Compliance of the Health Care Providers on the Standards

of Proper Peripheral Intravenous Insertion

in a Hospital Setting

A Term Paper Presented to the Faculty of Graduate

Schools of Arts, Sciences and Education
Our Lady of Fatima University

In Partial Fulfillment of the Requirements for the

Degree of Master of Arts in Nursing
Major in Nursing Administration

By:
Echevarria, George R.
Bondoc, Dessa Andrea

Abrera, Mariefe

Chapter 1
Introduction
The ability to obtain peripheral intravenous (IV) access is an
essential skill in medicine and is performed in a variety of settings by
health care providers such as nurses and physicians. Although the
procedure can appear deceptively simple when performed by an expert, it
is in fact a difficult skill which requires considerable practice to become
adept in performing it. Along with mastering the skill to insert an
intravenous line, one has to be continuously conscious of following the
aseptic and safe way of doing it. However, due to the busy setting or the
lack of proper monitoring in hospitals, some healthcare providers are
unable to comply with these standards. Nurses in some hospitals have
been required to have an intravenous therapy license. The medical
interns do not have such license requirements yet they are allowed to
insert I.V. lines.

The Code of Ethics for nurses uphold the standards of safe nursing
practice. The legal basis allowing nurses to perform IV therapy was first
established by R.A. 7164 otherwise known as The Philippine Nursing
Act of 1991. Section 27 provides that intravenous injection is
within the scope of nursing and that, in the administration of
intravenous injections, special training shall be required according
to protocol established.

R.A. 7164 was repealed by a newer law which is the RA No. 9173,
otherwise known as Philippine Nursing Act of 2002. Under Section 28
(a) of this law entitled Scope of Nursing, it is stated that Nursing care
includes, but not limited to, traditional and innovative approaches,
therapeutic use of self, executing health care techniques and
procedures, essential primary health care, comfort measures,
health teachings, and administration of written prescription for
treatment, therapies, oral topical and parenteral medications,
internal examination during labor in the absence of antenatal
bleeding and delivery.

The

Association

of

Nursing

Service

Administrators

of

the

Philippines, Inc. (ANSAP) believes that the certification of Registered

Nurses for IV Therapy should be continued to have a safe nursing
practice. Believes that only registered nurses who have been properly
trained and who have completed the training requirements of the IV
Therapy Program should be allowed to practice intravenous therapy.

In giving IV injections, nurses should follow the policies of their

agencies. Board of Nursing Resolution No.8 Sc. 30 Art. VII or
administratively under Sc. 21 Art. III states that any registered nurse
without training and who administers IV injections to patients shall be
held liable, either criminally, administratively or both.

Objectives
This study aims to:
1. Find out whether the standards of intravenous insertion is followed
by health care providers beginning with the preparation of the
materials up to the securing in place of the intravenous line.

2. Discover possible barriers to the correct and proper adherence of

the health care provider to the standards of peripheral intravenous
therapy.
3. Specify the legal basis of allowing doctors and nurses to perform
peripheral intravenous injection.
4. Synthesize available studies that cover concerns on the safety of
intravenous insertions, including infection that occur due to nonaseptic practices.

Assumptions
1. Lack of knowledge of the provider puts the client at great risk.
2. Health care providers know how to perform aseptic hand washing
inside and outside health facilities.
3. Nurses and resident doctors are duly licensed by the Philippine
Regulatory Board (PRC).
4. Safety is the top priority.
5. Encourage patients awareness of the nursing practice.

6. Agency policies must be consistently monitored.

Significance of the Study

The ability to obtain intravenous (IV) access is an essential skill in

medicine and is performed in a variety of settings by paramedics, nurses
and physicians. Although the procedure can appear deceptively simple
when performed by an expert, it is in fact a difficult skill which requires
considerable practice to perfect.
Intravenous cannulation is undertaken in a high proportion of
hospitalized patients. Much attention has been given to the use of care
bundles to reduce the incidence of infection in these patients. However,
less attention has been given to the systems required to ensure
availability of the equipment needed to support these care bundles.

The researchers are interested in observing the compliance of

health care providers in a specific hospital and finding out the barriers
towards compliance. In compiling secondary sources from books,
journals and reliable internet sources, and in gathering primary sources

of knowledge through observation, the researchers hope to bring the

issue of IVT compliance to the forefront, and benefit the following groups:

For patients, their awareness and participation about nursing

practice is encouraged. Timely, efficient, patient-centered delivery of care
is critical to quality and patient satisfaction. The patients may learn from
this study the dangers of unsafe peripheral intravenous injection. Being
knowledgeable on how it should be done can help the patient voice out
observations and concerns to the nurse-in-charge or the hospital
administrators. Patient satisfaction can serve as an effective indicator to
measure the success of doctors and hospitals.

For the staff nurses, resident doctors and medical interns,

this research is significant for the enrichment of their knowledge on the
consequences

of

unsafe

peripheral

intravenous

insertions.

The

awareness of evidence-based studies on infections and other risks of

unsafe IV insertions may help the health practitioners in becoming more
compliant to the set of standards.

For the hospital administrators, this study may serve as an eye

opener to be more keen in observing if their health care providers are
conforming to the standards of peripheral intravenous insertion.

For the nurse educators, may benefit from this research through
enlightenment of the difference in theory and actual practice observed in
the hospital. The nurse educators may use this study as an example to
the nursing students and emphasize to them at an early stage to be
compliant of what their future nursing licenses demand from them.

Eligibility Criteria

The researchers would like to observe the compliance of nurses

and resident doctors to the standards of peripheral intravenous
insertions. By hospital practice, these health providers are usually the
ones who prepare the I.V. materials and perform the I.V. insertions in the
hospitals. The specific hospital wherein the researchers will be observing

health care providers do not allow medical clerks or undergraduates of

medicine to train in its facility.

Limitation of the Study

Since this is a term paper, the researchers will include a narrative

report of the observations in the hospital instead of statistical analysis.
In the interest of reporting an unfiltered observation of health care
providers

peripheral

IV

performance

without

compromising

the

reputation of the chosen hospital, the researchers wish to keep the name
of the hospital in confidence and will only be revealed to the term paper
adviser.

Catheter - a hollow flexible tube for insertion into a body cavity, duct, or
vessel to allow the passage of fluids or distend a passageway. Its uses
include the drainage of urine from the bladder through the urethra or
insertion through a blood vessel into the heart for diagnostic purposes.

Compliance - The degree of constancy and accuracy with which a

patient follows a prescribed regimen, as distinguished from adherence or
maintenance.

Health care provider - any individual, institution, or agency that

provides health services to health care consumers.
Intravenous cannulation - is a technique in which a cannula is placed
inside a vein to provide venous access. Venous access allows sampling of
blood as well as administration of fluids, medications, parenteral
nutrition, chemotherapy, and blood products.
Medical intern - an advanced student or graduate in medicine gaining
supervised practical experience.
Resident Doctors - is a person who has received the title of "physician"
or in some circumstances, another health sciences terminal degree who
practices medicine usually in a hospital or clinic.
Iatrogenic - of or relating to illness caused by medical examination or
treatment.
Iatrogenesis or Iatrogenic Effect - a Greek term, meaning "brought
forth by the healer", is any consequence of medical treatment or advice to

a patient. Some iatrogenic effects are clearly defined and easily

recognized, such as a complication following a surgical procedure (e.g.,
lymphedema as a result of breast cancer surgery).

Review of Related Literature

Air Bubbles of Death

As patients look warily at the small bubbles of air travelling down

the IV line and into the arm, the nurses and doctors administering
peripheral intravenous injection try to assure the patients that the small
bubbles of air are harmless. But how much of those little air bubbles are
actually dangerous?

Venous air embolism (VEA) is a complication that occurs when

atmospheric gas is introduced into the systemic venous system of a
person. This medical condition was mostly associated in the past with

neurological procedures that were performed while on sitting position.

More recently, venous air embolism has been associated with other
procedures such as central venous catheterization, thoracentesis,
penetrating

chest

trauma,

high

pressure

mechanical

ventilation,

hemodialysis, lumbar puncture and peripheral intravenous lines. VEA is

a predominantly iatrogenic complication wherein two preconditions must
exist for it to occur: 1) a direct communication between a source of air
and vasculature and 2) a pressure gradient favoring the passage of air
into ones circulation.

Large volumes of air rapidly entering the systemic venous

circulation places a substantial strain on the right ventricle (> 0.30
mL/kg/min). If there is a substantial increase in pulmonary artery
pressure this can lead to right ventricular outflow obstruction and
further compromise pulmonary venous return to the left side of the
heart. When the pulmonary venous return decreases, it will result to
decreased left ventricular preload, which in turn can decrease cardiac
output and eventual systemic cardiovascular collapse.

Although VAE is primarily caused by surgical procedures, it is

notable to mention that peripheral intravenous injection was also
mentioned as a risk factor.

Generally, the small packets of air are fragmented into small

particles in the capillary bed and are absorbed from the circulation
without producing undesirable signs. Complications have been recounted
with as little as twenty (20) ml of air the length of an unprimed IV
infusion tubing that was injected intravenously. As little as 0.5 mL of
air injected in the left anterior descending coronary artery may cause
ventricular fibrillation. Two to three (2-3) mL of air into the cerebral
circulation can cause fatality. In gist, the closer the vein of entrainment
is to the right side of the heart, the smaller the lethal volume is.

Symptoms in patients who are awake

Acute dyspnea

Continuous cough

"Gasp" reflex (a classic gasp at times reported when a bolus of air

enters the pulmonary circulation and causes acute hypoxemia)
Dizziness/lightheadedness/vertigo

Nausea

Substernal chest pain

Agitation/disorientation/sense of "impeding doom"

Signs
Cardiovascular

Dysrhythmias (tachyarrhythmias/bradycardias)

Hypotension

Myocardial ischemia

Nonspecific ST-segment and T-wave changes and/or evidence of

right heart strain

Pulmonary artery hypertension

Increased CVP

Circulatory shock/cardiovascular collapse

Pulmonary

Adventitious sounds (rales, wheezing)

Tachypnea

Hemoptysis

Cyanosis

Decreased end-tidal carbon dioxide, arterial oxygen saturation, and

tension

Hypercapnia

Increased pulmonary vascular resistance and airway pressures

Pulmonary edema

Apnea

Neurological

Acute altered mental status

Seizures

Transient/permanent

focal

deficits

(weakness,

paresthesias,

paralysis of extremities)

Loss of consciousness, collapse

Coma (secondary to cerebral edema)

Ophthalmologic

Funduscopic examination may reveal air bubbles in the retinal

vessels.

The above neurologic, hemodynamic, and pulmonary complications

primarily result from gas gaining entry into the systemic circulation,
occluding the microcirculation and resulting to ischemic damage to these
end organs. Animal studies have also suggested the presence of
secondary tissue damage cause by the release of inflammatory mediators
and oxygen free radicals as a response to air embolism.

When the health provider chooses to use glass or collapsible

intravenous containers

A small air bubble that gets into the blood circulation and is
stopped at the lungs very rarely produces symptoms. However, death may
occur if a large amount of air or gas becomes lodged in the heart,
stopping blood from flowing from the right ventricle and into to the lungs.
As little as 20 ml/sec of air may show symptoms and 70-150 ml/sec of
air can be fatal.

Plastic IV containers have mostly replaced the glass IV bottles

because of several advantages such as ease of using plastic bottles with
rapid infuser system, and safe and easy handling. Self-collapsible plastic
IV infusion bags are preferred though over the conventional plastic
containers for increased margin of safety when it comes to the danger of
inadvertent air embolism.

However, a report by ________________________ mentions a case

involving a near fatal air embolism through the central venous catheter
using a rapid infuser system and self collapsible plastic bag. Although
this case mentions central venous catheter, the danger of inadvertently

infusing air into a peripherally inserted IV site due to unreplaced empty

bottles may pose the same danger.

Theoretical Framework

Thinking about nursing is as important as doing nursing. The

conceptual structure of the discipline of nursing must be known by those
who practice nursing and those who teach nursing. Nurses in practice
must be able to identify the phenomena that are of concern, and must
have a framework for reflecting on their practice. Dorothea Orems
general theory of nursing, referred to as the Self-Care Deficit Nursing
Theory, provides starting point for the development of the nurses
understanding of the practice.

"Orem's model focuses on each individual's ability to perform self-care,

defined as 'the practice of activities that individuals initiate and perform
on their own behalf in maintaining life, health, and well-being.'" (Allison,
2007). The basic premise of the model is that individuals can take
responsibility for their health and the health of others. In a general

sense, individuals have the capacity to care for themselves or their

dependents.

The responsibilities of todays nurses are as demanding as they are

varied. Broadly, the nurses task is that of modifying interventions and
techniques in approved directions. Stated in another way, the nurse has
the basic responsibility of translating and implementing medical
objectives into functional and valuable learning experience for patients.

Florence

Nightingales

Environmental

Theory

advocates

two

essential behaviors by nurses. First area of assessment is to ask what is

needed or wanted, i.e. ask many questions to know the actual status of
the patient. Also warned against asking leading questions and advocated
asking precise questions. The second was the use of observation. She
used precise observations concerning all aspects of the clients physical
health and environment.
Conceptual Framework

Conceptual framework of Nightingales theory