Safety

• Observe the Six Rights of Medication Administration.
• Know if the patient is right- or left-handed. For comfort and mobility, place an IV in the nondominant arm.
• Ensure that an IV system is intact, and there is no evidence of phlebitis or infiltration. An intact system ensures that you have maintained sterility and that no fluid or medication has been lost.
• Maintain sterility of a patent IV system using Infusion Nurses Society standards:
  • Perform hand hygiene before and after palpating, inserting, replacing, or dressing any intravascular device.
  • Use a catheter stabilization device that allows visual inspection of the access site.
  • Replace short peripheral venous catheters, and rotate sites if clinical assessment indicates signs or symptoms of IV-related complications.
• Use each vascular access device only once for each insertion attempt.
• A single nurse should not make more than two attempts at initiating IV access. After two attempts, the nurse should have another nurse attempt the insertion.

Equipment

(Roll cursor over items to see labels)

20- or 22-gauge catheter

IV Tubing

IV Extension set

IV Fluid

Waterproof pad or towel

2x2 gauze squares

Tourniquet

Tape

Clear, occlusive dressing

Clean gloves

Chlorhexideine swabs

Alcohol swabs

Delegation

The skill of initiating intravenous therapy may not be delegated to nursing assistive personnel (NAP). Delegation to licensed practical nurses (LPNs) varies by state Nurse Practice Act. Be sure to inform NAP of the following:

• Instruct NAP to notify you if the patient complains of any IV-related complications, such as pain, redness, swelling, or bleeding.

Preparation

• Review the accuracy and completeness of the health care provider’s orders for the type and amount of IV fluid, medication additives, infusion rate, and length of therapy.
• Follow the Six Rights of Medication Administration.
• Assess the patient’s knowledge of the procedure, reason for prescribed therapy, and arm placement preference.
• Assess for clinical factors/conditions that will respond to or be affected by administration of IV solutions:
  • Body weight
  • Clinical markers of vascular volume
  • Clinical markers of interstitial volume
  • Thirst
  • Behavior and level of consciousness
• Determine if the patient is to undergo any planned surgeries or procedures.
• Assess laboratory data.
• Assess the patient’s history of allergies, especially to iodine, adhesive, and latex.

Follow-up

• Secure the IV device, and apply a sterile dressing over the site. (For details, see the Video Skill “Dressing the Infusion Site.”)
• Observe the patient every 1 to 2 hours or at established intervals per your agency’s policies and procedures for the following:
  • Verify the type/amount of IV solution that has infused by observing the fluid level in the IV container.
  • Check the infusion rate on the EID, or count the drip rate (if the solution is infusing by gravity).
  • Check the patency of the vascular access device.
  • Observe the patient for signs of discomfort during palpation of the vessel (over the transparent semipermeable membrane [TSM] dressing).
  • Inspect the insertion site, noting its color, such as redness or pallor.
  • Inspect the site for the presence of swelling, which is a sign of infiltration, or pain and tenderness, which is a sign of phlebitis. Feel the temperature of the patient’s skin above the dressing.
• Observe the patient to determine his or her response to therapy, such as laboratory values, I&O, weights, vital signs, and postprocedure assessments.

Documentation

• Record the number of attempts and sites of insertion.
• Precisely describe the insertion site, such as “cephalic vein on dorsal surface of right lower arm, 2.5 cm [1 inch] above wrist.”
• Document the method of infusion (gravity or electronic infusion device); type and rate of infusion; device identification number (if you are using an electronic infusion device); size, length, and brand of catheter; when the infusion began; and the patient’s response to the insertion. Use an infusion therapy flowsheet when available.
• Follow your agency’s policy for recording the patient’s status, IV fluid used, amount infused, and integrity and patency of the system.
• Report to the oncoming nursing staff: the type of fluid, flow rate, status of the vascular access device, amount of solution remaining in the infusion bag, expected time for completion of infusion and need to hang subsequent IV containers, and the patient’s condition.
• Report to the health care provider any signs and symptoms of IV-related complications.