Starting an IV - Overview of the Skill

Overview: Performing venipuncture in order to establish venous access is a priority for clients
with fluid and electrolyte disturbances, clients who are critically ill, clients who are
NPO after surgery, or clients who for other reasons are not able to take fluids or
food by mouth. Venous access can be used for infusions of IV fluids, emergency
medications, parenteral nutrition, blood products, and routine IV medications.

There are a variety of IV needles and catheters. They vary in gauge from small bore
to large bore. A 20 to 22-gauge flexible catheter is used for adults while a 22 to 24-
gauge catheter is used for pediatric clients. If large volumes of fluid or blood
products are anticipated to be given, a larger bore (18 or 19-gauge) is
recommended.

A commonly used angiocatheter has an over-the-needle catheter (ONC) made of

plastic, Teflon, or other materials. These flexible catheters have a metal stylet that is
used to pierce the skin and vein and a plastic catheter that is threaded into the vein
and attached to the IV tubing after the stylet has been removed.

The other type of IV needle is a straight steel needle that is inserted into the vein
and secured after being attached to an IV tubing. With an increased emphasis on
safety, many health care facilities use a safety-shielded intravenous catheter or
retractable needle system when placing a peripheral intravenous line. This consists
of a traditional metal stylet used for the skin puncture covered by the plastic or
Teflon angiocatheter. Once the intravenous line is successfully placed, the health
care provider initiating the IV pushes a button and the stylet retracts completely into
a protective casing, thereby reducing the risk of needle-stick injury.

Needle sticks are common among health care workers, so strict care in handling
needles while starting an IV is imperative. Centers for Disease Control and
Prevention (CDC) guidelines must be followed in order to decrease the risk of
infection for the client such as changing the IV solution every 24 hours, changing
the IV site and catheter every 48 to 72 hours, and changing the IV tubing every 48
hours. Occupational Safety and Health Administration (OSHA) standards are
necessary to prevent exposure to blood-borne pathogens through the use of gloves,
puncture-resistant containers for sharps, and special training for health care
workers (see Figure 8-2-1).
Assessment: 1. Check the health care provider's order for the type of therapy
planned to determine the optimal needle size and type to use.
2. Review information regarding the insertion of the IV in order to
insert the catheter safely.
3. Know the agency's policy regarding who may start an IV as many
agencies require that nurses have special training before they
can perform this procedure.
4. Assess the client's veins to optimize planning of the IV site.
5. Check the client's fluid, electrolyte, and nutritional status to provide
baseline data for comparison with the client's response to IV
therapy.
6. Assess the client's understanding of the purpose of the procedure so
that client teaching can be used to decrease anxiety.

Diagnosis:  Deficient Knowledge, related to the need for IV therapy

 Risk for Infection
 Excess Fluid Volume
 Deficient Fluid Volume
 Impaired Skin Integrity

Planning

Planning Needs: Equipment Needed (see Figure 8-2-2):

 Appropriate safety needle or catheter for venipuncture

 Tourniquet
 Povidone-iodine swabs (3) or chlorhexidine alcohol (chloroprep)
  Alcohol swab sticks (3) (not needed if using chlorhexidine alcohol)
 Disposable gloves
 Arm board, if needed
 Towel or absorbent drape
 Povidone-iodine ointment (not used in all institutions)
 Gauze dressing
 Tape
 Scissors
 IV tubing and solution

Expected 1. The IV will be inserted into the vein without complications and will
Outcomes: remain patent.
2. Fluid and electrolyte balance will be restored to the client.
3. Nutrition will be restored or maintained.
4. The IV site will remain free of swelling and inflammation.

Client Education 1. Give the client oral and written instructions about the insertion of
Needed: an IV.
2. Teach the client to report any signs of inflammation, clotting,
leaking, or breaking.
3. Teach the client how to bathe without getting the dressing wet.
4. Instruct the client how to prevent the IV from becoming dislodged.
5. Instruct the client how to properly position the arm to maintain IV
flow if the IV is positional.
6. Teach the client how to walk with an IV pole.
7. Suggest client wear clothes with wide sleeves.
8. Discuss with the client what activities he or she engages in to be
sure such activities are safe and will not cause damage to the IV.

Starting an IV - Implementation—Action/Rationale

Implementation ACTION RATIONALE

Action/Rationale 1. Check health care provider's order for 1. Ensures accurate insertion of catheter.
an IV and identify client.
2. Wash hands and put on mask and 2. Reduces the transmission of
gown if needed. microorganisms.
3. Organize all equipment at bedside. 3. Ensures smooth procedure without
accidents or contamination.
4. Explain procedure and reason the 4. Information decreases anxiety.
catheter is being inserted.
5. Inspect potential veins to be used: 5. Promotes ease of placement of catheter.

 Place a tourniquet around the  Distends vein to allow visual and

upper arm close to the axilla. tactile examination.
 Examine the veins as they  To evaluate the viability of the
dilate. vein.
 Palpate the vein to test for  To determine the best site for
firmness (see Figure 8-2-3). venipuncture and IV placement.
 Release the tourniquet.  Prevents engorgement of vein.

6. Select vein for venipuncture: 6.

 Use most distal part of the vein  If the vein is later damaged, the
first. proximal part can be used.
 Avoid bony prominences.  Increases client comfort.
 Avoid client's wrist or hand.  Bending of the wrist or hand
 Avoid client's dominant hand increases the risk of infiltration or
and arm. phlebitis.
 Avoid an extremity with  Allows freedom of movement.
decreased sensation.  Promotes earlier detection of
 Avoid an area of skin affected infiltration.
by a rash or infection.  Decreases risk of infection.

7. Select safety shield or angiocatheter 7. Necessary to puncture vein.

that is appropriate for ordered IV fluid. Angiocatheter gauge sizes vary widely.
Select the correct size of gauge and Particular intravenous therapies, such as
length of catheter. transfusions, require specific sizes of
intravenous access. Age and quality or
 location of veins can affect choice of
size.
8. Prepare supplies: 8. Provides a clean working surface for an
efficiently performed procedure.
 Place towel or drape on table
for supplies.
 Place supplies on towel.
 Open needle adapter end of IV
tubing set.

9. Shave hair on skin at site if necessary. 9. Ensures adherence of dressing and that
removal is less painful. Shaving should
be avoided as it causes small abrasions
that increase the risk of infection.
10. Ask client to rest arm in a dependent 10. Allows better venous dilation and
position, if possible. visibility.
11. Put on disposable gloves. 11. Reduces transmission of
microorganisms.
12. Prepare insertion site (see Figure 8-2- 12.  Reduces transmission of
4): microorganisms.
 Alcohol removes fat on the skin
 Place absorbent drape under and vigorous scrubbing in circular
the arm. motion with povidone-iodine
 Scrub the insertion site with 3 removes bacteria. Using a
alcohol swabs then 3 povidone- separate swab and starting in the
iodine swabs. middle of the site working
 Follow institution protocol. outward prevents bacteria from
Some facilities use being reintroduced to the site.
chlorhexidine alcohol instead of  Povidone-iodine or chlorhexidine
iodine. alcohol must be dry to be
 Allow the antiseptic solution to effective.
air dry.

13. Apply tourniquet 5 to 6 inches above 13. Tourniquet is needed to allow the vein to
the insertion site. engorge for easier venipuncture.

 Secure it tightly enough to  Decreased arterial flow prevents

occlude venous flow, not venous filling.
arterial flow.  Ensures arterial flow is present.
 Check presence of distal pulse.

14. Perform the venipuncture: 14.

 Anchor the vein by placing  Stabilizes the vein for ease of

thumb over vein and stretching venipuncture.
the skin against the direction of  Prevents puncture of posterior
insertion 2 to 3 inches distal to wall of vein.
the site.  Venous pressure from tourniquet
 Insert the stylet needle at a 20 causes backflow of blood into
to 30° angle with the bevel up catheter or tubing.
(see Figure 8-2-5).  Some veins are close to an
 Watch for a quick blood return artery. Arterial blood is bright red
through the flashback chamber and pulses.
of the ONC.  Ensures the catheter is in the
 Verify needle placement in a vein.
vein, not artery.  Ensures proper placement of the
 Advance ONC 1/4 inch into the catheter.
vein while it is parallel to the  Prevents the catheter from being
skin. punctured by the stylet.
 Loosen stylet and advance  Prevents blood from leaking out
catheter into vein until hub rests of vein until IV tubing is
at venipuncture site (see Figure connected.
8-2-6).  Re-establishes venous blood
 Do not reinsert stylet. flow.
 Hold thumb over vein above
catheter tip.
 Release the tourniquet.

15. Attach IV tubing to ONC. 15.  Maintains catheter placement.

  Provides entry portal for IV fluids.
 Stabilize the catheter with one Reduces risk of inadvertent
hand. needle-stick injury.
 Remove the stylet from ONC or  Reduces blood loss.
if using a safety catheter push  Prompt initiation of infusion
the button on the protective maintains patency of IV.
casing and stylet will fully
retract into the casing.
 Quickly release pressure over
vein and quickly connect needle
adapter of IV set to hub of
ONC.
 Begin infusion at slow rate to
keep vein open (see Figure 8-2-
7).

16. Secure catheter in place: 16.  Ensures catheter's safe position.

 Controls bleeding and prevents
 Place tape over the hub of the infection. Allows visualization of
catheter. site through transparent dressing.
 Place transparent dressing over  Prevents dislodgement of IV if
the site and secure. tubing is pulled.
 Secure tubing in loop fashion
with tape.

17. Remove gloves and dispose with all 17. Reduces transmission of
used materials. microorganisms.
18. Place label with date and time of 18. Provides information to schedule next
insertion and size and gauge of dressing change.
catheter on the dressing. Follow
protocol for scheduled dressing
change.
19. Wash hands. 19. Reduces transmission of
microorganisms.

Starting an IV - Post-Skill
Evaluation:  The IV was inserted into the vein without complications and remains patent.
 Fluid and electrolyte balance were restored to the client.
 Nutrition was restored or maintained.
 The IV site remains free of swelling and inflammation.

Documentation: Nurses' Notes

 Note date and time the IV was inserted.

 Document type and gauge of catheter.
 Record date of dressing placement.
 Describe client's reaction to the procedure.
 Document fluid to be infused or if a saline or heparin lock.

Variations

Geriatric Variations:  The veins of elderly clients may be more fragile. Be aware of this when
assessing IV sites for continued patency.
 Be careful to use only minimal pressure of the tourniquet because of fragile
skin and veins.
 Use a 5 to 15° angle when inserting the needle as the elderly client's veins
are more superficial.
 Elderly clients develop fluid imbalances more rapidly because of a larger
extracellular fluid volume.
 Some elderly clients may have cardiac or renal failure that requires
specialized IV therapy because of increases in vascular volume or inability
to eliminate extracellular fluid.
 Tourniquet should be left in place a minimal amount of time because of
more fragile veins in the elderly.

Pediatric Variations:  In neonates, veins of the scalp and feet can be used.
 Use the smallest gauge needle possible according to the IV
therapy needed.
  Special precautions are needed to maintain an intact IV in
very young clients.
 Allow older children to help in the selection of the IV site in
order to increase cooperation and decrease anxiety.
 Teenagers and young adults often have thicker, tougher skin
than a middle-aged client. The nurse should bear this in
mind when starting an IV on someone this age.

Home Care Variations:  A more secure dressing may be necessary if the client is
active.
 Ensure that containers for proper disposal of equipment are
in place.
 Arrange for delivery of IV supplies.

Long-Term Care  Clients in the long-term care setting may have more contact
Variations: with nurses' aides than with nurses. The aides must be
taught to recognize and report IV infiltrations or other
problems.
 Be sure to assess the IV site often and to change the IV site
every 3 days or according to the policies of the institution.

Starting an IV - Common Errors

Possible Errors: The catheter is noted to be pulled out 1 inch at the time of the dressing change.
Prevention: Be sure to secure the catheter with tape. Advise the client to be careful of
the catheter during activity. If the catheter is pulled out, do not push
catheter back into vein. Check for patency of the catheter. If it is patent, it
may continue to be used when properly secured. If it is not patent, it will
need to be replaced.
Nursing Tips:  Methods to promote venous dilatation are:
o Stroking the extremity from distal to proximal below the
proposed venipuncture site
o Opening and closing the fist
o Light tapping with two or three fingers over the vein
o Applying a warm washcloth or other heat to the extremity

 Be sensitive to the client's dominant arm and need for some

movement.
 Use 18-gauge or larger needle if the infusion of blood products is
anticipated.
 Always insert the IV needle/catheter in the direction of venous
return (toward the heart) to avoid damaging the venous valve.

Critical Thinking Skill

Introduction: When an IV infiltrates, it damages the vein and tissue surrounding it. Some clients require
multiple venipunctures to maintain a patent IV. It is necessary to preserve the veins that
are remaining for future use.
Possible An elderly gentleman was admitted to the cardiac intensive care unit after
Scenario: complaining of chest pains. The nurse noted that the IV inserted in the
emergency room was placed in the large vein in the antecubital space. A
large-bore needle was used in case emergency medications were needed.
However, the site appeared to be slightly swollen after the client had been
moving his arm around during transport.
Possible The nurse assessed the IV site and determined that the IV was still patent.
Outcome: As the site was already punctured and a large-bore needle was used, the
nurse decided to place the client's arm on an arm board to prevent further
trauma and continued to use this site. Shortly afterward, the client's blood
pressure started to drop and his physician ordered dopamine to be started
immediately. The nurse started to hang the dopamine and reassess the IV
site and noted that the site was definitely swollen and infiltrated. This was
the client's only venous access site, and with his low blood pressure,
obtaining a new venous access site was difficult and time consuming. The
nurse was able, finally, to secure a new IV site and the dopamine infusion
was started. The client's blood pressure was stabilized but his life was
unnecessarily jeopardized by the lack of patent venous access.
Prevention: The nurse looked for another vein more distal on the opposite arm
after asking the client which was his dominant arm, and was
successful in starting a large-bore IV that was in a much more
comfortable site and preserved the proximal sites for later use if
needed. The nurse then removed the IV that would soon be
infiltrated.

In emergency situations, it is not always possible to select a

comfortable site; however, planning for short-term IV therapy should
be done whenever possible.