Peripheral Intravenous Line Placement by Brienne Leary.
Healthcare workers in all healthcare settings should always adhere to the latest World Health
Organization guidelines on hand hygiene and barrier precautions before and after contact
with a patient, bodily fluids, or patient's surroundings.
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Hi.
My name is Brienne Leary and I'm a nurse in the pediatric medical surgical ICU here at
Boston Children's Hospital.
Today, we're going to talk about the indications for peripheral intravenous catheter, also
known as a peripheral IV.
I will demonstrate the procedure to place a peripheral IV.
In closing, we'll discuss issues and troubleshooting.
And how you can manage and care for your peripheral IV.
Indications and Contraindications.
Peripheral intravenous access may be necessary when a patient requires fluid, medications,
blood products, or nourishment intravenously.
Contraindications to consider.
Avoid extremities with a broken bone or that have experienced trauma, an area with compartment
syndrome, any area with significant swelling or edema, a site of a previous infiltrate
in the same extremity.
However, it's important to note that you may access the same vein above the infiltration
site.
You should also avoid any areas with open wounds or broken skin.
Equipment and Procedure.
So, it is essential to gather the necessary equipment before you start.
The equipment you should plan to prepare is the appropriate sized IV catheter, a two by
two gauze, an alcohol or chloraprep solution, clear adhesive dressing, clean gloves, tourniquet,
a positive pressure cap if available, a T-connector or extension tubing, saline flush, stabilization
board, tape, and an alcohol-based hand sanitizer or soap and water to perform hand hygiene.
Now we're ready for the procedure.
You will have the most success if you prepare adequately prior to beginning the procedure.
First, choose the most appropriate sized IV catheter for your patient.
This should be chosen based on your patient's age, size, condition, and the primary use
for the IV.
Standard pediatric sizes are usually 24 to 20 gauge IV.
Next, you'll want to open the gauze and your alcohol or chlorhexidine cleaning solution.
If it is a presoaked pad, grasp the pad at the corner and place it in the center of the
two by two gauze.
Open the T-connector and then prepare your saline flush.
If available, open the positive pressure cap.
You'll want to attach the normal saline flush to the cap and prime the cap through with
normal saline.
This cap provides a safety feature that will prevent back flow of blood from the vein or
air entry into the vein when the extension tubing or T-connector is not clamped.
You'll flush through the cap and the T-connector to prime the tubing.
Ensure that all air is removed.
This is a note-- if you plan to draw labs upon placement of the peripheral IV, do not
flush the saline through the connector.
Instead, attach an empty syringe to the T-connector extension tubing so that you can withdraw
blood upon placement of the catheter into the patient's vein.
Now, you can open the transparent film dressing.
Next, you want to prepare your tape to have it ready to secure your IV once in place.
There are many variations of taping.
Here, tape is prepared by tearing a few half inch pieces along with a few short, one-inch
pieces.
Their application will be demonstrated shortly.
It's now time to wash your hands with an alcohol-based hand sanitizer or soap and water.
Next, you'll prepare to put on your clean gloves.
It is not necessary to use sterile gloves for this procedure.
You'll want to recruit other people to help hold the child, if necessary.
If possible, have parents present when doing an IV to help soothe and calm the child.
For infants, it can often help to swaddle them in a blanket.
Next, we'll talk about how to best choose a site for your patient's peripheral IV placement.
Sites most distal on any extremity are always preferred.
This allows you to use the same vein, but at a location further up the extremity in
the future.
This may be needed as a result of an infiltration or other issue that occurs at the original
site.
The dorsum of the hand is one of the most common areas used in the pediatric population.
Specifically, there is a large vein called the cephalic vein that runs along the thumb
down the wrist.
The basilic vein is also present in the hand and forearm.
There are also a number of smaller vessels which you might be able to access as well.
The saphenous vein is located in the ankle.
It is located right in front of the medial malleolus, or the ankle bone, and runs up
the inner part of the leg.
Again, you will see other small vessels across the dorsal surface of the foot and along the
lateral edge.
Any of these can be used if they appear large enough.
For infants or babies, scalp veins can also be a great resource, particularly in those
who are difficult to locate other veins.
These veins run along the forehead and behind the ear.
A point of caution here-- the temporal artery can often look like a large vein and runs
in front of the ear.
Be sure to palpate to make sure that you don't feel a pulse before you attempt to cannulate
for a peripheral IV.
The direction of a scalp vein in terms of valves always runs away from the top of the
head.
Here are some guiding principles.
No matter where you choose to place your patient's peripheral IV, the direction of the IV catheter
should always follow the direction of venous blood flow.
In the head, the catheter is placed to point down to the feet.
For the rest of the body, the catheter is always inserted aiming up toward the head.
Tourniquets are usually used to help find veins.
Elastic bands can be used on small babies instead of traditional tourniquets, and especially
for scalp IVs.
If a traditional tourniquet is not available, get creative.
You can use any object that is able to temporarily apply pressure in its place, such as a glove
or even an assistant's hand.
Now we're going to talk about the procedure to place the IV.
First, you will need to find the vein.
You should visualize for the vein or you can palpate and feel a bouncy tube.
Sometimes, you will need to place the tourniquet as your first step to help find the veins
and fill them with blood to make it easier to visualize.
Next, you're going to apply the tourniquet.
You'll loop the tourniquet under the patient's extremity and then pull both tabs upwards,
cross the ends over each other, and then pull one tab behind and under the other one.
Pull it partially through to create a small loop, but do not pull it all the way through.
This will leave a tail for easy removal.
Next, you'll want to prep the skin using your cleansing prep pad and gauze.
Let the area dry for approximately 30 seconds.
Remove the plastic covering from the IV catheter exposing the needle and cannula.
Loosen the catheter from the needle.
Prepare approach the vein with the IV catheter.
Make sure you hold the IV catheter with the bevel of the needle facing up.
Next, you'll want to puncture the skin using a 25 to 30 degree angle initially to access
the vein.
Insert the IV slowly to avoid going through the vessel.
Look for a flashback of blood in the catheter as an indication that the IV is in the vessel.
Once flashback is visualized, advance the catheter slightly and then decrease the angle
of the catheter to be more parallel with the skin.
Carefully advance the catheter off the introducing needle by simultaneously stabilizing the needle
and sliding the catheter completely under the skin.
If advancement stops, the catheter may be hitting up against a valve.
You can remove the tourniquet, attach a saline flush directly to the catheter, and then try
to advance while flushing in saline.
After advancing the catheter, remove the tourniquet.
If possible, apply pressure above the insertion site and remove the needle.
There should still be blood flowing back, indicating that the catheter is in the vein.
Secure your sharps, attach the T-connector, and flush the catheter, looking for infiltration.
Infiltration is caused when the catheter is no longer in the vein and fluid is now infusing
into the patient's soft tissue.
It can also occur when there is a hole in the vein that has gotten large enough to allow
for extra fluid to leak out around the insertion site and into the tissue.
Next, we'll talk about securing the IV.
If the T-connector has a metal or thick end, place a piece of gauze under the end before
putting the dressing on to protect the skin from breakdown.
You'll want to dress the site with a transparent occlusive dressing.
Make effort not to cover the insertion site with anything opaque.
This is important so that the site can be monitored for signs and symptoms of infiltration
or phlebitis.
Assess, again, for the patency by flushing and clamp the T-connector.
Secure the catheter with tape using the chevron technique.
This is shown here by taking a half-inch piece of tape, adhesive side up, sliding it under
the hub of the catheter and cross the tabs over one another, adhering them to the patient
on opposite sides.
When necessary, use a second piece of tape and secure the attachment device.
When an IV is placed over a joint, use a supporting device, such as an arm board, to keep the
child from bending the extremity.
A protective device can also be placed over the IV to avoid accidental removal, such as
with a sock or a wrap.
The protective device should be removable to allow for hourly assessment of the site
for signs and symptoms of infiltration or phlebitis.
Next, you'll want to put the date, time, and size of the catheter on a piece of tape across
the dressing.
Troubleshooting.
Now, we'll talk about some troubleshooting tips.
In younger children, it may be difficult to feel the veins.
Instead, you'll want to look for the telltale bluish color.
In older children, it can often be hard to see the veins.
In this case, you'll want to use palpation to find the veins.
Again, it should feel like a bouncy tube.
For patients who have limited veins, here are some things you could try.
In infants, remember to always check the scalp.
You can always look in the patient's upper arm area to assess for veins.
The small veins on the inside of the wrist or fingers can also be useful.
Just be cautious of the nerve supply that runs through here.
Finally, you can always check on the sides or the back of the patient's knees.
For patients that are edematous, hypotensive, in shock, or have signs or symptoms of poor
perfusion, here are some things to try.
Lower the extremity.
If available, use a transilluminator or flashlight.
This will work best if you dim the room light and place the light behind the patient's skin.
You can also try to use a steeper angle when accessing the vein and probe a bit deeper
to get through the edematous tissue.
Finally, you can take the plug out of the end of the catheter, flush the catheter before
you start to use it, and this will help the blood show you a flashback a little bit quicker.
Assessment and Monitoring.
Before using the IV, make sure that it is patent, for either continuous or intermittent
use.
If the infusion is continuous, monitor the IV site frequently, at least every hour.
Assess the site at the end of IV therapy.
Once the IV is placed and deemed patent, place an occlusive dressing that allows for visualization
of the site.
Manually flush the IV catheter to check for patency, leaking, redness, blanching, and
swelling.
You should check the patient's IV site frequently for patency or signs and symptoms of complications.
These complications can often include infiltration, phlebitis, dislodgement, leaking, or loss
of patency.
Signs and symptoms of infiltration include swelling and cooler temperature to touch around
the IV site, blanching or white areas around the IV site, difficulty flushing, cessation
of blood return with aspiration.
However, is important to note that this finding alone does not indicate that an IV no longer
works.
Again, you should always flush the IV to assess for patency and if it flushes easily without
signs of leaking or blanching it may still be usable and safe.
Phlebitis is a little bit different.
It is caused by medications or fluids that have been delivered to the patient intravenously
that have caused inflammation to the vein.
Indications that phlebitis has occurred include redness at the IV site, a red streak up the
extremity along the vein, a hot feeling of the skin, or the vein may now feel like a
hard cord underneath the patient's skin.
Last, we'll review documentation.
You should always put the date and time of the procedure in the patient's chart.
Note the size of the IV catheter used.
You will also want to note the number of attempts that were needed to place the peripheral IV
successfully.
Note the vital signs before, during, and after the procedure.
Chart the patient's comfort with the procedure and any interventions you took to provide
care and comfort.
Note any adverse outcomes.
And finally, you will need to document routine peripheral IV checks, again, monitoring for
signs and symptoms of complications.
Thank you for watching this video on how to place a peripheral IV in a pediatric patient.
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