venipuncture.	Pressure on the vein and surrounding tissues stabilizes the vein and helps prevent movement of the vein as the needle or catheter is being inserted. The planned IV insertion site is not palpated after skin cleansing unless sterile gloves are worn to prevent contamination (Gorski et al., 2021). Patient movement may prevent proper technique for IV insertion.
25. Align the IV catheter on top of the vein; enter the skin gently, holding the catheter by the hub in your dominant hand, bevel side up, at a 10- to 15-degree angle (Figure 9). Insert the catheter from directly over the vein or from the side of the vein. While following the course of the vein, advance the needle or catheter into the vein. A sensation of “give” can be felt when the needle enters the vein.	This allows the needle or catheter to enter the vein with minimal trauma and deters passage of the needle through the vein.
26. Continue to hold the skin taut. When blood returns through the catheter and/or the flashback chamber of the catheter, use the push-off tab to separate the catheter from the needle stylet and advance the catheter into the vein until the hub is at the venipuncture site. The exact technique depends on the type of device used.	The tourniquet causes increased venous pressure, resulting in automatic backflow. Placing the access device well into the vein helps to prevent dislodgement.
27. Release the tourniquet. Activate the safety mechanism on the needle stylet. Compress the skin well above the catheter tip to stop the flow of blood. Quickly remove the protective cap from the extension tubing, attach it to the catheter hub, and tighten the Luer lock. Stabilize the catheter or needle with your nondominant hand.	Bleeding is minimized and the patency of the vein is maintained if the connection is made smoothly between the catheter and extension tubing.
28. Continue to stabilize the catheter or needle and pull back on the syringe to assess for blood return, then flush gently with the saline, observing the site for infiltration and leaking. Remove the syringe from the end cap.	Presence of a blood return upon aspiration and lack of resistance when flushing indicate patency of the VAD (Gorski et al., 2021). Infiltration and/or leaking and the patient reports of pain and/or discomfort indicate that the insertion into the vein is not successful and should be discontinued. The syringe is no longer needed once flushing is complete.
29. Open the skin protectant wipe. Apply the skin protectant to the site, making sure to apply—at a minimum—the area to be covered with the dressing. Place a sterile transparent dressing and/or catheter securing/stabilization device over the venipuncture site. Loop the tubing near the entry site, and anchor it with tape (nonallergenic) close to the site.	The skin protectant aids in adhesion of the dressing and decreases the risk for skin trauma when the dressing is removed. A transparent dressing allows easy visualization and protects the site. Stabilization/securing devices preserve the integrity of the access device, minimize catheter movement at the hub, and prevent catheter dislodgement and loss of access (Gorski et al., 2021). Some stabilization devices also act as a site dressing. The weight of the tubing is sufficient to pull it out of the vein if it is not well anchored. Nonallergenic tape is less likely to tear fragile skin.
30. Label the IV dressing with the date, time, site, and type and size of the catheter placed (Figure 10).	Other personnel working with the infusion will know the site, type of device being used, and when it was inserted.
31. Using an antimicrobial swab, vigorously disinfect the connection surface and sides of the needleless connector or end cap on the extension tubing and allow it to dry. Remove the end cap from the administration set. Insert the end of the administration set into the needleless connector or end cap (Figure 11). Loop the administration set tubing near the entry site, and anchor it with tape (nonallergenic) close to the site. Remove your gloves. Perform hand hygiene.	Venous access device (VAD) administration set entry points, end caps, and needleless connectors must be disinfected prior to each access to reduce the risk for introduction of microorganisms and prevent VAD-related infection (Frimpong et al., 2015; Gorski et al., 2021; Harper, 2014; Loveday et al., 2014). Friction is needed to physically remove microorganisms from the top, sides, and threads of the needleless connector or end cap. Allow the antiseptic to dry completely following the manufacturer's directions for use (Gorski et al., 2021). Inserting the administration set allows initiation of the fluid infusion. The weight of the tubing is sufficient to pull it out of the vein if it is not well anchored. Nonallergenic tape is less likely to tear fragile skin. Removing gloves properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.
32. Open the clamp on the administration set. Set the flow rate and begin the fluid infusion (Figure 12). Alternatively, start the flow of solution by releasing the clamp on the tubing and counting the drops. Adjust until the correct drop rate is achieved. Assess the flow of the solution and function of the infusion device. Inspect the insertion site for signs of infiltration (Figure 13).	Verifying the rate and device settings ensures the patient receives the correct volume of solution. If the catheter slips out of the vein, the solution will accumulate (infiltrate) into the surrounding tissue.
33. Apply an IV securement/stabilization device if not already in place as part of the dressing, as indicated, based on facility policy. Explain to the patient the purpose of the device and the importance of safeguarding the site when using the extremity.	These systems are recommended for use on all venous access sites, particularly central venous access sites, to preserve the integrity of the access device, minimize catheter movement at the hub, and prevent catheter dislodgement and loss of access (Gorski et al., 2021). Some devices also act as a site dressing and may already have been applied.
34. Apply a passive disinfection cap to each access site on the administration set; use an antimicrobial swab to vigorously disinfect the connection surface and sides of each access site and allow it to dry. Attach a passive disinfection cap to each site (Figure 14).	Passive disinfection caps contain an antiseptic-impregnated sponge that dispenses the antiseptic over the connector's top and threads and protects the hub from contamination by touch or airborne sources (Gorski et al., 2021; Stango et al., 2014). VAD administration set entry points, end caps, and needleless connectors must be vigorously scrubbed and disinfected prior to each access to reduce the risk for introduction of microorganisms and prevent VAD-related infection (Frimpong et al., 2015; Gorski et al., 2021; Harper, 2014; Loveday et al., 2014). Friction is needed to physically remove microorganisms from the top, sides, and threads of the needleless connector or end cap. Allow the antiseptic to dry completely to ensure complete effectiveness.
35. Remove the equipment and return the patient to a position of comfort. Lower the bed, if it is not in the lowest position.	Positioning promotes patient comfort and safety.
36. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.
37. Return to check the flow rate and observe the IV site for infiltration and/or other complications 30 minutes after starting the infusion and at least hourly thereafter. Ask the patient if they are experiencing any pain or discomfort related to the IV infusion.	Continued monitoring is important to maintain the correct flow rate. Early detection of problems ensures prompt intervention.