Priority Nursing Actions

  PRIORITY NURSING ACTIONS
  Actions for Inserting a Peripheral Intravenous Line
Refer to Section VI, Initiation and Administration of IV Solutions, for additional preprocedure and postprocedure interventions.
1. Check the health care provider’s (HCP’s) prescription, determine the type and size of infusion device, and prepare
intravenous (IV) tubing and solution; prime IV tubing to remove air from the system; explain procedure to the client.

2. Select the vein for insertion; apply tourniquet and palpate the vein for resilience (see Fig. 14-4).
3. Clean the skin with an antimicrobial solution, using an inner to outer circular motion, or as specified by the
Centers for Disease Control and Prevention (CDC) guidelines and agency policy.
4. Stabilize the vein below the insertion site and puncture the skin and vein, observing for blood in the flashback
chamber; when observed, advance the catheter into the vein (if unsuccessful, a new sterile device is used for the next attempt at insertion).

 

5. Apply pressure above the insertion site with the middle finger of the nondominant hand and retract the stylet from the
catheter; connect the end of the IV tubing to the catheter tubing, secure it, and begin IV flow.
6. Tape and secure insertion site with a dressing as specified by agency procedure; label the tubing, dressing, and solution bags clearly, indicating the date and time.
7. Document the specifics about the procedure such as number of attempts at insertion; the insertion site, type and size of
device, solution and flow rate, and time; and the client’s response. In addition, follow agency procedure for documentation of procedure.
The nurse checks the HCP’s prescription for the IV line and then determines the type and size of
infusion device. The type and size are important to ensure adequate flow of the
prescribed solution. For example, if a blood product is prescribed, then the
nurse would need to insert an appropriate catheter gauge size for blood
delivery. The nurse also considers the client’s size, age, mobility, and other
factors in selecting the type and size of the infusion device. The nurse
prepares the appropriate IV tubing and primes the IV tubing to remove air from
the system. The appropriate vein is selected, the tourniquet is applied, and
the vein is checked and palpated for resilience. Strict surgical asepsis is
employed and the skin is cleaned with an antimicrobial solution (as specified
by the agency policy), using an inner to outer circular motion. The vein is
stabilized to prevent its movement and the skin is punctured. Blood in the
flashback chamber indicates that the device is in the vein and when noted the
catheter is carefully advanced to avoid puncture of the back wall of the vein.
The stylet is removed from the catheter device, the IV tubing is connected, and
the IV flow is started. The nurse tapes and secures the site and labels the
tubing, dressing, and solution bag appropriately and according to agency
policy. The nurse checks the site and ensures that the solution is flowing.
Finally, the nurse documents the specifics about the procedure.
M. See Priority Nursing Actions for instructions on removing an IV.
  PRIORITY NURSING ACTIONS
  Actions for Removing a Peripheral Intravenous Line
1. Check the health care provider’s (HCP’s) prescription and explain the procedure to the client; ask the client to hold
the extremity still during cannula/needle removal.
2. Turn off the intravenous (IV) tubing clamp and remove the dressing and tape covering the site, while stabilizing the
catheter.
3. Apply light pressure with sterile gauze or other material as specified by agency procedure over the site and withdraw the
catheter using a slow, steady movement, keeping the hub parallel to the skin.
4. Apply pressure for 2 to 3 minutes, using dry sterile gauze (apply pressure for a longer period of time if the client has
a bleeding disorder or is taking anticoagulant medication).
5. Inspect the site for redness, drainage, or swelling; check the catheter for intactness.
6. Document the procedure and the client’s response.
The nurse checks for a HCP’s prescription to remove the IV line and then explains the procedure to the
client. The nurse asks the client to hold the extremity still during removal.
The IV tubing clamp is placed in the off position and the dressing and
tape is removed. The nurse is careful to stabilize the catheter so that it is
not pulled, resulting in vein trauma. Light pressure is applied over the site
to stabilize the catheter and it is removed using a slow, steady movement,
keeping the hub parallel to the skin. Pressure is applied until hemostasis
occurs. The site is inspected for redness, drainage, or swelling and the
catheter is checked for intactness to ensure that no part of it has broken off.
Finally, the nurse documents the procedure and the client’s response.
Reference
Perry A, Potter P, Elkin M: Nursing
interventions and clinical skills
, ed 5, St. Louis, 2012, Mosby, p. 678.
VII. Precautions for IV
Lines
A. On insertion, an IV line can cause initial pain and discomfort for the client.
B. An IV puncture provides a route of entry for microorganisms into the body.
C. Medications administered by the IV route enter the blood immediately, and any adverse reactions or allergic
responses can occur immediately.
D. Fluid (circulatory) overload or electrolyte imbalances can occur from excessive or too rapid infusion of IV
fluids.
E. Incompatibilities between certain solutions and medications can occur.

 

A client with heart failure usually is not given a solution
containing saline because this type of fluid promotes the retention of water
and would therefore exacerbate heart failure by increasing the fluid overload.

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