SELF-LEARNING MODULE

PERIPHERAL INTRAVENOUS THERAPY (PIV) INITIATION AND

MAINTENANCE FOR NEWBORNS, CHILDREN, YOUTH, AND ADULTS
FOR RNs and LPNs

April 2015
Revised September 2015

TABLE OF CONTENTS
Purpose

Page 2

Objectives

Page 2

Related Policies

Page 2

Indications and Contraindications for PIV Therapy

Page 2

Osmolarity and pH of Intravenous Infusions and Medications

Page 2

The Basics: Anatomy and Physiology

Page 4

Veins

Page 5

Veins to Avoid

Page 8

Criteria to consider when choosing a PIV site

Page 8

Methods to improve venous distention

Page 9

Equipment required to initiate a PIV

Page 9

PIV Catheter Gauge Sizes

Page 10

Patient Education

Page 10

PIV Initiation Procedure

Page 11

Scalp IV Initiation Procedure (Advanced Competency)

Page 12

Local Complications of PIV Therapy

Page 13

Phlebitis Grading Scale

Page 15

Systemic Complications of IV Therapy

Page 15

References

Page 18

Appendix: Preparing Children and Adolescents for Medical Procedures

Page 20

Test Your Knowledge

Page 21

Test Answers

Page 23

Purpose
This self-learning module will assist in preparation for skill competence in insertion and
maintenance of peripheral intravenous (PIV) catheters for newborns, children, youth, and adults.
Objectives
After review of this learning package the nurse will:
1. Understand indications and contraindications for PIV therapy
2. Understand anatomy and physiology related to PIV initiation
3. Prevent and manage complications related to PIV therapy
4. Successfully initiate and maintain PIV therapy
Related Policies
RNs and LPNs will review the HHN Peripheral Intravenous Therapy (PIV) Policy
Indications for PIV Therapy:
Administration / Infusion of:
Fluids continuous or intermittent
Medication
Chemotherapy
Blood / blood products
Contraindications for PIV Therapy:
Insertion of a PIV catheter is an invasive procedure and as such, carries risk. As with most
treatments, there are situations where PIV access is not recommended.
Patient refusal
Patient with coagulation disorders
Treatment or medication ordered that may be safely and effectively given orally
Treatment or medication ordered that cannot be safely and effectively given peripherally
(i.e. must be given via central catheter)
Total Parenteral Nutrition (TPN) is NOT appropriate for peripheral infusion
Patients with compromised peripheral venous access
Osmolarity and pH of Intravenous Infusions and Medications:
Osmolarity is the osmotic pressure of a solution due to the concentration of solute per kilogram
of water. Think of it as the number of particles suspended in water. Osmolarity of IV solutions
that are significantly different from the osmolarity of blood may cause pain and phlebitis when
given into a peripheral vein. The more similar in osmolarity the solution is to blood, the easier it
is on the vein.

Osmolarity of solutions:
blood
hypotonic solutions
isotonic solutions
hypertonic solutions

280 - 295 mOsm/L

less than 250 mOsm/L
250 - 350 mOsm/L
greater than350 mOsm/L

Risk of damage to vessel:

Low Risk
Moderate Risk
High Risk

less than 450 mOsm/L

450 - 600 mOsm/L
greater than 600mOsm/L

Intravenous Solutions:
Low Osmolarity Solutions
D5W
Normal Saline
Normal Saline

Osmolarity:
260mOsm/L
308mOsm/L
154mOsm/L

High Osmolarity Solutions

D10W
D12.5W
D15W
D20W
D10 with balanced electrolytes
D10 + 2% amino acids
and balanced electrolytes

505 mOsm/L
625 mOsm/L
757 mOsm/L
1010mOsm/L
600 mOsm/L
800 mOsm/L

If the final osmolarity of a solution cannot be altered and if it is necessary for the osmolarity to
remain > 800 mOsm/L, central venous access is recommended.
Drug pH as related to IV Therapy:
pH level of a drug refers to the number of hydrogen ions present in a compound
The scale is 0 14 with 7 pH being neutral
Less than 7 - pH is acidic Greater than 7 - pH is alkaline
blood pH is 7.35 - 7.45
medications / fluids are classified as either acid or base
The pH of some of the commonly used drugs
Vancomycin
Gentamycin
Dilantin
Dopamine
Morphine
Ampicillin

pH 3.3
pH 2.4
pH 12.0
pH 2.5
pH 3.0 - 6.0
pH 8.0 - 10.0

The Basics: Anatomy and Physiology - Vascular System: Composed of both veins and
arteries
There are palpable differences between arteries and veins. Since they are frequently located
close together, nurses must familiarize themselves with the differences. Using the same 2
fingers and consistently palpating with every cannulation, palpation skills will become more
sensitive.

Arteries

Deep
Protected
Firm walls with 3 layers
Firm walls
More contractile
No valves
Arteriospasm painful
Pulsate
Atypical locations

Veins

Superficial
Less fixed
Walls have 3 thin layers
Collapse easily
Distend easily
Valve structures are present
Vasospasm less severe
No pulse

The veins of the hand and forearm are the preferred sites for initiation of PIV therapy in children,
youth, and adults.

Veins of the Hand

Veins of the Forearm

Upper Extremity Veins (Refer to diagram above):

Location
Digital Dorsal Veins

Dorsal Metacarpal
Veins

Basilic Vein

Cephalic Vein

Advantages
None
Used as last
resort & only used
if no other sites
available

Easily visible
Bones provide
support

Ulnar surface of forearm

(joins with median cubital
vein just below elbow)

Good size vein

Good position for
infusion of large
volumes &
irritating solutions

Not always easily

visible or located
Increased risk of
trauma due to
position on arm

Along radial surface of

forearm

Good size vein

Good position for
infusion of large
volumes and
irritating solutions
Easily secured &
generally easily
located

None

Large size
Away from areas
of flexion

Not always
visible
Insertion can be
more painful on
inner aspect of
forearm

Large size
Easily found by
palpation
Good use in
emergencies

Large vein
Often used for
blood sampling or
very large IV
catheters

Tip: To
differentiate
between scalp
veins and arteries,

Lateral portion of the

fingers

Outer aspects of hands

Median Antebrachial
Vein

Accessory Cephalic
Vein

Inner aspect of forearm

(below elbow)

Posterior aspect of
forearm

Median Cubital Vein

Scalp, temporal veins

Neonates &
infants
**Advanced

Disadvantages

In the antecubital fossa

(ACF)

See Diagram
Arteries are at
times superficial
on the scalp;

Small size
Difficult to secure
& stabilize
Finger may have
to be immobilized
Increased risk of
extravasation
Restricts use &
mobility of hands

Not always
visible
Over area of
flexion
May be close to
arteries
Over area of
flexion
Close to arteries
Should only be
used in
emergencies
Can only be used
in neonates and
infants
Must only be

Competency,
certification
required

however have a
palpable pulse
while veins have
no pulse
For neonates
requiring PIV
therapy for up to 6
days, the scalp
usually contains
veins that are
close to the
surfac3e and
more visible than
veins in the
extremities

remember that
arteries flow
upward toward the
scalp and veins
flow downward
toward the heart
and away from the
vertex
When using scalp
veins begin with
the vein closest to
the crown, saving
the distal veins for
later use
The hair must be
clipped back far
enough to reveal
the entire vein
Do not use sites
beyond the
hairline

Saphenous
Neonates and
infants

Inner aspect of lower leg

Easy to identify
and access. Site
usually lasts well if
properly
splinted/supported

Dorsal Venous Arch

Neonates and
infants

Superficial veins of the

foot

Easy to identify
and access in
neonates and
infants. Site
usually lasts well if
properly
splinted/supported

started by RNs
with advanced
training

Lower extremities
Veins of the lower extremities should not be used routinely in the adult population due to risk of
tissue damage, thrombophlebitis, embolism, and ulceration due to connection with deeper leg
veins. In the event that the PIV cannot be inserted in the upper extremities, notify the attending
physician. If ordered, the site should only be used for Short-term PIV therapy until a more
suitable site can be located or alternative venous access can be obtained (i.e. central venous
catheter).
Paediatric Considerations
Upper extremity sites are readily chosen for venous access in children. Sites in the feet are
used in infants and young children who have not mastered walking and can be considered in
older children when other sites are unavailable.

Site Selection

Vein Sites to AVOID:

Bruised, sclerosed or thrombosed veins

Areas with swelling, disease or skin breakdown
Areas below traumatized tissue
Red, swollen veins
Sites near a previously discontinued site
Areas below an existing phlebitis or infiltrated site
Limbs where vascular return may be compromised such as affected side of mastectomies, CVAs
or arterial venous grafts
Antecubital Fossa (ACF) or any area of flexion if possible. The two nerves most often injured
during a venipuncture are the radial and median nerves.
Inner aspect of arm and wrist insertion is more painful; increased risk of bruising, phlebitis and
infiltration

Criteria to consider when choosing a PIV site

Consider:
Location

Consider:
Condition

Consider:
Purpose

Proximity to joints IV catheters should not lie over a joint as the

movement from flexion can cause mechanical phlebitis, infiltration, or flow
rate difficulties
Age of the patient in elderly patients, the skin on the hand is thin and the
inadequacy of tissue makes the dorsal surface an unsuitable choice
Start low (distal) in the forearm the antecubital fossa (ACF) veins should
never be the first choice except in an emergency
If you cannot find a good vein in the forearm, the next area to assess is the
hand
Patient comfort and mobility inserting the PIV in the patients nondominant hand will maximize their independence and mobility
Upper extremity sites are readily chosen for venous access in children.
Sites in the feet are used in infants and young children who have not
mastered walking. Sites in the feet can be considered in older children
when other sites are unavailable
The condition of a vein is determined by visualization and palpation.
Palpate for the presence of a pulse a vein should not have one
Look for soft, spongy, full, straight, secure and unobstructed veins
Palpate along the vein for signs for trauma (vein will be hard, cord like &
lack resilience) as from IV drug use
Palpate for location of valves they feel like bumps along the vein
Palpate vein for side to side movement called rolling
When considering scalp veins, stroke the vessel with an antiseptic swab to
test the direction of blood flow in the vessel to determine whether it is an
artery or a vein.
The type of solution to be infused (and the flow rate)
Hyper-tonic solutions require large veins with adequate blood flow to dilute
the solution
Many medications can irritate the vein if not infused into a large vein
Blood product transfusion requires blood flow due to viscosity
Rapid infusions of fluids or blood require the largest vein possible

Consider:
Duration

Length of time the IV infusion may be required if it is anticipated it will be

for long term use then the initial and all following sites should be as distal
as possible
Remember to alternate arms to help preserve veins

Consider:
Cooperation &
Understanding of
the Patient

Patients with altered mental states and young children cannot always
understand the reason or importance of PIV therapy
Choosing sites that are easy to secure during initiation and that can be
safely secured after initiation while causing the least trauma to the patient
are best in children and adults this is often the mid-forearm

Methods to improve venous distention

Apply tourniquet ABOVE THE ANTECUBITAL FOSSA (ACF) and above intended insertion
site. Ensure the tourniquet is not applied for too long only apply prior to PIV insertion and
remove immediately after insertion completed.
Check for pulse after applying the tourniquet; if you are unable to palpate a radial pulse the
tourniquet is too tight. Alternatively, use a blood pressure cuff set to a level below 50 mmHg.
Place the extremity in a dependent position and stroke below the proposed site gently from
distal to proximal.
Apply warmth to the extremity for several minutes.
If available vein visualization devices improve success rates when attempting initiation in
patients with difficult or poor venous access.
Equipment for Initiating PIV Therapy

Tourniquet- check for latex allergies

Non-sterile gloves
2% chlorhexadine gluconate in 70% alcohol
Appropriate size needle or catheter (See table below)
Transparent dressing for securement of catheter
Primed IV administration set or an intermittent infusion device with extension set
Stabilization device (i.e. armboard) as required
IV pole and infusion pump as required
Tape to secure tubing
Labels for site, tubing and solution bags
Vein visualization device (optional)

Needle Device and Size

The purpose of the infusion, the condition and age of the patient, along with the size and
location of the veins are the most important factors in determining what size of device should be
inserted.
The Intravenous Nurses Society (INS) recommends that the smallest gauge needle that allows
for delivery of the required flow rate should be inserted.

PIV Catheter Gauge Sizes

Gauge (#)

Color
Code
(Catheter
Hub)

Purpose

14

Orange

Trauma, emergency situations

PICC and midline insertions

16

Grey

Trauma, emergency situations

Midline insertions
Phlebotomy

18

Green

Trauma, emergency situations

Pre-op, procedural
Phlebotomy
General PIV Therapy

20

Pink

** Most common **
Pre-op, procedural
General PIV Therapy
Blood transfusions

22

Blue

** Most common **
General PIV Therapy
Blood transfusions
Commonly used with infants and children

24
Short = 0.56 inch
Long = 0.75 inch

Yellow

General IV Therapy
Small veins and scalp IVs, commonly used in
neonates and children with small veins
** In adult populations: Not recommended for
long-term use
Usually only for patients with limited venous
access and fragile veins and skin

23, 25, 27
Short butterfly
needle

Scalp IVs only in special clinical circumstances

Patient Education

Inform patient of need for you to start a PIV and explain the reason for having the PIV
Explain the procedure for initiating the IV and that it can hurt during insertion but once
the needle is removed it is usually pain free
The patient must give you verbal consent to start a PIV the patient can refuse the
procedure at any time

Paediatric Considerations:
Peripheral IVs will be inserted in such a manner as to minimize stress and pain to the
patient/family (i.e. consultation with Child Life Specialists where available, use of distraction
techniques, pharmacological methods). Provision of adequate pain control will be provided

10

when possible (i.e. topical anesthetics, breastfeeding, skin to skin, local anesthetic, 24%
Sucrose oral solution).
Additional Pediatric Resources:
See Appendix (hyperlink) and view YouTube video Comfort Positioning for Medical
Procedures (Dell Medical Centre). Found at: Comfort Positioning for Medical Procedures
YouTube.
PIV Initiation Procedure:
1. Perform hand hygiene
2. Apply tourniquet or blood pressure cuff around arm above antecubital fossa 4 6 inches
(10-15 cm) above proposed insertion site
3. Palpate for a suitable vein (may need to use methods to improve venous distention). Avoid
lateral surface of wrist 4 5 inches (10-12.5 cm) because of potential for nerve damage.
4. Remove tourniquet once site is found
5. Clip hair if necessary (do not use razor to remove hair)
6. Perform hand hygiene
7. Apply clean gloves
8. Cleanse site using 2% chlorhexadine gluconate swab in 70% alcohol, using friction in a
horizontal plane with first swab, in a vertical plane with second swab, and in a circular
motion moving outward with third swab. Allow to dry completely.
9. Set up supplies
10. Reapply tourniquet 4 - 6 inches (10-15 cm) above prepared site
11. Check radial pulse (you should be able to palpate a pulse)
12. Stabilize vein by applying slight pressure with the thumb or forefinger just below the site
(using non-dominant hand)
13. With bevel up, enter the skin at a 20-30 degree angle and gently advance needle until blood
flashback is seen. Lower the angle of the needle until almost flush with the skin. Advance
catheter approximately inch into vein and loosen stylet of over-the-needle catheter after
blood return
14. Gently slide the plastic catheter off the needle and up into the vein until the hub is flush with
the puncture site
15. Release tourniquet
16. Apply pressure above catheter site and occlude blood backflow as you remove the needle
from the catheter. Dispose of sharps in the sharps container.
17. Once the needle is removed, attach to an IV line or an intermittent infusion device to lock
18. Cover the site with a transparent dressing and label with the date of insertion. Failure to
allow drying prior to application can cause chemical burn.
19. Document the procedure including date; time; catheter size; location; good blood return and
flushed without resistance; whether locked or attached to IV infusion; appearance of the site;
pain reduction strategies used; and, how the patient tolerated the procedure
http://www.youtube.com/watch?v=EC-h3F_6jFk (New England Journal of Medicine)

11

Pediatric Considerations:
For children, you may need a second person to assist with securely holding the child.
Some patients require an IV support (armboard) to stabilize the intravenous and decrease the
risk of dislodgement:

Use an armboard only if necessary, such as when IVs are started in the hand,
antecubital area, feet or ankle area
Generally armboards are not needed for IVs above the wrists that do not involve the
antecubital area
The armboard only needs to be large enough to secure the area around the joint
adjacent to the intravenous. For example, restrain the wrist joint (as opposed to the wrist
and antecubital area) when using hand veins
Secure the limb in a natural anatomic position
Leave the thumb free to avoid the dangers of contractures
Leave some fingers or toes visible to assess circulation
Asses IV site with direct observation and palpation every hour
Assess/inspect the armboard at least once per 12 hour shift. Reapply the armboard as
required

Scalp IV Initiation Procedure: All Scalp IVs are advanced competencies for RNs and
require certification
1. Immobilize the infant
2. Hold the infants/newborns head with both hands towards the inserter. The head is supported
to prevent extreme flexion or extension of the neck. The helpers fingers fan out over the scalp
so that the index fingers or thumbs are situated on either side of the proposed IV site with
moderate lateral tension
3. The inserter uses the thumb and forefinger of the non-dominant hand to stretch the skin taut
and stabilize the vein. Needle must be placed in the direction of blood flow (downwards, toward
the heart and away from the vertex)
4. Line up the needle directly with the vein and, using a 10-30 degree angle with bevel up; insert
the needle exactly where you want to enter the vein
5. Once the needle is through the skin, lower the angle of the needle and advance the needle
slowly
6. In special clinical circumstances where a winged-device is used: on entering the vein there
may be blood return into the tubing of the needle
7. If there is no blood return and you think you are in the vein, attempt to draw back gently on
the saline syringe attached
8. Once blood return has been observed, lower the angle of the needle and advance the
catheter slightly into the vein
9. Slide the catheter forward into the vein while keeping the stylet stable
10. Before attaching the intravenous tubing, attempt to flush the vein with the attached saline
syringe
11. The saline should infuse easily and there should be no blanching, redness or edema. If any
of these signs are noted, the needle is not in the vein and should be removed.

12

Local Complications of PIV Therapy

Symptom

Prevention

Intervention

Infiltration: the escape of solutions into the extra vascular tissue

Swelling
Pain, tenderness,
discomfort
Feeling of skin tightness
Cool skin temperature
Fluid leakage from
insertion site

Ensure stabilization of
catheter with appropriate
dressing
Assess IV site & flow
rate regularly
Arm board to minimize
movement of catheter

Discontinue IV
Elevate extremity
Apply warm compresses
for isotonic solutions with
normal pH; cold
compresses for
hypertonic or elevated
pH solutions (i.e. K+)

Phlebitis: inflammation of the vein, caused by mechanical and/or chemical injury

Redness
Tenderness, pain
Edema
Venous cording
(hardening)

Anchor IV catheter to
prevent motion
Promote limited physical
use of extremity
Do not leave IV catheter
in longer than 96 hours

Discontinue IV
Apply warm moist
compresses to aid
healing and provide
comfort
See Phlebitis Grading
Scale

Thrombophlebitis: inflammation caused by clot formation

Site is sore, hard,

cordlike and warm
Red line above site
Edema
Sluggish or stopped IV

Anchor IV catheter to
prevent motion
Do not leave IV catheter
in longer than 96 hours

Discontinue IV
Initially apply cold
compresses, then warm
compresses
Caution patient against
rubbing or massaging
area, which could cause
the release of an
embolus

Local Infection: caused by pathogenic organisms

Redness & Swelling

Tenderness at insertion
site
Cellulitis
Purulent drainage

Aseptic technique on
insertion
Maintain clean, dry,
adherent dressing
Change bags every 24
hours
Change tubing every 96
hours
Change site every 96
hours
Avoid frequent opening
of line

Remove IV catheter
Warm compresses to
site
If site not allowed to
dry prior to application
of occlusive dressing a
chemical burn can
occur

13

Hematoma: A Collection of blood in the tissue caused by laceration of the vein wall by the IV catheter or
by an unsuccessful attempt at venipuncture. Can also occur if inadequate pressure is applied when
catheter is discontinued.
For unsuccessful IV
Remove the IV
attempts apply firm
immediately and apply
Swelling and discomfort
pressure to insertion site.
pressure until bleeding
at the site
It is recommended to
stops. Reinsert IV in
Raised area of
avoid applying a
opposite limb if possible.
discolored or bruised
tourniquet to the same
Elevate the affected limb
skin
limb.
as appropriate.
Occasional bleeding at
Be aware of patients
Apply cold compresses
the site
taking anti-coagulants.
Extravasation: Unintended discharge or leakage of a vesicant solution or medication into surrounding
tissues as a result of cannula dislodgement or infiltration
Do not remove PIV
Secure IV site to
until site is assessed
minimize catheter
by physician as
movement
medication for tissue
Assess the PIV site
damage may be
every hour for
administered through
mechanical,
the PIV device.
pharmacologic,
obstructive, and
inflammatory factors
(Including: observation
Swelling, blanching, &
and palpation).
bleb formation
Observe the site closely
Stretched firm &/or cool
when infusing any
skin
medication that has the
Can progress to form
potential to cause a burn
blisters with subsequent
or necrosis. If the
sloughing/ necrosis of
infiltration involves a
tissues depending on the
medication that may
type of fluid infiltrated,
cause severe tissue
(e.g.: solutions
damage (e.g.:
containing KCL).
chemotherapy) a
physician should be
notified ASAP.
Early recognition of
extravasation is critical to
limit the amount of fluid
that escapes into the
subcutaneous tissue and
potential subsequent
tissue injury.

14

Phlebitis Grading Scale:

Phlebitis Grading Scale
Severity (Grade)

Assessment Findings

Erythema / edema at site

Erythema / edema at site

Pain at site

Erythema / edema at site

Pain at site
Streak formation
Palpable venous cord

Erythema / edema at site

Pain at site
Streak formation
Palpable venous cord > 1 inch (2.5 cm) in length
Purulent drainage

Systemic Complications of PIV Therapy:

Symptom

Prevention

Intervention

Septicemia: systematic infection caused by pathogenic microorganisms or their toxins in the bloodstream

Aseptic technique on
insertion
Maintain clean, dry,
Remove IV catheter
adherent dressing
Warm compresses to
Change bags every 24
Fever, chills
site
hours
Altered mental status
If site not allowed to dry
Change tubing every 96
prior to application of
diaphoresis
hours
occlusive dressing a
Change site every 96
chemical burn can occur
hours
Avoid frequent opening
of line
Pulmonary/Air Emboli: mass carried via venous system to heart & eventually occluding a pulmonary
vessel
Dyspnea, sub sternal
Avoid veins in lower
pain
extremities
Unexplained cough,

Use filters when

hemoptysis
appropriate (blood, TPN,
Lightheadedness
Place patient in semietc.)
Hypotension
fowlers position
Expel air from tubing
Nausea
Administer Oxygen
Never irrigate/flush the
(100%)
Tachycardia, tachypnea
catheter if the IV is not

Monitor vital signs

Cyanosis
flowing
Notify physician
Weak, rapid pulse
Inspect medication and
Altered metal status,
solution containers for
altered speech,
particulate matter prior to
Numbness and paralysis
use
Syncope or loss of

15

consciousness
Shock or cardiac arrest

Circulatory Overload: the presence of more fluid than the circulatory system can manage

Increased pulse, cough,

increasing SOB
Hypertension

Monitor fluid balance

Careful monitoring of IV
flow rate to avoid bolus

Decrease IV rate 30cc

per hour
Assess vital signs
Notify physician

Pulmonary Edema: An increase in venous pressure with increased pressure in the right ventricle,
pulmonary artery and subsequent fluid in the alveoli.
EARLY Signs:
Place patient in high
Restlessness slow
Maintain prescribed flow
fowlers position
increase in pulse rate
rate with regular patient
Slow the IV to keep vein
assessment
Headache
open
Use volumetric infusion
Shortness of breath
Notify the physician
pump for patients
Non-productive cough
Administer medications
whenever possible to
as requested by
Skin flushing
avoid accidental fluid
physician
LATE Signs:
overload
Monitor vital signs
Hypertension
Administer high-flow
Severe dyspnea with
Oxygen
coarse crackles
Engorged neck veins
Pitting edema
Pink, frothy sputum
Puffy eyelids
Shock, respiratory or
cardiac arrest

16

Inadvertent Arterial Cannulation: Potential damage to tissues, ischemia related to the unintended
insertion of a PIV device into an artery.
EARLY signs:
Discomfort and pain
distal to the site of
injection/infusion
Failure of medications to
have the expected effect
LATE Signs:
Pallor, paraesthesia,
hyperaemia, and
cyanosis of the affected
limb develop and severe
cases may progress and
develop profound edema
and gangrene
Avoid insertion sites
such as: antecubital
fossa and groin because
of the proximity of
arteries and veins in
these sites. The forearm
and hand can also be at
risk, as sometimes can
involve the presence of
radial artery branches.

Upon insertion of the PIV watch

for warning signs:
blood cannula flashback
appears pulsatile;
flashback blood appears
redder than expected;
ability to palpate a pulse
proximal to the PIV
cannula; and
PIV insertion is more
painful than expected.

Note: If there is doubt as to the

placement of the PIV, remove the
device.

Notify the physician

Slow the IV to keep vein
open
Elevate the affected limb
to improve venous and
lymphatic drainage.
Administer medications
as requested by
physician (i.e. analgesia
etc)

17

References
AccuVein Evidence. Retrieved from: http://www.accuvein.com
Chukhreu, A. & Grekov, I. (2000). Local complications of nursing interventions on peripheral
veins. Journal of Intravenous Nursing, 23(3), 167-169.
Clinical and Laboratory Standards Institute (2007).Procedures for the collection of diagnostic
blood specimens by venipuncture: Approved Standard- 6th edition. 27(26). ISSN 02733099.
Ernst, D. (1995). Flawless phlebotomy: Becoming a great collector. Nursing, 25 (10), 54-57.
Fraser Health online peripheral intravenous initiation module. Retrieved from:
http://www.fraserhealth.ca/media/peripheralintravenousinitiationmodule.pdf.
Horizon Laboratory Medicine Manual (2012).
Infusion Nurses Society (2011). Infusion nursing standards of practice. Journal of Infusion
Nursing, 34(1S).
Insertion and Maintenance of Peripheral Intravenous Devices for Newborns, Children, Youth,
and Adults Self -Directed Learning Package. IWK Health Centre. Halifax NS. Oct 28,
2014.
Millam, D., and Hadaway, L. (2000). On the Road to Successful IV Starts. Nursing 30(4), 34-50.
Perry, A. and Potter, P. (2010). Clinical nursing skills and techniques. St. Louis: Mosby.
Phlebotomy Central website. Retrieved from:
http//phlebotomy.com/Merchant2/merchant.mvc?screen-subr
Providence Health Care. Peripheral IV Therapy Peripheral IV Catheter Insertion SelfDirected Learning and Information Package. 2007.
Saint John Zone Vascular Support Manual, retrieved from:
http://skyline/PoliciesProcedures/Pages/Saint-John-Area-Policies-andProcedures.aspx?RootFolder=%2FPoliciesProcedures%2FSaint%20John%20Policies%

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Weinstein, S. (ed) 2001. Plumers Principles &Practice of Intravenous Therapy, Lippincott 7th
Edition.

19

Appendix: Preparing Children and Adolescents for Medical Procedures

Three common elements underlie effective preparation and result in improved psychosocial
outcomes:
1) The provision of developmentally appropriate information
2) The encouragement of emotional expression
3) The formation of a trusting relationship with a health professional
The provision of developmentally appropriate information
Includes providing accurate medical information using clear and accurate
language
Includes what will happen and why it will happen, based on the childs age and
developmental level.
Includes sensations that the child can expect to experience, such as the sights,
sounds, smells and feelings.
Includes potential coping techniques, such as visual and auditory distraction,
tactile stimulation, counting and singing, and verbal interaction.
Opportunities for emotional expression
Anticipate potential stressors and misconceptions and address fears by
encouraging children to ask questions and express feelings about the procedure
Children who ask questions and express concerns are known to be less
distressed and spend significantly less time seeking information during
procedures
Establishing Trust with members of the pediatric health care team
Use rapport-building strategies such as asking the child questions about topics such as age,
grade in school, pets, and number of siblings.

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Test Your Knowledge

1.

List 3 situations where PIV access is not recommended.

1.
2.
3.

2.

List 3 differences between arteries and veins.

1.
2._____________________________________________________________________
3._____________________________________________________________________

3.

List 4 veins that are acceptable (preferred sites for initiation) of PIV therapy.
1.
2.
3.
4.

4.

Veins of the lower extremities should not be used routinely in the adult population
a. True
b. False

5.

Vein sites to avoid.

a. areas with swelling, disease or skin breakdown
b. bruised, sclerosed or thrombosed veins
c. sites near previously discontinued site
d. inner aspect of arm and wrist
1. a and b
2. a and c

6.

3. a and d
4. a, b, c, and d

List 3 methods to improve venous distention.

1.
2._____________________________________________________________________
3._____________________________________________________________________

7.

How many attempts should a single nurse make to initiate PIV therapy?
a. 1
b. 2
c. 5
d. 10

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8.

Peripheral IV sites should be changed every:

a. 24 hours
b. 48 hours
c. 96 hours
d. 72 hours

9.

IV tubing and extension sets for continuous infusions must be changed every:
a. 24 hours
b. 48 hours
c. 96 hours
d. 72 hours

10.

In an emergency situation, an RN/LPN may initiate an IV infusion of normal saline at:

a. 10mL per hour
b. 30mL per hour
c. 15mL per hour
d. 60mL per hour

11.

Signs of infection at the insertion site include:

a. redness at site
b. pain at site or along vein
c. purulent drainage
d. warmth at site or along vein / arm
e. all of the above

12.

Documentation of peripheral IV starts includes:

a. date and time
b. location of insertion site
c. size of IV catheter
d. # of attempts
e. all of the above

13.

Describe the education that should be provided to a patient before initiating a peripheral
IV
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
________________________

14.

Osmolarity of IV solutions given into a peripheral vein that is significantly different from
the _______________ may cause pain and phlebitis.

15.

The more __________ the solution, the easier it is on the vein.

16.

The directional flow of a scalp vein is almost always away from the vertex of the skull
a. True
b. False

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Test Answers
1. patient refusal; patient with coagulation disorders; treatment or medication may be safely
given orally; treatment or medication cannot be safely and effectively given peripherally;
TPN; patient has compromised peripheral venous access
2. a. arteries pulsate and veins have no pulse
b. arteries are very deep and veins are superficial
c. arteries have firm walls and veins collapse easily
d. arteries are well protected and veins are less fixed
3.

a. metacarpal
b. cephalic
c. basilica
d. median antebrachial

4. True
5. 4. a, b, c, and d
6. a. tourniquet, BP cuff
b. hang arm dependent
c. light tapping
d. warm moist compress (10-15 minutes)
7. b. 2 attempts
8. c. 96 hours
9. c. 96 hours
10. b. 30mL per hour
11. e. all of the above
12. e. all of the above
13. Inform patient of need to start an IV and the reason. Explain the procedure and
that it can hurt during insertion but once the needle is removed it is usually pain
free.
14. Osmolarity of blood may cause pain and phlebitis
15. Isotonic
16. True

23

Appendix A
Peripheral Intravenous Therapy - Saline Lock Procedural Reference Tool
Flushing a Saline Lock:
1.
2.
3.
4.
5.
6.
7.
8.

Gather supplies
Perform hand hygiene
Identify patient and introduce self to patient
Explain procedure, obtain verbal consent & position patient appropriately
Assess insertion site for swelling, redness, pain, and temperature
Set up supplies (use prefilled syringe of 0.9% NaCl)
Apply clean gloves
If disconnecting a running IV line, detach IV line from the needless injection cap and
place a sterile cap on the end of tubing
9. Cleanse the needleless injection cap with 2% Chlorahexadine Gluconate & 70%
Isopropyl Alcohol for a minimum of 30 seconds and allow to air dry for 2 minutes
10. Connect the syringe to the needless injection cap
Gently inject 3 mL saline using a turbulent flush technique. If resistance met, stop.
Ensure that clamps are open and reassess site
Monitor insertion site during instillation of saline to ensure fluid is not interstitial
11. Remove syringe and perform hand hygiene
12. Document

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