ASSESSING AND MAINTAINING AN IV INSERTION SITE

ASSESSING AN IV SYSTEM
Always review and follow your hospital policy regarding this specific skill.
• Safety considerations:
• IV systems must be assessed every 1 to 2 hours or more frequently if required.
• An IV system should be assessed at the beginning of a shift, at the end of a shift, if the electronic infusion
device alarms or sounds, or if a patient complains of pain, tenderness, or discomfort at the IV insertion site.
• Review the patient’s chart to determine insertion date and type of solution ordered.
• A peripherally inserted catheter is usually replaced every 72 to 96 hours, depending on agency policy.
• If the peripheral catheter is not in use, or is being used intermittently, flushing is required to keep the site
patent. Refer to agency policy for flushing guidelines.
• A not-in-use peripheral IV site is generally flushed every 12 hours with 3 to 5 ml of normal saline.
• Review the in-and-out sheet to determine expected amount in the IV solution bag.
• Patients with cardiac or renal disease, as well as pediatric patients, are at a higher risk for IV-related
complications.
• Elderly patients often have fragile veins and may require closer monitoring.
1. Perform hand hygiene.
2. Introduce yourself and explain the purpose of the assessment.
3. Confirm patient ID using two patient identifiers (e.g., name
and date of birth), and compare the MAR printout with the
patient’s wristband.
4. Apply non-sterile gloves (optional).
5. Assess the IV insertion site and transparent dressing on IV site.
6. Inspect the patient’s arm for streaking or venous cords; assess Assess complications on hand and arm for signs and symptoms of
skin temperature. phlebitis are localized redness, heat and
swelling, which can track further along the length of the vein,
eventually leading to induration and a “palpable venous cord”
(Jackson, 1998). The patient may complain of pain, either
continuously or during infusion of drugs through the cannula
This step reduces the transmission of microorganisms.
This builds trust with patient and allows time for the patient to
ask questions.
This step ensures you have the correct patient and complies with
agency standard for patient identification.
This reduces the transmission of microorganisms.
Check IV insertion site for signs and symptoms of phlebitis or
infection. Check for fluid leaking, redness, pain, tenderness,
and swelling. IV site should be free from pain, tenderness,
redness, or swelling.
Ensure patient is informed to alert the health care provider if
they Timely and accurate documentation promotes patient
safety.at the IV site. If patient is unable to report pain at IV site,
more frequent checks are required.
phlebitis and infiltration/extravasation.
7. Assess IV tubing for kinks or bends.
8. Check the rate of infusion on the primary and
secondary IV tubing. Verify infusion rate in physician
orders or medication administration record (MAR).
9. Assess the type of solution and label it on bag.
Check volume of solution in bag.
10. Assist patient comfortable position into, place
call bell in reach, and put up side rails on bed as per
agency policy.
Kinks or bends in tubing may decrease or stop the flow of IV fluids.
Ensure tubing is not caught on equipment or side rails on bed.
Tubing should be properly labelled with date and time.
If IV solution is on gravity, calculate and count the drip rate for one
minute.
If solution is on an IV pump, ensure the rate is correct and all clamps
are open as per agency protocol.
If secondary IV medication is infusing, ensure clamp
IV solutions become outdated every 24 hours.
Ensure the correct solution is given.
If 100 ml of solution or less is left in the bag, change the IV solution
and document on in-and-out sheet.
If an IV pump is used, ensure it is plugged into an outlet.
Ideally, the IV solution should be 90 cm above patient heart level.
These precautions prevent injury to the patient.
10. Assist patient into comfortable position, place call bell in These precautions prevent injury to the patient.
reach, and put up side rails on bed as per agency policy.

11. Perform hand hygiene. This step prevents the spread of microorganisms.

12. Document procedure and findings as per agency policy. Timely and accurate documentation promotes patient safety.
 FACTORS INFLUENCING THE FLOW RATE OF
INFUSIONS

Tube occlusion May occur if the tubing is kinked or bent. Tubing may become kinked if caught under the
patient or on equipment, such as beds and bed rails.

Vein spasms Irritating or chilled fluids (fluids stored in the fridge) may cause a reflex action that causes the
vein to go into spasm at or near the intravenous infusion site. If fluids or medications are chilled,
bring to room temperature prior to infusion.

Height of the fluid container The IV tubing drip chamber should be approximately 3 feet above IV insertion site.

Location/position of IV cannula If the cannula is located in an area of flexion (bend of an arm), the IV flow may be interrupted
when the patient moves around. To avoid this issue, replace IV cannula.

Infiltration or extravasation If the cannula punctures the vein, the fluid will leak into the surrounding tissue and slow or stop
the flow, and swelling will develop.

Accidental touching/bumping
of the control clamp or raising
arm above heart level
Needle or cannula
gauge/diameter
Instruct the patient not to touch the roller clamp and to take care not to bump the clamp, as this
may accidentally change the flow rate. Instruct patient to keep hand/arm below heart level;
an elevated hand/arm will slow or stop an infusion running by gravity.
The smaller the needle or cannula, the slower the fluid will flow.