Module 11

The goals of IV therapy are to prevent fluid and electrolyte imbalances,

administer continuous or intermittent solutions or medications, replenish
blood volume, and assist in pain management. Assessments of a patients
anatomy and physiology of the circulatory system, fluid and electrolyte
balance, disease pathophysiology, type and duration of prescribed therapy,
allergies and patients response to illness play a key role in decision making
to ensure safe delivery of infusion solutions or medications. Evidence-based
practice guides the safe, efficient, quality care necessary to provide infusion
therapy. For the skills in this module, follow the six rights of administering
parenteral solutions or medications:
Right drug/solution
Right dose/concentration
Right patient
Right route
Right date/time
Right documentation (Alexander et al., 2010; INS 2011; Policy and
Procedures, INS, 2011).
Defined further, these Rights include: knowledge of the correct solution and
equipment, how to initiate an infusion, regulate the infusion rate, care and
maintenance of the infusion equipment, identify and correct any infusionrelated complications, and discontinue the infusion. To safely and correctly
provide infusion therapy, you need astute clinical management and
specialized IV therapy skills in addition to your knowledge and professional
accountability.
Safety Guidelines
Know the patients baseline vital signs before initiating IV therapy. Fluid and
electrolyte imbalances affect vital signs. Dehydration sometimes produces
hypotension and tachycardia. Fluid overload often results in hypertension
and bounding pulses.
Know the patients medical history, current medications, and therapies.
Some medications affect fluid and electrolyte balance (e.g., diuretics or
steroids). Determine the patients previous experience with IV therapy.
Beware of prolonged environmental conditions that affect the patients fluid
status (e.g., exposure to hot, humid weather) leading to fluid and electrolyte
imbalances, particularly in the infant, older adult, and the chronically ill.
Know if the patient is right- or left-handed. For comfort and mobility, place
an IV in the nondominant arm.
Ensure that an IV system is intact, and that there is no evidence of phlebitis
or infiltration. An intact system ensures that you have maintained sterility
and that no fluid or medication has been lost.

Note the date of the last IV administration set and dressing change.
Maintain sterility of a patent IV system using the INS standards.
Know the standard precautions for infection control and the Occupational
Safety and Health Administration (OSHA) standards for occupational
exposure to blood-borne pathogens.
Patient Centered Care
Communication and education are essential components of positive
therapeutic outcomes with diverse populations. Educating patients and
family caregivers regarding the prescribed IV therapy and goals of therapy
may be difficult with attention focused on any cultural and linguistic needs.
Education includes clear and concise terms for all aspects of IV therapy and
individualized training that includes self-care practices (INS, 2011). Nursing
interventions utilized during the insertion of the vascular access device to
help alleviate anxiety and fear would include preparing the patient prior to
insertion of the short peripheral IV catheter by placing them in a comfortable
position, speaking directly to the patient, and answering questions as
honestly as possible. Have the patient breathe in and out slowly to help
lessen anxiety and direct the patient to avoid looking at the short peripheral
IV catheter during insertion. Encouraging the patient to focus on a pleasant
image or past experience may also help to divert his or her attention to the
procedure being performed. Your ability to recognize diversity in patients,
whether it is cultural, linguist, religious, or past experiences will prepare you
to be confident in providing infusion therapy to patients.

Anatomy and Physiology

Common IV puncture sites include the hand and the arm. These sites utilize
the cephalic, basilic, and median cubital veins. The use of the foot for an IV
site is common with children but is contraindicated in adults because of the
danger of thrombophlebitis. When possible, place IVs at the most distal site.
Using a distal site first allows for the use of proximal sites later if the patient
would need a venipuncture site change.
When assessing the patient for potential venipuncture sites for IV infusion,
consider conditions and contraindications that exclude certain sites such as:
The dorsal surface of the hand in the very young and older adult (these
patients have fragile veins and this site may be easily bumped)
An infected siteas indicated by redness, tenderness, swelling, warmth at
the siteand possibly the presence of exudate (danger of introducing
bacteria from the skin surface into the bloodstream)
An extremity with compromised circulationfor example, vascular (dialysis)
graft/fistula, mastectomy, or paralysis (venous alterations can increase risk
of complications)
A site with signs of infiltration or thrombosis (to prevent further

complications of pain and swelling and to allow accurate assessment of the

already compromised site)
Sites distal to previous venipuncture site (insertion needs to be proximal to
compromised area of vein)
Sclerosed or hardened cordlike veins that are firm and often tortuous
(making it difficult to puncture the vein, and increasing the risk of going
through the vein when applying force).
Areas of venous valves or bifurcation (increases risk of damaging vein with
catheter insertion and impedes flow of IV fluids)
Veins in the antecubital fossa (veins in the antecubital fossa are used for
blood draws, and placement in this area limits mobility of the elbow)
Veins on the ventral surface of the wrist (inner wrist contains numerous
tendons and nerves that could be damaged)
Prior to a catheter or needle insertion, the hair of the IV site may be clipped,
but shaving should be avoided. Hair impedes venipuncture and adherence of
dressing. Shaving can cause microabrasions and predispose the patient to
infection.
Place at the most distal site when possible. Using a distal site allows for the use of
proximal sites later if the patient would need a venipuncture site change. Using the
nondominant arm facilitates mobility.

Intravenous Solutions
Intravenous solutions will fall into the following categories:
Isotonichave the same osmolality as body fluids and are used most often
to replace extracellular (intravascular) volume (e.g., simple dehydration after
prolonged vomiting)
Hypotonichave an osmolality less than body fluids and are used most often
to hydrate cells (e.g., hypertonic dehydration, required water replacement)
Hypertonichave an osmolality greater than body fluids and are used most
often to increase extracellular fluid volume (e.g., replace electrolytes, treat
shock)
The patients specific fluid and electrolyte imbalance and serum electrolyte
values guides the need for administration of the appropriate intravenous
fluid (Alexander et al., 2010). Administer all IV fluids carefully; isotonic
solutions could cause increased fluid overload in patients with renal or
cardiac disease; hypotonic solutions could exacerbate a hypotensive state in
a patient with low blood pressure; and hypertonic solutions are irritating to
the vein as well as have the potential to cause increased risk of heart failure
and pulmonary edema.
Premixed solutions are available in which medications or electrolytes have
been added by the manufacturer. Advantages are the increased stability of
the solution, selection of the correct medication, and diluents. A
disadvantage is that admixtures come in more than one dosage, leading to

potential medication errors. As the choices of premixed solutions increase so

does the risk of related complications. A complete review of the patients
history, physical assessment, and laboratory findings needs to be completed
prior to initiation of any solutions or medications. When initiating IV therapy
you must verify that the order is complete. Elements of a complete order
include patient identification, type of solution or medication, volume, rate of
infusion, frequency of infusion, route, dosage (medication) and any special
considerations. The nurse administering IV solutions or medications should
be aware of the indications for the prescribed therapy, any adverse
reactions, special monitoring (lab values, vital signs, intake and output) and
appropriate interventions (INS, 2011).
Potassium chloride should never be given by IV push or added to a
small volume of IV solution. A direct IV infusion of KCl can cause
cardiac arrest and may be fatal. Potassium chloride is administered orally
or as a premixed IV additive by pharmacy or the manufacturer in a larger
volume of IV fluids.
Verify that the patient has adequate renal perfusion (i.e., at least 30 mL/hr
urine output for adults) before administering IV fluids containing potassium
chloride.
Solution
Dextrose in Water
Solutions

Concentration

Other Names

Isotonic

D5W

Hypertonic

D10W

Hypertonic

D50W

Hypotonic

NS

Dextrose 5% in water*
Dextrose 10% in water
Dextrose 50% in water
Saline Solutions
0.45% sodium chloride
(half normal saline)

0.45% NS
0.33% sodium chloride
(one-third normal
saline)
0.9% sodium chloride
(normal saline)

Hypotonic

NS

Isotonic

NS
0.9% NS
0.9% NaCl

Hypertonic
3% sodium chloride
3% NS
5% sodium chloride
5% NaCl
Dextrose in Saline
Solutions
Hypertonic
Dextrose 5% in 0.9%
sodium chloride

D50.9% NaCl
D50.9% NS
D5NS
D50.45% NaCl

Hypertonic
Dextrose 5% in 0.45%
NaCl sodium chloride

D50.45% NS
D5 NS

Multiple Electrolyte
Solutions
LR
Lactated Ringers

Isotonic

Dextrose 5% in lactated Hypertonic

Ringers

D5LR

A hypertonic solution used carefully in patients at risk for fluid overload

because it pulls fluid into the vascular space
A hypertonic IV solution (e.g. D5 NS) will pull fluid into the vascular space by osmosis,
resulting in an increased vascular volume that will possibly result in pulmonary edema.
This is common in high-risk patients with cardiac (e.g. heart failure) or renal disease.
A hypotonic solution (e.g. 0.45% sodium chloride) is used to rehydrate cells (increasing
intracellular volume). With fluid volume deficit both water and electrolytes are lost
proportional to normal body fluids. In dehydration, more water is lost than electrolytes,
resulting in shrinkage of cells and hypertonicity. A hypotonic solution will draw fluid into
the cells and create greater equilibrium in sodium levels.
Catheter Size
14, 16, 18
20
22

Clinical Indication
Trauma surgery blood transfusion
Continuous or intermittent infusions,
blood transfusion
Continuous or intermittent infusions,
children and elderly patients;

24-26

Butterfly needle

administration of blood or blood

products in peds and neonates
Fragile veins for intermittent or
continuous infusions; administration
of blood or blood products in peds or
neonates
Admin of IV fluids in infants

Selecting Appropriate EquipmentTubing

Different types of tubing are used to administer medications or IV fluids.
A solution given rapidly needs to be infused with macro drip tubing, which
delivers large drops (standard drop size is 10 or 15 gtt per mL, depending on
the manufacturer).
In contrast, micro drip tubing is used to allow precise regulation of IV fluids
even at slow rates. Micro drip tubing delivers small drops (standard drop size
is 60 gtt/mL) for children, infants, and patients requiring close monitoring of
IV fluid administration (e.g., patients with cardiac or renal disease).
Infusion of blood products requires a blood administration set, which
contains an in-line filter.
IV extension tubing added to the primary tubing is frequently used to
increase the patient's mobility, decrease manipulation and potential
contamination at the insertion site, or facilitate patient changes in position.
Determine the type of tourniquet to use based on patient assessmentfor
example, latex free tourniquet if patient has a latex allergy. Tourniquets are
used to reduce venous return and cause distention in the veins where an IV
catheter will be inserted. The veins of older patients are more fragile, and
therefore a blood pressure cuff may be used instead. In infants, rubber
bands may be used because they are smaller than tourniquets. Use latex
free tourniquet if patient has a latex allergy. Because tourniquets can be a
source of contamination, single-use products are preferred.
vidence-based practice (EBP) in the prevention of infusion related
complications such as catheter related blood stream infections (CR-BSIs)
and central line associated bloodstream infections (CLABSI) could
significantly reduce patient morbidity and mortality (Alexander et al., 2010;
Gabriel, 2008; Policy and Procedures, INS 2011). It is imperative that you
follow established infection prevention strategies.

Performhandhygienebeforeandaftertouchingthepatient;before
handlinganinvasivedevice;beforedonningandafterremovinggloves;
andaftercontactwithinanimateobjectsnearthepatient.
Cleanseskinsitebeforevenipuncturewithanappropriatesingleuse

antisepticsolution.
Routinesitecareanddressingchangesarenotrequiredonshort
peripheralcathetersunlessthedressingissoiledornotintact.
Chlorhexidinesolutionispreferredforskinantisepsis.Povidineiodine,
70%alcohol,ortinctureofiodine(1or2%)mayalsobeused.
Chlorhexidineisnotrecommendedforinfantsunder2monthsofage.
Useacatheterstabilizationdevicethatallowsforvisualinspectionofthe
insertionsite.
Gauzedressingsmaybeplacedunderatransparentdressingbutmustbe
changedevery48hours.
Primaryandsecondarycontinuousadministrationsetsusedtoadminister
fluidsotherthanlipid,blood,orbloodproductsshouldbechangedat
leastevery96hours.
A patient who requires surgery should be prepared with a catheter large enough (i.e.,
16- to 18-gauge) to bolus IV fluids at a rapid rate or in the instance transfusion of blood
products becomes necessary.
A blood pressure cuff is often suitable for the elderly patient. If the patient has fragile
skin and veins, use minimal tourniquet pressure. If used, place over the patient's sleeve
to decrease shearing of fragile skin.

Procedure Guide / Nursing Skills Online, IV Fluid Administration

Module Hand Hygiene
1. First inspect your hands and nails.
1. Be sure fingernails are short, filed, and smooth.
2. Remove all nail polish and artificial nails or extenders, if indicated.
3. Remove any jewelry and push up sleeves, wristwatch, or both above
the wrists.
2. If hands are not visibly soiled, use an alcohol-based, waterless antiseptic
hand rub.
1. Dispense ample amount of product into palm of one hand.
2. Rub hands together, covering all surfaces of the hands and fingers,
until alcohol

is dry.
3. Hands must be dry before applying gloves.
3. Perform hand antisepsis using plain or antiseptic soap and water.
1. Keep hands and uniform away from sink surface.
2. Turn on the hand faucet or push the foot or knee pedal, if appropriate.
3. Avoid splashing water against uniform. Adjust the temperature to
warm.
4. Wet hands and wrists under running water, keeping hands and
forearms lower
than elbows.
5. Apply a small amount of soap or antiseptic, and lather thoroughly,
wiping from
fingers up to wrists and forearms for at least 15 seconds. Keep
fingertips pointed
down during hand washing.
6. Interlace fingers and rub palms and back of hands with a circular
motion at least
five times each.
7. Clean under fingernails with the nails of the opposite hand.
4. Verify
5. Describe the procedure to the patient.

Which of the following sites should be avoided for IV insertion?

(Select all that apply.)
foot of an adult
site distal to a previous site
inner wrist
areas of venous bifurcation
Adults major surgery- 18
Older adult requiring IV- 22

Infant requiring IV- butterfly

Young adult requiring fluid maintenance- 20
Lesson 2
Infusion therapy provides access to the venous system to deliver solutions
and medications or blood and blood products. Reliable venous access for
infusion therapy administration is essential.

You need to recognize the appropriate vascular access device needed in

order to place a short peripheral IV catheter or assist with placement of a
midline or central vascular access device. Additionally, skills are needed to
prepare the infusion equipment and be familiar with the various infusion
systems utilized during an infusion. Some solutions and medications can be
administered continuously while others are given intermittently. Various
types of administration sets, needleless devices, extension sets, flushes and
pumps are required as well as knowledge and skills for correct and safe use.
Know and follow INS standards, your facility policy and procedures, and
state or government practice guidelines when providing IV therapy.
Successful delivery of peripheral IV therapy depends on:
Patient preparation
Patient assessment and vein selection
Selection of appropriate equipment including: catheter, tubing, solution
Skilled catheter insertion
It is recommended by the Infusion Nurses Society (INS) that a single nurse
should not make more than two attempts at inserting an IV on any one
patient.
Because the potential for exposure to blood-borne pathogens is high, adhere
to principles of asepsis and utilize standard precautions.
Delegation
The skill of initiating intravenous therapy cannot be delegated to nursing
assistive personnel (NAP). Delegation to licensed practical nurses (LPNs)
varies by state Nurse Practice Act. The nurse instructs the NAP to:
Inform the nurse if the patient complains of any IV related complications
such as pain, redness, swelling, bleeding.
Inform the nurse if the patients IV dressing becomes wet or soiled.

Inform the nurse if the solution of fluid in the IV bag is low or the
electronic infusion device (EID) alarm is sounding. If the alarm is
sounding because of low battery, the NAP should plug the EID into an
appropriate electrical outle

Getting IV tray of supplies

Assessing for Signs and Symptoms of Fluid and Electrolyte

Imbalances
Assess for clinical factors/conditions that will respond to or be affected by
administration of solutions or medications:
Body weight is one of the initial clinical parameters. Changes in body weight
reflect fluid loss or gain. One kilogram or 2.2 pounds of body weight is
equivalent to the gain or loss of 1 liter of fluid (Alexander et al., 2010).
Intake and Output. Amounts should be measured accurately. Infusion
containers may be overfilled (1 L container may actually have 1100 L of
fluid). Output may be sensible (urine output) or insensible (perspiration).
Vital Signs:
1 Blood pressure, respirations, pulse, temperature. Changes in
blood pressure may be associated with fluid volume status (fluid
volume deficit [FVD] seen in postural hypotension; increase in
blood pressure seen in fluid volume excess [FVE]). Respirations
can be altered in the presence of acid-base imbalances.
Temperature elevations increase the need for fluid requirements
(a temperature of 101 F to 103 F [38.3 C to 39.4 C]
requires at least 500 mL of fluid replacement within a 24 hour
period) (Alexander et al., 2010).
Distended neck veins. Suggests fluid volume excess.
Auscultation of crackles or rhonchi in lungs. May signal fluid buildup in the
lungs due to fluid volume excess (FVE).
Skin turgor (after pinching, skin fails to return to normal position within 3
seconds). With FVD, turgor is decreased and the pinched skin stays elevated
for several seconds. This is called "tenting" (Alexander et al., 2010; Perry
and Potter, 2011).
Edema (pitting or non-pitting)
Pittingafter pressing the tissue with the fingers the indentation remains.
Pitting edema seen with a weight gain of 4.5 to 6.8 kg (10 to 15 pounds) of
retained fluid (Alexander et al., 2010; Perry and Potter, 2013).
Thirst mechanism will increase with water loss. Ingestion of sufficient
amounts of water is necessary for metabolism.
Behavioral changes (e.g., restlessness, confusion). Occurs with FVD or acidbase imbalance.
Dry skin and mucous membranes. Occurs with FVD.
Assessment
In addition to assessing for signs and symptoms of fluid and electrolyte
imbalance, the nurse should assess the patient for the following:
Determine if the patient is to undergo any planned surgeries or procedures.
Allows anticipation and placement of appropriate vascular access device for
infusion and to avoid placement in an area that will interfere with medical
procedures (INS, 2011).

Assessment of appropriateness for vascular access is based upon:

1 Patients condition, age, and diagnosis
2 Vein integrity, size, and location
3 Type and duration of prescribed therapy
4 Patients infusion history
5 Patients preference for location as appropriate
6 Allows for appropriate placement of vascular access device while
minimizing infusion related complications (Alexander et al.,
2010; Policy and Procedures INS, 2011).
Assess patients history of allergies, especially to iodine, adhesive, or latex.
Equipment used during VAD insertion may contain substances to which
patient is allergic.
Equipment

Because fluids are instilled into the bloodstream, sterile technique is

necessary for IV catheter insertion. The nurse should have all equipment
organized and at the bedside before beginning IV fluid administration.
The necessary equipment for insertion of a peripheral intravenous device
includes the following:
Appropriate short-peripheral IV catheter for venipuncture. Selection shall be
of the smallest gauge and length possible to administer the prescribed
therapy (INS, 2011).
IV start kit (available in some agencies): may contain a sterile drape to place
under the patients arm, tourniquet, tape, clear occlusive dressing, cleansing
agents(s) (2% chlorhexidine or povidone-iodine and 70% alcohol) and 2x2
inch gauze pads.
Clean gloves (latex free for patients with latex allergy)
Extension set with needleless connection device
Prefilled 5-mL syringe with flush agent (preservative-free normal saline
0.9% NSS [INS, 2011])
Alcohol pads
Stabilization device (optional)
Prescribed solution or medication
Administration set (either macro drip or micro drip depending on prescribed
rate). If using electronic infusion device (EID), appropriate administration
set
0.2-micron filter for non-lipid (fat emulsions) solutions (may be incorporated
into the infusion set).
Protective equipment: goggles and mask (check facility policy)
IV pole, rolling or ceiling mounted
Electronic infusion device (EID) if available
Watch with second hand to calculate drip rate
Special patient gown with snaps at shoulder seams (makes removal with IV

tubing easier), if available

Needle disposal container (also called sharps container or biohazard
container)

Expected Outcomes
Expected outcomes following completion of procedure:
Fluid and electrolyte balance returns to normal.
Vital signs are stable and within normal limits for patient.
No redness, drainage, swelling or pain present at venipuncture site.
Infusion of solutions and medications is delivered at ordered rate.
Patient is able to explain purpose and risks of IV therapy.
Gerontological Considerations
Veins of the older population are very fragile; there is less subcutaneous
support tissue, and there is thinning of the skin (Alexander et al., 2010).
Avoid sites that are easily moved or bumped. Use a commercial protective
device to protect site and reduce manipulation at the site.
In older patients, the use of a 22- or 24-gauge catheter is appropriate for
most therapies. Smaller-gauge catheters are less traumatizing to the vein
but still allow blood flow to provide hemodilution of the IV fluids or
medications. (Alexander et al., 2010).
Minimize pressure from tourniquets, or avoid them if possible due to the
increased risk of hematoma. Place tourniquet over clothing to avoid bruising
or skin tears (Alexander et al., 2010). Use a blood pressure cuff if possible.
As older adults lose subcutaneous tissue, the veins lose stability and roll
away from the needle. To stabilize the vein, pull the skin taut and toward
you with your nondominant hand, and anchor the vein with your thumb.
Some older adults do not complain of pain at the insertion site; however, a
large amount of fluid may infiltrate before a patient experiences discomfort.
If possible, avoid the back of the older adult's hand or the dominant arm for
venipuncture because use of these sites interferes with the older adults
independence.
Reduce angle of insertion (e.g., 5 to 15 degrees on insertion) to
accommodate more superficial veins.

Procedure Guideline for Insertion of Peripheral Infusion Device

1. Verify the health care providers orders.
2. Gather the necessary equipment and supplies. If possible, prepare all equipment prior to
entering the patients room.

3. Introduce yourself to the patient and family, if present.

4. Provide for the patients privacy.
5. Perform hand hygiene.
6. Identify the patient using two identifiers such as the patients name and birth date or
name and medical record number, according to your agencys policy. Compare the
identifiers in the MAR/medical record with the information on the patients identification
bracelet.
7. Inform the patient about the rationale for the infusion, the solution and medications
ordered, the procedure for initiating an IV, and signs and symptoms of complications.
8. Raise the bed to a comfortable working height, and help the patient into a comfortable
sitting or semi-Fowlers position. Provide adequate lighting.
9. If necessary and available, change the patients gown to a more easily removed gown
with snaps at the shoulders.
10. Ask about hand dominance and choice of insertion site. Visually determine the likely site
of insertion, using a tourniquet if necessary. Remove the tourniquet right away once the
site is determined. Place a towel under the chosen arm.
11. Organize the equipment on a clean, clutter-free bedside stand or overbed table.
12. Apply clean gloves.
13. Open sterile packages using aseptic technique.
14. Option: Prepare short extension tubing with a needleless adaptor or stand-alone saline lock
(injection cap) to attach to the VAD catheter hub:
1. Remove the protective cap from the needleless connector. Attach the syringe with sterile
0.9% normal saline solution (NS) flush, and inject it through the cap into the short
extension set, keeping the syringe attached.
2. Maintain the sterility of the distal end of the connector, and set it aside for attaching to
the catheter hub after venipuncture has been completed.
15. Prepare the IV tubing and solution for continuous infusion:
A. Check the IV solution using the six rights of medication administration. Refer to the Video
Skill Ensuring the Six Rights of Medication Administration. If you are using a bar code system,
scan the code on the patients wristband and then on the IV
fluid container. Be sure that the prescribed additives, such as potassium and vitamins, have
been added. Check the solution for color, clarity, and expiration date. Check the bag for leaks.

2. Open the infusion set, maintaining the sterility of both ends of the tubing. Electronic
infusion devices (EID) have a dedicated administration set.
3. Place the roller clamp about 2 to 5 cm (1 to 2 inches) below the drip chamber, and move
the roller clamp to the off position.
4. Remove the protective sheath over the IV tubing port on the plastic IV solution bag or on
top of the bottle.
5. Remove the protective cap from the tubing insertion spike (not touching the spike), and
insert the spike into the port of the IV bag. If the solution is in a glass bottle, clean the
rubber stopper with a single-use antiseptic and insert the spike into the black rubber
stopper of the IV bottle. Bottles need special vented tubing. Hang the bag or bottle on
the IV pole.
6. Compress the drip chamber and release it, allowing it to fill one-third to one-half full.
7. Prime the infusion tubing by filling it with IV solution: Remove the protective cap on the
end of the tubing (you can prime some tubing without removing it), and slowly open the
roller clamp to allow fluid to travel from the drip chamber through the tubing to the needle
adapter. Invert the Y connector to displace any air.
8. Return the roller clamp to the off position after priming the tubing (filling it with IV fluid).
Replace the protective cap on the end of the infusion tubing.
9. Be certain that the tubing is clear of air and air bubbles. To remove small air bubbles,
firmly tap the IV tubing where air bubbles are located. Check the entire length of the
tubing to ensure that all air bubbles have been removed.
16. Select the vein for VAD insertion. Veins on the dorsal and ventral surfaces of the arms, such
as the cephalic, basilic, or median, are preferred in adults. Avoid using the veins on the thumb
side or palmar side of the wrist, because of the potential for nerve damage.
1. Choose a site that will not interfere with the patients activities of daily living (ADLs), use
of assist devices, or planned procedures.
2. Avoid vein selection in:
1. (1) Areas with tenderness, redness, rash, pain, or infection
2. (2) An extremity affected by previous cerebrovascular accident (CVA), paralysis,
dialysis shunt, or mastectomy
3. (3) Any site distal to a previous venipuncture site, sclerosed or hardened veins,
a site of infiltrate, areas of venous valves, or phlebitic vessels
4. (4) Fragile dorsal hand veins in older adults

17. Perform hand hygiene, and apply clean gloves. Put on a mask, goggles, or a face shield if
splashing is likely, according to your agencys policy.
18. Apply a tourniquet around the patients arm 10 to 15 cm (4 to 6 inches) above the
proposed insertion site. Do not apply the tourniquet too tightly, to avoid injury, bruising of
the skin, or occlusion of the artery. Check for the presence of a radial pulse.
1. Option A: Apply the tourniquet on top of a thin layer of clothing, such as a gown
sleeve, to protect fragile or hairy skin.
2. Option B: Use a blood pressure cuff in place of a tourniquet: Inflate the cuff to just
below the patients diastolic pressure [less than 50 mm Hg].
19. Select a vein large enough for VAD insertion:
1. Use the most distal site in the nondominant arm if possible.
2. Select a well-dilated vein. If necessary, use one of the following methods to
improve venous distention:
1. (1) Place the extremity in the dependent position, and stroke the selected
vein from a distal to proximal direction below the proposed venipuncture
site.
2. (2) Apply warmth to the extremity for several minutes using a warm
washcloth or dry heat.
3. With your index finger, palpate the vein by pressing downward. Note the resilient,
soft, bouncy feeling as you release the pressure.
20. After you have identified the vein you are going to use, release the tourniquet
temporarily and carefully.
1. Option: Clip arm hair with scissors if necessary (explain to the patient).
2. Option: Apply a topical local anesthetic to the IV site 30 minutes before insertion.
Monitor for an allergic reaction if a local anesthetic is going to be used.
21. Apply clean gloves, if not already done in step 17.
22. Place the distal end of the short infusion tubing or extension/injection cap for the saline
lock nearby in a sterile package.
23. If the area of insertion appears to need cleansing, use soap and water first and dry
thoroughly. Then, use a chlorhexidine antiseptic swab or applicator to cleanse the
insertion site:

A. With chlorhexidine, cleanse the area with repeated back-and-forth strokes of the applicator
for 30 seconds. Let dry for 30 seconds. If using 70% alcohol or an iodine/povidone swab,
cleanse in a circular motion, beginning at the insertion site and spiraling out away from the
insertion site. Allow 2 minutes to dry.
24. Refrain from touching the cleansed site.
25. When the antiseptic has dried, perform the venipuncture:
1. reapply the tourniquet 10 to 15 cm (4 to 6 inches) above the intended insertion
site. Check for the presence of a distal pulse.
2. Anchor the vein below the site by placing your thumb over the vein and gently
stretching the skin against the direction of the insertion 4 to 5 cm (l to 2 inches)
distal to the site. Ask the patient to relax his hand.
3. Caution him that he will feel a quick stick.
4. Insert the vascular access device with the bevel up at a 10- to 30-degree angle
slightly distal to the actual site of venipuncture in the direction of the vein.
26. Observe for blood return through the flashback chamber of the catheter, indicating that
the bevel of the needle has entered the vein.
A. Lower the catheter until it is almost flush with the skin.
B. Advance the catheter 0.6 cm (14 inch) into the vein, and loosen the stylet of the overthe-needle catheter (ONC). Continue to hold the skin taut while stabilizing the needle.
Advance the catheter off of the needle to thread just the catheter into the vein until the
hub rests at the venipuncture site.
C. Do not reinsert the stylet once it has been loosened.
D. As you advance the catheter, the safety device will automatically retract the stylet.
This technique will vary by product type used. Follow the manufacturers guidelines.
27. While stabilizing the catheter, release the tourniquet or blood pressure cuff. Apply firm
but gentle pressure to the vein about 1 inch above the insertion site with one finger while
keeping the catheter stable.
28. Quickly connect the Luer-Lok end of the prepared extension set, the saline lock, or the
primary administration set tubing, to the end of the catheter. Do not touch the point of
entry of the connection. Secure the connection.
29. Flush the VAD. Slowly flush the primed extension set with the remaining saline from the
attached prefilled syringe, or begin the primary infusion by easing open the slide clamp
or adjusting the roller clamp on the IV tubing. Watch for swelling.

30. Follow up by securing the catheter and applying a dressing:

31. Open sterile packages using sterile aseptic technique.
32. For applying a transparent dressing (TSM):
1. Carefully remove the adherent backing. Apply one edge of the dressing and gently
smooth the remaining dressing over the IV site, leaving the connection between the IV
tubing and the catheter hub uncovered. Remove the outer covering, and smooth the
dressing gently over the site.
2. Next, place a 2.54-cm (1-inch) wide piece of tape over the extension or administration
set tubing. Do not apply tape on top of the transparent dressing.
3. Loop the short extension set alongside the arm, and secure it with a second piece of
tape. Be careful not to kink the tubing.
4. Label the IV dressing according to your agencys policy. Include the date and time of the
IV insertion, VAD (vascular access device) gauge and length, and your initials.
33. For applying a catheter protection device for patients with fragile skin:
1. Apply the transparent dressing as directed above.
2. Coil the loop of the tubing or extension set to fit under the curve of the domed end of the
device.
3. Tape across the dome to hold it in place. Allow the tubing to exit the open end.
4. Change the housing device each time a new IV is inserted.
34. For applying a sterile gauze dressing:
1. Place a narrow piece of tape over the catheter hub. Do not apply tape over the insertion
site or around the arm.
2. Place a 2 2inch gauze pad over the insertion site and catheter hub. Secure all edges
with tape. Do not cover the connection between the IV tubing and catheter hub.
3. Fold a 2 2inch gauze pad in half, and cover it with 2.54-cm (1-inch)wide tape
extending about 1 inch from each side. Place this under the tubing/catheter hub junction.
4. Looptheshortextensiontubingorthecontinuousinfusionadministrationtubing alongside the
arm, and place a second piece of tape directly over the tubing to secure it.
5. Once the dressing is secured, open the line clamp and initiate the infusion.
35. Dispose of the used stylet or other sharps in the appropriate sharps container. 36. Remove
your gloves, and perform hand hygiene.

37. Discard used supplies.

38. Instruct the patient on how to move or tum without dislodging the IV.
39. To ensure the patients safety, raise the appropriate number of side rails and lower the bed
to the lowest position.
40. Document and report the patients response and expected or unexpected outcomes.

The nurse wishes to promote venous distention making the vein larger and
more visible for IV insertion. Which of the following measures would foster
venous dilation and access to the vein?
- Lowering the arm to a dependent position
- Rubbing or stroking arm from distal to proximal below the
proposed site
The following is the correct sequence of the steps for initiating a peripheral intravenous
infusion beginning with insertion of the catheter and ending with releasing the
tourniquet: Anchor the vein by placing the thumb over the vein beneath the insertion site
and by stretching the skin against the direction of insertion 2 to 3 inches distal to the
site. Warn the patient of a sharp stick. Puncture the skin and vein, holding the catheter
at a 10- to 30-degree angle with the bevel pointed upward. The needle will be parallel to
the vein, so when the vein is punctured, the risk of puncturing the posterior vein wall is
reduced. Look for blood return through the tubing of the butterfly needle or flashback
chamber of the over-the-needle catheter (ONC), indicating that the needle has entered
the vein. The increased venous pressure from the tourniquet increases the backflow of
blood into the catheter or tubing. Lower the catheter/needle until it is almost flush with
the skin. Advance the butterfly needle until the hub rests at the venipuncture site.
Lowering the angle and advancing the cannula slightly allows for full penetration of the
vein wall, placement of the catheter within the vein's inner lumen, and easy
advancement of the catheter off the stylet. Advance the ONC catheter one-quarter inch
into the vein and then loosen the stylet. Advance the catheter off the stylet into the vein
until the hub rests at the venipuncture site. Advance the safety device by using the
push-off tab to thread the catheter. Never reinsert the stylet once it is loosened.
Threading the catheter up to the hub reduces the risk of the introduction of infectious
organisms along the catheter length. Reinsertion of the stylet can cause catheter
damage and potential catheter embolization. Stabilize the catheter. Apply gentle but firm
pressure with the index finger of the nondominant hand 1.25 inches above insertion site.
Release the tourniquet or BP cuff with the dominant hand and retract the stylet from the
ONC. This permits venous flow, reduces the backflow of blood, and prevents accidental
withdrawal or dislodgement of the catheter.
he catheter should be inserted with the bevel up at a 10- to 30-degree angle slightly
distal to the actual site of venipuncture. The tourniquet should not be released until after
the catheter is advanced and the stylet retracted.
Evaluation

Routine site care and dressing changes are not performed on short
peripheral catheters unless the dressing is soiled or no longer intact. An
occlusive transparent dressing is changed at the time of site rotation
(Alexander et al., 2010; INS, 2011; Policy and Procedures INS, 2011).
Gauze dressings are changed every 48 hours (INS, 2011).
Observe patient every 1-2 hours or at established intervals per facility policy
and procedure for the following:
Correct type/amount of IV solution or medication has infused by assessing
fluid level in IV bag and infusion totals on the electronic infusion device.
Count drip rate (if gravity drip) or check rate on infusion pump.
Check patency of the VAD.
Observe patient during palpation of vessel for signs of discomfort.
Inspect insertion site, note color (e.g., redness or pallor). Inspect site for
presence of swelling (which is a sign of infiltration), or pain and tenderness
(which is a sign of phlebitis). Palpate temperature of skin above dressing.
Observe patient to determine response to therapy (e.g., intake and output
[I&O], weights, vital signs, post-procedure assessments).
Unexpected Outcome
Fluid volume deficit (FVD) as
manifested by decreased urine
output, dry mucous membranes,
decreased capillary refill, a disparity
in central and peripheral pulses,
tachycardia, hypotension, shock.
Fluid volume excess (FVE) as
manifested by crackles in the lungs,
shortness of breath, edema.
Electrolyte imbalances indicated by
abnormal serum electrolyte levels,
changes in mental status,
alterations in neuromuscular
function, cardiac dysrhythmias, and
changes in vital signs.
Infiltration as indicated by slowing
of infusion, insertion site is cool to
touch, pale and painful.

Phlebitis is indicated by pain and

tenderness at IV site with erythema
at site or along path of vein.

Intervention
Notify prescriber . Requires
readjustment of infusion rate

Reduce IV flow rate and notify

provider
Notify provider. Adjust addives in IV
or type of IV per order

Stop infusion and DC IV; elevate

affected extremity; restart new IV if
continued therapy is necessary
above previous location of
infiltration or opposite extremity.
Document degree of infiltration and
nursing intervention
Stop infusion and discontinue IV;
restart new IV if continued therapy
is necessary in area above previous

Insertion site is warm to touch and

rate of infusion may be altered.

Bleeding occurs at venipuncture

site.

IV site infection. Assess site for

signs and symptoms of infection
which may include: redness, pain,
edema, induration, temperature,
and drainage

location or opposite extremity; place

moist warm compress over area of
phlebitis. Continue to monitor site
for 48 hours after catheter is
removed for post-infusion phlebitis
(INS, 2011). Document degree of
phlebitis and nursing interventions
per facility policy and procedure.
Verify that the system is intact and
replace transparent occlusive
dressing if loosened. Restart new IV
if bleeding from site does not stop
or if IV is dislodged.
Notify health care provider for
appropriate interventions such as
culturing of device or site. Restart
new IV if continued therapy is
necessary in area above location or
opposite extremity. Document the
presence and severity of infection
and interventions.

Lesson 3: Trouble shooting IVs

Delegation
The skill of troubleshooting intravenous therapy cannot be delegated to
nursing assistive personnel (NAP). This skill requires the critical thinking and
knowledge application unique to a nurse. In many states, these skills are
included within the scope of practice for licensed practical nurses.
Other aspects of the patients care may be delegated to nursing assistive
personnel (NAP). The nurse instructs NAP to inform the nurse:
If the patient complains of burning, bleeding, swelling, or coolness at the
catheter insertion site
If the IV dressing becomes wet or soiled or if IV lines become disconnected
If the volume of fluid in the IV bag is low or the electronic infusion device
(EID) alarm is sounding (e.g., due to occlusion or air in line). If alarm is
sounding because of low battery, the NAP should plug the EID into an
appropriate electrical outlet.
An infiltration occurs when IV fluids enter the surrounding space around
the venipuncture site. This is manifested at the intravenous site as:
Swelling (from increased tissue fluid)
Pallor and coolness (caused by decreased circulation)

Fluid may be flowing through the IV line at a decreased rate or may have
stopped flowing. Pain may also be present. It usually results from edema
and increases proportionately as the infiltration continues.

Phlebitis is inflammation of the vein. Selected risk factors for phlebitis

include:
The type of catheter material
Chemical irritation of additives and medications given intravenously (e.g.,
antibiotics)
The anatomical position of the catheter
Length of time catheter has been in place
Dehydration
Signs and symptoms may include:
Pain (palpate the catheter site through the intact dressing for complaints of
tenderness, pain, or burning, which could indicate phlebitis)
Edema
Erythema
Increased skin temperature over the vein
In some instances, redness travelling along the path of the vein
Dehydration may be a contributing factor because of the increase in blood
viscosity.
Fluid volume excess occurs when the patient has received a too-rapid
administration of IV solutions. The assessment findings include:
Shortness of breath
Crackles in the lungs
Tachycardia
Edema
Neonates, very young children, older adults, patients with severe head
trauma, and patients susceptible to volume overload (those with cardiac or
renal disease) must be protected from sudden increases in infusion volumes.
Volume-control devices can prevent sudden excessive increases in the
volume of IV solution infused. An example of a volume-control device is a
calibrated chamber placed between the IV container and the insertion spike
and drip chamber of the administration set. You place a small volume of IV
fluid in the chamber and regulate it for administration. The advantage of this
system is that only the smaller volume of fluid infuses.
Another infusion safety system is the smart pump. Smart pumps have
built-in software programmed from health care pharmacy databases with
unit-specific profiles. The pump has an audible and visual alert when the
pump setting does not match the medication administration guidelines,
assisting in preventing infusion errors.
Bleeding can occur around the venipuncture site as a result of local trauma

to the vein. Bleeding also can occur through the catheter if it becomes
disconnected from the tubing. The resultant backflow of blood will result in
soiling of the IV dressing. Bleeding is common in patients who have received
anticoagulants or who have a bleeding disorder (e.g., leukemia or
thrombocytopenia).

Once an IV is inserted there are many possible sites where infection can
develop and spread. The nurse should assess for these signs and symptoms
of localized infection:
Elevated temperature
Drainage at the insertion site
Erythema (redness) at the insertion site
Complaints of pain at the insertion site
IV patency
Patency of the IV needle or catheter means that the tip of the needle or
catheter is without clots and that the catheter or needle tip is positioned
away from the vein wall. Patency allows IV fluids to run freely. IV flow
patency can be affected by:
A knot or kink in the tubing
The height of the solution container
A restrictive IV dressing
The position of the patients extremity
Position of control clamp
If blood return does not occur and fluid cannot flow easily from the drip
chamber when the roller clamp is opened, the nurse should assess for
potential causes (e.g., patient lying on the tubing, restrictive dressing).
Flushing to clear an IV catheter must be approached carefully (see facility
policy). If resistance is met, first assess mechanical causes (e.g., closed
clamps, kinked tubing, position of extremity). Never forcefully attempt to
flush. Fibrin formation, medication precipitates, and blood clots can occlude
the catheter lumen. Forceful flushing against these occlusions can cause
fracture of the catheter and possible embolization, or rupture of the vein.
The size of syringe used for flushing should be in accordance with the
manufacturers guidelines for pounds per square inch (psi). A recommended
size is a 10-mL syringe. The Infusion Nurses Society (INS) standards
suggest flushing with a minimum volume equal to at least twice the volume
capacity of the catheter.
Occlusion Corrective Measures
If a catheter is occluded, determine if the occlusion is caused by:
Kinked tubing
The patient lying on the tubing
The presence of a restrictive IV dressing

A closed roller clamp on the infusion tubing

If mechanical factors are absent, assess for patency by checking for a blood
return. If you are unable to observe a blood return and you are unable to
flush the catheter, you will have to discontinue the IV and insert a new IV
catheter in a different location.
Educating the patient about symptoms to report is an important aspect of
communication and care. The patient may be unsure of what is significant
regarding his or her IV infusion, creating undue concern. Advise the patient
to report any pain at the IV site.
Infiltration: Corrective meausres
When infiltration occurs, the infusion must be discontinued, and if IV therapy
is still necessary, a new catheter should be inserted at a new site above the
area of complication or in the other extremity. To reduce discomfort and help
decrease edema, wrap the extremity in a warm, moist towel for 20 minutes
while keeping it elevated on a pillow. This promotes venous return, increases
circulation, and reduces pain and edema.
Phlebitis Corrective Measures
When phlebitis develops, the IV line must be discontinued. Restart a new
catheter in the other extremity if continued therapy is necessary.
Warm, moist heat on the site of phlebitis can offer some relief to the patient.
Phlebitis can be dangerous because blood clots (thrombophlebitis) can
develop in the vein and in some cases may result in emboli. This may result
in permanent damage to veins as well as an extended stay in the health care
facility. The Infusion Nurses Society recommends replacing peripheral
venous catheters and rotating sites based on clinical assessment indicating
signs or symptoms of IV related complications.

Fluid Volume Corrective Measures

In the event of fluid volume excess:
Slow the rate of infusion.
Notify health care provider.
Raise the head of the bed.
Monitor vital signs.
Bleeding Corrective Measures
If bleeding occurs around the venipuncture site and the catheter is within
the vein, apply a pressure dressing over the site to control the bleeding.
Bleeding from a vein is usually a slow, continuous seepage and is non-life
threatening. If bleeding is the result of disconnection of the tubing,
immediately cleanse the ends of the connectors with an antiseptic swab and
reconnect. Then recheck the infusion rate.

Infection Corrective Measures

The patient may display the following signs and symptoms of infection:
Erythema of skin around IV site
Pain at the IV insertion site
Purulent drainage at the IV insertion site
If the patient displays any of these signs and symptoms, discontinue the IV
and notify the health care provider. Retain the IV catheter for possible
culture to determine the presence of bacteria

Procedure Guideline for Troubleshooting Intravenous Infusions

1. After performing hand hygiene and ensuring privacy, introduce yourself to the patient.
2. Identify the patient using two identifiers, such as name and date of birth or name and
account number, according to agency policy. Compare these identifiers with the
information on the patients identification bracelet.
3. To troubleshoot IV infusions, prepare by determining the patients level of comfort and
the expected response to IV therapy. Assess the patients vital signs, fluid status, and
intake and output at least every 8 hours or according to agency policy, and more often if
indicated. Document your findings.
4. Observe your patient every 1-2 hours to evaluate the IV infusion.
5. To determine if the correct amount of IV solution has infused, review the infusion pump
record.
6. If the volume of fluid that has been infused is less than that which should have been
instilled by this time, check for possible causes. First, check the flow rate on the infusion
pump or count the drip rate.
7. If the infusion rate is set correctly but the pump is sounding the alarm for occlusion,
look for kinks in the tubing, which can occur if the patient lies on the tubing or if it
becomes caught in a side rail. Make sure the entire length of the tubing is patent and
intact.
8. Next, assess the IV device. The hub connecting the tube to the catheter should be intact,
with no signs of leakage or bleeding.
9. Bleeding may be caused by:
A. DisconnectionofthetubingfromtheIVdevice
B. Ableedingdisorder
C. Anticoagulanttherapy

10. Inspect the dressing, which should be dry and intact. Also inspect the insertion site for
color changes, swelling, and purulent drainage.
11. Palpate along the vessel and around the insertion site to detect venous cords. As you do
so, note the skin temperature.
12. Be alert for signs of phlebitis and infiltration. Stop the infusion and evaluate the severity
of the problem. If you detect any signs, use a phlebitis scale to grade the severity of the
problem.
A. Zerorepresentsnosignsorsymptoms.
B. Symptom severity increases up to a score of four, which reflects pain, redness, and swelling
at the site; streaking; a palpable venous cord more than 1 inch (2.5 cm) long; and purulent
drainage.
13. Intervene appropriately. For phlebitis or infiltration, stop the infusion and discontinue the
IV, as shown in the Video Skill, Discontinuing Intravenous Therapy. If ordered by a
provider, insert a new IV device in a different location. If agency policy advises to do so,
elevate the affected extremity, and wrap it in a warm, moist compress for 20 minutes.
14. Help the patient into a comfortable position, and place personal items within reach.
15. Place the call light within easy reach, and make sure the patient knows how to use it to
summon assistance.
16. To ensure the patients safety, raise the appropriate number of side rails and lower the
bed to the lowest position.
17. Dispose of used supplies and equipment.
18. Remove and dispose of gloves, if used. Perform hand hygiene.
19. Document and report any complications. Note your corrective action(s) and the patients
response.

Phlebitis Scale
Grade
0
1
2
3
4

Clinical Criteria
No clinical symptoms
Erythema at access site with or without pain
Pain at access site with erythema and or edema
Pain at access site with erythema and or edema
Streak formation
Palpable venous cord
Pain at access site with erythema and or edema
Streak formation

Palpable venous cord greater than 1inch in length

Purulent drainage
Preventive Measure
Use of volume controls, such as
Volutrol
Rotating IV sites based on clinical
assessment indicating signs or
symptoms of IV related
complications
Avoid IV running dry
Maintain strict asepsis

IV Complication
Fluid volume excess
Phlebitis

occlusion
Infection

Lesson 4 DC peripheral IV Access

Delegation
The skill of discontinuing a short peripheral intravenous line cannot be
delegated to nurse assistive personal (NAP). Delegation to LPNs varies by
state Nurse Practice Act. The nurse instructs the NAP to:
Report to the nurse any bleeding at the site after the catheter has been
removed.
Report any complaints by patient of pain or observations of redness at the
site.
Assessment prior to discontinuing peripheral IV access includes the
following:
Observe existing IV site for signs and symptoms of infection, infiltration, or
phlebitis (indications for discontinuing IV).
Determine whether patient has been receiving an anticoagulant or has a
history of a coagulopathy. Anticoagulants and thrombocytopenia affect
length of time to apply pressure to site.
Review health care providers order for discontinuation of IV therapy
(required to discontinue IV therapy).
Determine patients understanding of the need for removal of peripheral IV
catheter.
The necessary equipment to discontinue peripheral IV access includes the
following:
Clean gloves
Sterile 2 2 or 4 4 gauze
Tape
Antiseptic swab
Expected outcomes following completion of procedure:

IV will be removed with minimal trauma to the patient

IV site will remain free of infection

Procedure Guideline for Discontinuing Intravenous Therapy

1. Perform hand hygiene.
2. Provide for the patients privacy.
3. Introduce yourself to the patient and family, if present.
4. Identify the patient using two identifiers, according to your agencys policy. Compare the
identifiers in the MAR/medical record with information on the patients identification
bracelet, and/or ask the patient to state his or her name.
5. Explain the procedure to the patient before you remove the catheter. Instruct him or her
to hold the affected extremity still.
6. Turn the IV tubing roller clamp to the off position, or turn the electronic infusion device
(EID) off and the roller clamp to the off position.
7. Perform hand hygiene, and apply clean gloves.
8. Carefully remove the IV site dressing and stabilize the IV device. Then remove the tape
securing the extension set.
9. Place clean sterile gauze above the insertion site, and withdraw the catheter using a
slow, steady motion. Keep the hub parallel to the skin.
10. Apply pressure to the site for a minimum of 30 seconds until bleeding has stopped. Note:
Apply pressure for at least 5 to 10 minutes on the site if the patient is on anticoagulant
therapy.
11. Inspect the catheter for intactness after removal; note the integrity and length of the
catheter tip.
12. Watch for complications such as bleeding, pain, exudate, and swelling.
13. Apply a sterile, folded gauze dressing over the insertion site, and secure it with tape.
14. Discard the IV catheter in the sharps container.
15. Discard your used supplies, remove your gloves, and perform hand hygiene.
16. Help the patient into a comfortable position, and place personal items within reach.

17. Place the call light within easy reach, and make sure the patient knows how to use it to
summon assistance.
18. To ensure the patients safety, raise the appropriate number of side rails and lower the
bed to the lowest position.
19. Document and report the patients response and expected or unexpected outcomes. 2014,
2011 by Mosby, an imprint of Elsevier Inc. All right reserved.

The tip of the catheter can break off, causing an embolus, and emergency situation. The
physician should be notified if the tip is broken.

After discontinuing peripheral IV access, evaluate the following:

Observe for evidence of bleeding (to ensure hemostasis).
Continue to monitor site for 48 hours after catheter is removed for postinfusion phlebitis (INS, 2011).
Document discontinuation of the IV access device in the nurses note and/or
IV flow sheet. Recording should include:
The time the peripheral IV was discontinued
Site assessment information
Gauge and length of catheter removed
Condition of catheter tip to determine that it is intact (because of the risk of
an embolus)
Unexpected Outcomes
Catheter tip is broken off resulting
in an embolus
Hematoma formation

Site is reddened and tender

Nursing Intervention
Monitor patient
Notify provider ASAP
Apply a pressure dressing to the site
Apply ice to slow or stop bleeding
Assess circulatory, motor, and neuro
function of extremity
Notify provider

Which of the following situations indicates discontinuation of

peripheral IV access?
The health care provider has ordered normal saline at 100 mL per
hour and the patient's bag of IV fluids is empty.
The patient is drinking fluids well postoperatively and has an
order for morphine IV every 3 hours as needed.
The patient's arm is swollen and cool to the touch; the patient
complains of pain at the IV site.
The patient's arm appears reddened and is tender to the touch

The IV access site is dated 4 days ago

With dry gauze or an alcohol swab held over the site, apply light
pressure and withdraw the catheter by using a slow, steady
movement with the hub at a 10- to 30-degree angle. Apply
pressure to the site for 1 to 2 seconds by using a dry, sterile
gauze pad.
Discontinuing an intravenous infusion is necessary after the
prescribed amount of fluid has been infused (i.e., the patient is
going home on PO medications), when an infiltration occurs
(indicated by swelling, pain, pallor, and coolness to the touch at
the insertion site), if phlebitis is present (indicated by the
presence of redness and pain along the vein pathway), if the
infusion catheter or needle develops a clot at its tip (evidenced by
an inability to flush the catheter), or it has been 72 hours (3 days)
since the site was rotated. The patient, whose bag of IV fluids is
empty, with a health care provider's order for a continuous
infusion, requires a new bag of IV fluids to be hung. IV fluids may
be unnecessary in a patient with sufficient oral fluid intake;
however, discontinuing peripheral IV access is unwarranted,
because this route is necessary to administer the patient's pain
medication. If an occlusion occurs because of clot formation at the
catheter tip, the peripheral intravenous infusion device will have
to be discontinued and relocated. The nurse should first
determine the presence of any kinks in the tubing or the patient
lying on the tubing. The nurse may flush the catheter in an
attempt to get the IV functioning properly prior to discontinuing
the existing IV catheter.