Successful IV Starts

Revised February 2014

Why Intravenous Therapy?

Used for access to the body’s circulation

Indications:

Administer fluids, blood, medications, and nutrition

Obtain laboratory specimens

Correct electrolyte imbalances

Patient History and Assessment

What Needs to Be Considered?

Fluid volume status: Is the patient dehydrated or

over-hydrated?

Condition of veins: Does the patient need a PICC,

central line or midline instead of a peripheral IV?

Clinical conditions to consider: Does the patient

have a history of a mastectomy, have a dialysis

access, have impaired circulation of the extremity,

have a fracture proximal to infusion area and/or is

this a pediatric patient?

Prior history with IV therapy (fears, anxiety)

Which is the dominant extremity of the patient?

Catheter Sizes - Learn your colors!

18 gauge: green

Medium to large bore needle

20 gauge: pink

Most common size for adults

22 gauge: blue

Used for adults and children; can

be used for blood products

24 gauge: yellow

Used for infants, neonates

and small veins

Peripheral IV Site Selection:

Arms and Hands

Initiating a Peripheral IV

1. Know your colors. Choose the appropriate size catheter for the

patient and the clinical situation.

2. Verify any allergy history (including medications, latex, betadine,

iodine, chlorhexidine, or tape).

3. Review patient history for clinical conditions that may affect the

site placement.

4. Verify order for IV or saline lock start.

5. Identify patient verbally with two patient identifiers and check the

patient ID bracelet.

6. Explain the procedure to the patient.

7. Gather supplies – Start Kit (non-sterile gloves, IV catheter,

stabilization device, and extension tubing).

Procedure for Starting a Peripheral IV

1. Wash hands and don non-

sterile gloves.

2. Prime your extension tubing

or end cap with normal

saline.

3. Apply a tourniquet and

select your site.

4. Be confident and positive

with the patient.

5. Methods to improve venous

distention include:

Encourage patient to “pump”

hand

Dangle the arm below body

Apply heat over the selected

site for a few minutes

Tourniquet should be tight

enough to slow blood flow

but not stop it.

7. Remove hair as necessary.

8. Prepare large area with

chlorhexidine and allow to dry. If

patient is allergic to

chlorhexidine, use the providone

iodine prep in a circular motion.

Allow to dry and follow with

alcohol.

9. Insert the catheter with the bevel

up into the skin at a low angle of

10 – 30 degrees.

10.Upon flashback visualization,

lower the catheter almost

parallel to the skin.

11.Advance the stylet a few

millimeters more to ensure

catheter is in the vein and then

gently advance the catheter off

the stylet.

12.Release the tourniquet and

occlude the blood flow above

the tip of the catheter.

13.Engage the safety devise to

withdraw the stylet from the

catheter.

Finishing the Peripheral IV start

1. Attach the pre-filled extension tubing set.

2. Attach the securement devise to the catheter hub. If appropriate, prep the skin on either side of the IV catheter hub.

3. Apply transparent occlusive dressing.

4. Label the dressing with date, catheter size, and your initials.

5. Tape extension tubing or end cap securely.

6. Flush the extension tubing or end cap with normal saline to ensure patency.

Documenting Your IV Start

Document in SCM under vascular access

Enter new time column and document insertion

Make sure to right click and modify row label to include catheter gauge, date, site and type of catheter.

Documenting you IV Start

Remember, you

must document

all attempts to

start an IV –

even if

unsuccessful.

Managing Difficult Sticks

Use warm packs

Lightly tap vein

Have patient dangle arm below the body and then put the

tourniquet on

Apply a 2nd tourniquet about 3-4 inches below the first

tourniquet

Have the patient relax…..engage them in conversation to

help them relax

Attempt IV starts only 2 times and then ask for back up

help

If all else fails, re-apply heat and ask an IV Super Starter

or another co-worker for assistance

Who Needs a PICC Line?

Those who will be on antibiotic therapy for

longer than a few days

Those receiving TPN

Those receiving vesicants or irritants longer than

a couple of doses or longer than a short period

of time

Those will very poor IV access choices who will

need extended IV’s and lab draws

When to Consider a Midline

Consider a Midline if the patient has:

Poor access with frequent restarts

Difficult lab draws

IV fluids NOT requiring a central access

IV or medication therapy that will last less

than 29 days

Complications of IV Therapy

Infiltration

Thrombophlebitis

Bacteremia

Circulatory overload

Air embolism

Mechanical failure

Hemorrhage

Extravasation

Clinical Presentation

Swelling

Skin cool to touch

Pain at insertion site

Decreased or absent

IV flow

Infiltration is the inadvertent administration of a

non-vesicant solution or medication into the surrounding

tissue

Management of Peripheral IV

Infiltration

1. Stop IV infusion and discontinue IV

2. Elevate extremity

3. Apply heat or ice for comfort

4. Add parameter under SCM vascular access for

vascular infiltrate

5. Document in SCM and Safety Zone Portal per

Health First policy CP 2.07

6. Restart IV in alternate extremity or proximal site

Phlebitis indicates irritation and/or inflammation to the

vein

Clinical presentation

Pain

Erythema which may

follow the course of the

vein

Edema

Warmth at affected area

Hardened vessel

Management of Phlebitis

1. Stop IV infusion and discontinue IV

2. Add parameter in SCM under vascular access for vascular

phlebitis

3. Document in SCM and Safety Zone Portal per Health First

policy CP 2.07

4. Restart IV in unaffected extremity or proximal to site

5. Apply heat to affected area

If an IV is not good, remove it! No IV is better

than a bad IV in an emergency.

Central Line-Associated Bloodstream

Infections (CLABIs)

These infections result in thousands of deaths each year

and billions of dollars in added healthcare costs – yet

these infections are preventable!

Approximately 90% of these infections occur with CVCs

Remember, PICC lines are also central lines

Prevention of CLABSIs

Perform hand hygiene before and after inserting,

replacing, accessing, or dressing a central line

Use Maximal Barrier Precautions during insertion

A mask, cap, sterile gown and sterile gloves are to be worn by all

healthcare personnel involved in the central line insertion procedure

The patient must be covered with a large sterile drape during

insertion

Chlorhexidine Skin Antisepsis

Use a chlorhexidine-based antiseptic for skin preparation in patients

older than 2 months of age

The antiseptic solution must be allowed to fully dry before making

the skin puncture for central line insertion

After Insertion of Central Lines

Disinfect catheter hubs, needleless connectors and

injection ports with alcohol before accessing the catheter

Before accessing catheter hubs or injection ports, clean

them with 70% alcohol to reduce contamination. Scrub

the hub!

Assess the need for the central line on a daily basis.

Remove unnecessary central lines promptly.

Central Line Sterile Dressing Change

1. Wash hands, don non-sterile gloves, set up supplies and

remove old dressing.

2. Remove gloves and wash hands again. Open CVC or

PICC dressing kit. Apply face mask and don sterile

gloves.

3. Cleanse site with chlorhexidine OR alcohol applicators (x

3) and then betadine applicators (x 3). Start at site and

work outward in a circular motion. Allow to air dry fully.

4. Apply antimicrobial patch unless patient is allergic to

chlorhexidine. Use hemostatic powder for a bleeding site.

Change the antimicrobial dressing every 7 days and

change a gauze dressing every 48 hours (per Health First

policy CP 2.02)

Central Line Sterile Dressing Change

(continued)

5. Apply occlusive dressing. Date and label the dressing

with your initials also.

6. Document in SCM the assessment, dressing change and

injection cap changes.

7. Change the catheter patency device caps (injections caps)

every 7 days.