• Keeping the drip chamber flat, close the lower clamp. Now release the drip chamber so that it fills halfway.

• Open the lower clamp, prime the tubing, and close the clamp. To use the set as a primary line, insert the distal end of the tubing into the catheter or needle hub. To use the set as a secondary line, attach a needle to the adapter on the volume-control set. Wipe the Y-port of the primary tubing with an alcohol pad, and insert the needle. Then tape the connection.

• If you're using a needle-free system, attach the distal end of the tubing to the y-port of the primary tubing, following the manufacturer's instructions.

• To add medication, wipe the injection port on the volume-control set with an alcohol pad and inject the medication. Place a label on the chamber, indicating the drug, dose, and date. Don't write directly on the chamber because the plastic absorbs ink.

• Open the upper clamp, fill the fluid chamber with the prescribed amount of solution, and close the clamp. Gently rotate the chamber (as shown below) to mix the medication.

• Turn off the primary solution (if present) or lower the drip rate to maintain an open line.

• Open the lower clamp on the volume-control set, and adjust the drip rate as ordered. After completion of the infusion, open the upper clamp and let 10 ml of I.V. solution flow into the chamber and through the tubing to flush them.

• If you're using the volume-control set as a secondary I.V. line, close the lower clamp and reset the flow rate of the primary line. If you're using the set as a primary I.V. line, close the lower clamp, refill the chamber to the prescribed amount, and begin the infusion again.

Special considerations

• Always check compatibility of the medication and the I.V. solution. If you're using a membrane-filter set, avoid administering suspensions, lipid emulsions, blood, or blood components through it.

• If you're using a floating-valve set, the diaphragm may stick after repeated use. If it does, close the air vent and upper clamp, invert the drip chamber, and squeeze it. If the diaphragm opens, reopen the clamp and continue to use the set.

• If the drip chamber of a floating-valve diaphragm set overfills, immediately close the upper clamp and air vent, invert the chamber, and squeeze the excess fluid from the drip chamber back into the graduated fluid chamber.

Documentation

If you add a drug to the volume-control set, record the amount and type of medication, amount of fluid used to dilute it, and date and time of infusion.

PERIPHERAL I.V. LINE INSERTION

Peripheral I.V. line insertion involves selection of a venipuncture device and an insertion site, application of a tourniquet, preparation of the site, and venipuncture. Selection of a venipuncture device and site depends on the type of solution to be used; frequency and duration of infusion; patency and location of accessible veins; the patient's age, size, and condition; and, when possible, the patient's preference.

If possible, choose a vein in the nondominant arm or hand. Preferred venipuncture sites are the cephalic and basilic veins in the lower arm and the veins in the dorsum of the hand; least favorable are the leg and foot veins because of the increased risk of thrombophlebitis. Antecubital veins can be used if no other venous access is available, to accommodate a large-bore needle, or to administer drugs that require large-volume dilution.

A peripheral line allows administration of fluids, medication, blood, and blood components and maintains I.V. access to the patient. Insertion is contraindicated in a sclerotic vein, an edematous or impaired arm or hand, or a postmastectomy arm and in patients with a mastectomy, burns, or an arteriovenous fistula. Subsequent venipunctures should be performed proximal to a previously used or injured vein.

Equipment

Alcohol pads or other approved antimicrobial solution, such as tincture of iodine 2% or 10% povidone-iodine • gloves • tourniquet (rubber tubing or a blood pressure cuff) • I.V. access devices • I.V. solution with attached and primed administration set • I.V. pole • sharps container • sterile 2″ × 2″ gauze pads or a transparent semipermeable dressing • 1″ hypoallergenic tape • optional: arm board, roller gauze, tube gauze, warm packs, scissors.

Commercial venipuncture kits come with or without an I.V. access device. (See Comparing venous access devices.) In many facilities, venipuncture equipment is kept on a tray or cart, allowing choice of correct access devices and easy replacement of contaminated items.

Preparation of equipment

Check the information on the label of the I.V. solution container, including the patient's name and room number, type of solution, time and date of its preparation, preparer's name, and ordered infusion rate. Compare the physician's orders with the solution label to verify that the solution is the correct one. Then select the smallest-gauge device that's appropriate for the infusion (unless subsequent therapy will require a larger one). Smaller gauges cause less trauma to veins, allow greater blood flow around their tips, and reduce the clotting risk.

If you're using a winged infusion set, connect the adapter to the administration set, and unclamp the line until fluid flows from the open end of the needle cover. Then close the clamp and place the needle on a sterile surface, such as the inside of its packaging. If you're using a catheter device, open its package to allow easy access.

Implementation

• Place the I.V. pole in the proper slot in the patient's bed frame. If you're using a portable I.V. pole, position it close to the patient.

• Hang the I.V. solution with attached primed administration set on the I.V. pole.

• Verify the patient's identity by comparing the information on the solution container with the patient's wristband.

• Wash your hands thoroughly. Then explain the procedure to the patient to ensure his cooperation and reduce anxiety. Anxiety can cause a vasomotor response resulting in venous constriction.

Selecting the site

• Select the puncture site. If long-term therapy is anticipated, start with a vein at the most distal site so that you can move proximally as needed for subsequent I.V. insertion sites. For infusion of an irritating medication, choose a large vein distal to any nearby joint. Make sure the intended vein can accommodate the cannula.

• Place the patient in a comfortable, reclining position, leaving the arm in a dependent position to increase capillary fill of the lower arms and hands. If the patient's skin is cold, warm it by rubbing and stroking the arm, or cover the entire arm with warm packs for 5 to 10 minutes.

E QUIPMENT

COMPARING VENOUS ACCESS DEVICES

Most I.V. infusions are delivered through one of three basic types of venous access devices: an over-the-needle cannula, a through-the-needle cannula, or a winged infusion set. To improve I.V. therapy and guard against accidental needle sticks, you can use a needle-free system and shielded or retracting peripheral I.V. catheters.

Over-the-needle cannula

Purpose:

Long-term therapy for an active or agitated patient

Advantages:

Makes accidental puncture of the vein less likely than with a needle; more comfortable for the patient when it's in place; contains radiopaque thread for easy location. Some units come with a syringe that permits easy check of blood return; some units include wings.

Disadvantage:

More difficult to insert than other devices.

Through-the-needle cannula

Purpose:

Long-term therapy for an active or agitated patient

Advantages:

Makes accidental puncture of the vein less likely than with a needle; more comfortable for the patient when it's in place; available in many lengths; most plastic cannulas contain radiopaque thread for easy location. One variant, the peripherally inserted central catheter, is commonly inserted in the antecubital vein by a specially trained nurse.

Disadvantages:

Leaking at the site, especially in an elderly patient. The cannula may be severed during insertion if pulled back through the needle.

Winged infusion set

Purpose:

Short-term therapy for cooperative adult patient; therapy of any duration for a neonate or a child or for an elderly patient with fragile or sclerotic veins

Advantages:

Less painful to insert; ideal for I.V. push drugs.

Disadvantages:

May easily cause infiltration if a rigid-needle winged infusion device is used.

Applying the tourniquet

• Apply a tourniquet about 6″ (15 cm) above the intended puncture site to dilate the vein (as shown at top of next page). Check for a radial pulse. If it isn't present, release the tourniquet and reapply it with less tension to prevent arterial occlusion.

• Lightly palpate the vein with the index and middle fingers of your nondominant hand. Stretch the skin to anchor the vein. If the vein feels hard or ropelike, select another.

• If the vein is easily palpable but not sufficiently dilated, one or more of the following techniques may help raise the vein. Place the extremity in a dependent position for several seconds, and gently tap your finger over the vein or rub or stroke the skin upward toward the tourniquet. If you have selected a vein in the arm or hand, tell the patient to open and close his fist several times.

• Leave the tourniquet in place for no longer than 3 minutes. If you can't find a suitable vein and prepare the site in that time, release the tourniquet for a few minutes. Then reapply it and continue the procedure.

Preparing the site

• Put on gloves. Clip the hair around the insertion site if needed. Clean the site with alcohol pads or another approved antimicrobial solution, according to your facility's policy.

• NURSING ALERT Don't apply alcohol after applying 10% povidone-iodine because the alcohol negates the beneficial effect of the povidone-iodine.

Work in a circular motion outward from the site to a diameter of 2″ to 4″ (5 to 10 cm) (as shown below) to remove flora that would otherwise be introduced into the vascular system with the venipuncture. Allow the antimicrobial solution to dry.