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Intravenous Therapy: Peripheral-Short

Indications
Maintenance and restoration of uid and electrolyte balance

Drug administration

Parenteral nutrition

Blood transfusion

(See Device selection algorithm on p. 31.)

Preparation
As with any medication administration, ensure the 5 Rights: Right
drug, right dose, right patient, right route, right time.

Identify the patient prior to initiation of therapy or procedure, using

at least two methods of identication.

Verify physicians order. Be familiar with patients disease process,

appropriate clinical and laboratory data (including allergies),
and treatment goal. Be familiar with agent you are infusing/
administering including issues of compatibility, drug/agent stability,
side eects and potential complications, special precautions, or
institutional protocols.

Instruct client on procedure and goals as appropriate.

Prepare and have readily available all necessary equipment.

Equipment
Gather solution (medication, blood component), administration set,
inline lter (if needed), pole, pump (if needed), volume-control set
(if required), alcohol sponges, medication. and label if necessary.

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Verify equipment/medication expiration dates and inspect product
intactness (e.g., chips, cracks, leaks). Inspect uids/meds for abnormal
particles, discoloration, and cloudiness.

Priming
1. Wash hands and always use aseptic technique when preparing intra-
vascular devices. If solution or administration set is contaminated,
replace them with a new one and start over.

2. Close clamp prior to spiking container.

3. Spiking container: Hang the bag/bottle on pole/pump and remove

coverings for both the insertion port and the spike. Hold port and
insert spike rmly. (If using a bottle instead of a bag, remove metal cap,
wipe rubber stopper with alcohol and insert spike in similar manner.
If no medication has been added, the seal should be present and you
should hear a hissing sound that alerts you to vacuum being intact.
Vented bottles have a latex diaphragm that is removed after the metal
cap to release the vacuum. In either case, if vacuum is not intact,
discard the bottle and start over.)

4. Purge tubing (invert all Y sites and backcheck valves, and tap if
necessary to prime). Follow manufacturers instructions for pump
tubing and proper priming. Attach lter if needed (usually at distal
end) and purge tubing, forcing all air out of line (remember to practice
a sterile techniquekeep the tip of the tubing in sight and above
waist level).

Twenty years from now you will be more disappointed by the

things you didnt do than by the ones you did do. So throw
off the bowlines. Sail away from the safe harbor. Catch the
trade winds in your sails. Explore. Dream. Discover.
Mark Twain

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Infusion set

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Special equipment
Filters: Used to decrease potential for vascular/pulmonary obstruction and
air emboli. Generally, lter should be located as close to the catheter inser-
tion site as possible (follow manufacturers instructions). For non-lipid-
containing solutions that require ltration, a 0.2-micron lter containing a
membrane that is bacteria- and particulate-retentive, and air-eliminating
shall be used. For lipid or other uids that require ltration, a 1.2-micron
lter containing a membrane that is particulate-retentive and air-eliminating
shall be used. Blood and blood components are administered through
special lters designed specically for their administration. Other size
lters are available for special circumstances (e.g., microaggregate blood
lters and leukocyte-depleting blood lters). When using lters, adhere to
the manufacturers labeled use(s), directions, and ltration requirements of
therapy. Be aware that some therapeutic agents can not be ltered.

Volume-control set: A graduated chamber that delivers a precise and

predetermined amount of uid and shuts o when this amount is admin-
istered. This device is used primarily in children (see Special Populations
and Infection Control, pp. 4146), or as a secondary line in adults for
intermittent infusion of medications.

Infusion pumps: Electronic devices that generate ow under positive

pressure. Various models and manufacturers are available (including peri-
staltic, pulsatile, and syringe pumps). Follow manufacturers instructions
for proper operation and maintenance.

Site selection (short-term peripheral IVs)

Several factors aect site selection including patients condition, age,
and diagnosis; clinical condition (including condition of veins); as well
as type and duration of therapy.

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Common areas for peripheral placement of an IV cannula in adults
include metacarpal, cephalic, basilic, and median veins.

For neonate and pediatric patients, additional sits selections may

include veins of the head, neck and lower extremities (see Special
Populations and Infection Control, pp. 4146).

If possible, select a vein in the patients nondominant arm.

Use an extremity that does not have the patients ID band to avoid
circulatory impairment if complications occur. Move ID band to
another site per policy, if necessary.

Start with the most distal site available and move proximally as
needed for subsequent cannulations (if an inltration occurs,
cannulation must be performed proximal to the old site or in the
opposite extremitysee Site complications, p. 22).

Avoid using veins at areas of exion unless area is immobilized.

Avoid using veins in the antecubital fossa (save these for midlines,
PICCs, and lab draws).

Avoid veins in the arm of a patient who has undergone surgery (e.g.,
mastectomy, axillary dissection, AV stula/graft) or has a condition
where circulation to the arm is compromised (consult institutional
policy for proper protocol/physicians approval).

Consult local policy and protocol for cannulation of AV stulas and

grafts for IV therapy (some used exclusively for other treatments/
therapies such as dialysis).

Adult cannulation of the lower extremities is avoided because of

increased risk of embolism and thrombophlebitis (consult institutional
policy for proper protocol/physicians approval). If IV is placed on
lower extremities, change as soon as more appropriate site is found.

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Venous access: Arm

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Venous access: Foot

To help locate hard-to-nd veins, a transillumination device is sometimes

used. Although dierent models are available, the general principle is to
illuminate the extremity at the point of where you suspect the vein to be.
As light passes through tissue, the vein appears as a dark line.

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Site preparation (short-term peripheral IVs)
Excess hair may be removed to help visualize the vein and secure the
catheter/dressing. Hair is clipped with scissors/clippers; shaving is not
recommended (potential risk for infection).

Place patients arm in a dependent position to increase venous dilation.

Warm compress for 510 min before procedure will help dilation (use
warm water, do not microwave).

Tourniquet is applied above intended puncture site to help dilate vein.

Use a loop (not a knot) to tie it in place. Check distal pulse to ensure
arterial ow is not impeded. Do not leave tourniquet in place longer
than 2 minutes. Prolonged use of tourniquet may cause circulatory
impairment. Also, prolonged use may cause overstretching of the
vein wall and atten the vein. It may be necessary to release the
tourniquet and allow the vein to rell prior to insertion. Tourniquets
are a potential source for cross-contamination, therefore, the tourni-
quet should be single-patient use. A tourniquet may be contraindicat-
ed in some circumstances, including a patient who has undergone
breast surgery, who may have existing stulated access or other
existing devices or complications.

Tap skin over vein or ask patient to open and close hand to help
visualize the vein.

Palpate vein (no pulse) to avoid accidental arterial cannulation.

Put on gloves; use universal precautions and an aseptic technique

(see Infection Control, p. 44).

Use tincture of iodine 2%, 10% povidone-iodine, or chlorhexidine. If

patient has a known allergy to iodine, prep site with 70% isopropyl
alcohol (apply it with friction for a minimum of 30 seconds). Do not
apply alcohol after 10% povidone-iodine prep because alcohol negates

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its eect. Apply solution in circular motion working outward from
intended site to an area of 24 inches.

Do not blot excess solution at the intended insertion site. Allow

solution to completely air dry.

Prepare for venipuncture.

Anesthetics
Local anesthesia: Local anesthetic agents including, but not limited to,
intradermal lidocaine, iontopheresis, low-frequency ultrasonication,
pressure-accelerated lidocaine, or topical transdermal agents, should be
considered and used according to organizational policies and procedures
and manufacturers labeled use(s) and directions. As with all medications,
be aware of patients allergies and drug actions/side eects.

Topical anesthetics: Use of topical anesthetics prior to painful dermal

procedures in children (and adults) should be encouraged, in addition to
the use of adjunctive and less-invasive anesthetic and anxiolytic therapies.
Various topical anesthetic products are available. Use according to
manufacturers labeled use(s) and directions. As with all medications,
be aware of patients allergies and drug actions/side eects.

Venipuncture equipment
Solution and primed infusion set hanging ready on pole/pump.

If site started is for access only (i.e., a saline or hep-lock), have

prepared an access port device devoid of airushed with normal
salineready to lock end of hub after cannulation.

Some clinicians prefer a predrawn ush with attached connector to

verify ow and check for inltration after cannulation. Prepare

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connector and maintain it aseptically; ush air out completely with
normal saline.

2 x 2 or 4 x 4 gauze to prevent blood spillage during insertion.

Arm board if indicated (areas of exion, children, or patients with

altered level of consciousness).

Dressing equipment (tape, gauze, label, transparent semipermeable

dressing, etc., as available and indicated).

Catheter (peripheral-short catheters and winged infusion sets

should be equipped with a safety device with engineered sharps-
injury protection).

Catheter gauge selection

As with site and catheter selection, catheter gauge selection will depend
on clinical factors such as prescribed therapy, diagnosis, medical history,
activity level, age, and status of veins.

Remember to use the shortest length and smallest diameter catheter that
will get the job done. Also, the smaller the catheter gauge number, the
larger the diameter.

General considerations are indicated in the chart on the following page.

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Catheter gauge selection (cont.)
Gauge Uses
16 Large fluid/volume; rapid
infusions (high-risk surgical
procedures, trauma).
18 Surgery, viscous solutions
(whole blood, packed RBCs).
Various emergent situations.
20 Routine infusions and routine
IV access. Minor surgical
procedures.
22 Suitable for most infusions at
slower rates. Recommended for
small and/or fragile veins. Not
appropriate for rapid flow rates.
24, 26 Slower flow rates. Neonatal,
pediatric, and elderly patients.
Consult local institutional policies for specific guidelines and protocols if applicable.
No one can make you feel inferior without your consent.
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Implications
Increased likelihood of pain on insertion
(# anesthesia). Large vein needed.
? likelihood of irritation to vein wall.
Large vein needed to accommodate
catheter.
Frequently selected gauge size.
Easier to insert into small, thin, fragile
veins but may be difficult to insert into
tough skin.
Easier to insert into extremely small
veins; difficult to insert into tough skin.
Eleanor Roosevelt
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Peripheral-short devices*

Winged-needle set: (stainless steel)

Used for single-dose administration
of meds (third-world countries);
blood collection.

Over-the-needle set: For continuous

or intermittent IV access.

Winged-catheter set: (Saf-T Intima)*

Many newer devices oer safety
features. Following insertion of this
catheter, the needle is withdrawn
and automatically covered inside a
safety chamber.

* Courtesy and of Becton, Dickinson and Company.

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Venipuncture
Dierent products will require dierent implementation. It is important to
follow specic manufacturers instructions. Below are general guidelines.

Before beginning, explain to the patient what you are planning to do

using a language and words appropriate for their condition, age, and
level of understanding.

Use universal (standard) precautions and an aseptic technique.

Inspect cannula for product integrity. Catheters should be radiopaque.

Remember to use the smallest gauge and shortest catheter available
that will accommodate the therapy.

Grasp needle/catheter with dominant hand. Hold skin taut with other
hand to stabilize vein.

Approach at 3045 angle; bevel up. Enter skin directly over vein.

Advance device into skin. To prevent puncture of posterior vein wall,

lower needle until parallel to skin. Advance device slightly into vein.
Look for blood ashback (ashback is not always visible, especially in
small or hardened/diseased veins. Flashback can also occur before the
catheter tip has entered vein). Sometimes you will feel a pop after
entering vein lumen but this is not always the case. Advance device
further in according to product instructions.

Thread catheter up to the hub or until resistance is met. Do not reinsert

needle through the catheter because of potential for severing and/or
puncturing catheter (risk for causing an embolus).

Apply slight pressure with your nger on the catheter tip to prevent
bleeding (place nger right over patients skin), and remove needle.
Some catheter devices have a spring-loaded-needle-retrieval system
that is activated with the push of a button, others require a rm pull,

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and others a careful withdrawal. Ensure you are familiar with equip-
ment and follow manufacturers instructions.

Remove tourniquet. Stabilize hub and attach IV tubing or saline ush.

Check for ow/inltration by pushing ush or opening infusion ow.
If catheter is properly placed, uid should ow freely and unimpeded
and good blood return should be visible on line/ush; blanching,
swelling or obstructed ow indicate catheter is not in place. If so,
remove and retry (the Intravenous Nursing Society recommends a
max of 2 tries per clinician).

Insertion of peripheral IV
Only nurses who have been certied as competent in the insertion of IV
cannula will perform this procedure. As always follow specic manufac-
turers instructions and hospital policy. Below are general steps and advice.

Procedure Additional information

1. Explain procedure to patient/parent

2. Wash hands with antiseptic soap
and wear gloves.
3. Apply the tourniquet above
insertion site.
Strict adherence to hand washing and
aseptic technique remains the cornerstone of
prevention of cannula related infections.
For pediatric patient, an assistants hand used
as both as a tourniquet and restraint is often
more acceptable to a child than a tourniquet.

4. Disinfect the selected site with skin Do not touch the skin with the fingers after
prep and allow to dry preparation solution has been applied.
5. Inspect the cannula before insertion Do not touch the shaft or tip of the cannula.
to ensure that the needle is fully
inserted into the plastic cannula and
that the cannula tip is not damaged.

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Insertion of peripheral IV (cont.)
6. Ensure the bevel of the cannula is
facing upwards.
7. Insert the needle and the cannula
into the vein.
8. Partially withdraw the needle and
advance the cannula.
9. Release the tourniquet.
10. Secure the hub of the cannula with
clean adhesive tape.
11. Flush the cannula with
normal saline.
12. Cover the intravenous and
surrounding area with a sterile
transparent dressing.
13. If infusion ordered, prime the line
and connect the intravenous and
surrounding area with a sterile
transparent dressing.
14. Note the date and time of insertion
in the patients medical record.
15. If the site needs to be immobilized,
use a well-padded splint and
strapping if necessary.
16. Dispose of equipment safely.
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Facilitates the piercing of the skin by
the bevel.
Gentle traction on skin may stabilize the vein
under the skin.
Do not cover the puncture site. Cut tape
immediately prior to use only.
Ensures the line is patent accessible.
Ensure that the insertion site and the
area proximal to the site are visible for
inspection purposes.
Ensure that the insertion site and the
area proximal to the site are visible for
inspection purposes.
Intravenous lines used for intermittent
infusions must be labeled with the
patients name, and the date and time of
commencement.
For infants < 12 months, a transparent tape
must be used.
If a bandage is used, apply it at each end
of splint so that the central area is lightly
covered for easy inspection.
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Securing the catheter
Great job! You got the IV in. Now you have to keep it in! Special
precautions for taping and securing an IV site should be followed
according to the clinical situation. A confused patient, an active
child, or placement on a joint will require extra attention to your
technique. Assess the situation for the need for splints, and special
taping measures.

Remember: A still IV site is a good IV site. Motion and physical activity

on or around the site will increase chances for catheter movement and
subsequent complications. . Use sterile tape, sterile wound closure
strips, or a manufactured catheter stabilization device to minimize
unscheduled restarts and loss of vascular access. But, you must assess
the site for patency/inltration and general status so do not tape or
secure the site in a manner that will impede assessment or circulation.

Good catheter stabilization does not just maintain patency but it also
reduces the chances of phlebitis, inltration, sepsis, and cannula
migrationnot to mention the happy patient that wont have to get
poked again!

! When tape is used, it should be applied to cannula hub/wings and not
directly over the junction between the skin and catheter. Do not
encircle limb with tape.

Transparent semipermeable dressings oer a great way to both secure

and protect the site from potential complications. Follow the specic
manufacturers instructions. Do not cover tubing and do not over-
stretch dressing; this may cause itching. If removal is dicult, try
loosening the edges with alcohol or water.

Sutures are seldom used for catheter stabilization, but if they are used,
follow institutional protocols and manufacturers instructions. Replace
sutures if they become loose, or are not intact. Do not readvance a
catheter that has migrated.

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What is the best method for securing a catheter?
Healthcare workers have customarily used tape or sutures to secure
medical catheters. Typically sutures are used for central venous catheters,
arterial catheters, and chest tubes. Improved adhesive products and
securement devices may decrease or eliminate the need for sutures and
thus directly reduce the risk of needlestick to the healthcare provider.

Advanced securement devices may also reduce risk of micromovements

that can result in potentially dangerous patient complications such as
dislodgement, disconnection, inltration, extravasation, infection
and phlebitis.

Tape-free catheter securement devices use a bond between a sterile,

adhesive pad and the patients skin.

Appropriate products and work practices are essential to provide increased

catheter stability. Such products and work practices may reduce catheter
dislodgment and the necessity of reinsertion with its associated needle-
stick risk.

Additional tips to avoid infection

Site selection:

The site at which a catheter is placed inuences the subsequent risk for
catheter-related infection and phlebitis. The inuence of site on the risk
for catheter infections is related in part to the risk for thrombophlebitis
and density of local skin ora.

Phlebitis has long been recognized as a risk for infection. For adults,
lower extremity insertion sites are associated with a higher risk for

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infection than are upper extremity sites. In addition, hand veins have a
lower risk for phlebitis than do veins on the wrist or upper arm.

Hand hygiene and aseptic technique:

For short peripheral catheters, good hand hygiene before catheter

insertion or maintenance, combined with proper aseptic technique
during catheter manipulation, provides protection against infection.
Good hygiene can be achieved through the use of either a waterless,
alcohol-based product or an antibacterial soap and water with adequate
rinsing. Appropriate aseptic technique does not necessarily require
sterile gloves; a new pair of disposable nonsterile gloves can be used in
conjunction with a no-touch technique for the insertion of peripheral
venous catheters. However, gloves are required by the Occupational
Safety and Health Administration as standard precautions for the
prevention of bloodborne pathogen exposure.

Replacement of catheters:

Scheduled replacement of intravascular catheters has been proposed

as a method to prevent phlebitis and catheter-related infections. Studies
of short peripheral venous catheters increases when catheters are left
in place > 72 hours. However, rates of phlebitis are not substantially
dierent in peripheral catheters left in place 72 hours compared with
96 hours. Because phlebitis and catheter colonization have been
associated with an increased risk for catheter-related infection, short
peripheral catheter sites commonly are rotated at 7296-hour intervals
to reduce both the risk for infection and patient discomfort associated
with phlebitis.

Evaluate the catheter insertion site daily, by palpation through the dress-
ing to discern tenderness and by inspection if a transparent dressing is in
use. Gauze and opaque dressings should not be removed if the patient

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has no clinical signs of infection. If the patient has local tenderness or
other signs of possible CRBSI, an opaque dressing should be removed
and the site inspected visually.

Remove peripheral venous catheters if the patient develops signs of

phlebitis (e.g., warmth, tenderness, erythema, and palpable venous
cord), infection, or a malfunctioning catheter.

Documentation in nursing notes is key with IVs

Exact specics of procedure using only factual information. This is
including, but not limited to, the following: type, brand, length, and
size of vascular access device; date and time of insertion; number and
location of attempts; type of catheter stabilization and dressing; use
of visualization or guidance technologies; patient response to the
insertion; and identication of person inserting the device.

Complete and accurate site condition, before and after inspection.

Interventions used:
Monitoring IV site, ushing, dressing changes, blood draws,
insertion, device removal, patient education, patient compliance
cap, dressing, volume and type of ush, and tube changes, catheter
selection, patient education, drugs, allergy history.

Timely physician notication.

If appropriate, photograph of complications. (Check with your

institution regarding the policy on photographing complication.
This can be useful for sta education and documentation, but is
not a standard of practice.)

Risk management, infection control, and standards of care are met.

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Reviewers

Jill Duncan, RN, MS, MPH

Clinical Nurse Specialist
Washington, DC

Elizabeth R. Santulli, RN, BSN, MA, COHN-S

Occupational Health Nurse
Washington, DC

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