Inserting a Butterfly Needle - Overview of the Skill

Overview: Performing a venipuncture in order to establish a 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 expected to be given, a larger bore (18 or 19-gauge) is recommended.
A butterfly needle is commonly used for short-term venous access or for pediatric
clients. It is called a butterfly because of the flexible wings on either side of a short
needle and 2 to 3-inch tubing that ends with a hub. This design makes it easy for
the nurse to guide the needle into a vein to draw blood or to infuse medication or
fluid. Unlike the flexible catheters commonly used for IVs, the butter- fly needle uses
a rigid, sharp needle as the venous access port. Because the sharp tip remains in
the vein during the IV infusion, infiltration of the IV is more common than with the
flexible catheter. Butterfly needles are not commonly used for long-term IV therapy,
although they may still be used in clients who have very small veins or in areas
where a larger catheter cannot be advanced into the vein. Butterfly needles may be
used when venous access is only required for short-term IV therapy. When a
butterfly needle has been used for IV access, the nurse must check the IV site
frequently for infiltration.
Assessment: 1. Assess the purpose of the IV. Butterfly needles are more often
used in short-term IV therapy.
2. Assess the client's veins. A butterfly needle may be necessary if
the client's veins are small or the vein is in a difficult position to
access.
3. Check the client's fluid, electrolyte, and nutritional status to provide
baseline data for comparison with the client's response to IV
therapy.
4. Assess the client's understanding of the purpose of the procedure so
that client teaching can be used to decrease anxiety.

Diagnosis:  Deficient Knowledge

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

Planning

Planning Needs: Equipment Needed (see Figure 8-3-1A and B):

 Appropriate gauge butterfly needle for venipuncture

 Tourniquet
 Povidone-iodine swabs (3) or chlorhexidine alcohol
 Alcohol swab sticks (3) (not needed if use chlorhexidine alcohol)
 Disposable gloves
 Arm board, if necessary
 Towel or absorbent drape
 Povidone-iodine ointment
 Gauze dressing or transparent 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. The IV site will be without signs or symptoms of infiltration.
 3. The IV will be started and will infuse with a minimum of trauma
and discomfort to the client.

Client Education 1. Teach the client to report any signs of inflammation or swelling.
Needed: 2. Teach the client how to bathe without getting the dressing wet.
3. Instruct the client how to prevent the IV from becoming dislodged.
4. Provide written and oral instructions about the care of an IV.
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. 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.

Inserting a Butterfly Needle - Implementation—Action/Rationale

Implementation ACTION RATIONALE

Action/Rationale 1. Check health care provider's
order for an IV, and identify
client.
2. Wash hands; put on mask and
gown, if needed.
3. Organize all equipment at
bedside.
4. Explain procedure and reason
the IV needle is being inserted.
5. Inspect potential veins to be
used (see Figure 8-3-2):
1. Ensures accurate insertion of IV
needle.
2. Reduces the transmission of
microorganisms.
3. Ensures smooth procedure
without accidents or
contamination.
4. Information decreases anxiety.
5. Promotes ease of placement of
IV needle.

 Place a tourniquet  Distends vein to allow

around the upper arm visual and tactile
close to the axilla. examination.
 Examine the veins as  To assess blood return in
they dilate. veins.
 Palpate the vein to test  To assess fragility of
for firmness. veins.
 Release the tourniquet.  Prevents engorgement of
blood.

6. Select vein for venipuncture: 6.  If the vein is later

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

7. Select appropriate gauge 7. Chooses needle necessary to

butterfly needle. puncture vein.
8. Prepare supplies: 8. Provides a clean working surface
for an efficiently performed
 Place towel on table for procedure.
supplies.
 Place supplies on towel.
 Open needle adapter
end of IV tubing set.

9. Clip hair on skin at site if 9. Ensures adherence of dressing

necessary. and that removal is less painful.
Shaving should be avoided as it

10. Ask client to rest arm in a 10. Allows better venous dilation and
dependent position, if possible.
11. Put on disposable gloves. 11. Reduces transmission of
12. Prepare insertion site: 12.
 Place absorbent drape
under the arm.
 Scrub the insertion site
with 3 alcohol swabs
then 3 povidone-iodine
swabs or chlorhexidine
alcohol antiseptic
solution (see Figure 8-3-
3).
 Follow institution
protocol for cleaning
insertion site regarding
use of iodine or
chlorhexidine alcohol.
 Allow the antiseptic
solution to dry.
13. Apply tourniquet 5 to 6 inches 13. Tourniquet is needed to allow the
above the insertion site.
 Secure it tightly enough
to occlude venous flow,
not arterial flow.
 Check presence of distal
pulse.
14. Perform the venipuncture: 14.
 Anchor the vein by
placing thumb over vein
and stretching the skin
against the direction of
insertion 2 to 3 inches
distal to the site.
 Grasp the wings of the
butterfly needle and
insert the butterfly
needle at a 20 to 30°
angle with the bevel up
slightly distal to the
venipuncture site
(see Figure 8-3-4).
 Watch for a blood return
through the tubing of the
butterfly needle.
 Verify needle placement
in a vein, not artery.
 Advance the butterfly
needle into the vein until
the hub rests at the
venipuncture site
(see Figures 8-3-
5 and 8-3-6).
 Release the tourniquet.
15. Attach IV tubing to butterfly 15.
needle.
causes microscopic abrasions
that increase the risk of infection.
visibility.
microorganisms.
 Reduces transmission of
microorganisms.
 Alcohol removes fat on
the skin and vigorous
scrubbing in circular
motion with povidone-
iodine removes bacteria.
Using a separate swab
and starting in the middle
of the site working
outward prevents bacteria
from being reintroduced to
the site.
 Many institutions have
switched to chlorhexidine
alcohol swabs as clients
may be sensitive to
iodine.
 Povidone-iodine or
chlorhexidine alcohol
must be dry to be
effective.
vein to engorge for easier
venipuncture.
 Decreased arterial flow
prevents venous filling.
 Ensures arterial flow is
present.
 Stabilizes the vein for
ease of venipuncture.
 Prevents puncture of
posterior wall of vein.
 Venous pressure from
tourniquet causes
backflow of blood into
tubing.
 Some veins are close to
an artery. Arterial blood is
bright red and pulses.
 Ensures the IV needle is
in the vein and proper
placement of the IV
needle.
 Re-establishes venous
blood flow.
 Maintains IV needle
placement.
 Reduces blood loss.
  Prompt initiation of
 Stabilize the needle with infusion maintains
one hand. patency of IV.
 Connect needle adapter
of IV set to hub of
butterfly needle tubing.
 Begin infusion at slow
rate to keep vein open.

16. Secure needle in place 16.  Ensures needle's safe

(see Figure 8-3-7): position.
 Controls bleeding and
 Place tape over the prevents infection. Allows
wings of the butterfly visualization of site.
needle.
 Place transparent
dressing over insertion
site and secure.

17. Remove gloves and dispose of 17. Reduces transmission of

all used materials. microorganisms.
18. Place label with date and time 18. Provides information to schedule
of insertion and size and gauge next dressing change.
of needle on the dressing.
19. Wash hands. 19. Reduces transmission of
microorganisms.

Inserting a Butterfly Needle - Post-Skill

Evaluation:  The IV was inserted into the vein without complications and remains patent.
 The IV site is without signs or symptoms of infiltration.
 The IV was started and is infusing with a minimum of trauma and discomfort to
the client.

Documentation: Nurses' Notes

Note the following:

 Date and time IV was started

 Type and gauge of needle used
 Insertion site
 Type of dressing placed over site
 Any unusual occurrences during the IV insertion
 Type and rate of fluid

Variations

Geriatric Variations:
 The veins of elderly clients may be more fragile so care must be taken not
to traumatize them with the tip of the needle.
 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.

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 IV intact in
very young clients. Restraints may be required to immobilize
the IV site.
 Allow older children to select the IV site in order to increase
cooperation and control.

Home Care Variations:  The butterfly needle can be inserted in the home by a nurse.
 A more secure dressing may be necessary if the client is
active.
  Ensure that containers for proper disposal of equipment are
in place.

Long-Term Care  Butterfly needles are not generally used for long-term IV
Variations: therapy.
 If a butterfly needle is placed for a long-term IV, the site
should be inspected frequently for infiltration.

Inserting a Butterfly Needle - Common Errors

Possible Errors: Blood is noted in the tubing of the butterfly set after the venipuncture, but when the
needle is advanced, a resistance is felt and no more blood flows into the tubing.
Prevention: Be sure to advance the needle carefully at a 20 to 30° angle so it does not
puncture through the vein. If this error does occur, pull back on the needle.
If a brisk blood return in the tubing is seen, secure the needle to the skin. If
no blood return is seen, the IV may need to be restarted in another site.
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 the smallest gauge possible for pediatric and elderly clients
with fragile veins.
 Always insert the IV needle in the direction of venous return
(toward the heart) to avoid damaging the venous valves.

Critical Thinking Skill

Introduction: Clients with small veins may require a small-gauge needle. Using a butterfly needle gives
the nurse more control guiding it into a vein. The needle is also shorter so it may be less
frightening to pediatric clients or people from another culture.
Possible Mrs. Nguyen was admitted to the emergency room with complaints of
Scenario: abdominal pain. The emergency room physician ordered a complete blood
count (CBC) and chemistry panel and then ordered an abdominal
computerized tomography (CT) scan. The nurse noted that the woman's
veins were quite small and delicate.
Possible The nurse caring for Mrs. Nguyen felt that butterfly needles were
Outcome: never appropriate to use because of the frequency of venous
trauma and infiltration. He attempted to gain IV access using a 21-
gauge venous catheter. When he inserted the venous catheter,
there was a blood flashback. However, when he attempted to
advance the venous catheter, the vein tore and bled into the
surrounding tissue. The nurse made three attempts at starting the IV
using a 21-gauge venous catheter without success. Mrs. Nguyen
became increasingly upset and agitated with each failure. Finally the
nurse asked another staff member to try to start the IV.
The nurse chose a 21-gauge butterfly needle. She used it to draw
the blood samples and then connected it to an IV solution of normal
saline and set it at a rate to keep the vein open. When the client was
sent for a CT scan, she had a vein open to be used for contrast dye.
Prevention: Keep in mind the reason for the IV, when choosing an insertion site and
infusion equipment. When the nurse realized that the client's veins were
too fragile to sustain the passage of an over-the-needle catheter, he
should have re-evaluated the client's needs and his approach.
Recognizing that the IV access was only required for a short time, the
nurse could have saved the client undue trauma by changing to a butterfly
needle sooner.