This article discusses intravenous (IV) therapy, including how to insert an IV and best practices for IV care and medication administration. We'll also cover central venous catheters (CVCs) — what they are and how to use them.
This series follows along with our Pharmacology Basics and Safe Medication Administration Flashcards for Nursing Students which are intended to help RN and PN nursing students build a strong foundation going into Pharmacology and as preparation for the ATI, HESI, and NCLEX.
Pharmacology - Nursing Flashcards
What is a catheter?
When you hear the term catheter, you might automatically think urinary catheter, but the medical definition of catheter is a tube for insertion into canals, vessels, passageways, or body cavities, to permit injection or withdrawal of fluids.
IV Therapy
“IV” stands for intravenous, which means “in the vein." An IV (sometimes called a peripheral IV) is a small, short plastic catheter that is placed through the skin into a vein, usually in the hand, elbow, or foot.
IVs are usually hooked up to tubing that carries fluid, medicine, or blood to the patient. The delivery of these fluids is called IV therapy.
IV therapy works by using an injection with a syringe or via infusion, often referred to as a drip. IV therapy is the fastest way to deliver medications, blood products, and more into the bloodstream. IV therapy can be used to help with various health conditions, alleviate dehydration, and to transfuse blood.
How to insert an IV
Here are some best practices for inserting an IV.
Choose the correct catheter size
When inserting an IV, it is important to know the proper catheter size for the job. Choose as small a catheter size as possible to maintain maximum blood flow. When it comes to gauge size, the higher the number, the smaller it is. For example:
- 16 gauge for trauma patients
- 18 gauge for surgery patients
- 20 – 24 gauge for medical patients
How to choose and prepare a vein for IV insertion
When attempting to insert an IV, place the patient's arm in a dependent position, that is, hanging down or below the middle of the body. This will encourage blood flow into the arm more efficiently than if the arm is in a horizontal or raised position.
Place a tourniquet about 5 to 6 inches above the insertion site. If you have an older patient, you can use a blood pressure cuff instead of a tourniquet.
Try to choose a distal vein on the arm first. Distal means located away from the center; for example, the hand is distal to the bicep. We attempt to insert the catheter in a vein distally first because in the event of an error that "blows out" the vein (if the needle punctures the vein in a way that causes the vein to rupture), we can work our way up the arm to another point in the vein and try again. If we try to insert the catheter too high on the arm and cause the vein to rupture, we won't be able to move down the arm to try again.
Veins to avoid
Avoid placing the IV in veins in flexion areas (the joints). On the arm, the antecubital fossa is a flexion area. The antecubital fossa (or AC) is a depression on the anterior surface of the elbow joint (the crook of your elbow). Note that in an emergency situation when it is important to insert the IV as fast as possible, the AC would be appropriate as an insertion point.
Another reason to avoid the AC or any flexion area is in a stable patient. An alert, active patient will bend their arms when they eat or move about their room, which will cause the IV to become occluded. This will set off an alarm on the IV pump. Place the IV for a stable patient in another part of their body to avoid having to repeatedly enter their room to turn off the IV alarm.
Avoid using hard or sclerosed veins for an IV. Sclerosis is the hardening of the tissue, which makes it harder to insert the catheter.
With older patients, try to avoid the veins in the hand. There are many nerve endings there, which can make IV insertion painful. Also, the veins in the hand tend to be more difficult to hit with the needle.
Finally, do not place an IV on the same side as a mastectomy (a surgery to remove a whole breast) or AV fistula (a surgical connection between an artery and a vein often used in dialysis). Pick the side that is not already affected by another procedure, surgery, or catheter.
Angle of insertion
Remember always to use a new, sterile needle for each insertion attempt.
Insert the catheter at a 10- to 30-degree angle with the bevel up. If you cannot hit the vein with the needle, you cannot remove it and then reinsert it. This could cause an infection. Instead, find another kit and start again. For inexperienced nurses, consider bringing two or three kits when it is time to insert an IV.
IV Care and medication administration best practices
Here are some best practices for IV care and medication administration, including how to ensure the line is sterile and functioning properly.
Maintain IV patency
Once an IV line has been successfully inserted, it is important to maintain the patency of the line. Patency means the line is open and not blocked (like a patent airway)! A patent IV line is one that is correctly placed, allowing the treatment to flow directly into the patient's vein. If the patient is not getting continuous IV fluids through the line, flush the line every 8 to 12 hours with normal saline.
Change IV sites and tubing regularly
Change IV sites every 72 hours and IV tubing every 24 hours, or in accordance with your facility policy.
How to connect a line or syringe
When connecting a line or syringe to an IV access site, first wipe the port with an antiseptic alcohol wipe for 15 seconds before connecting the line or syringe. Use an alcohol swab to ensure the port is disinfected.
Check medication compatibility
When giving medication through an IV, always check the compatibility of that medication with the IV fluids that the patient is receiving.
Never give medications through a line delivering total parenteral nutrition (TPN) or blood products. Those are dedicated lines and need to be left on their own. Start a separate line to give the patient their IV medication.
How to administer medication
Always flush the line with normal saline before and after the administration of any IV medications. Have extra flushes handy with the medication syringe.
Attach a normal saline flush to the port, then aspirate and check the blood return to make sure the IV line is patent (there is no clotting or other issues).
When it is clear that the blood is returning, flush the line with the normal saline. Then, disconnect the saline flush and attach the medication syringe. Push the medication at the prescribed rate, disconnect the syringe, and then flush again with another normal saline syringe.
Remember, always flush the line before and after medication administration.
Central venous catheters (CVCs)
A central venous catheter (CVC) is a catheter that terminates in the superior vena cava, just above the right atrium. The vena cava is a large and robust vein, and it can accommodate harsher medications such as vancomycin or chemotherapy. While peripheral IVs are standard for short-term use, if the patient requires long-term therapy, they need a catheter that can remain in the body for a longer period of time.
CVC uses include long-term antibiotic therapy, chemotherapy, and total parenteral nutrition, as well as blood draws and CVP (central venous pressure) monitoring.
Types of CVCs
There are several types of CVC, including tunneled and nontunneled, implantable ports, and PICC lines. A pregnant woman with hyperemesis, for example, requires TPN, which, in turn, requires a central venous catheter.
Tunneled CVC
A tunneled CVC is a small plastic tube placed into a major vein that can remain in place for long-term use. A tunneled path is formed away from the actual vein entrance point in order to decrease the risk of infection. Tunneled central venous catheters are used for total parenteral nutrition, fluid resuscitation, antibiotics, chemotherapy, and hemodialysis (administered in the event of renal (kidney) failure). A patient with a tunneled catheter can continue to receive intravenous therapy even after leaving the hospital.
Nontunneled CVC
A nontunneled catheter is designed to be temporary and may be inserted into a large vein in the neck, chest, or groin. Often a nontunneled CVC is used when urgent or emergent access is needed, for example hemodialysis in the event of renal failure, or resuscitation.
Implantable ports
An implantable port is shaped like a disk and is connected to a flexible tube that has been placed into a vein in the chest during surgery. Implantable ports can remain in place for years, until a provider determines it is no longer needed. Ports can be used for giving IV (intravenous) medicines, fluids, food, or taking blood samples.
PICC lines
A PICC line (peripherally inserted central catheter) is a long, thin tube inserted through a vein in the arm and passed through to the larger veins near the heart. Sometimes (rarely) the PICC line may be placed in a person's leg. A PICC line is generally used to give medications or liquid nutrition.
Nursing care of CVCs
There are a number of protocols to follow when working with a central venous catheter. You’ll see that some are the same as when working with a peripheral IV.
When to change a CVC dressing
Change a patient's dressing 24 hours after the insertion of a CVC. Then, continue to change the dressing on a weekly basis (or as timed per facility policy). Perform a complete dressing change over the insertion site using the aseptic technique.
How to access implantable ports
Access implantable ports with a non-coring Huber needle, which provides a strict aseptic no-touch technique during vascular access procedures. This is to reduce the risk of catheter-related infection. This is a job that requires skill and experience — it is advisable to reach out to a mentor nurse or charge nurse for help showing how to do this the first time.
How to flush the line of a CVC
As with peripheral IVs, it is important to flush CVCs on a regular basis. Flush the line with normal saline, or depending on the facility, use heparin.
Always flush with a 10ml syringe or bigger. Using a smaller syringe can put too much pressure on the catheter.
Where to take a patient's BP
Do not take a patient's blood pressure in the arm with a PICC line. This is because the pressure of the cuff might cause bleeding at the insertion site. It also increases the risk of thrombus (clot) formation or can cause retrograde blood flow, which raises the risk of catheter occlusion.
How to remove a CVC
Place the patient in supine position when removing a central venous catheter. Also, instruct the patient to perform the Valsalva maneuver (bearing down as if having a bowel movement) during removal.
2 comments
Please clear up some confusion/debate. If you have a PICC line that flushes , but does not draw,, can you consider it a patent line and chart it as such.
The Tips are great, short and very educative.