1-3. Procedures for initiating an intravenous

The following description of procedures for initiating an IV can be applied in a clinical or field environment. Two types of needles will be discussed which you may use when initiating an IV.

a. Determine Need for an Intravenous. Usually you will be directed to administer an IV by the doctor's orders or supervisor's directive. In the field environment, you may have to rely upon your individual judgment for administering an IV. If a patient has lost considerable blood or you suspect shock, you will administer an IV. In the field environment, you will usually have Ringer's lactate solution as part of your supply.

b. Perform Patient Care Handwash.

(1) In the hospital, you will wash your hands using an antimicrobial soap.

(2) In the field, you will use the best handwash possible that the situation permits.

c. Obtain Required Equipment.

(1) Solution in bag or bottle.

(a) Use only solutions labeled as specifically prepared for IV therapy.

(b) Veins in the arms are usually the most accessible and easy to find for intravenous infusions. For short-term therapy, the left hand is used when the patient is right-handed and vice versa. For long-term therapy, alternate arms are used.

(c) Check to verify that you have the right solution. Compare the label on the solution container with the patient's record and provider's order; check the type of solution, amount, route, hours of administration, and rate of flow. Sometimes in the hospital, the pharmacy will prepare the IV for you.

(2) Intravenous injection set.

(a) There are several types of needles. The synthetic catheter/needles and stainless steel needles are two types that are commonly used.

(b) The advantage of the synthetic catheter/needle is the flexibility of the catheter while it is in the vein. This increases stability and reduces the possibility of infiltration (see figure 1-1). We will discuss this needle first in this lesson. This is also the needle found in your aidman's kit.

(c) The stainless steel needles (known as wing-tipped needles or "butterflies") are used for short-term therapy or when the IV site must be changed frequently. Although this type of needle is safer and less traumatic for the patient, it is more likely to become dislodged or puncture the vein (see figure 1-2). The procedures for using this needle are at the end of the lesson.

Figure 1-1. Catheter/needle and straight needle.

Figure 1-2. Wing-tipped needle.

(3) One roll each of one-inch wide adhesive tape, 1/4-inch wide adhesive tape, and, if available, transparent IV site adhesive tape.

(4) Constricting band.

(5) Gauze sponge (2 by 2- inch).

(6) Antiseptic sponge. In the field situation, this is usually a cotton alcohol swab.

(7) Arm board, if required for stabilization.

(8) Waterproof pad to protect area under site.

d. Inspect Equipment for Defects and/or Contamination. This is an important step. Using contaminated equipment or solution can cause life-threatening infections in your patients.

(1) Intervenous solution bag or bottle.

(a) Check the fluid in the bag or bottle for discoloration, condensation, and sedimentation.

(b) Check the bottle or plastic bag for cracks, scratches, and leaks. If IV solution comes in a plastic bag, gently squeeze it to make defects more visible. Be sure to check the expiration date.

(2) Intravenous injection set (see figure 1-3). This set includes the tubing, drip chamber, clamps, and needle adapter. Examine this set carefully. It may include a catheter/needle unit or the catheter needle may be issued separately.

(a) Inspect package for tears, rips, or watermarks that may indicate contamination of contents.

(b) Inspect the needle adapter, drip chamber, and spike for discoloration, cracks, and holes.

(c) Release the clamp, slide it six to eight inches below the drip chamber, and reclamp.

(d) Inspect the catheter/needle for burrs or other flaws.

Figure 1-3. Intravenous injection set.

e. Prepare Equipment.

(1) If using bag solution:

(a) Remove the protective covers from the spike and from the tube on the end of the bag.

(b) Insert the spike into the end of the solution container tube with one quick motion. Make sure the spike is inserted to the hub. Do not touch the end of the tube or the spike at any time.

(2) If using bottle solution:

(a) Remove the protective metal cap and diaphragm. Avoid cutting your fingers on the edges of the cap. Do not touch or contaminate the sterile surface when you open the bottle.

(b) Swab the stopper with alcohol pad.

(c) Push the spike firmly into the rubber stopper. If there is no sound that indicates a release of the vacuum, DO NOT use the fluid. It may be contaminated.

(3) Hang the bag above the level of the patient's heart.

(4) With tubing clamp closed, squeeze the drip chamber until it is half full of solution. This allows the solution to flow properly.

(5) Air entering the bloodstream is rapidly transported to the heart. Depending on the amount of air injected, the patient may or may not experience serious complications, including cardiac arrest. Remove air from the tubing as follows (see figure 1-4):

Figure 1-4. Removing air from the tubing.

(a) Hold the end of the tubing over a basin or other container to collect any fluid that may run out as you clear the tubing.

(b) Hold the tubing above the bottom of the bag or bottle; then remove the protective cover from the needle adapter and hold it for later use. Be careful not to touch the end of the adapter or allow it to touch any non-sterile surface.

(c) Release the clamp on tubing.

(d) Gradually lower the tubing and allow the fluid to run through the tubing until the solution reaches the end of the adapter. This forces the air out of the tubing.

(e) Clamp the tubing to prevent air from re-entering the tubing.

(f) Replace the protective cover.

(6) Tear off three four-inch pieces of one-inch tape and one three-inch piece of 1/4-inch tape and hang on the side of the bag or bottle or another readily accessible location.

f. Prepare the Patient for Procedure. Identify the patient and tell him what you are going to do.

(1) If performing this procedure in other than a field environment, identify the patient as follows:

(a) Ask the patient his name.

(b) Check the identification band and bed card.

(2) Prepare the patient by explaining:

(a) Why the IV therapy is needed.

(b) How much discomfort there will be.

(c) How the venipuncture is performed.

(d) How therapy will limit activities.

(e) Why the needle and flow clamp are not to be manipulated.

(f) How to call the nurse should help be required.

g. Select Infusion Site. Select the most distal and accessible vein of an uninjured arm or hand (see figure 1-5). Veins in the arm are usually accessible and easy to find. Consideration for choosing an infusion site includes:

Figure 1-5. Preferred sites for an IV.

(1) Longevity of therapy.

(a) Short term. When possible, use the left hand if the patient is right-handed. Use the right hand if the patient is left-handed.

(b) Long term. Alternate arms when changing sites.

(2) Avoid sites over joints. Sites over joints are hard to stabilize. Selecting these areas may cause the catheter or needle to dislodge or the fluid to infiltrate.

(3) Patient's condition. Avoid veins in infected, injured, or irritated areas. Using sites in close proximity to such areas increases the chances of contamination and infection.

h. Prepare Infusion Site.

(1) Place waterproof pad under arm selected.

(2) Apply a constricting band two to three inches above the site you have chosen.

(3) Palpate the vein selected.

(4) Cleanse the skin of the site you have selected. Use the same procedures you have been taught to cleanse the site of an injection (spiral motion from the center outward).

i. Don Gloves. If you have not done so, put on non-sterile or sterile gloves.

j. Insert Catheter/Needle into Vein. Follow the procedure below to insert the over-the-needle catheter.

(1) Remove the protective cover from the catheter/needle, being careful not to touch the catheter/needle.

(2) Touching only the catheter/needle hub, rotate catheter in needle to make sure it moves freely. Do not move catheter up and down on the needle.

(3) Place your thumb about one inch directly below the injection site. Pull the skin taut using a firm downward pressure of the thumb over the vein.

(4) Hold the flash chamber firmly between thumb and forefinger (figure 1-6).

(5) With the catheter/needle in the bevel up position, position the needle at about a 20 to 30 degree angle and sharply pierce the skin slightly to the side of the vein (see figure 1-7). If the point of insertion is slightly to the side of the vein, there is less chance of pushing it completely through the vein.

Figure 1-6. Inserting the over-the-needle catheter.

 

Figure 1-7. Angle of insertion of the needle.

(6) Decrease the angle until almost parallel to the skin surface and direct it toward the vein (see figure 1-8).

Figure 1-8. Straighten and lower needle to pierce vein.

(7) Maintaining traction on the skin below the insertion site, pierce the vein wall. Resistance is felt as the needle and catheter begin to puncture the vein wall.

(8) When the vein is entered, you will see blood in the flash chamber of the catheter/needle.

(a) If you do not see any blood in the flash chamber, pull the catheter/needle back slightly, but not above the skin surface, and attempt to direct the needlepoint into the vein again. If you still are not successful, release the constricting band so that blood does not backflow, then withdraw the catheter/needle. Using a new catheter/needle, reattempt the venipuncture at a point higher than the previous attempt. If you are still not successful, obtain assistance if available.

(b) If you see blood in the chamber, advance the catheter and needle approximately 1/2 inch further to assure the catheter tip is completely in the vein. Release the constricting band and ask the patient to open his fist. If the constricting band is not released, the patient will bleed excessively when the needle is removed.

(9) Stabilize the flash chamber with dominant hand, grasp the catheter hub with nondominant hand, and thread the catheter into the vein up to the hub.

(10) While continuing to hold the catheter hub with the nondominant hand, you must press lightly on the skin over the catheter tip with a finger of same hand. Pressing lightly on the skin over catheter tip will decrease or stop blood flow from the catheter hub after the needle is removed.

(11) With the dominant hand, remove the needle from the catheter and lay aside, taking care to avoid placing it where you, the patient, or others may be stuck before it is properly discarded.

(12) Remove the protective guard from the needle adapter on the tubing and connect adapter quickly and tightly onto the catheter hub.

(13) Release the tubing clamp to begin the flow. After the hub is taped, you will adjust the flow to the prescribed rate.

k. Tape and Secure Site. Tape and secure the site in accordance with (IAW) local standard operating procedure (SOP). One method is described below.

(1) Place the strip of 1/4-inch tape under the hub, sticky side up. (Use the tape that you placed on the bottle or bag earlier.)

(2) Criss-cross the ends and secure to the skin (see figure 1-9).

(3) Cover the insertion site with a sterile dressing (2 x 2 gauze or clear IV site adhesive) and tape it down (see figure 1-10).

Figure 1-9. Secure hub.

 

Figure 1-10. Cover insertion site with sterile dressing and tape it down.

(4) Retrieve and dispose of needle in biohazard container.

(5) Clean the area around the site as needed to remove any blood.

(6) When the area is cleaned and you are no longer at risk for contamination by the patient's blood, your gloves may be removed to facilitate taping and adjustment of the tubing.

(7) Loop the tubing on the extremity and secure it again with tape (see figure 1-11). The loop prevents pull on the catheter, which could dislodge if the patient moves around.

(8) Apply an armboard to immobilize or support the arm as needed.

Figure 1-11. Loop and secure tubing.

l. Readjust Flow. Calculate the flow according to the prescribed order as follows:

(1) Check the package to determine the number of drops per milliliter of IV fluid, which the IV set has been designed to deliver. The package will have a statement identifying the number of drops it will take to deliver one milliliter (cc) of fluid, for example: "Set will deliver 10 drops of IV fluid per milliliter."

(2) Determine total IV dosage and total time patient is to receive IV dosage by the doctor's orders. The orders will state a total dosage in milliliters and total time in hours during which IV fluid is to be administered or the number of ml of fluid per hour.

(a) EXAMPLE: 1,000 ml over four hours.
(b) EXAMPLE: 250 ml per hour

(3) Determine the number of milliliters of IV fluid to be administered per minute by dividing the total IV dosage by the total minutes during which IV fluid is to be administered.

(a) EXAMPLE: 1,000 ml / 240 minutes = 4.2 ml per minute
(b) EXAMPLE: 250 ml / 60 minutes = 4.2 ml per minute

(4) Determine the number of drops per minute of IV fluid to be administered by multiplying the milliliters of IV fluid required per minute by the number of drops of IV fluid per milliliter delivered by the tubing used. Round off drops per minute to the nearest whole number.

EXAMPLE: 4.2 ml of IV fluid per minute x 10 drops of IV fluid per ml = 42 drops per minute.

(5) Using the tubing clamp, adjust the rate of flow to equal the number of drops per minute you have calculated. You may count the number of drops delivered in 15 seconds and multiply by four.

m. Clear the Area. Clear the area of used supplies and equipment and make the patient comfortable.

n. Document Intervenous Therapy. The dressing covering of the needle is used to document when therapy started and time of each change of dressing. The dressing should be changed every twenty-four hours to keep the site clean and to prevent irritation and contamination. The directions for labeling the dressing bag or bottle and medical records are as follows:

(1) Dressing.

(a) Cut one piece of adhesive tape, and place it on a flat surface. Do not write on the dressing, as it will irritate the venipuncture site. You may also use the tab of the edge of the transparent adhesive site cover to label the dressing.

(b) Write the following data on the tape or tab:

1 Initials of person initiating the IV.
2 The date and time the IV was started. 3 Gauge of catheter/needle used. (c) Place the labeled tape over the dressing.

(2) Container (bag or bottle). Label bag or bottle once the infusion is started and with each change of solution. The bag or bottle should be changed every 24 hours, even if not all the fluid is used, to prevent irritation or contamination.

(a) Write the information required by your facility's local policy on a label or piece of tape. This may include:

1 Patient's name, identification number, and room number.
2 Drip rate.
3 Date and time container was hung.
4 Initials of the person hanging the container.

(b) Place the labeled tape on the bag or bottle.

(c) Prepare and attach a timing label as follows:

1 Place a piece of adhesive tape vertically on the container.
2 On the tape, write the approximate time the solution level should reach each volume mark on the container (usually at each 100 cc mark). This will involve mathematical computation. Write the time the container should be empty at the bottom of the label.

(d) Label the tubing IAW local policy or as follows:

1 Wrap a strip of tape around the tubing, leaving a tab.
2 Mark your initials and the date and time the tubing was last changed on the tab.

(3) Medical records. Record the following in the nursing notes or field medical card:

(a) Date and time IV was started.

(b) Amount and type of solution.

(c) Rate of infusion.

(d) Type and gauge of needle and cannula set.

(e) Insertion site.

(f) Patient's condition.

(g) Your name.

(h) If patient has an intake and output (I&O) form, complete the proper areas.

o. Perform Handwash. Perform a patient care handwash.

p. Record Treatment and Observations. Record information on the patient's record (Field Medical Card or Nursing Notes) as applicable.