IV Therapy: Going Into Battle (Installing IVs)

Assemble The Troops

In addition to the IV catheter, you will also need a tourniquet or a blood-pressure cuff, an antimicrobial wipe, several small gauze pads, tape, a transparent dressing, and gloves. These are commonly supplied in commercially available “IV start kits.”  If your facility does not use these kits, gather all these supplies before initiating IV access.  Also consider that there may be slight variations on the style of the supplies packaged in the kits.  Familiarize yourself with the supplies packaged in the kit, especially when a new order arrives, or if there is a change in vendor.

If your patient will receive a continuous infusion, you’ll also need the bag or bottle of prescribed fluid to be infused and tubing to deliver said fluid (an infusion set).  In many situations, a pharmacist will add any prescribed medications, vitamins, or electrolytes to the IV fluid.  However, if you are adding any of these, be sure to put a label on the bag indicating what you added and the amount, date, and time, plus your initials or signature and any other information your facility’s policy requires.  You must not write on the bag directly.  Writing instruments can puncture the bag and ink may migrate into the solution.

Also place a piece of time tape on the bag to help you monitor the flow rate.  This provides an easy reference for determining the accuracy of the flow rate.  If the fluid is infusing too slowly or too quickly, you can adjust the roller clamp or pump rate.  A time tape may also help you detect a problem with the patency of the IV line early on.  

Before starting the infusion, spike the bag of fluid and allow the fluid to run to the end of the tubing.  This removes all air from the tubing and avoids infusing that air into the patient.  Although nitrogen dissolves fairly easily into blood, too much air may cause a gas embolus to form in the right atrium and may block the flow of blood through the heart.  If you will be using a secondary tubing, fill the tubing backward, from the connecting end to the drip chamber before inserting the plastic spike into the medication bag.  This ensures that none of the medication in the secondary bag is wasted or lost during the priming process.

Adding an extension tubing to the end of the infusion tubing may prove to be helpful later.  For an ambulatory patient, the IV may be temporarily disconnected at the extension set, and locked, to allow him / her to use a toilet or shower.  Once done, the primary tubing may be reconnected to the extension set and infusion can continue.  Hang the bag on an IV pole about 36 inches above the IV site for optimal flow.

If your patient will not have a continuous infusion, you may be ordered to initiate a saline lock, also known as a heparin lock. A saline lock consists of an IV catheter and a short piece of extension tubing that is filled with saline.  Since fluids are not continuously infused through a saline lock, flush 5 to 10 mL of saline through the lock before and after administering medications or at a regular interval.  This maintains the patency of the lock, and ensures the medication administered is pushed into the vein.  Specific procedures for flushing a saline lock vary with the facility, so be sure to familiarize yourself with your facility’s policy.

You must clean the site before initiating IV access, otherwise you will push bacteria and other foreign bodies into the bloodstream. The most common cleaning agents are alcohol, chlorhexidine, and povidone-iodine.  Usually, you will use whatever happens to be in the “start kit”.  Apply the agent in concentric circles outward from the point of intended venipuncture.  This mobilizes and transports the materials you are removing away from the IV site.  Rubbing the site back and forth may mobilize the materials, but does not transport them away from the site of venipuncture.

Be sure to allow the cleaning agent to air-dry completely, before sticking the patient, to effectively reduce the microbial count and reduce the sensation of “burning”.  This will take 30 seconds for chlorhexidine, 60 seconds for alcohol and a full minute for povidone-iodine.  Be patient; do not wave your hand over the site or blow on it to speed up drying.  This will defeat your purpose of using a cleaning agent.  After the site is dry, avoid touching it with your finger as micro-organisms from your glove will transfer to the once clean area.  If you touch the site after you clean it, clean it again.  If you are using a combination of agents use the alcohol first because the antiseptic effect of alcohol does not last as long as povidone-iodine.  Allow the alcohol to dry completely before applying the povidone-iodine because alcohol negates the povidone-iodine’s antimicrobial effect.  Do not wipe the povidone-iodine away with alcohol because alcohol does not provide a long-lasting antiseptic effect like povidone-iodine does.

Initiating IV therapy can be uncomfortable for the patient, and may provoke a sense of anxiety.  To reduce anxiety, be sure to explain the procedure to the patient, in a calm, non-menacing voice to gain trust.  Talk to your patient throughout the process and be sure not to poke him/her without fair warning, as this will degrade any trust you built in an instant.  Try “counting to three” to ensure the patient is aware of when the stick will happen.  

To help make the procedure more tolerable, consider numbing the IV insertion site with a local anesthetic, such as lidocaine 1%.  Before numbing the IV site, make sure that your patient is not allergic to local anesthetics.  Use a 25- or 26-gauge ⅝-inch needle to inject 0.1 to 0.2 mL of the anesthetic intradermally.  Use just enough to produce a wheal, being cautious to to inject the local anesthetic on the side of the vein, not into the vein.   Note that this method requires additional needle sticks, and may not accomplish the goal of pain and anxiety reduction.  You may need to rely on your judgement.  Lidocaine usually takes effect within 10 seconds or so.  

Consider asking for help with temporary manual or mechanical restraints for patients who are unable to remain still during the procedure, or whom you feel may flail wildly.  Remember, your safety comes first.

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