5 Chapter Five: Initiating Intravenous Therapy

In this chapter, the critical components of initiating peripheral intravenous (IV) therapy will be explored. The objectives of this chapter include discussing the assessment of the patient prior to insertion of a peripheral IV catheter, explaining the equipment and the process of site selection, summarizing the techniques and rationale for IV initiation, and addressing the procedures for dressing and documentation. Additionally, specific aspects of central intravenous therapy and the unique needs of older adults will be considered.

Assessment of the Patient Prior to Insertion of a Peripheral IV Catheter

Before proceeding with the insertion of a peripheral IV catheter, a comprehensive assessment of the patient is essential. This initial evaluation is conducted to ensure patient safety and to enhance the likelihood of successful venous access. A medical history, as well as a physical assessment, should be completed.

Medical History

A thorough review of the patient’s medical history is the first step in this assessment. Important factors to be considered include the patient’s previous experiences with IV access, as these can reveal potential complications such as phlebitis or difficult venous access. For example, if multiple unsuccessful IV attempts have been made in the past, a more cautious approach may be indicated.

In the assessment process allergies should also be explored. Any allergies, particularly to antiseptics, latex, tape, or specific medications that may be administered via IV, must be identified. The patient’s allergies should be confirmed to ensure that appropriate precautions are taken.

Chronic conditions such as diabetes, hypertension, pulmonary disease, cardiovascular disease, renal impairment, or coagulation disorders can influence the choice of IV site and catheter size. For instance, compromised circulation in diabetic patients may affect the quality of their veins and complicate the insertion process. In patients with a history of cardiovascular disease, IV fluid therapy must be closely monitored to avoid fluid overload or other complications. Increased risks of bleeding or hematoma formation may be present in patients with coagulation disorders.

A history of mastectomy (particularly with axillary lymph node removal), a history of lymphedema, or dialysis access should also be noted. The affected extremity should be avoided.

Physical Assessment

Following the medical history, a focused physical assessment is crucial. The arms and hands should be inspected for suitable veins. Ideally, the selected veins should be visible, palpable, and free from inflammation or edema. Commonly chosen sites include the forearm or the dorsal veins of the hand.

The condition of the skin at the proposed insertion site must also be assessed. Signs of infection, irritation, or dermatological conditions that could impact the procedure should be looked for. Areas with bruising, lesions, or dermatitis should be avoided for catheter insertion.

Patient Preferences and Comfort

Engaging the patient in conversation is essential for building rapport and ensuring a smooth procedure. Previous experiences with IV therapy should be discussed, as this information can help tailor the approach to the patient’s specific needs and preferences. Any concerns or anxieties the patient may have should be addressed to improve cooperation and comfort. Techniques such as deep breathing exercises or providing reassurance may be beneficial in alleviating patient anxiety.

Equipment and Process of Site Selection for a Peripheral IV Catheter

The successful initiation of IV therapy relies on the use of appropriate equipment and the careful selection of the insertion site.

Equipment Needed

(Pictures of IV start kit, transparent dressing, antiseptic wipe — I could not find an openly licensed start kit image but found this one below, if that might work)

Many facilities have IV start kits available which typically include many of the needed supplies. They normally include gauze, tape, tourniquet, transparent dressing, antiseptic wipe, and a label.

Several essential items are required for the initiation of peripheral IV therapy. IV catheters are available in various sizes, typically ranging from 18G to 26G. The catheter gauge is selected based on the patient’s age, size, and the type of fluid being administered. Smaller gauges (22G or 26G) are often preferred for pediatric or older adult patients to minimize trauma to fragile veins.

A tourniquet is used to distend the veins and facilitate access. It should be applied about 4-6 inches above the intended insertion site, ensuring that it is tight enough to engorge the veins but not so tight as to cause discomfort.

(tourniquet image)

Antiseptic solutions, such as alcohol wipes or chlorhexidine, are crucial for skin preparation. Chlorhexidine is often preferred for its residual antimicrobial effects. The facility’s procedure for cleaning the site should always be followed. Additionally, gauze and tape or securement devices are needed to keep the catheter in place. Transparent dressings are commonly used, as they not only secure the catheter but also allow for continuous monitoring of the insertion site.

Clean gloves are needed. Sterile gloves may be used to palpate the site after cleaning if needed.

At least one normal saline (0.9% sodium chloride) flush, an IV extension set, IV tubing, and fluids (if starting IV fluids) should also be available. (Picture of extension set, flush, fluids and tubing)

Some facilities may have a vein finder device to assist in visualizing the insertion site.

Site Selection Process

The process of selecting an appropriate site for IV catheter insertion is multifaceted. Anatomical factors should first be considered; preferred sites include the forearm and the dorsum of the hand. Veins should be assessed for size, visibility, and palpability. Veins that are hard, inflamed, or previously used for IV access should be avoided. (Picture of IV sites)

Starting most distal is preferred. The most critical reason for starting distal is to preserve more proximal veins (those located closer to the torso) for future use. IV insertion in the distal veins leaves the larger and more easily accessible veins in the forearm and upper arm available for future insertions, particularly in patients who may require repeated or long-term IV access.

If possible, the non-dominant side should be used to allow patient mobility and comfort. Sites with flexion, such as the antecubital or wrist area, should be avoided, as the IV may occlude when the patient bends these areas.

The condition of the veins should be carefully evaluated, noting their softness and flexibility. Patient factors, such as age and mobility, should also be considered. Older adults, whose veins may be more fragile, may require gentler techniques.

Proper positioning of the patient is vital to facilitate access and promote relaxation. The patient should be comfortably positioned, with the arm supported and slightly elevated to help engorge the veins.

Techniques, Rationale, and Procedure Used in Initiating IV Therapy

The techniques employed during the initiation of IV therapy are critical for minimizing complications and ensuring successful access. Proper techniques must be used during IV insertion to minimize the risk of complications such as infiltration, phlebitis, or infection. Key principles include maintaining aseptic technique throughout the procedure to prevent infection. This includes meticulous hand hygiene and the use of sterile equipment.

Venipuncture should be performed using a quick and controlled insertion at a 15–30-degree angle to help the catheter enter the vein effectively. A smooth motion should be used to reduce trauma to the vessel, thereby enhancing the likelihood of success.

(Picture of VAD at 15-30 degrees)

Procedure

Here add video of all steps and pictures also video of priming tubing

The procedure for initiating IV therapy can be broken down into several key steps:

Assessment/Recognize Clues

1. Review the healthcare provider’s order: Confirm the order’s date, time, IV solution, route, volume, rate, duration, and provider’s signature. Follow the rights of medication administration. [Ensures the order is complete to prevent medication errors. A provider’s order is required before starting IV therapy.]
2. All necessary equipment should be gathered, and hand hygiene should be performed. [Ensures all supplies are readily available once in the room as well as infection prevention.]
3. Check drug reference resources for solution details, potential incompatibilities, and side effects. [Ensures correct and safe IV therapy and appropriate selection of VAD.]
4. Perform hand hygiene and assess clinical factors: Review the patient’s EHR and/or conduct a physical examination. [Reduces infection risk and establishes a baseline for therapy effectiveness.]
   1. Assessment of past medical history
   2. Assessment of hydration status
   3. Assessment of level of consciousness
   4. Assessment of patient labs
   5. Assessment of patient allergies
   6. Assessment of past IV experiences and site preference
   7. Selection of appropriate catheter size
5. Explain the procedure to the patient: Discuss the IV therapy, solution, medications, and potential complications. [Informs and reassures the patient, reducing anxiety]
6. Evaluate for upcoming procedures or surgeries. [Ensures appropriate VAD placement, avoiding interference with procedures.]
7. Assess allergies: Inquire about any allergies, focusing on latex, adhesives, and medications. [Identifying allergies prevents allergic reactions.]
8. Assess knowledge and experience with IV therapy and assess concerns about the procedure. [Determines the level of instruction needed and identifies the need for emotional support and pain management strategies.]
9. Assess site preference for IV placement. [Ensures patient-centered care and considers the best site for IV insertion.]

Planning/Generate Solutions

1. Prepare the environment: Close doors or curtains and clear and clean the bedside table. [Provides privacy and organizes the space for the procedure.]
2. Perform hand hygiene and organize equipment: Ensure easy access to necessary tools. [Reduces infection risk and increases efficiency.]
3. Select the appropriate catheter and prepare sterile packages keeping items in the sterile package or a clean surface. [Ensures correct equipment size, use of smallest appropriate catheter, and sterile technique.]
4. Position the patient comfortably and provide adequate lighting. [Promotes patient comfort and ease during the procedure.]

Implementation/Take Actions

1. Identify the patient: Use at least two identifiers to ensure proper patient identification. Make sure you follow facility policy. [Complies with safety standards and ensures the correct patient.]
2. Prepare the IV setup: Attach short extension tubing to NS flush and prime with 1-3 ml making sure you maintain sterility. [Removes air from the extension set.]
3. Prepare the IV tubing and solution. Check the solution using the rights of medication administration. Open the IV infusion set and maintain sterility. Close roller clamp on IV tubing. Remove protective cover from IV solution bag then remove the cover from the IV tubing spike. Insert spike into port on IV solution bag using a twisting motion. Compress the drip chamber and release. The drip chamber will fill, and it should be 1/3-1/2 full. [Prevents air from entering the patient’s vein.]
4. Slowly open the roller clamp to remove the air from the tubing. The fluid will flow from the drip chamber to the distal end of the tubing. Once the tubing is completely primed, close the roller clamp. Label the tubing following the facility policy. [Prevents air from entering the patient’s vein.]
   1. The primed tubing should be free of air bubbles. If bubbles are found, you can tap the tubing to move the air bubbles to the drip chamber.
5. The tourniquet should be applied above the chosen site to engorge the vein. It should be applied about 4-6 inches above the intended insertion site, ensuring that it is tight enough to engorge the veins but not so tight as to cause discomfort. If the patient feels uncomfortable, the tourniquet should be released momentarily. [Makes it easier to locate and feel an appropriate site.]
6. Vein Palpation: Use your fingertip to palpate veins at the intended insertion site. The fingertip provides better sensitivity for assessing vein location and condition, feeling a resilient, soft, bouncy sensation when pressure is released. [Allows for insertion at the best site for the patient.]
   1. Improving Vascular Distention: To enhance vein visibility, position the extremity lower than the heart, have the patient open and close their fist, or stroke the vein downward.
   2. Applying dry heat for a few minutes can help improve vein dilation, increasing the success of catheter insertion.
   3. Avoid vigorous friction, slapping, or tapping of veins, especially in older adults, as it may cause venous constriction or bruising.
   4. Veins on the dorsal and ventral side of the arm are commonly used in adults. If possible, start most distal in the non-dominant arm.
   5. Using the tip of your finger palpate for a vein. Feeling for one that is soft and bouncy.
   6. Avoid:
      1. Joints (wrist, antecubital)
      2. Venous valves or branching of veins
      3. Sites that are distal to a previous IV site
      4. Areas of skin breakdown, bruising, wounds, infection, or pain
      5. Upper extremities post breast surgery with axillary node removal or lymphedema, fistulas or grafts, or upper extremities affected by a CVA
7. Once the site is chosen, release the tourniquet until ready to start IV. [Allows for perfusion to the extremity while supplies are being prepared.]
8. If excess hair is present at the insertion site, trim it using single-use scissors or disposable clippers, avoiding shaving to prevent infection risk. [Reduces infection risk.]
9. Hand Hygiene and PPE: Perform hand hygiene, then apply clean gloves. Wear eye protection and a mask if there’s a risk of blood splash or spray. [Reduces infection risk.]
10. Cleaning the Insertion Site: If the site is visibly soiled, clean it with soap and water, then perform antisepsis using 2% chlorhexidine solution in a back-and-forth motion for 30 seconds. Allow it to dry completely (make sure you follow the facility policy for cleaning). [Reduces infection risk.]
    1. If the site is palpated after cleaning, repeat antisepsis site to prevent contamination.
11. Reapply Tourniquet: Reapply the tourniquet 4-6 inches above the insertion site to further distend the vein. Ensure that a pulse is still detectable distal to the tourniquet. Ensure the site is not touched during the tourniquet application. [Makes it easier to locate site and insert the IV. Also reduces infection risk.]
12. Perform Venipuncture: The skin should be held taut with one hand, and the catheter should be inserted with a quick motion. Insert the vascular access device (VAD) with the needle bevel up at a 15–30-degree angle, depending on vein depth. Blood return should be observed in the flashback chamber to confirm placement. Once flashback is seen, the catheter should be lowered parallel with the skin and advanced slightly, followed by advancing just the catheter while holding the needle in place. The catheter hub should be flush with the skin. [Allows for correct insertion and prevents going through the vein.]
    1. Limit IV access attempts to two unsuccessful tries per clinician to avoid patient discomfort and complications.
13. Stabilize the VAD with your nondominant hand while gently releasing the tourniquet with the dominant hand. [Ensures the IV does not come out.]
14. Occlude the vein with the nondominant hand and remove the needle (make sure the safety device is utilized). [Ensures minimal bleeding.]
15. Attach the short extension set or needleless connector to the catheter hub. Connect the prefilled 10-mL syringe of saline, aspirate to ensure blood return, then flush the line. [Ensures the IV is still in the vein.]
16. Flush and Initiate IV Infusion: Flush the line with saline to ensure patency and prevent clotting. If the VAD will be saline locked, use positive pressure to close. [Ensure patency of the IV.]
    1. Observe for Complications: Monitor the insertion site for any signs of infiltration, such as swelling, which would require catheter removal.
17. Secure the IV: Apply a securement device to hold the catheter in place and reduce complications like migration or infection. If no securement device is used, apply sterile tape or a transparent semipermeable dressing. [Reduces infection risk.]
18. Finalizing Dressing and Labeling: Label the dressing with the date, time, and catheter details. Secure the catheter tubing with additional tape, ensuring there’s no pressure on the insertion site. [Ensures other providers know when the IV was placed.]
19. If IV fluids have been ordered connect the IV primary line to the extension set ensuring sterility. Set rate according to the order. [Reduces infection risk and ensures safety.]
20. Disposal and Clean-up: Dispose of sharps in the appropriate container, discard all contaminated supplies, and perform hand hygiene. [Reduces infection risk and ensures safety.]
21. Patient Positioning: Ensure the patient is comfortable and provide instructions on how to move or turn without dislodging the catheter. [Ensures patient safety.]
22. Patient Safety: Raise side rails, lower the bed, and make the nurse call system accessible to ensure patient safety. [Ensures patient safety.]
23. Document: Record the date and time of insertion; description of insertion site; catheter gauge, type, length number of attempts at insertion; type of solution and additives infusing; rate and method of infusion; patient’s response to insertion; number of attempts; and when infusion was started. Always complete the entry with full signature and credentials.

Evaluation/Evaluate Outcomes

Is this section missing? It looked like the list/table was meant to continue. I don’t believe header is correct for the section below.  

Dressing the IV line is an essential step in maintaining sterility and protecting the insertion site. A sterile dressing should be applied to create a barrier against infection and to keep the catheter secure.

A transparent adhesive covering should be used that entirely encases the IV site. This allows for continuous observation while providing protection. The dressing should be applied smoothly to avoid wrinkles, which could permit bacteria to enter. Facility protocols for dressing changes should be followed, and the dressing should be replaced if it becomes wet, soiled, or loosened. It should be labeled with date, time and initials.

The line should be primed to remove any air before starting the infusion. Connect the IV time to the IV port maintaining sterility.

Documentation

Accurate documentation of the IV insertion is critical for ensuring continuity of care. Essential details to be documented include:

• Date and time of insertion.
• Size and type of catheter used, including the gauge of the catheter.
• Number of attempts to insert the IV catheter. If unsuccessful after 2 attempts, someone else should be called to start the IV.
• Site selected (e.g., right forearm).
• Patient’s response, including any discomfort, complications, or notable reactions during the procedure.
• How the site is dressed.
• IV solution and flow rate.
• Patient education provided.
• Documentation serves to inform all healthcare providers involved in the patient’s care, ensuring they have access to pertinent information essential for ongoing treatment and monitoring.

Additional Considerations Associated with Central Intravenous Therapy

Central intravenous therapy presents unique challenges and considerations that differ from peripheral IV therapy.

Central line access devices are typically placed in larger veins, such as the subclavian, internal jugular, or femoral veins. Careful anatomical consideration is necessary to avoid complications such as pneumothorax or arterial puncture. Specialized training is often required for central line placement, which typically involves sterile techniques, ultrasound guidance, and advanced procedural skills. The patient’s vital signs should be closely monitored during insertion to identify any immediate complications.

Monitoring and Maintenance

The insertion site should be regularly assessed for early detection of complications, such as infection or thrombosis. Strict protocols for flushing (usually with normal saline and/or heparin, if indicated) and dressing changes should be followed to maintain line patency and prevent infection.

Complication Awareness

Healthcare providers must remain vigilant for complications associated with central lines, including pneumothorax, air embolism, and catheter-related infections. Knowledge of the signs and symptoms of these complications is essential, as well as protocols for their management.

Considerations for the Older Adult When Initiating Intravenous Therapy

Initiating IV therapy in older adults requires special attention due to physiological changes that affect both veins and skin.

Physiological Changes

As individuals age, decreased skin elasticity and more fragile veins may be encountered, making access more challenging. Vein quality should be assessed particularly in this population. Smaller gauge catheters may be used to minimize trauma to delicate veins.

Cognitive and Communication Factors

Engagement with older patients should be approached with sensitivity. Clear, simple language should be used to explain the procedure, ensuring that the patient understands what to expect. Cognitive function should be assessed to tailor communication and ensure comprehension.

Comfort Measures

Additional comfort measures should be provided during the procedure. Warm compresses should be considered on the selected site to promote vein dilation and minimize discomfort during insertion.

Medication Sensitivity

Older adults may experience altered pharmacokinetics, making them more susceptible to adverse reactions from medications administered via IV. Close monitoring for potential complications or reactions should be conducted, and medication dosages may need to be adjusted accordingly.

Key Takeaways

In summary, initiating peripheral intravenous therapy is a multifaceted process that demands thorough patient assessment, careful site selection, precise technique, and diligent monitoring. Understanding the unique needs of different patient populations—especially older adults and those requiring central lines—helps ensure safe, effective IV therapy and improves patient outcomes.

Review Questions

References