Nursing Procedure 7.4, 7.5, 7.6
Assessment should focus on the following:
Nursing diagnoses may include the following:
Outcome Identification and Planning
A sample desired outcome is: IV insertion site is clean and dry, with no pain, redness, swelling, or drainage.
Special Considerations in Planning and Implementation
Wear gloves, because contact with blood is likely. Maintain aseptic technique. Choose tubing and a short-peripheral IV catheter appropriate for the solution to provide optimal fluid flow. Choose the smallest gauge and shortest length catheter that will meet the prescribed need. Small catheters cause less vein wall irritation and greater hemodilution around the catheter lumen than do large ones. It is desirable to place catheters in the distal parts of the extremity and then subsequently perform cannulation in the proximal areas as needed. However, assessment considerations include the patient's condition, age and diagnosis, vascular condition, and type and duration of infusion therapy. The patient's vein should be large enough to accommodate the catheter with effective hemodilution. Avoid cannulation in areas of flexion. A short-peripheral IV IS NOT appropriate for vesicants, parenteral nutrition, medications, and solutions with pH less than 5 or greater than 9, or those with an osmolality greater than 600 mOsm/L. If it is difficult to insert a catheter fully, wait until fluid infusion is initiated and then gently advance the catheter. NEVER ATTEMPT TO RETHREAD A CATHETER. (Most devices are now manufactured with a safety feature to prevent rethreading after a needle has been withdrawn from the plastic sheath.) If the client is confused or restless, have an assistant hold the extremity still.
For accurate 24-hr management, each shift should report to the oncoming shift the amount of IV fluid remaining and the need for new bottle/bag, tubing or site change, or site care. Check manufacturer's labels and watch medication expiration warnings on labels or drug inserts. Although agencies can use CDC guidelines to determine standard times for fluid bag and tubing changes, some solutions are prepared with medications or products (either by the manufacturer or on site) in such a manner that tubing or bags must be changed more frequently.
Have a parent or an assistant hold the child's extremities still. Use armboards to stabilize an IV in an extremity. Use microdrip tubing with volume control chambers for strict volume control. Infusion devices are often used for additional safety. Provide clear explanations along with a demonstration of the equipment (except needles), using a puppet or game. Explain that a helper is needed to help the child hold the extremity stable during IV insertion. Talk to the child during the procedure. Anticipate using scalp vein needles (butterfly devices) for infants.
The veins of older adults are often fragile. When veins are elevated and clearly visible, perform insertion without a tourniquet, if appropriate.
The infusion of fluids and nutritional supplements in dying clients is controversial in terms of its palliative versus lifesustaining potential. Consider the desires of the client and family, doctor's orders, and agency policies regarding fluid and nutrition therapy for dying clients.
If nursing visits are intermittent and IV therapy is continuous, instruct client and family on rate regulation, signs and symptoms of infiltration, and method for discontinuing IV catheter.
Unlicensed assistive personnel should not perform IV site care. Although licensed practical nurses do not commonly administer IV medication, they often provide site care to peripheral lines. Delegating site care should be based on agency policy and the skill level of the person providing the care.
| Action | Rationale | |
|---|---|---|
| Selecting a Vein for IV Therapy | ||
| 1 | Perform hand hygiene and organize equipment: | Reduces microorganism transfer; promotes efficiency |
| Promotes hemodilution; prevents irritating the lining of the vein, which could lead to phlebitis and infiltration | |
| Prevents delay if a second attempt is needed or a smaller vein must be used | |
| 2 | Explain procedure to client, including any client assistance needed. | Reduces anxiety; promotes cooperation |
| 3 | Encourage client to use bedpan or commode before beginning. Help client into gown. | Promotes comfort and prevents interruption during IV insertion process; promotes easier gown changes during IV therapy |
| 4 | Lower side rail and assist client into a supine or semi-Fowler’s position; raise bed to high position. Ask client which hand is dominant. | Provides access to IV site; promotes comfort; promotes use of proper body mechanics; placing IV in nondominant hand or arm allows full use of dominant extremity |
| 5 | Apply tourniquet on arm 3–5 in below elbow. | Distends distal arm and hand veins for assessment |
| 6 | Ask client to open and close hand or hang arm at side of bed. May place warm, moist compress in each hand. | Promotes blood flow to the extremity and aids in dilating veins |
| 7 | Inspect the extremity, looking for veins with the largest diameter and fewest curves or junctions: | Facilitates IV insertion |
| Promotes use of lower arm as natural splint from radial and ulnar bones; permits taping with greater stability | |
| Permits use of larger upper extremity veins for larger catheter gauges | |
| For PICC catheters, the upper arm vasculature is most appropriate with placement performed by a competently trained registered nurse or a doctor. | |
| 8 | Release tourniquet and allow client to relax. | Reestablishes blood flow and promotes comfort |
| 9 | If area has excessive hair growth, use scissors to clip excessive hair, wash area with soap and water, then dry. | Prevents skin microabrasions; helps protective dressing adhere to skin |
| Preparing Solutions for IV Therapy | ||
| 1 | Select vein (see Nursing Procedure 7.4). | |
| 2 | Open new tubing package and check tubing for cracks or flaws. Check ends for covers and verify that regulator/roller clamp is closed (rolled down, clamped off, or screwed closed). | Ensures that tubing is intact, without defects; maintains sterility of tubing; allows for better fluid control, minimizing air in tubing |
| 3 | Open IV fluid container by removing outer bag covering; hang fluid container on IV pole, then holding bag by neck in one hand, pull down on plastic tab with other hand to remove tab (Fig. 7.6). | Prevents squeezing of fluid or air from bag when spike is inserted, increasing accuracy of fluid measurement; maintains control of solution; prepares bag for insertion of tubing without contaminating insertion site |
| 4 | Remove protective covering from tubing spike (pointed end) and aseptically attach tubing to solution container. Push spike into port until flat end of spike and port meet. | Promotes a closed system for fluid administration; ensures complete connection of bag and tubing; prevents entry of microorganisms |
| 5 | Prime the tubing: | Removes air from the tubing |
| Provides enough fluid to prime tubing | |
| Removes air from tubing; forces air bubbles from ports and filters; maintains sterility of system | |
| Reestablishes a closed sterile system | |
| 6 | Label the solution container with the client’s name, room number, date and time initiated, rate of infusion, and nurse’s initials. Apply time strip or attach to infusion pump (see Nursing Procedure 7.8). | Identifies time of initiating therapy and need for replacement (no longer than 24 hr); helps monitor fluid infusion |
| 7 | Label tubing with date and time hung and nurse’s initials. | Indicates time of tubing application and need for replacement (usually every 24–72 hr, or according to agency policy) |
| 8 | Proceed to bedside with solution setup. Drape tubing over pole. | Ensures solution with tubing is readily available for connection once IV catheter is inserted; maintains sterility of tubing |
| Inserting a Catheter/IV Lock for IV Therapy | ||
| 1 | Select vein (see Nursing Procedure 7.4) and prepare solution (see Nursing Procedure 7.5). Place IV tubing with sterile cap in place on bed beside client. | Selects most appropriate vein; provides fluid for infusion; places tubing for easy access |
| 2 | Lower side rail and assist client into a supine position. Raise bed to high position. | Provides access to IV site; promotes comfort; promotes use of proper body mechanics |
| 3 | Tear three 1-in tape strips. Cut one piece down the center. | Allows for quick access to tape to secure catheter once inserted; narrow strip will secure catheter without covering insertion site |
| 4 | Prepare short peripheral IV catheter for insertion. Examine over-the-needle catheter for cracks or flaws, rotating the catheter and holding the needle securely. Check the butterfly needle tip for straight edge without bends or chips. | Ensures that catheter or needle is intact and will thread smoothly into the vein |
| 5 | Open several alcohol pads or antiseptic agent. | Provides easy access to supplies; promotes efficiency |
| 6 | Place towel under extremity. | Prevents soiling of linens |
| 7 | Apply tourniquet on extremity and locate the largest, most distal vein. | Restricts blood flow, distending vein; permits entrance of vein at higher point so that future punctures can be made without leakage |
| 8 | Place IV tubing on bed beside client. | Permits ready access to tubing |
| 9 | Don gloves. | Prevents contamination of hands; reduces risk of infection transmission |
| 10 | Use alcohol pad (or appropriate antiseptic agent) to clean area, beginning at the vein and circling outward to a 2-in diameter. Allow alcohol to dry. | Maintains asepsis |
| 11 | Encourage client to take slow, deep breaths as you begin. | Promotes relaxation |
| 12 | Hold skin taut with one hand while holding catheter with other (Fig. 7.7). | Stabilizes vein and prevents skin from moving during insertion |
| Allows viewing of initial flashback in catheter and reduces risk of additional line contamination | |
| Provides control of needle | |
| 13 | Hold the patient’s arm or hand while keeping skin pulled taut. Maintaining sterility, insert catheter into vein parallel to the straightest section of the vein with bevel up. Puncture skin at a 30-degree angle or less (Fig. 7.8). | Anchors the skin and vein to prevent rolling; ensures simultaneous entry of skin and tissue |
| 14 | When needle has entered skin, lower needle until almost parallel with skin (Fig. 7.9). | Decreases risk of penetrating opposite wall of vein |
| 15 | Following path of vein, insert catheter moving toward the side of vein wall. | Ensures proper location for needle insertion |
| 16 | Watch for first backflow of blood, then push needle gently into vein about a quarter-inch after blood backflow is noted. | Indicates that needle has pierced vein wall and has entered the vein |
| Allows insertion without needle to prevent puncturing of opposite vein wall; facilitates insertion as vein becomes filled with fluid | |
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| 17 | Holding catheter securely, remove cap from IV tubing and insert into hub of catheter or twist on cap for an IV lock (Fig. 7.11A). | Prevents dislodging of catheter; establishes closed system for administration |
| 18 | Remove tourniquet. | Reduces backflow of blood and exposure to blood |
| 19 | Open roller clamp and allow fluid to flow freely for a few seconds. | Establishes fluid flow and helps to determine if catheter is in the vein or wedged against vessel wall; reduces risk of clot formation. |
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| Swelling or pain indicates infiltration. | |
| 20 | Tape catheter in position that allows free flow of the fluid. | Reduces risk of positional flow of IV fluids |
| Maintains sterility of insertion site | |
| Stabilizes catheter without covering insertion site | |
| 21 | Slow IV solution to a moderate infusion rate. | Prevents accidental fluid bolus while completing site care |
| 22 | Cover IV with transparent dressing. | Reduces risk of contamination and infection of site |
| 23 | Secure tubing: | Prevents disconnection of tubing from client |
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| 24 | Regulate IV flow manually or set infusion device at appropriate rate (see Nursing Procedure 7.8). | Ensures flow rate as ordered |
| 25 | On a piece of tape or label, record needle size, type, date and time of insertion, and nurse’s initials. Place label over top of dressing. | Provides information needed for follow-up care |
| 26 | Apply armboard if needed. | Stabilizes site |
| 27 | Remove and discard gloves and perform hand hygiene. | Reduces microorganism transfer |
| 28 | Restore or discard all equipment appropriately. | Reduces transfer of microorganisms among clients; prepares equipment for future use |
| 29 | Review limitations in range of motion with client. Instruct client in signs and symptoms to report and encourage client to notify nurse immediately of any problems or discomfort. | Enlists client’s assistance in maintaining therapy; promotes feeling of control |
| 30 | Position client appropriately, raise side rail, lower bed, and place call light within reach. | Promotes comfort; promotes safety; facilitates communication |
| 31 | Check infusion rate and site after 5 min and again after 15 min. Check volume every 1–2 hr. | Ensures accurate administration as ordered; detects the need for any adjustments |
Were desired outcomes achieved? An example of evaluation includes:
The following should be noted on the client's record:
