Peripheral IV Insertion and Care; Catheter Insertion Preparation

In 2011 the INS, Infusion Nurse Society released their latest “Infusion Nursing Standards of Practice.”

Many changes in recommendations of how we care for infusion patients were made in this publication.  Remember it is the INS standards that the nursing profession will be held accountable to in a court of law; therefore it is imperative that we are familiar with and follow these standards. We will begin a blog series to review the current standards of infusion therapy to keep you current and knowledgeable in your practices of infusion therapy.

Previously we reviewed the criteria of catheter selection in Peripheral IV Insertion and Care; Catheter Selection.

Let’s review the latest recommendations for peripheral IV therapy in adults as it relates to the peripheral insertion site preparation.

Patient Education

Prior to the insertion of any device or performing any procedure, we as nurses are responsible for educating the patient, family, and potential caregivers. They should understand why the catheter is necessary, plan of treatment, length of treatment, potential adverse reactions, and complications. The patient and caregivers should also be familiar with the care and maintenance of the device and the signs and symptoms of complications. The patient should be able to verbalize the signs and symptoms of complications and what should be immediately reported to healthcare providers. Patient education is necessary for informed consent and is a critical step for the safety of the patient during infusion therapies.

Assessment

A careful and thorough visual assessment of your patient’s potential insertion sites is probably one of the most important steps in peripheral IV insertions. Take your time, inspect both upper extremities and remember to not only use your sense of sight, but your sense of feel as well. Many veins are not readily visible, but can easily be palpated and make great candidates for peripheral IV insertion. All healthcare personnel that have the responsibility of peripheral IV insertions should practice venous palpation without the use of their sense of sight. I personally have practiced for hours palpating veins with my eyes closed. Most family members were willing to let me practice palpation, though very few were permissive of letting me practice actual insertions! All of your previous anatomy and physiology lessons should come in to play in infusion practices. If the vessel is pulsating, what does that mean?  It is an artery- don’t go there! If the vessel is in the area of known nerves, what should you do? Consider using what is called landmarking techniques to avoid nerves. If the vessel is an area that the patient flexes such as the wrist or antecubital area, is this really a suitable area to insert the catheter for the need of the therapy ordered? In most cases these are not suitable choices. If the patient uses ambulatory aides such as a cane, walker or wheelchair; is a vein on the hand a good choice for them? No; the frequent movement of the hand with the use of these ambulatory aids makes the veins of the hand an unsuitable choice. Remember placing a catheter in an area of flexion such as the antecubital fossa is not recommended. Movement of the catheter with flexion disturbs the catheter and causes venous irritation leading to potential thrombosis. It is also important to remember that should an insertion be attempted and unsuccessful in the antecubital area, all vessels below this sight have now been eliminated as a potential site.

Vein Distention

I now cringe at many of the practices of infusion therapy that were once employed in my early nursing career, yes about 28 years ago. Many a “seasoned” nurse will remember hanging on to their “lucky” tourniquet. The re-use of a tourniquet is now an unacceptable practice, for the obvious reasons of infection control. We now live in a day and age of the super bugs, VRE, and MRSA that many patients are carriers of, to re-use a tourniquet presents obvious breaches in infection prevention. Tourniquets are meant to be used on one patient and then thrown away! Some other vein distention methods that may be tried is gravity, opening and closing the fist, lightly stoking the vein downward. Thank goodness gone are the days of “slapping” a vessel to distend it. You have ditched that method haven’t you? My favorite “trick” is warmth or heat. Since most of my peripheral IV insertions were performed on the chronically ill, chemotherapy recipients, and the elderly, the application of dry heat was always a part of my IV insertion prep routine. Studies have shown that dry heat is the preferred application of warmth. There are several companies that make chemically activated dry heat packs. Depending upon the setting in which you practice many nurses may have access to warm blankets or towels from the warming cabinet. A warm patient and warm extremity always makes peripheral IV insertions easier.

Site Prep and Cleansing of the Skin

If the skin is visibly soiled wash it thoroughly with soap and water. Another age old practice that is no longer accepted is razor shaving of hair from a patient’s skin before IV insertion. We now understand that this practice leaves microscopic abrasions on the skin. Remember skin is our first barrier to infection, so to break this line defense is not a good idea and promotes infection. The acceptable methods now for removing hair are single patient use scissors or disposable head electric shavers.

There are several accepted antiseptics for disinfecting the skin with the old stand by of povidine iodine. This product should be applied to the site using a concentric pattern starting from the intended insertion site and working outward. It is of utmost importance to let this product dry before attempting the IV catheter insertion. It is the drying of this product that actually kills the bacteria. The second and preferred antiseptic of choice is alcohol and chlorhexidine solutions. This product usually comes packaged in some sort of applicator and is intended to disinfect the skin using a scrub. A 30 second back and forth scrub, then allow the solution to dry for at least 30 seconds is the usual manufacturers recommendation.

The gloves that accompany most IV insertion kits are clean gloves and not sterile. Remember once the skin is prepped, the site should not be touched again with a gloved or non-gloved hand, or the site will need to be cleansed again.

So now you have your patient all prepped and ready- take a deep breath, put on your “air of confidence”, go ahead say a little prayer- and get ready to stick ‘em.

Capra Dalton, Registered Nurse, has more than 28 years of experience in infusion therapy and the instruction of licensed nurses in infusion therapy continuing education. Her experience comes from multiple infusion settings: acute care, ambulatory infusion centers, home infusion, long term care continuing education provider, and long term care pharmacy quality assurance consultant. As the CEO, Capra is responsible for all operational aspects of Pedagogy, including education course content, author recruitment, and management. She is a member of the National Nurses in Business Association and received her nursing education from Lamar University in Beaumont, Texas. Capra has an avid interest in holistic healing, nutrition, herbs, and alternative therapies for the treatment of disease in humans as well as animals. She and her husband, Patrick, live on a ranch near Tyler, Texas.