iv basicsmm,mn

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IV Basics(Checklist step #5)

Objectives of IV Therapy:

Restore and maintain fluid and electrolyte balance

Provide medications and chemotherapy Transfuse blood and blood products

Deliver parenteral nutrients and nutritional supplements

Benefits of IV Therapy:

Allows more accurate dosing

Medications can act instantaneously

Can be used to administer fluids, medications and nutrients when thepatient cannot take them orally

Risks of IV Therapy:

Bleeding Infiltration (when fluids are infused into the surrounding tissue instead of

the vein)

Infection

Overdose (fluid overload, speed shock)

Anaphylaxis, Syncope

Fluids and ElectrolytesThe body is made up of mostly liquid. Two-thirds of total body weight in an adultand three-fourths of the body weight in an infant consist of fluid.

Body fluids are composed of water and solutes (dissolved substances) which areelectrolytes and non-electrolytes.

ElectrolytesThere are six major electrolytes:

Sodium

Potassium

Calcium

Chloride

Phosphorous Magnesium

These are associated with the electricity (chemical compounds) of the body andare vital to the function of the cells. Too much or too little of any of theelectrolytes will cause problems if they are out of balance; fluids and electrolytesgo together.

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Electrolytes are contained either intracellularly (potassium, magnesium andphosphorous) or extracellularly (sodium and calcium).

(Not required for this course, but highly recommended, is further study into thebalance of fluids and electrolytes and the fluid movement process).

Osmosis is a term for this movement of fluids and electrolytes and the fluidmovement gradient. Water flows from higher to lower concentration. When thesolute concentration is equal on both sides of a membrane the osmosis stops. Itis possible for the osmosis to create an equal concentration if the concentrationisnt optimal, then the balance must be corrected.

Osmosis is the force which causes water to move when solute (solid) particlesdraw it toward them. Osmosis only occurs when the concentration of solute onone side of a membrane (like the cell membrane) is different than theconcentration of solute on the other side. The side with more solute

concentration will draw water to it. As the water moves toward the side with moresolute it will eventually cause that side to become the same concentration as theside it is drawn from; at that point, osmosis stops.

Osmotic pressure is based on solute concentration which is referred to asosmolarity (or how much solid is dissolved in the water). The prefixes iso(equal), hyper (higher) and hypo (lower) denote the tonicity or osmolarity of asolution. In the picture above, side A is hypertonic to side B in the left picture,but isotonic to side B in the right picture.

IV solutions all have a tonicity; therefore they can have an osmolar effect on thehuman body. Isotonic IV solutions (iso-osmolar to the blood) will go in to the

person without causing any osmotic effect between the plasma, extracellular, orintracellular spaces in the body.

SolutionsThere are three types of IV solutions:

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Isotonic- this has the same osmolarity as serum and other body fluids. Itwill not cause any osmotic effect on the body. Examples: lactated ringers,ringers, normal saline, dextrose 5% in water and 5% albumin.

Hypertonic- this has a higher osmolarity than serum. It will pull fluid from

the interstitial and intracellular compartments into the blood vessels.Examples: dextrose 5% in half-normal saline, dextrose 5% in normalsaline, dextrose 5% in lactated ringers, 3% sodium chloride, 25% albuminand 7.5% sodium chloride.

Hypotonic- this has a lower osmolarity than serum. Fluid moves from theblood vessels and into the cells and interstitial spaces. Examples: Sterilewater, half-normal saline, 0.33% sodium chloride and dextrose 2.5% inwater.

*Since blood products and parenteral nutrition are rarely administered in an office

or clinic, they are not addressed here.

Delivery MethodsThere are two types of IV administration:

Peripheral

Central

There are three basic methods to infuse IV fluids and medications via bothdelivery methods:

Continuous infusion- this allows a carefully regulated amount of fluid to begiven over a long period of time, helping maintain a constant drug leveland is used for fluid therapy and parenteral nutrition.

Intermittent infusion- this is the most common and flexible method of IVtherapy. Drugs can be administered over a specific period of time atintervals and can be infused through a primary line or a secondary linethat has been connected (or piggybacked) to the primary line.

Direct injection- the most direct method. This gets the medication or fluidright into the patient right away. It is also called giving a bolus or an IV

push.

Central Venous TherapyThis is IV therapy using major veins instead of those in the limbs and otherperipheral veins. It is most useful when a patient needs infusion of a largeamount of fluid, requires multiple infusions, and /or requires long-term therapy. Acentral line may be inserted directly into the superior or inferior vena cava or the

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right atrium of the heart. In addition, one can be inserted into a peripheral veinand threaded up into the vena cava.

There are additional risks to central venous therapy including:

Perforation of the vein and adjacent organs

Requires more time and skill than peripheral IVs

Air embolism or thrombus

Sepsis

Pneumothorax

Access DevicesTypes of access devices include:

Non-tunneled and tunneled catheters Peripherally inserted central catheters (PICCs)

Implanted vascular access ports (VAPs)

Supplies and EquipmentThe tubing for an IV is called an administration set. Which set you choosedepends on the type of infusion needed, the infusion container, and whether youare using a volume control device or not.

Administration sets can be vented for bottles or un-vented for IV bags. Other

items and features include ports for infusion of additional medications, filters forblocking particulates in the fluid, tubing which is designed to enhance devices inregulating flow or for continuous or intermittent infusion or for blood and nutrition.

There are also various types of clamps for stopping the flow through the tubingas well as pumps that automatically deliver fluids and medications.

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OrdersWhen the physician orders IV administration, it may be a standard or standingorder (to be followed for certain illnesses and needs) or it may be anindividualized order. They may be limited in the duration of time they are effective

for, such as a 24-hour period, when a new order must be given.

All orders should include the type and amount of solution to be administered, anyadditives and their concentration, rate and volume of infusion and the duration ofthe infusion therapy.

Flow RatesTwo basic types of flow rates are:

Microdrip

Macrodrip.

Each one delivers a certain amount of drops per milliliter (gtts/mL) and each usesthe same calculation formula:

Volume of infusion (milliliters) X drip factor (gtts/mL) = flow rate (gtts/minute)Time of infusion (minutes)

When calculating the flow rate, the number of drops needed to deliver 1mL willvary on whether you are using the macrodrip (delivers 10, 15, or 20 gtts/mL) orthe microdrip (delivers 60 gtts/mL) administration set.

After the flow rate has been calculated, use your watch while checking the dropsper minute. Adjust the clamp or roller to slow or speed the flow until the correctnumber of drops per minute has been achieved. Always count for one full minute.There are also pumps that automatically deliver the medication at the correct rateprovided it has been set accurately.

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Risks, Complications and DisadvantagesThere are numerous risks and complications in various aspects of IV therapy.This list is a majority, but is not necessarily all-inclusive:

All risks related to phlebotomy Infection

Infiltration

Irritation at the site or along the vein

Incompatibility of drugs

Restricted mobility

Clotting

Too rapid or too slow flow rate can cause many problems for the patient

Wrong medication given

Using the wrong syringe when multiple syringes are required

Allergic response or adverse reaction

Hematoma

Vasovagal reaction

Nerve, tendon or ligament damage

Spasm of the vein

Patient TeachingHaving an IV is frightening to many patients and it is a little painful. You will needto explain the procedure and try to decrease the patients anxiety. Some things toinclude are:

What intravenous means, and that a plastic catheter will be inserted andleft in the vein, not a needle.

What fluid or medications they are receiving and why. (Most times theprovider will do this).

How long the IV will be in.

Admit that there may be some discomfort (do not say pain) that shouldstop once the IV is in place.

Explain any sensations the fluid or medication may cause such ascoldness, a feeling of it going up the arm, a burning sensation, etc Tellthem to report any pain or discomfort once the IV is placed.

Explain the restrictions as needed such as ambulating, showering, etc

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Teach them how to help care for the IV such as not pulling on it, not toremove the medication from the pole, not to crimp or kink the tubing and toreport any redness or irritation at the site or numbness in the fingers etc

DocumentationCharting is always required on every task, procedure, instruction, phone

conversations, etc with the patient. IV is no exception. There must be anaccurate accounting of all care that was given and any problems. There may beseveral places that it must be charted or recorded.

Below is a sample of a pre-printed label that can be completed and stuck to thechart note:

For the insertion of an IV it must include:

Size and type of device

Name of the person administering (inserting)

Date and time Site location

Type of solution and any additives

Flow rate

Whether a pump is used

Complications and patient response

Patient teaching

Number of attempts

If an attempt is unsuccessful, it must be recorded in case problems occur laterbecause of it. Label the dressing as well when inserting the IV and whenchanging the dressing. Label the fluid container and place a strip of tape downthe side to monitor amount of time that fluid is infused.

Maintenance of an IV is also charted and should include:

Condition of the site

Site care provided

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Dressing changes

Site changes

Tubing and solution changes

Additional patient teachingThere may also be flow sheets, medication sheet and/or intake/output records to

document as ell. All of these are vital.

Discontinuing an IV is charted as well as insertion and maintenance. When youdiscontinue an IV, include in your documentation:

Date and time

Reason for stopping the therapy

Assessment of the site before and after removal

Complications

Patient reaction

Integrity of the device upon removal

Any follow-up tasks such as a dressing or insertion in another site

Legal IssuesAdministering fluids and medications by IV therapy is one of the most legallyrisky tasks performed in the medical setting. There are numerous lawsuitsagainst those who have made errors involving IV solution administration. It isespecially risky for the medical assistant who works under the physician-employers license, whereas nurses have their own license. Errors in medicationdosage, incorrect placement of an IV line, and failure to monitor adversereactions, infiltration, and dislodgement of IV equipment are the commonproblems. The medical assistant CANNOT place, start, monitor or remove an IVunless they are fully trained to the full extent of their State laws and only whenyour physician-employer has allowed you to do so.

(**See the State laws of Washington called the Healthcare Assistant Law inanother assignment of the checklist in your packet for more information on this).

The medical assistant must be fully knowledgeable about the laws that governtheir right to practice within their scope of training. Be fully aware of the policiesin your office/clinic and follow all Federal and State laws for infection controlwhen performing tasks that involve body fluids (OSHA, WISHA, CDC,Bloodborne Pathogen Standard, Standard Precautions).

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Answer the following questions and submit with completed packet:

Questions

1. How much of the body weight of an infant is fluid?

2. Name four of the six electrolytes.

3. What are the two types of IV therapy?

4. Name the three types of IV solutions.

5. According to this handout of IV basics, which of the three deliverymethods is the most common and flexible?

6. Is it Federal or State laws that govern whether an MA can do IVs?

7. Name three risks or complications of IV therapy.

8. How many drops per minute can a microdrip system deliver?

9. Are electrolytes only contained within the cells (intracellularly)?

10.Name the two vessels that central venous therapy uses.

11.Of the IV solutions named here, which has a higher osmolarity thanserum?

12.What is the type of delivery method also know as an IV push?

13.Name two additional risks in central venous that are not in peripheral IVtherapy.

14.What are the five major risks of peripheral IV therapy?

15.Name two of the four objectives of IV therapy.

16.What type of IV solution is lactated ringers?

17.What are the three types of IV administration sets?

18.What does the acronym PICC stand for?

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19.How long should you compare your watch to the drop count to ensure theflow rate is being delivered accurately?

20. How long do you count on your watch to ensure the flow rate of drops isrunning at the correct speed of administration?

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IV Therapy:

Nearly 85% of all patients admitted to the hospital will receive IV therapy duringtheir stay. Patients may also receive infusion therapy in clinics, medical offices,nursing homes, and in their own homes.

General IV Policies:

Prior to initiating IV therapy for any patient, you must receive an order from thephysician. The order must include the date, route, volume of solution, namedsolution, and any additives, rate of flow and the physicians signature.

Before performing an IV venipuncture it is imperative that the agency has IVpolicies and procedures in place and that the administrator is aware of all that isincluded in the manual. Remember, the licensed professional performing thisprocedure is legally accountable for all the actions performed. Other resources toconsult are the infection control manual and the OSHA standards on bloodbornepathogens, which describe the employer and employee responsibilities toprevent the transmission of bloodborne infections.

Preparing for Venipuncture:

Once an order is obtained, gather all the equipment needed. This includes an IVpole, the ordered IV solution, appropriate IV administration set, IV catheter,sharps container, alcohol prep pad, gloves, tourniquet, gauze, tape andtransparent dressing , or if your agency provides, a prepackaged IV start pack.

An integral part of all nursing procedures is good hand washing to removesurface dirt and bacteria from the skin. Properly identify the patient beforeproceeding any further and explain the procedure to the patient fully interminology they can understand. It is illegal to perform a venipuncture on apatient who refuses. Perform a preliminary assessment of both upper extremities,assessing for scars, bone deformities, areas of infiltration or phlebitis. AffectedCVA and post-mastectomy arms should be avoided due to their impaired abilitiesto reabsorb infiltrated IV fluids. When choosing the intended IV venipuncture site,the non-dominant arm is usually preferred. Apply the tourniquet to the selectedupper extremity about three to four inches above the antecubital fossa.

The most appropriate tourniquet is made of a latex material since it isinexpensive and can be readily discarded. A properly applied tourniquet will stop

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venous blood return to the heart causing the veins below the tourniquet toengorge. Some additional methods that can be sued to distend veins include:

- Gently tapping the vein over the intended insertion site, this willcause irritation of the middle or muscular layer of the vein wall.

- Having the patient open and close the fist, ,which will cause the

muscles of the forearm to externally massage the vein wall, thusfacilitating venous blood return to the heart and causing theoccluded veins to distend.

Location of Veins: Hand and Wrist

For a successful venipuncture, the person performing it must have a workingknowledge of the location of all the major superficial veins of the upperextremities. The digital veins flow along the lateral portions of the fingers. Themetacarpal veins are formed by the union of the digital veins at the knuckles andflow on the back of the hand. The dorsal venous arch is formed by the union of

the metacarpal veins on the dorsal side of the wrist. The dorsal venous archflows upward along the dorsal surface of the forearm and turns at a right angle tojoin other veins. The digital veins are located in areas of multiple joint flexures.These veins can easily infiltrate and therefore should only be used as a lastresort. If digital veins have to be used, stabilization of the joint with a paddedtongue blade or finger splint is necessary.

The metacarpal vein is the site of choice for pre-op patients due to easyaccessibility by the anesthesiologist. When choosing a metacarpal vein, theclinician must be sure that the fully inserted catheter lies on the flat of the hand.

Avoid placing the IV catheter over areas of joint flexure, such as the wrist. An

additional location to avoid is the knuckles. Venipuncture at this site can easilylead to mechanical phlebitis due to the catheter moving in the vein.

The dorsal venous arch is a comfortable venipuncture site. The dorsal surface ofthe forearm is callused as opposed to the less exposed, more tender ventralsurface.

The cephalic vein originates at the wrist and flows along the radial portion of theforearm. This is often called the nurses vein. The basilica vein originates at thewrist and flows upward along the ulnar portion of the forearm. The medianantebrachial vein arises from the palm of the hand and extends upward, locatedon the ventral portion of the forearm. The cephalic vein is one of the mostprominent veins of the forearm and is frequently used because it is easy to see. Itcan accommodate a large gauge IV catheter. Avoid catheter placement over thewrist joint or in the antecubital fossa. Catheter movement in these areas canpuncture the vein wall and lead to infiltration. The basilic vein is visualized byhaving the patient flex the arm. It is located on the posterior aspect of theforearm. To assure correct catheter placement, lower and gently rotate the armand access the vein with the catheter tip pointed towards the heart. The median

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antebrachial vein is extremely superficial but has a narrow lumen casing it to bedifficult to access. Small gauge IV catheters should be used. Avoid using veins ofthe antecubital fossa. Antecubital veins are not appropriate for routine IV therapy.These larger lumen veins should be used for peripherally inserted centralcatheters and routine phlebotomy. The cephalic and basilic veins extend above

the antecubital fossa and merge at the shoulder to become the subclavian veinwhich in turn becomes the superior vena cava. The median antebrachial veinarises from the palm of the hand, crosses over the antecubital fossa and usuallymerges with the basilic vein.

Palpating and Prepping the Venipuncture Site:

When choosing the appropriate venipuncture site on your patient, the cephalicand basilic veins of the upper arm should not be overlooked. Locating the vein isnot the only determining factor in IV site selection. The vein must also bepalpated to assess its condition. Palpation is achieved by gently rolling two

fingers over the intended insertion site from left to right. These fingers willdevelop a sensitivity in picking up bifurcations and abnormalities in the veins, forexample, sclerosed veins or valves. Avoid palpating the vein using an up anddown motion. This will flatten the vein, and therefore decrease vein visibility.

Once the intended insertion site is selected, prep the area vigorously with alcoholand allow to air dry. The best prepping technique is to use an upward motion.This will cause the vein to distend. Avoid prepping with a circular motion or an upand down motion. This will cause the vein to flatten out and become difficult tosee. Alcohols antiseptic properties will kill staph on the epidermis which is themajor organism responsible for peripheral IV site infections. The site is

adequately prepped when the prep pad is clean.

Selecting the IV Catheter:

An important step prior to the venipuncture is choosing the appropriate IVcatheter gauge. The correct gauge selection depends on several factors, such asthe ordered flow rate, the type of fluid, the patients vein status and the viscosityof the IV fluid. A 22 gauge catheter is the standard gauge for infusing routine IVfluids and antibiotics. This catheter can deliver up to 500 cc of IV fluid per hour ina good vein. A smaller 24 gauge catheter is considered standard size forpediatric and geriatric populations and is appropriate in small lumen veins suchas the median antebrachial vein. This gauge catheter can deliver up to 250 ccper hour in a good vein. A larger 20 gauge catheter is used for infusion of bloodand blood products, since these infusions tend to be viscous and a larger lumencatheter will allow for a quicker infusion time. When you are selecting the gaugefor your patient, remember the golden rule of IV therapy: use the smallest gaugepossible in the largest vein possible.

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The IV catheter is made up of several parts. These include the air vent, a plasticor styrofoam plug which prevents blood from shooting out of the back of hecatheter; the flashback chamber, where blood return is visible when the lumen ofhe vein has been accessed; the color-coded hub, colors will vary among themanufacturers; the catheter, a radiopaque plastic type tube which remains in the

patients vein; the stylet, a stainless steel needle located inside the catheter thatis longer than the catheter and extends beyond the catheter tip. The styletpierces the skin and vein wall and it is removed once the vein is accessed. Thebevel is the sloped, exposed opening at the tip of the stylet.

Holding the Catheter Properly:

In keeping with universal precautions and OSHA standards for bloodbornepathogens, proper fitting gloves should be worn for venipuncture. With properlygloved hands, remove the selected IV catheter from the package and discard theprotective cover. When holding the IV catheter, the index finger, middle finger

and thumb are placed on either side of the flashback chamber level with thecatheter. The clinicians hand should be on top of the device. This holdingtechnique will afford good control over the catheter, thus allowing for smoothentry into the vein. The IV catheter should not be held from the back nor with theclinicians hand placed under the device. This would cause a dart-like insertionand afford less control of the IV catheter entering the skin and vein. The correctposition is always with the hand on top of the IV catheter and fingers on eitherside of the flashback chamber. Using the non-sticking hand, retract the skin atthe site tightly with a downward motion. Press to anchor the vein approximatelythree inches below where you intend to pierce the skin.

One of the most important steps in the IV insertion procedure is the entry angleof the IV catheter. If the vein is superficial and easily visualized, the entry levelshould range from 0 degrees to 5 degrees maximum. If the vein is deeper, noteasily visualized and can only be palpated, the entry angle should range from 5degrees to 15 degrees maximum.

IV Insertion:

The IV catheter should be inserted directly over the vein. Holding the flashbackchamber at the correct angle, with the bevel up, push the IV catheter through theskin and into the vein with one smooth, quick motion. The IV catheter will gothrough two layers of skin: the epidermis, the outer calloused layer; and thedermis which contains capillaries and thousands of nerve fibers. Any pain thepatient experiences during venipuncture is directly related to the IV catheterpassing through the dermis where the nerves are located. The IV catheter thenpenetrates the three layers of the vein. The outermost layer, which is puncturedfirst, is the tunica adventitia. This layer supports and protects the vessel. Thetunica media, or middle layer, consists of nerve and muscle fibers which cancause the vein to constrict or dilate. The innermost layer is the tunica intima

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which consists of endothelial cells and semilunar valves. These valves move theblood back to the heart.

When the catheter enters the lumen of the vein, blood return will be seen in theflashback chamber. Retract the skin with your non-sticking hand. To level off the

entry level of the catheter, lower the flashback chamber. Advance the catheteruntil one third of the catheter is in the vein. This will ensure that the bevel and thecatheter have entered the lumen of the vein. In a correctly inserted catheter, thebevel of the stylet and the tip of the catheter are definitely within the lumen of thevein. Avoid removing the stylet prematurely. If you were to remove the styletimmediately after the initial puncture of the vein, only the bevel of the stylet andnot the catheter would have penetrated the vein wall. Remember, the stylet islonger than the catheter. Also, if you continue to advance the catheter farther atthe same angle used for the initial penetration, the stylet would pierce the far wallof the vein, exit the vein and lead to the formation of a hematoma. The correctprocedure is to level off the angle after the initial penetration and continue

insertion until one third of the catheter is in the vein.

Completing and Dressing the Venipuncture:

Once the catheter has been properly placed, remove the tourniquet. Hold the hubof the IV catheter. With the sticking hand, grasp the flashback chamber andgently remove the stylet from the IV catheter Attach the primed IV tubing andopen the IV flow clamp. Retract the skin, and with the sticking hand holding thecatheter hub, gently advance the catheter completely into the vein. The IV fluidwill cause the vein to dilate and will also lubricate the catheter. Regulate the rateof flow and apply the dressing.

A simple tool to remember the major steps for completing a venipunctureproperly is the acronym BLATS.

B Blood return enters the flashback chamber.L Level the catheter.

A Advance the catheter.T Tourniquet is removed.S Stylet is removed.

Applying a gauze and tape dressing: gently lift the catheter. Place one strip oftape under the catheter hub with the adhesive side up. Chevron or cross the tapeover the junction of the hub and IV tubing. At this time the clinician shouldremove the gloves to prevent the tape from sticking to the gloves. Place twothree-inch strips of tape below the catheter hub and work upward. Do not placetape over the insertion site. Fold a two-by-two gauze pad in half and place it overthe insertion site. Use tape to anchor the gauze in place. The IV tubing should betaped in a looped fashion and placed on the patients arm. The site can now beinspected, if needed, by simply lifting the tape covering the gauze and reapplying

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it once the site inspection is complete. The venipuncture site could also bedressed using a transparent dressing.

Documenting the Procedure:

The IV insertion procedure must be documented on the patients record. Thenotes for IV insertion must include the following: the insertion date and time, thegauge of catheter, the length of catheter, the style and brand of IV catheter, thespecific vein name, the type of infusion and the number of attempts required for asuccessful venipuncture.

7/7/08 10:30am a 22 gauge, 1 Deseret Insyte catheter inserted into right midcephalic. 1000cc D5 NS with 20 MEQ KCl infusing at 125cc/hr by gravity.Patient states IV site feels good. M. Allen, CMA

Catheter Removal:

IV catheter removal should be performed on a routine basis every 48 hours or atthe first suspected sign of contamination or complication. The followingequipment is needed for IV catheter removal: tape, gloves, gauze and a sharpscontainer.

Gloves should be worn in keeping with universal precautions. Stop the IVinfusion by clamping the tubing. Carefully remove either the gauze or thetransparent dressing, pulling the tape in the direction of the hair growth. Place atwo-by-two gauze pad over the insertion site with the non-dominant hand andgently remove the IV catheter. Once the tip of the catheter is out of the skin,

apply pressure over the site with the gauze. Once the bleeding has stopped, tapea clean gauze in place over the insertion site. Discard the removed catheterproperly in a sharps container and document the IV catheter removal in thepatients record.

Review of Main Steps:

Obtain and check the IV order

Gather the appropriate equipment

Wash your hands

Identify the patient and assess the condition of the patients arm

Apply the tourniquet Select appropriate vein

Prep with alcohol in an upward manner

Put on gloves

Hold the catheter bevel up, at the appropriate angle

Retract the skin

Insert until the blood return is visible in the flashback chamber

Level off the angle of entry

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Advance the catheter slightly

Remove the tourniquet

Remove the stylet

Attach the IV tubing

Open the flow control clamp

Retract the skin Advance the catheter to the hub

Regulate the flow rate

Remove gloves

Center the transparent dressing over the site to anchor the catheter inplace

Loop the IV tubing and tape in place

Document the procedure in the patient chart

The insertion of a peripheral IV catheter is a complex procedure, but skill and

dexterity come with practice. A review of the insertion steps, especially the criticalpoints, will help to enhance the clinicians skills.

IV catheters

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IV cannulas

Hand positioning

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Looping and dressing style

Hand IV placement

Arm IV placement

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