EQUIPMENT NEEDED PICTURE

Tourniquet (nonlatex preferred)

Disposable gloves (nonlatex)

Antiseptic swab (chlorhexidine,

alcohol,
iodine, povidone-iodine)

If continuous infusion:

IV solution

IV tubing
If intermittent access device:

Extension set or PRN adapter

Heparin or normal saline solution

(1 to 2 mL) in sterile syringe

Tape

Transparent IV dressing or other

dressing supplies

Covered armboard (if necessary)

Desired cannula

Catheter (Teflon, Silastic polyurethane,

or polyvinyl chloride) in
chosen bore size (gauges 14−25)
 Winged (“butterfly”) needle
PROCEDURE
NURSING ACTION
PREPARATORY PHASE
Explain the procedure to the patient. Ascertain Helps alleviate anxiety about the procedure. Start
whether the patient is left- or right-handed. the infusion in the opposite arm, if possible.
Prime all IV and winged-needle tubing (clear the Prevents infusion of air and potential air embolus.
tubing of air with fluid from infusion tubing by
attaching a needle, or by irrigating the needle with
saline in a sterile syringe).
Put on gloves.
Select a site for insertion. (See the discussion on
site selection, page 95.)
Apply a tourniquet 2−6 inches (5−15 cm) above the
desired insertion site and ascertain satisfactory
distention of the vein. Distal pulses should remain
palpable.
Have the patient open and close fist several times.
Remove the tourniquet.
Clip the hair if site is obscured and clean as follows:
a. Cleanse the skin with a chlorhexidine
solution
b. If preferred over chlorhexidine, clean
skin with alcohol first, using the swab in a
RATIONALE
Complies with CDC requirements to minimize
passing of blood-borne pathogens between the
patient and nurse.
The vein must be visible or palpable before
venipuncture is attempted. The tourniquet should
not be applied too tightly so it does not interfere with
arterial blood flow.
Increases blood supply in the area. Further
techniques to aid in vein distention are discussed on
page 95. A tourniquet may not be necessary on
greatly distended veins.
Prevents trauma to the arm from extended
application of the tourniquet. It can be reapplied
later.
Reduce the number of skin microorganisms and
minimizes risk of infection.
a. Chlorhexidine is the preferred solution.
b. Alcohol should be used as part of a two-
step process, but may be used alone if the
 circular motion outward from the site for at
least 30 seconds; then povidoneiodine
swab for 1 minute, working from the center
of the proposed site to the periphery until a
circle of 2−4 inches (5−10 cm) has been
disinfected.
c. Allow the area to air-dry.
Reapply a tourniquet.
patient is allergic to iodine. If a 1%−2%
iodine solution is used, it should be used
before alcohol for 30−60 seconds and
allowed to dry.
c. Drying allows for additional disinfection.
Facilitates catheter insertion.

PERFORMANCE PHASE: Catheter insertion

Remove the needle guard.
Hold the patient’s arm so your thumb is positioned Stabilizes the vein and facilitates successful
approximately 2 inches (5 cm) from the site. Exert cannulation.
traction on the skin in the direction of your hand.
Insert the needle, bevel up, through the skin at an Bevel-up position allows for the smallest and
angle. Use a slow, continuous motion. sharpest point of the needle to enter the vein first.
If the vessel rolls, it may be necessary to penetrate Satisfactory penetration is evidenced by a sudden
the skin first at a 20-degree angle and then apply decrease in resistance and by the appearance of
a second thrust parallel to the skin. blood coming back into catheter.
When the vein is entered, lower the catheter to skin Prevents puncturing the vessel wall.
level.

When inserting, always hold the catheter by the

clear plastic flashback chamber and not by the
colored hub.
Advance the catheter approximately ¼ to ½ inch Ensures entry into the vein.
(0.5 to 1.5 cm) into the vein.
Pull back on needle to separate needle from Pulling back on the needle prevents inadvertent
catheter about ¼ inch and advance the catheter puncture of the vein and provides stability of catheter
into the vein. for insertion.
Once the catheter is positioned within the vein, Reduces blood leakage while removing the needle
apply pressure on the vein beyond the catheter tip and connecting tubing to the infusion set.
with your little finger (see illustration); release the
tourniquet and slowly remove the needle while
holding the catheter hub in place.
If a continuous infusion, attach the primed
administration set to the hub of the catheter and
adjust the infusion flow at the prescribed rate.
If an intermittent access device, attach lock cap
and extension set, taking care to maintain sterility
of the set. Flush with 0.5 mL heparin or normal
saline solution.
Apply transparent dressing to the site or use Transparent dressing secures the IV catheter and
dressing according to facility protocol (see prevents infection.
illustration).

Loop tubing and tape to dressing or arm. Prevents tension on the IV catheter itself.
Apply a stabilization device or site protection Further secures and protects site placement in
device per facility policy. difficult areas or in restless patients.

Label the strip of tape with an arrow indicating the
path of the catheter, size of catheter, date, time of
insertion, and your initials. Affix the tape to the
dressing. Prepare a similar label with each
dressing change.
Labeling the dressing is dictated by facility policy.
Such a practice provides information useful in
determining the next dressing change and the
capability of the needle to accommodate various
types of infusion.
NURSING ALERT: Standard dwell time for a short peripheral catheter is 96 hours. However, exceptions
may be made due to the patient’s venous access, type of solution, and catheter material. A facility with a
higher than average phlebitis rate should review their policies and procedures regarding dwell time.

FOLLOW UP PHASE
Evaluate the IV site daily for evidence of infection: To ensure that there is no pain near or around the
rubor (redness), calor (warmth), dolor (pain), and catheter.
tumor (swelling). Palpate the site. If the site is
covered by tape and there is tenderness at the
catheter site, remove the tape to evaluate the
catheter site.
If evidence of infection exists, remove the IV
catheter and place another in a different location.
Encourage patients to report any changes or
discomfort at the catheter site.
Document the relevant data, including
assessments.

1. Record the start of the infusion on the client’s

chart.
2. Include the date and time of the venipuncture
3. The gauge and length of the device
4. Specific name and location of the accessed
vein
5. Amount of solution used, including any
additives
6. Container number
7. Flow rate
8. Type, length and gauge of the needle or
catheter
9. Venipuncture site, how many attempts were
made and location of each attempt
10. The type of dressing applied
11. The client’s general response
12. Your signature