Mastering Peripheral Intravenous Cannulation:

An Evidence-Based Guide for Nurses

I. Introduction: Mastering Peripheral IV Cannulation
Significance of IV Therapy in Nursing
Intravenous (IV) therapy stands as a cornerstone of modern medical
treatment and a fundamental skill within the nursing profession. It
provides a direct route into the vascular system for the administration
of essential fluids, medications, electrolytes, blood products, and
parenteral nutrition.1 The prevalence of this intervention is
underscored by estimates suggesting that up to 70-80% of
hospitalized patients require some form of intravenous access during
their stay.3 Globally, healthcare providers insert over a billion
peripheral IVs annually.3

Despite its ubiquity, peripheral IV cannulation is recognized as one of

the most common invasive procedures performed in healthcare
settings.11 It is frequently associated with significant patient anxiety
and discomfort, often cited by patients and families as a particularly
stressful hospital experience.10 Furthermore, the procedure carries
inherent risks of complications if not performed and maintained
according to best practices. The nurse holds a critical position and
profound responsibility in ensuring the safe, effective, and
patient-centered delivery of IV therapy, encompassing everything
from initial insertion to ongoing maintenance and timely removal.1
Adherence to ethico-legal standards, including interpreting physician
orders, administering treatments correctly, assessing for adverse
reactions, and meticulous documentation, is paramount.1

Overview of Evidence-Based Best Practices

Achieving proficiency and ensuring patient safety in peripheral IV
cannulation necessitates strict adherence to evidence-based
standards and guidelines promulgated by reputable national and
international organizations, such as the Infusion Nurses Society (INS),
the Centers for Disease Control and Prevention (CDC), and the Royal
College of Nursing (RCN).1 These standards provide a framework for
practice aimed at minimizing common complications like infection
(local and systemic), phlebitis (inflammation of the vein), infiltration
(leakage of non-vesicant fluid), extravasation (leakage of vesicant
fluid), occlusion, and catheter dislodgement.4

A primary goal of current best practices is to maximize the success

rate of first-attempt cannulation.13 Multiple failed attempts not only
cause patient pain and distress but also lead to delays in treatment,
increased healthcare costs, potential vein damage limiting future
access, and diminished patient trust.10 This report provides a
comprehensive overview of peripheral IV cannulation, structured to
guide nurses through foundational principles, governing standards,
detailed procedural steps, best practices for maintenance and
complication management, considerations for special patient
populations, relevant equipment, and strategies for patient
education, all grounded in current evidence and expert
recommendations.

II. Foundational Principles

Relevant Venous Anatomy and Physiology
A fundamental understanding of peripheral venous anatomy and
physiology is essential for successful and safe IV cannulation.
Peripheral veins are composed of three layers: the innermost tunica
intima (a single layer of endothelial cells), the middle tunica media
(smooth muscle and elastic tissue), and the outermost tunica
adventitia (connective tissue).32 The tunica intima is particularly
delicate and susceptible to irritation from the catheter (mechanical
phlebitis) or the infusate (chemical phlebitis).32

Many peripheral veins, particularly in the limbs, contain valves –

typically bicuspid folds of the tunica intima – that prevent the
backflow of blood and direct flow towards the heart.27 While essential
for circulation, these valves can pose challenges during cannulation.
Attempting to advance a catheter through or against a valve can
cause pain, damage the valve or vein wall, lead to catheter kinking or
occlusion, and potentially cause the vein to "blow" or rupture.27
Therefore, palpating for valves (felt as small bumps or areas of
resistance) and selecting insertion sites that avoid them is an
important aspect of vein assessment.27 Knowledge of valve location
also informs the insertion technique, potentially requiring slight
adjustments in angle or gentle rotation during advancement to
navigate past them successfully.

Commonly accessed peripheral veins for IV therapy are located in the

upper extremities.9 These include:
●​ Dorsal Metacarpal Veins (Hand): Easily visible and accessible
but tend to be smaller, more mobile, and associated with
increased pain due to thinner skin and more nerve endings.9
Catheters here may be more prone to dislodgement with hand
movement.
●​ Cephalic Vein: A large vein running along the radial (thumb) side
of the forearm and upper arm. Often a good choice due to its
size and relatively straight course, though may be less visible in
obese individuals.9 The portion crossing the anatomical snuff box
at the wrist is sometimes used but requires caution.37
●​ Basilic Vein: Runs along the ulnar (pinky finger) side of the
forearm and upper arm. It is typically large but may be deeper
and lie closer to nerves and arteries, requiring careful
assessment.9
●​ Median Cubital Vein: Located in the antecubital fossa (inner
elbow), it is large and easily accessible, often used for blood
draws.9 However, cannulation here significantly restricts elbow
movement and increases the risk of kinking, occlusion, and
dislodgement, making it generally unsuitable for ongoing
infusions unless necessary and properly stabilized.36
●​ Median Antebrachial Vein: Ascends in the middle of the
forearm; size can vary.9

Understanding the typical location, size, depth, and potential

proximity to nerves and arteries of these veins guides the selection of
the most appropriate site and catheter size for the individual patient
and prescribed therapy.

Aseptic Technique and Infection Prevention Standards

Preventing infection is paramount in IV therapy due to the direct
access provided to the bloodstream. Strict adherence to aseptic
technique and established infection prevention protocols is
non-negotiable.

Aseptic Non-Touch Technique (ANTT): This is a foundational

principle requiring that sterile equipment ("key parts") does not come
into contact with non-sterile surfaces, including the clinician's hands,
and that susceptible patient sites ("key sites") are protected from
contamination.2 Key parts include the IV catheter itself, the
needleless connector hub, the tip of the flush syringe, and the part of
the antiseptic swab used for cleaning.2 The key site is the prepared
skin insertion point.2 Maintaining sterility throughout the procedure is
critical.

Hand Hygiene: Meticulous hand hygiene is the single most important

measure to prevent healthcare-associated infections. Hands must be
decontaminated using either alcohol-based hand rub (ABHR) or soap
and water (if visibly soiled) immediately before and after palpating
potential insertion sites, before donning gloves for insertion, after
insertion, before and after accessing the IV system (including flushing
or administering medication), before and after dressing changes, and
after removing gloves.5 It is critical to avoid re-palpating the insertion
site after skin antisepsis has been performed; if palpation is deemed
necessary after cleaning, aseptic technique must be maintained (e.g.,
using sterile gloves) or the site must be re-cleaned.23

Personal Protective Equipment (PPE):

●​ Gloves: Clean (non-sterile) gloves are generally considered
acceptable for peripheral IV insertion, provided the prepared
insertion site is not touched after antiseptic application.22 This
practice reflects a risk-based approach where the primary
barrier against infection at the insertion site is the skin antiseptic
and the maintenance of ANTT. Sterile gloves are mandatory for
the insertion of central venous catheters (CVCs), peripherally
inserted central catheters (PICCs), and arterial lines, as these
procedures carry a higher intrinsic risk of infection.22 Clean or
sterile gloves should be worn when changing IV dressings.22 New
sterile gloves are required when performing guidewire
exchanges.23
●​ Maximal Sterile Barrier Precautions: For CVC and PICC
insertions, maximal sterile barrier precautions are recommended,
including a cap, mask, sterile gown, sterile gloves, and a large
sterile drape.22 These are generally not required for standard
peripheral IV insertion.
●​ Eye Protection: Protective eyewear should be worn during
insertion to prevent exposure from potential blood splashes.22

Skin Antisepsis: Proper skin preparation at the insertion site is

crucial for reducing the microbial load and preventing
catheter-related infections.
●​ Agent: The preferred antiseptic agent recommended by major
guidelines (CDC, INS, RCN) is an alcohol-based chlorhexidine
gluconate (CHG) solution, typically >0.5% or 2% CHG in 70%
isopropyl alcohol.14 The strong consensus across guidelines
reflects substantial evidence supporting the superior efficacy
and residual activity of CHG/alcohol combinations compared to
older agents like povidone-iodine alone in preventing infections.
●​ Alternatives: If CHG is contraindicated (e.g., known allergy,
infants <2 months due to potential skin irritation), alternatives
include tincture of iodine, an iodophor (like povidone-iodine,
preferably with alcohol), or 70% alcohol alone.22
●​ Application: Cleanse the skin using friction (e.g., back-and-forth
motion for CHG applicators, vigorous scrubbing) for at least 30
seconds.34
●​ Drying: Allow the antiseptic to air dry completely according to
the manufacturer's instructions (typically 30 seconds or longer)
before puncturing the skin.23 Drying is essential for the antiseptic
to achieve its full antimicrobial effect and prevents stinging upon
needle insertion.35 Use single-use antiseptic applicators rather
than multi-use bottles.59

Environmental Cleaning: Maintaining a clean patient care

environment, including routine cleaning and disinfection of surfaces,
especially those frequently touched or near the patient, contributes
to overall infection prevention.48

Sharps Safety: Needles used for IV insertion pose a risk of

needlestick injury. Immediately dispose of the stylet (needle) into a
designated sharps container after withdrawal from the catheter
hub.22 Utilize safety-engineered catheters that feature mechanisms to
shield or retract the needle after use whenever possible.32 Never
attempt to reinsert the stylet into the cannula once it has been
separated.29
III. Guiding Standards: Recommendations from
Leading Organizations
A synthesized understanding of recommendations from key
professional and regulatory bodies provides a robust foundation for
best practices in IV cannulation. While core principles are largely
consistent, nuances exist, and guidelines are periodically updated
based on emerging evidence.
●​ Centers for Disease Control and Prevention (CDC): The
CDC's guidelines primarily focus on preventing intravascular
catheter-related infections.23 Key recommendations include:
○​ Hand Hygiene: Before and after patient contact and
catheter manipulation.23
○​ Aseptic Technique: For insertion and care.23
○​ Skin Preparation: Preferential use of >0.5% chlorhexidine
with alcohol; allow adequate drying time.23
○​ Site Selection: Upper extremities for adults.24
○​ Catheter Selection: Based on intended use/duration;
consider midline/PICC for therapy >6 days.24
○​ Dressing: Sterile gauze or transparent semipermeable
dressing (TSM); change when compromised.24 Specific
change intervals for CVC dressings (TSM ≥7 days, gauze 2
days).24 Avoid topical antibiotic ointments.24
○​ Chlorhexidine-Impregnated (CI) Dressings:
Recommended for short-term, non-tunneled CVCs in
patients >2 months (updated for adults ≥18 years) if CLABSI
rates are not decreasing with basic measures, but NOT
recommended for premature neonates due to skin
reactions.24
○​ Site Monitoring: Daily evaluation (palpation/inspection);
remove dressing for thorough exam if tenderness/infection
suspected.24
○​ Catheter Removal: Promptly remove when no longer
necessary; do not routinely replace CVCs/PICCs to prevent
infection.46 Remove PIVCs for
phlebitis/infection/malfunction.23
○​ Hub Care: Scrub access port with antiseptic before each
use.2
○​ Education & Competency: Educate staff on indications,
 insertion, maintenance, and infection prevention; designate
competent personnel; use checklists; conduct periodic
assessments of knowledge/adherence.47
●​ Infusion Nurses Society (INS): The INS publishes
comprehensive Infusion Therapy Standards of Practice, updated
regularly.1914 Key standards emphasize:
○​ Nurse Expertise: Utilize skilled vascular access teams or the
most knowledgeable clinician available.15
○​ Patient/Caregiver Engagement: Educate and involve
patients/caregivers in the care plan and recognizing
complications.15
○​ Pain/Anxiety Management: Employ nonpharmacologic
measures (distraction, relaxation) and pharmacologic options
as appropriate.15
○​ Site Selection: Prioritize vessel health preservation,
collaborate with patient, avoid areas of flexion.14
○​ Catheter Selection: Use the smallest gauge catheter
appropriate for the therapy.14
○​ Insertion Attempts: Limit to two attempts per clinician;
escalate to a more skilled clinician if unsuccessful.14
○​ Difficult Intravenous Access (DIVA): Assess all patients for
DIVA; use validated tools (e.g., A-DIVA); employ vascular
visualization technology (ultrasound, NIR) for DIVA patients;
establish escalation policies.14
○​ Disinfection: Proper hand hygiene; skin antisepsis with
CHG/alcohol preferred, allow to dry.14
○​ Securement & Stabilization: Use appropriate methods
(dressings, ESDs, tape) to prevent dislodgement and
micro-movement; stabilize joints near flexion sites.22
○​ Filtration: Updated recommendations align with ASPEN
regarding filter use (e.g., 1.2-micron for PN).59
○​ Competency: Provide education (e.g., FIT program) and
validation (e.g., CCVP).19
●​ Royal College of Nursing (RCN): The RCN provides Standards
for Infusion Therapy.2121 These standards cover a broad range of
topics:
○​ Patient Safety & Quality: Emphasis on safe practices and
monitoring.21
○​ Patient Experience: Addressing patient comfort and
 involvement.21
○​ Infection Prevention: General principles, hand hygiene, PPE,
ANTT, safe sharps handling.22
○​ Equipment: Administration sets (types, changes), flow
control devices (manual, electronic), add-on devices.22
○​ Site Selection & Insertion: Prefer forearm/hand, start distal,
avoid complications/flexion, consider ultrasound, hair
removal (clipping), local anesthesia, aseptic prep
(CHG/alcohol preferred), device stabilization (ESDs preferred
over sutures).22
○​ Site Care & Maintenance: Aseptic access, site checks (each
shift), cleansing during dressing change, flushing for patency
(0.9% NaCl, volume ≥2x catheter), dressing management
(TSM preferred, change q7 days or prn).22
○​ Complication Management: Detailed guidance on
recognizing, preventing, and managing phlebitis (using VIP
scale), infiltration (using scale), extravasation (policy
required, vesicant precautions), CR-BSI, thrombosis,
hematoma, hemorrhage, air embolus, pneumo/hemothorax,
speed shock, fluid overload.22
○​ Documentation: Requirements for recording insertion, care,
and complications.22
○​ Competency: The NHS IV Therapy Passport program
provides a standardized pathway for learning and
competency assessment.66
●​ Philippine Nurses Association (PNA) / Board of Nursing
(BON): Regulations in the Philippines emphasize specific training
and competency requirements.1
○​ Training Mandate: Nurses require special training in IV
therapy, historically through ANSAP, now via CPD-accredited
providers, with content aligned with the National Nursing
Core Competency Program.1 Basic IV therapy is integrated
into the BSN curriculum.67
○​ Employer Responsibility: Hospitals must verify competency
upon hiring and provide necessary training at no cost to the
nurse if needed.67 Training completion may be considered for
promotion but isn't mandatory.67
○​ Ethico-Legal Duties: Nurses are accountable for
interpreting orders, safe administration (meds, fluids, blood),
 assessment (adverse reactions, incompatibilities), care
planning, infection control, equipment care, documentation,
patient advocacy, and adhering to the Code of Ethics.1
Liability exists for untrained administration.1
○​ Professional Standards: PNA works to enhance
competencies and uphold standards.17

While core principles like asepsis, careful technique, and patient

monitoring are universal across these guidelines, specific
recommendations regarding aspects like dressing change frequency,
the number of permitted insertion attempts, or the mandatory nature
of specialized training can vary. Furthermore, guidelines are dynamic
and subject to revision as new evidence emerges (e.g., CDC updates
on CI dressings 24, INS updates on filtration 59, RCN standards under
review 21). This variability underscores the critical need for nurses to
remain current with international best practices while also strictly
adhering to their specific institutional policies and procedures, which
should ideally be evidence-based and regularly updated.1

A noticeable trend across guidelines is the increasing emphasis on

formal competency validation beyond basic nursing licensure.
Programs like the RCN's IV Therapy Passport 66, the INS's Clinical
Competency Validation Program (CCVP) 19, the specific training
requirements in the Philippines 67, and the CDC's recommendation for
designated, competency-assessed personnel 49 all point towards a
recognition of IV cannulation as a complex skill requiring specialized
training and ongoing validation. This focus on demonstrated
proficiency aims to standardize care, reduce complications, and
ultimately enhance patient safety across diverse healthcare
settings.15

IV. The Peripheral IV Cannulation Procedure: A

Detailed Walkthrough
Successful peripheral IV cannulation requires a systematic approach,
meticulous attention to detail, and adherence to best practices at
each step.

A. Patient Assessment and Preparation

Thorough assessment and preparation before attempting cannulation
are crucial for success, patient comfort, and safety. This phase
involves more than just locating a vein; it encompasses a holistic
evaluation of the patient and readiness for the procedure.
1.​ Verification and Consent:
○​ Confirm the physician or nurse practitioner's order for IV
therapy, verifying the type of fluid or medication, the
prescribed rate of infusion, and the intended duration.5
○​ Introduce yourself to the patient, stating your name and
role.16
○​ Verify the patient's identity using at least two unique
identifiers (e.g., name and date of birth), comparing with the
medical record or wristband.34
○​ Explain the procedure clearly using patient-friendly
language, including the reason for the IV, what the patient
might feel (e.g., "sharp scratch"), and the approximate
duration.16
○​ Obtain informed verbal consent to proceed.41
○​ Ensure patient privacy.34
2.​ Allergies and History:
○​ Explicitly ask about and check records for allergies,
particularly to tape, latex, and skin antiseptics like
chlorhexidine or iodine.16
○​ Inquire about the patient's previous experiences with IV
insertions. Ask about any history of difficult intravenous
access (DIVA), preferred sites, or sites where previous
attempts were unsuccessful.11 Document DIVA status if
identified.26
○​ Review the patient's medical history for conditions that could
affect vein access or increase risks, such as diabetes, renal
failure (potential future fistula needs), mastectomy, lymph
node dissection, history of IV drug abuse, chemotherapy,
vasculopathy, paralysis, edema, dehydration, obesity, or
conditions affecting skin integrity.9
3.​ Site Assessment Factors:
○​ Assess potential sites based on the therapy required
(considering duration, flow rate, fluid viscosity).2
○​ Evaluate the patient's limb, noting hand dominance (prefer
non-dominant arm).9
 ○​ Inspect skin integrity, avoiding areas with scars, bruises,
rashes, infection, edema, tattoos, or compromised
circulation.9 Avoid sites distal to recent venipuncture
attempts.9
○​ Assess joint mobility and avoid inserting directly into areas of
flexion (like the wrist or antecubital fossa) if possible, as
movement increases the risk of complications and
dislodgement.5 If such a site is necessary, stabilization (e.g.,
with an armboard) is crucial.16
4.​ Pain and Anxiety Management:
○​ Assess the patient for pre-existing pain or anxiety related to
needles (needle phobia).10
○​ Implement nonpharmacologic comfort measures appropriate
for the patient's age and condition. This may include
distraction techniques (conversation, music, tablets/VR for
older children), relaxation or breathing exercises, ensuring a
calm environment, swaddling or pacifiers for infants, and
allowing parental presence and comfort holds for children.15
○​ Consider pharmacologic pain relief options based on patient
need, institutional policy, and available resources. Topical
anesthetics like Lidocaine/Prilocaine cream (EMLA™®),
Lidocaine cream (LMX®), or Amethocaine gel (AnGel®) can
be effective but require application well in advance (30-60
minutes).22 Vapocoolant sprays offer rapid, short-acting
anesthesia immediately before insertion.25 Injectable local
anesthetic (e.g., buffered lidocaine) can also be used.22 For
anxious children, nitrous oxide may be an option if available.41
5.​ Positioning:
○​ Position the patient comfortably, usually sitting or reclining.34
○​ Adequately expose the chosen arm.55
○​ Place a pillow or protective pad under the arm for support
and comfort.52
○​ Ensure adequate lighting for visualization.36
○​ Position the arm dependently (below heart level) initially to
encourage venous filling using gravity.27

This comprehensive pre-procedural assessment moves beyond

simply identifying a target vein. It involves preparing the patient
psychologically (addressing anxiety/phobia 10), ensuring physical
comfort (positioning 34), managing anticipated pain (analgesia
options 25), and identifying potential risks or contraindications
through history and physical assessment.16 Adopting this
patient-centered approach, rather than a purely technical focus on
vein access, is more likely to lead to successful cannulation, improved
patient satisfaction, and safer outcomes.

B. Equipment Selection and Preparation

Careful selection and preparation of equipment are essential for a
smooth and aseptic procedure.
1.​ Gather Supplies: Assemble all necessary items on a clean,
dedicated surface or tray before approaching the patient for
insertion.34 Check expiration dates on all sterile supplies.18 A
typical setup includes:
○​ IV start kit (often contains tourniquet, antiseptic swabs,
gauze, tape, dressing label).54
○​ Appropriate size and type of IV catheter.34
○​ Extension set and/or needleless connector (cap).34
○​ Prefilled 10 mL syringe(s) of sterile 0.9% sodium chloride (or
vial and sterile syringe/needle to draw up).34
○​ Clean gloves.34
○​ Sterile transparent semipermeable dressing.34
○​ Sharps container.56
○​ Optional: Armboard/splint, local anesthetic supplies, skin
protectant.34
2.​ Catheter Selection:
○​ Gauge: Select the smallest gauge catheter that can
effectively deliver the prescribed therapy and meet the
patient's needs.2 This principle is consistently emphasized
across guidelines because smaller catheters occupy less
space within the vein lumen, allowing for better blood flow
around the catheter and minimizing irritation to the vein wall
(tunica intima), thereby reducing the risk of mechanical
phlebitis and thrombosis.24
○​ Factors: Balance the need for the smallest gauge with
therapy requirements. Consider:
■​ Vein Size/Condition: Assess the patient's veins; smaller,
fragile veins (common in elderly or pediatric patients)
 necessitate smaller gauges (e.g., 22G or 24G).4
■​ Therapy Type/Duration: Routine fluids or medications can
often be delivered via 20G or 22G.4 Rapid fluid
resuscitation, viscous solutions, or blood product
administration typically require larger gauges (e.g., 18G,
16G, or even 14G in emergencies) to achieve necessary
flow rates.4 If IV therapy is expected to exceed 6 days, a
midline catheter or PICC should be considered.5
■​ Flow Rate: Catheter gauge directly impacts potential flow
rate (see table below).4
○​ Identification: IV catheters are color-coded by gauge for
easy identification.9
○​ Material & Features: Most modern catheters are made of
polyurethane or similar biocompatible plastics, considered
less thrombogenic than older materials.4 Use
safety-engineered catheters with needle-shielding or
retraction mechanisms to prevent needlestick injuries.32 Avoid
using steel needles ("butterfly" needles) for infusions,
especially vesicants, due to rigidity and risk of
infiltration/necrosis.24 Winged catheters may offer stability
but require careful securement.4 Ported cannulas allow
medication injection via the port but require specific flushing
protocols.
Table: Common IV Catheter Gauges and Approximate Flow
Rates(Adapted from 4)
Gauge (G) Typical Color Approx. Flow Rate General Uses
(mL/min)

14 Orange 250–350 Rapid large-volume

replacement (traum
major surgery),
viscous fluids

16 Grey 180–215 Trauma, major

surgery, rapid
fluid/blood
transfusion

18 Green 90–104 Blood products,

irritant medications,
 contrast studies,
large volume fluids

20 Pink 60 General use,

maintenance fluids,
most medications,
antibiotics, blood
transf

22 Blue 36 Smaller/fragile veins

standard infusions,
elderly, pediatric

24 Yellow 24 Neonates, infants,

children, very fragile
veins, short-term
infusions

*(Note: Flow rates are approximate and can vary by manufacturer and
clinical conditions)*​

3.​ Prepare Flush and Extension Set:

○​ Aseptically attach the needleless connector (if separate) to
the extension set tubing.
○​ Aseptically attach the prefilled saline syringe to the
needleless connector/extension set port.34
○​ Expel any air from the saline syringe.88
○​ Flush (prime) the entire extension set with saline, ensuring all
air is removed from the tubing and connector.34 Maintain
sterility of the distal end connector that will attach to the IV
catheter hub.
○​ Leave the flush syringe attached to the primed extension
set.34
○​ Loosen the protective cap on the distal end of the extension
set (but do not remove it yet) to allow for quicker connection
after catheter insertion.88
4.​ Prepare Cannula:
 ○​ Open the sterile catheter package using aseptic technique
just prior to insertion.73
○​ Remove the protective needle sheath/cover.44
○​ Visually inspect the catheter tip and needle for any damage,
burrs, or defects.44
○​ Depending on the catheter model, you may need to slightly
loosen the catheter hub from the needle assembly (e.g., by
gently twisting) to ensure smooth advancement later.55 Do
not completely separate them. Open wings if present.55

C. Vein Selection: Identifying the Optimal Site

Choosing the right vein is a critical step influencing insertion success,
catheter longevity, and patient comfort.
1.​ Systematic Assessment: Begin assessment distally on the
upper extremities and progress proximally.9 This "start distal,
move proximal" approach preserves more proximal sites for
future attempts if needed, a core principle of vessel health
preservation. Systematically examine potential sites on both the
dorsal (back) and ventral (inner) surfaces of the hand and
forearm.9
2.​ Preferred Sites:
○​ Upper Extremities: Hands and arms are the preferred
locations in adults.5
○​ Forearm Veins: The cephalic and basilic veins in the forearm
are often ideal choices as they are generally larger and allow
for better catheter stabilization and longer dwell times
compared to hand veins.9 Using the forearm also tends to be
less restrictive for the patient.42
○​ Hand Veins: Dorsal metacarpal veins are accessible but
smaller and may be more painful.9
○​ Non-Dominant Arm: Whenever possible, use the patient's
non-dominant arm to minimize disruption to daily activities
and reduce the risk of accidental dislodgement.9
3.​ Sites to Avoid: Strict avoidance criteria help prevent
complications:
○​ Lower Extremities (Adults): Avoid leg and foot veins due to
increased risk of thrombophlebitis, deep vein thrombosis
(DVT), infection, and ulceration, unless specifically ordered
 by a physician in exceptional circumstances.22 (Note:
Foot/scalp veins may be used in infants/young children 3).
○​ Areas of Flexion: Avoid the wrist and antecubital fossa (ACF)
when possible for ongoing infusions, as movement can lead
to catheter kinking, occlusion, infiltration, phlebitis, and
dislodgement.5 If an ACF site is used (e.g., for emergencies or
large-bore access), it requires careful stabilization.16
○​ Compromised Limbs/Areas: Do not use an extremity
affected by mastectomy, lymph node dissection,
arteriovenous (AV) fistula or graft, stroke with motor deficit,
paralysis, lymphedema, or presence of a cast/orthotic
device.4
○​ Problematic Veins/Skin: Avoid veins that are visibly inflamed
(phlebitic), sclerosed (hardened, rope-like), thrombosed,
tortuous (very curvy), or bruised.9 Avoid areas with skin
breakdown, rash, infection, scarring, edema, or recent
venipuncture/IV sites.9 Avoid areas over joints where
movement is likely.43 Avoid known venous valves or
bifurcations (points where veins divide).9
○​ Palmar Wrist: Avoid the volar (inner) surface of the wrist due
to the proximity of nerves and arteries, increasing the risk of
damage.9
4.​ Vein Assessment Criteria: Look for veins that exhibit the
following characteristics:
○​ Visibility: Easily seen (though palpation is often more
reliable, especially in patients with darker skin tones or more
subcutaneous fat).9
○​ Palpability: Feels soft, bouncy, and resilient ("springy") when
gently pressed.9 Avoid hard or cord-like veins.34
○​ Size: Sufficiently large to accommodate the chosen catheter
gauge without occluding the vein.9
○​ Straightness: A straight segment of at least ¼ to ½ inch
(approx. 1-2 cm) is ideal for threading the catheter easily.9
○​ Location: Situated in an area that minimizes patient
discomfort and risk of dislodgement.40
5.​ Techniques for Difficult Veins (Dilation/Visualization): If veins
are not readily apparent, employ these techniques:
○​ Tourniquet Application: Apply snugly 4-5 finger widths
(approx. 7-15 cm or 3-6 inches) above the intended site.27
 Ensure it impedes venous return but not arterial flow (check
distal pulse).27 Limit application time to 1-2 minutes
continuously.27 Releasing and reapplying may enhance
dilation.29 Consider alternatives like double tourniquets or a
blood pressure cuff inflated below diastolic pressure (e.g.,
60-90 mmHg) for fragile veins.77
○​ Gravity: Have the patient dangle the arm below heart level.27
○​ Warmth: Apply warm compresses, towels, or blankets to the
limb for 5-10 minutes to promote vasodilation.26 Ensure the
patient is systemically warm.77
○​ Gentle Palpation/Tapping/Stroking: Lightly tapping or
stroking the vein can stimulate histamine release and
enhance visibility.27 Avoid vigorous slapping, which can cause
venospasm.77 Rubbing the alcohol wipe in the direction of
venous flow may also help.77
○​ Fist Clenching: Ask the patient to repeatedly make a fist.29
○​ Transillumination: Devices that shine a bright light through
the tissue can help visualize veins, especially in infants.26
○​ Vascular Visualization Technology: For patients identified
with DIVA, the use of near-infrared (NIR) light devices or
ultrasound guidance (USG) is strongly recommended by INS
and other bodies to improve first-attempt success rates.14
These technologies require specific training and
competency.25 Ultrasound allows visualization of deeper veins
not visible or palpable otherwise.38

The selection of an appropriate vein is thus a complex decision

integrating anatomical knowledge, patient-specific factors, therapy
requirements, and available techniques for enhancing visualization.
The adherence to the "start distal, move proximal" strategy is
fundamental for preserving venous access options over the long
term.22 Choosing an unsuitable vein (e.g., too small, near flexion,
previously damaged) significantly increases the risk of procedural
failure and subsequent complications like phlebitis or infiltration.5

D. Skin Preparation and Infection Control Measures

Once a suitable site is selected, meticulous skin preparation is
performed to minimize the risk of introducing microorganisms.
1.​ Hand Hygiene and Gloves: Perform hand hygiene thoroughly.16
 Don a clean pair of non-sterile gloves.16
2.​ Site Cleansing:
○​ Select the appropriate antiseptic agent, preferentially >0.5%
or 2% CHG in 70% alcohol, unless contraindicated.14 If the
site is visibly soiled, clean with soap and water first.14
○​ Apply the antiseptic using vigorous friction over the intended
insertion site and surrounding skin (covering an area of at
least 5cm) for the manufacturer-recommended time,
typically 30 seconds.34 Application technique
(back-and-forth vs. concentric circles) may depend on the
applicator type.35
3.​ Drying Time: Allow the antiseptic solution to air dry completely
before proceeding with venipuncture.23 This usually takes at least
30 seconds and is crucial for antimicrobial efficacy.35
4.​ Maintain Asepsis (No-Touch Technique): After the site is
prepped and dried, do not touch or re-palpate the insertion
site.16 If the site is inadvertently touched, it must be cleaned
again with antiseptic and allowed to dry before proceeding.
5.​ Hair Removal: If excessive hair interferes with site visualization,
dressing adherence, or antisepsis, remove it using clippers with a
disposable head.22 Do not shave the site with a razor, as this can
cause micro-abrasions that increase the risk of infection.22

E. Cannula Insertion: Technique and Best Practices

This phase requires dexterity, precision, and adherence to technique
to ensure successful vein entry and catheter placement while
minimizing trauma.
1.​ Reapply Tourniquet: If it was released during site preparation,
reapply the tourniquet snugly above the insertion site.34 Verify
the presence of a distal pulse.34
2.​ Stabilize the Vein: Use the thumb of your non-dominant hand to
gently pull the skin taut distal to (below) the insertion site.32 This
anchors the vein, prevents it from rolling during puncture, and
makes skin penetration easier. Maintain traction throughout the
insertion process.35
3.​ Inform Patient: Just before insertion, warn the patient they will
feel a "sharp scratch".34
4.​ Insert the Needle:
 ○​ Hold the catheter device in your dominant hand, ensuring the
needle bevel is facing upwards.35 The sharpest point of the
bevel enters first, facilitating smoother skin penetration.35
○​ Approach the vein directly from above or slightly from the
side, aligning the needle with the direction of the vein.41
○​ Puncture the skin smoothly at a low angle, typically 10-30
degrees relative to the skin surface.29 The angle may need
adjustment based on vein depth: shallower (e.g., 10-15°) for
superficial veins (common in hands, elderly, pediatrics) and
steeper (e.g., 30-45°) for deeper veins (often targeted with
ultrasound).32
5.​ Observe for Flashback: Advance the needle slowly and steadily
into the vein. Watch the flashback chamber at the back of the
needle hub for the appearance of blood.35 This primary flashback
confirms the needle tip has entered the vein lumen. Note that
flashback may be slow or even absent in very small veins or when
using small gauge cannulas (e.g., 24G), particularly in neonates.41
6.​ Advance Unit Slightly and Lower Angle: Once primary
flashback is observed, pause advancement momentarily. Lower
the angle of the entire device so it is almost parallel to the skin.32
Then, advance the entire unit (needle and catheter together) a
small distance further into the vein, typically 2-3 millimeters.32
This critical maneuver ensures that the tip of the plastic catheter,
which sits slightly behind the needle's bevel, is fully inside the
vein lumen before attempting to thread the catheter off the
needle.32 Skipping this step or advancing the catheter
prematurely is a common cause of infiltration or "blowing" the
vein during catheter advancement.32
7.​ Advance the Catheter (Threading): Hold the needle hub
stationary with one hand (or fingers) while using the index finger
or thumb of the same or other hand to gently push the plastic
catheter hub forward, sliding it off the needle and advancing it
fully into the vein until the hub rests against the skin.35 Advance
the catheter smoothly and without force. Maintain skin traction
with the non-dominant hand during this process.44 If resistance
is met, do not force the catheter; it may indicate hitting a valve or
exiting the vein.
8.​ Release Tourniquet: Once the catheter is fully advanced,
release the tourniquet.35
9.​ Apply Pressure and Remove Needle: Place a small piece of
sterile gauze under the catheter hub if desired.55 Apply gentle
digital pressure to the vein proximal to (just above) the tip of the
indwelling catheter to occlude venous flow and minimize blood
spillage when the needle is removed.35 While maintaining
pressure and stabilizing the catheter hub, carefully withdraw the
stylet (needle) completely.35 Immediately activate the needle
safety mechanism if present.44
10.​Dispose of Sharps: Immediately discard the needle/stylet into a
designated sharps container within arm's reach.41
11.​ Connect Extension Set and Flush: Quickly and aseptically
remove the protective cap from the primed extension
set/needleless connector and attach it securely to the catheter
hub (usually a Luer-lock connection).35 Release digital pressure
over the vein. Gently aspirate the attached saline flush syringe to
check for blood return (verifies placement, but may not occur
even with correct placement, especially with small
catheters/veins).18 Slowly and gently flush the catheter with 3-5
mL (for adults) of sterile 0.9% sodium chloride using a pulsatile
(push-pause) technique.41 During the flush, carefully observe the
insertion site for any signs of swelling, leakage, or blanching, and
ask the patient about any pain or discomfort.18 The flush should
proceed easily with minimal resistance.56 If resistance, swelling,
or pain occurs, stop flushing immediately, as the catheter may be
malpositioned or infiltrated. After flushing, clamp the extension
set (if applicable) using positive pressure technique (clamping
while injecting the last small amount of saline) to prevent blood
reflux into the catheter tip.2 Remove the flush syringe.
12.​Limit Attempts: Adhere strictly to institutional policy and best
practice guidelines regarding the maximum number of insertion
attempts. Generally, no more than two attempts should be made
by a single clinician.14 After two unsuccessful attempts by one
nurse, escalate to a colleague with greater skill, a vascular
access specialist/team, or consider alternative access methods
(e.g., ultrasound guidance, central line if indicated).9 A maximum
total of 3 or 4 attempts per patient episode is often
recommended before reconsidering the need for peripheral
access or escalating further.11 Multiple failed attempts increase
patient trauma, risk of complications, and delay necessary
 treatment.10

F. Securing the Cannula and Dressing Application

Proper securement and dressing are vital to prevent catheter
dislodgement, minimize movement, protect the site from
contamination, and allow for ongoing assessment.
1.​ Catheter Securement:
○​ Immediately after confirming placement and flushing,
stabilize the catheter hub to prevent pistoning (in-and-out
movement) or accidental removal.22
○​ Utilize a securement method according to best practice and
institutional policy. Options include:
■​ Sterile Tape: Apply sterile tape strips directly over the
catheter wings (if present) or across the hub.41 Common
methods include the "U," "H," or "Chevron" taping
techniques.97 An "under and over" taping method (tape
under the hub, crossed over top) has shown significantly
greater securement force compared to simple horizontal
taping.108
■​ Engineered Stabilization Devices (ESDs): These are
adhesive devices specifically designed to anchor the
catheter hub to the skin. They are recommended by
guidelines like the CDC and RCN to reduce catheter
movement and potentially lower infection risk compared
to tape or sutures alone.5
■​ Tissue Adhesive: Medical-grade cyanoacrylate glue
applied under the hub at insertion can provide strong
securement, reduce micro-movement, and aid
hemostasis.34
■​ Integrated Securement Dressings: Some transparent
dressings incorporate built-in securement borders or
strips.34
○​ Avoid using non-sterile tape directly on the insertion site or
under the primary sterile dressing.
○​ Avoid circumferential taping around the limb, as this can act
as a tourniquet, impairing circulation and infusion.63
○​ Ensure the securement method does not obscure the view of
the insertion site itself.2
 ○​ The combination of a primary securement method
(tape/ESD/glue) plus a sterile dressing offers the best
protection against both macro-dislodgement and
micro-movement.63 Preventing micro-movement within the
vein is increasingly recognized as crucial for reducing
mechanical irritation, subsequent phlebitis and thrombosis,
and ultimately extending the functional dwell time of the
catheter.63
2.​ Dressing Application:
○​ Apply a sterile, transparent, semipermeable membrane (TSM)
dressing (e.g., Tegaderm™, IV3000™) centered over the
insertion site, ensuring it completely covers the site and the
catheter hub.2 TSM dressings allow continuous visual
inspection of the site, are impermeable to external
contaminants, yet allow moisture vapor to escape.2
○​ If the insertion site is bleeding or oozing significantly, a sterile
gauze dressing may be applied initially, but it should be
replaced with a TSM dressing as soon as the bleeding/oozing
resolves.22 Gauze dressings obscure site visualization and
require more frequent changes (typically every 2 days for
CVCs).22
○​ Apply the dressing smoothly without stretching it, as tension
can cause skin irritation or blistering and may lead to
premature loosening.63 Gently pat or press the dressing
edges to ensure a complete seal.63
○​ Consider placing a small piece of sterile gauze or cotton ball
under the catheter hub before applying the dressing to
cushion the area and prevent pressure injury, especially in
pediatric or frail-skinned patients.41
3.​ Tubing Securement:
○​ Create a "J-loop" or safety loop with the extension tubing
and secure it to the patient's skin with additional tape,
separate from the primary dressing.97 This prevents direct
pulling on the catheter hub if the tubing gets caught,
reducing the risk of dislodgement and irritation.
4.​ Labeling:
○​ Label the edge of the dressing (not obscuring the site) with
the date and time of insertion, the catheter gauge and
length, and the inserter's initials, according to institutional
 policy.16
5.​ Splinting:
○​ If the IV site is near a joint (e.g., wrist, ACF, or in active
children/infants), consider applying a commercially available
or appropriately padded splint or armboard to immobilize the
joint and prevent catheter kinking or dislodgement.2
○​ Ensure the splint is applied correctly, does not impair
circulation (check distal pulses/capillary refill), does not
cause pressure points, and does not cover the insertion site,
allowing for continued assessment.2 Remove periodically
(e.g., every 8 hours) to assess skin and circulation if policy
dictates.69

G. Documentation Essentials
Accurate, complete, and timely documentation is a critical
component of safe IV therapy practice and professional
accountability.
1.​ Record Promptly: Document the procedure and related
assessments in the patient's medical record immediately after
completion, adhering to agency policy and standards.1
2.​ Essential Elements: Documentation of PIVC insertion should
include, at minimum:
○​ Date and Time of insertion.16
○​ Number of Attempts: Record the number of attempts made
for successful insertion, as well as any unsuccessful
attempts.22
○​ Catheter Details: Type of catheter used, gauge size, and
length.16
○​ Insertion Site: Precise anatomical location (e.g., "dorsal
aspect of left hand, metacarpal vein," "right forearm, cephalic
vein, 5 cm proximal to wrist").16
○​ Site Preparation: Antiseptic agent used (e.g.,
CHG/alcohol).53
○​ Dressing and Securement: Type of dressing applied (e.g.,
TSM) and method of securement (e.g., tape, ESD).22
○​ Patency Confirmation: How patency was confirmed (e.g.,
"good blood return aspirated," "flushed easily with 5mL 0.9%
NaCl without resistance or swelling").18
 ○​ Patient Tolerance: How the patient tolerated the
procedure.34
○​ Complications: Any difficulties or complications
encountered during insertion (e.g., hematoma formation,
nerve paresthesia) and actions taken.22
○​ Patient Education: Confirmation that patient education
regarding the IV was provided.34
○​ DIVA Status: If the patient meets criteria for Difficult
Intravenous Access.26
○​ Ultrasound Use: If ultrasound guidance was used for
insertion.54
○​ Initiated Fluids: If an infusion was started immediately,
document the type of fluid, rate, and method (pump or
gravity).115 If a saline lock was placed, document this.115
○​ Nurse Identification: Signature and credentials/designation
of the nurse performing the insertion.16
3.​ Purpose and Importance: This detailed documentation serves
multiple critical functions. It provides a legal record of the care
provided.1 It ensures clear communication among the healthcare
team regarding the access device details and status. It allows for
tracking of the catheter's dwell time, informing decisions about
routine replacement or removal. It facilitates monitoring of
complication rates (e.g., using documented VIP scores for
phlebitis 22) both for individual patients and for institutional
quality improvement initiatives.22 In essence, meticulous
documentation is not merely an administrative task but an
integral part of providing safe, accountable, and high-quality IV
therapy.

V. Maintaining Optimal IV Access

Once peripheral IV access is successfully established, ongoing
vigilance and adherence to maintenance protocols are essential to
ensure the catheter remains functional, prevent complications, and
provide safe therapy.

A. Routine Site Assessment and Monitoring

Regular and systematic assessment of the PIVC site and infusion
system is the cornerstone of effective maintenance and early
complication detection.
1.​ Frequency: The required frequency of assessment depends on
the patient's condition, the type of infusion, and institutional
policy, but must be performed regularly:
○​ Continuously Infusing PIVCs: Assess at least every 4 hours
for standard infusions (e.g., maintenance fluids).2 More
frequent assessment (at least hourly) is required for patients
receiving critical care, high-risk medications (e.g., vesicants,
vasopressors, concentrated electrolytes), continuous
infusions with intermittent medications added, or
large-volume boluses.2 All pediatric and neonatal patients
typically require hourly checks.2 Agency policy may dictate
more frequent checks (e.g., q 1-2 hours).5
○​ Saline Locked PIVCs: Assess regularly when not in use,
typically every 8 to 12 hours or per institutional policy.2
Assessment should also occur immediately before and after
any intermittent use (flushing or medication administration).
○​ Other Triggers: Assess the site whenever the patient reports
pain or discomfort, if the infusion pump alarms frequently, or
if there is any change in the patient's clinical condition.2
Assessment frequency should be increased for patients who
are unable to report symptoms (e.g., non-verbal, sedated,
cognitively impaired).71
2.​ Assessment Method (TLC): Employ a systematic approach,
often summarized as "Touch, Look, Compare" (TLC) 2:
○​ Touch: Gently palpate the insertion site through the intact
transparent dressing to assess for tenderness, pain, firmness
(induration), edema (swelling), and temperature (coolness
suggesting infiltration, warmth suggesting
phlebitis/infection).2
○​ Look: Visually inspect the insertion site and surrounding area
through the transparent dressing.2 Look for redness
(erythema), swelling, blanching, blistering, leakage, purulent
drainage, or streaking along the vein. Ensure the dressing is
clean, dry, and intact, with edges well-adhered.2 Check that
the catheter hub is secure and that the tubing is free of kinks
and properly connected.2 Assess the infusion: check the type
of solution hanging against the order, the programmed rate
 on the pump (if used), the volume remaining in the bag, and
whether the fluid is dripping correctly (if on gravity).2
○​ Compare: Compare the assessed limb with the patient's
opposite limb, looking for differences in size (swelling), color,
or temperature.2
3.​ Phlebitis Scoring: Utilize a standardized Visual Infusion Phlebitis
(VIP) scale or similar tool adopted by the institution to objectively
grade the severity of any observed phlebitis.22 This aids in
consistent assessment, communication, and determining
appropriate interventions. See example scale below.​
Table: Example Visual Infusion Phlebitis (VIP) Scale​
(Adapted from 59)

Score Clinical Criteria Action

0 IV site appears healthy Observe Cannula

1 One of the following is Observe Cannula

evident: Slight pain near IV
site OR slight redness near IV
site

2 Two of the following are Resite Cannula

evident: Pain at IV site,
Erythema, Swelling

3 All of the following signs are Resite Cannula, Consider

evident: Pain along path of Treatment
cannula, Erythema, Induration

4 All of the following signs are Resite Cannula, Consider

evident and extensive: Pain Treatment
along path of cannula,
Erythema, Induration,
Palpable venous cord

5 All of the following signs are Resite Cannula, Consider

evident and extensive: Pain Treatment
along path of cannula,
Erythema, Induration,
Palpable venous cord, Pyrexia
(Fever)
 4.​ Documentation: Meticulously document all assessment findings
in the patient's record at the frequency required by policy.2 This
includes site appearance (redness, swelling, etc.), presence of
pain/tenderness, dressing condition, confirmation of infusion
rate/solution, any complications noted, interventions performed,
and patient response. Use the standardized phlebitis score if
applicable.

The rationale for such frequent and systematic assessment lies in the
potential for complications like infiltration, extravasation, or phlebitis
to develop rapidly, especially with certain medications or in
vulnerable patient populations.5 Relying solely on scheduled checks
(e.g., every 4 or 8 hours) may result in delayed detection, potentially
leading to more severe tissue damage, nerve injury, compartment
syndrome, or infection.33 Constant vigilance and adherence to
rigorous assessment protocols are therefore critical preventative
strategies, enabling early intervention and minimizing patient harm.

B. Flushing Protocols for Patency

Regular flushing of PIVCs is essential to maintain catheter patency
and prevent complications related to occlusion or incompatible drug
mixing.
1.​ Purpose: Flushing clears the catheter lumen of blood, fibrin
deposits, medication residue, or precipitates, thereby preventing
thrombotic and non-thrombotic occlusions.2 It also serves to
separate incompatible medications administered sequentially
through the same line.22 Flushing is also used to assess patency
before administering any medication or infusion.22
2.​ Solution and Volume:
○​ Solution: Sterile 0.9% sodium chloride (normal saline) is the
standard flushing solution for peripheral IV catheters and
midlines.2 Studies suggest saline alone is as effective as
heparin for maintaining patency of peripheral lines and even
some central lines, avoiding the risks associated with
heparin.25 Prefilled saline syringes are preferred when
available as they reduce the risk of contamination during
preparation.105
○​ Volume: The volume flushed must be sufficient to clear the
internal volume of the catheter and any attached extension
 set or needleless connector.2 A general guideline is to use at
least twice the internal volume of the catheter system.22 For
PIVCs and midlines, typical flush volumes range from 3 mL to
10 mL.2 For central lines (PICCs, CVCs), a 10 mL flush is
standard.25 After infusing viscous solutions like parenteral
nutrition or lipids, a larger flush volume (e.g., an additional 10
mL) may be needed to adequately clear the lumen.106
3.​ Frequency: Flushing should occur at specific intervals and
events:
○​ Immediately after catheter placement to confirm patency.2
○​ Immediately before and immediately after each intermittent
medication administration or bolus injection.2
○​ Between the administration of incompatible medications.22
○​ Before and after drawing blood samples from the line (more
common with CVCs).2
○​ Before initiating an infusion and after an infusion bag runs
dry (as normal venous pressure can cause blood reflux into
the catheter when infusion pressure is lost).2
○​ Routinely for catheters that are not in continuous use (saline
locks) to maintain patency. Frequency varies by institutional
policy but is often every 12 to 24 hours.70
4.​ Technique: The method of flushing is crucial for effectiveness:
○​ Asepsis: Always use ANTT. Vigorously scrub the needleless
connector hub with a CHG/alcohol or alcohol swab for at
least 15 seconds and allow it to air dry completely before
attaching the flush syringe.2
○​ Syringe Size: Use a syringe with a 10 mL barrel diameter
(e.g., a standard 10 mL syringe or a 5 mL prefilled syringe
manufactured in a 10 mL barrel).104 Smaller diameter syringes
(e.g., 3 mL, 5 mL) generate significantly higher pressure per
unit of force applied to the plunger, which can potentially
damage the vein or rupture the catheter.104
○​ Aspiration: Before flushing, gently attempt to aspirate for
blood return.18 Presence of blood confirms intraluminal
placement, but its absence does not definitively rule it out,
especially in small PIVCs. If blood return is absent, proceed
cautiously with the flush, assessing for resistance or signs of
infiltration.70
○​ Turbulent (Push-Pause) Flush: Inject the saline using short,
 alternating pulses of pressure on the plunger (e.g., injecting
1-2 mL, pausing briefly, injecting the next 1-2 mL, etc.).2 This
push-pause technique creates turbulence within the catheter
lumen, which is thought to be more effective at dislodging
and clearing debris, fibrin, and medication residue compared
to a smooth, continuous injection.104
○​ Avoid Bottoming Out: Do not push the syringe plunger all
the way to the end of the barrel, as this can cause negative
pressure and reflux of blood back into the catheter tip upon
disconnection.106
○​ Positive Pressure Locking: To prevent blood reflux into the
catheter tip when disconnecting the syringe (which can lead
to occlusion), use a positive pressure technique. This involves
maintaining forward pressure on the syringe plunger while
clamping the extension set (if it has a clamp) just before or
as the syringe is disconnected.2 The exact sequence
(flush-clamp-disconnect vs. flush-disconnect-clamp)
depends on the type of needleless connector used (positive,
negative, or neutral displacement); refer to manufacturer
instructions and institutional policy.106
5.​ TKVO vs. Intermittent Locking: The choice between
maintaining line patency with a continuous low-rate "To Keep
Vein Open" (TKVO) infusion (typically 10-25 mL/hr) or using
intermittent saline locks depends on the patient's needs.2 TKVO
provides constant flow but tethers the patient to an infusion
pump. Intermittent locking allows for greater patient mobility
between doses but relies heavily on consistent and correct
flushing protocols (frequency, volume, technique) to prevent
occlusion.2 Limited evidence directly compares the two methods
for PIVCs not requiring continuous infusion, making it a clinical
decision based on patient factors and adherence capabilities.2

Proper flushing is not merely about injecting saline; it is a skilled

procedure requiring knowledge of the correct solution, volume,
frequency, and, critically, the technique (asepsis, syringe size,
push-pause method, positive pressure locking). Consistent
application of these principles is vital for maintaining IV access and
preventing complications.
C. Dressing, Tubing, and Needleless Connector Changes
Routine changes of IV site dressings, administration sets (tubing),
and needleless connectors are essential components of infection
prevention and IV site maintenance. Change intervals are based on
evidence balancing infection risk reduction with the potential harms
and costs of frequent manipulation.
1.​ Dressings:
○​ Indications for Change: Peripheral IV dressings (typically
TSM) must be changed immediately if the integrity is
compromised (e.g., damp, loose, lifting edges, visibly soiled)
or if infection at the site is suspected.16
○​ Routine Change Frequency: While guidelines specify
routine change intervals for CVC dressings (TSM at least
every 7 days, gauze every 2 days 22), the optimal frequency
for routine PIVC dressing changes is less clearly defined and
often dictated by institutional policy.22 Some sources align
PIVC TSM changes with CVCs (e.g., every 7 days) 22, while
others focus primarily on changing only when indicated
(loose, soiled, damp). Adhere to institutional policy.
○​ Procedure: Use aseptic technique. Perform hand hygiene
and don clean or sterile gloves.22 Carefully remove the old
dressing "low and slow," pulling parallel to the skin in the
direction of hair growth while supporting the skin to minimize
trauma.63 Inspect the site thoroughly. Cleanse the site with an
appropriate antiseptic (e.g., CHG/alcohol) and allow it to dry
completely.22 Apply a new sterile TSM dressing. Label with
date of change and initials.69
2.​ Administration Sets (Tubing): Change frequency depends on
the type of infusion:
○​ Continuous Infusions (non-lipid, non-blood): Replace
tubing used for continuous infusions no more frequently than
every 96 hours (4 days), but at least every 7 days.49 This
reflects evidence showing longer intervals are safe and
reduce cost/manipulation.
○​ Blood and Blood Products: Tubing used for transfusing
blood or blood components must be changed after
completion of the unit or every 4 hours, whichever comes
first, but generally within 24 hours of initiating the transfusion
 sequence.22
○​ Parenteral Nutrition (PN) / Fat Emulsions (Lipids): Tubing
used for lipid-containing solutions (including 3-in-1 PN)
should be changed every 24 hours.22 If lipids are infused
separately, change that tubing every 12 hours. Tubing for
amino acid/dextrose solutions (without lipids) follows
continuous infusion guidelines (q 96h - 7 days).
○​ Propofol Infusions: Due to lipid base and risk of microbial
growth, change propofol tubing every 6 to 12 hours, or
whenever the vial is changed, per manufacturer guidelines.49
○​ Intermittent Infusions: Administration sets used for
intermittent infusions (e.g., IV piggybacks) that are
disconnected between uses should generally be changed
every 24 hours due to the increased risk of contamination
with repeated connections/disconnections.
○​ Labeling: Always label IV tubing with the date and time it was
initiated or changed.71
○​ Compatibility: Ensure all components of the infusion system
(tubing, connectors, pump) are compatible to prevent leaks
or malfunctions.24
3.​ Needleless Connectors (Caps):
○​ Change Frequency: Change needleless connectors at least
as frequently as the administration set is changed (e.g., every
72-96 hours or up to 7 days, depending on set type and
policy).24 Some manufacturers may have specific
recommendations. Do not change more frequently than
every 72 hours solely for infection prevention purposes.24
Change immediately if contaminated, contains residual blood
or debris, or is damaged. Change weekly for PICCs.104
○​ Access: Crucially, always disinfect the connector surface by
scrubbing vigorously with an appropriate antiseptic
(CHG/alcohol, alcohol, povidone-iodine) for the
recommended time (e.g., 15 seconds) and allow it to dry
completely before every access with a syringe or tubing.2
Access only with sterile devices.24
○​ Type: When possible, split-septum valves may be preferred
over some mechanical valve designs due to potentially lower
infection risks associated with the latter.24
○​ Antiseptic Caps: Consider using antiseptic-impregnated
 caps that cover the connector when not in use, particularly
for central lines, as a supplemental strategy.49

Adherence to standardized change intervals for these components is

a key element of infection control bundles. Policies must be
evidence-based, reflecting current understanding (e.g., extended
tubing change intervals for continuous fluids 49) while accounting for
the specific risks associated with different infusates like blood, lipids,
or propofol, which necessitate more frequent changes due to their
potential to support microbial growth.22

VI. Recognizing and Managing IV Complications

Despite meticulous technique and maintenance, complications
associated with peripheral IV therapy can still occur. Prompt
recognition and appropriate management are crucial to prevent
patient harm. Complications can be broadly categorized as local
(occurring at or near the insertion site) or systemic.

A. Local Complications
1.​ Phlebitis: Inflammation of the vein's inner lining (tunica intima).
○​ Signs/Symptoms: The hallmark signs include pain or
tenderness along the vein pathway, erythema (redness),
warmth at the site, palpable induration (hardness), and
potentially a palpable venous cord.2 Swelling may also be
present. If purulent drainage occurs, infectious phlebitis is
likely.22 Use a standardized scale (e.g., VIP Scale, see Table
above) for objective assessment and grading.22
○​ Causes: Can be mechanical (catheter movement irritating
the vein wall), chemical (infusate characteristics like high/low
pH, high osmolarity, or specific irritating medications), or
infectious (bacterial contamination).2
○​ Prevention: Use the smallest appropriate gauge catheter,
secure it well to prevent movement, avoid insertion near
joints, dilute irritating medications according to pharmacy
recommendations, administer infusions at the prescribed
rate, maintain strict asepsis during insertion and care, and
remove the catheter promptly when therapy is complete or
complications arise.5
○​ Management: Management depends on the severity and
 suspected cause. For mild phlebitis (VIP score 1), continue
observation; consider slowing the infusion rate or further
diluting the infusate if chemical irritation is suspected, or
improving catheter stabilization if mechanical cause is likely.2
If symptoms worsen or if phlebitis is moderate to severe (VIP
score ≥2), remove the peripheral IV catheter
immediately.2 Apply warm compresses to the affected area
to promote comfort and vasodilation.33 Elevate the limb to
reduce swelling.33 Consider non-steroidal anti-inflammatory
drugs (NSAIDs) for pain and inflammation, if ordered.33 If
infectious phlebitis is suspected (purulent drainage), remove
the catheter, obtain cultures of the drainage and potentially
the catheter tip per policy, clean the site, apply a sterile
dressing, and monitor the patient closely for signs of
systemic infection.22 Document all findings, interventions, and
patient response.22
2.​ Infiltration: The inadvertent leakage of a non-vesicant
(non-damaging) IV solution or medication into the surrounding
subcutaneous tissue.
○​ Signs/Symptoms: Swelling, puffiness, or edema at or near
the insertion site; skin feeling cool to the touch, taut, and
possibly blanched (pale); tenderness, pain, or discomfort;
altered IV flow rate or frequent pump occlusion alarms; fluid
leaking from the insertion site.2
○​ Causes: Common causes include the catheter becoming
dislodged from the vein, the needle piercing through the
opposite vein wall during insertion, excessive patient
movement, inadequate securement, using a fragile vein, or
infusing fluids too rapidly.5
○​ Prevention: Careful site selection (avoiding areas of flexion),
using the appropriate catheter size, securing the catheter
firmly with tape and/or an ESD, stabilizing the limb if
necessary, frequent site assessment (especially
before/during boluses or high-risk infusions), and educating
the patient to report any pain or swelling immediately.5
○​ Management: Stop the infusion immediately upon
suspicion of infiltration.5 Disconnect the tubing and remove
the IV cannula.5 Elevate the affected extremity to promote
fluid reabsorption.33 Apply warm or cold compresses
 according to institutional policy and the type of fluid
infiltrated (warm compresses may aid absorption of isotonic
solutions, while cold may limit spread).69 Assess the extent of
swelling and check distal circulation/nerve function. Monitor
the site for resolution or worsening. Document the infiltration
using a standardized scale if available, the estimated amount
and type of fluid infiltrated, interventions performed, and
patient response.22 Notify the healthcare provider.69 Restart
IV in a different limb or well proximal to the infiltrated site if
continued therapy is needed. Large volume infiltrations can
potentially lead to compartment syndrome, requiring urgent
intervention.81
3.​ Extravasation: The inadvertent leakage of a vesicant (an agent
capable of causing tissue damage, blistering, or necrosis) IV
solution or medication into the surrounding subcutaneous tissue.
This is a more serious event than infiltration.
○​ Signs/Symptoms: Similar to infiltration (swelling, coolness,
pain), but often accompanied by more severe symptoms such
as intense burning or stinging pain, significant erythema,
blistering, ulceration, and potentially tissue necrosis (death)
in later stages.4 Skin discoloration may occur with certain
drugs (e.g., IV iron).81
○​ Causes: Same potential causes as infiltration, but the
consequences are far more severe due to the damaging
nature of the extravasated agent.5 Vesicant drugs include
many chemotherapy agents, vasopressors (like
norepinephrine, dopamine), concentrated electrolytes (e.g.,
potassium chloride, calcium chloride/gluconate), high
osmolarity solutions, and promethazine.
○​ Prevention: Extreme caution is required. Whenever
possible, administer known vesicants through a central
venous access device (CVC or PICC), as these terminate in
large veins where the drug is rapidly diluted.5 If peripheral
administration is unavoidable, use a newly inserted catheter
in a large vein (e.g., forearm), avoid hand/wrist/ACF sites, use
the smallest appropriate gauge, confirm patency with blood
return and a saline flush before starting the vesicant, infuse
slowly, and monitor the site continuously throughout the
infusion.22 Secure the catheter meticulously. Educate the
 patient to report any sensation changes immediately. Obtain
specific informed consent for high-risk drugs like IV iron if
required by policy.81
○​ Management: Extravasation is an emergency requiring
immediate action. Stop the infusion immediately.5 Do not
remove the catheter yet. Disconnect the administration set
from the catheter hub. Attempt to gently aspirate any
residual drug back through the catheter using a small syringe
(e.g., 3-5 mL) to minimize the amount remaining in the
tissue.33 Then, remove the catheter.33 Notify the healthcare
provider and pharmacy immediately.22 Follow institutional
protocols and specific antidote guidelines for the
extravasated drug (these vary widely; some require specific
injectable antidotes like hyaluronidase or phentolamine, while
others involve specific compress application – cold for most
chemotherapy agents, warm for vinca alkaloids and
vasopressors).22 Elevate the affected limb.117 Avoid applying
pressure to the area. Mark the affected area, and photograph
it per policy.117 Document the event meticulously, including
the drug, estimated volume extravasated, signs/symptoms,
time of discovery, interventions (including antidote
administration), and patient response, using specific
extravasation forms and incident reporting systems.22 Close
follow-up is essential, as tissue damage can evolve over
days; surgical debridement or skin grafting may be required
in severe cases.117
4.​ Hematoma: A localized collection of blood that leaks out of the
vein into the surrounding tissue, essentially a bruise at the IV site.
○​ Signs/Symptoms: Discoloration (bruising, ecchymosis),
localized swelling, and tenderness at the site.3
○​ Causes: Most commonly occurs if the needle punctures
through the posterior (back) wall of the vein during insertion,
if inadequate pressure is applied to the site after catheter
removal, or in patients with fragile veins or those on
anticoagulant therapy.22
○​ Prevention: Use careful, controlled insertion technique to
avoid puncturing the back wall. Apply firm, direct pressure
with sterile gauze for at least 2-3 minutes immediately after
removing the catheter, longer if the patient is on
 anticoagulants.22 Assess patient's bleeding risk beforehand.22
○​ Management: If it occurs during insertion and the catheter is
not functional, remove it. If the catheter is functional, the
hematoma may resolve on its own, but monitor closely. If it
occurs after removal, apply firm direct pressure until bleeding
stops.22 Apply a pressure bandage if necessary.119 Elevate the
limb. Cold compresses initially may help limit bruising,
followed by warm compresses later if desired.
5.​ Occlusion/Catheter Blockage: The inability to infuse fluids or
flush the catheter.
○​ Signs/Symptoms: Resistance felt when attempting to flush,
inability to infuse fluids, sluggish flow rate, frequent
downstream occlusion alarms on the infusion pump.2
○​ Causes: Can be thrombotic (blood clot within or at the tip of
the catheter), non-thrombotic (e.g., medication precipitate
due to incompatibility, lipid residue), or mechanical (kinked
catheter or tubing, clamped line, patient positional changes
compressing the vein or catheter, catheter tip against the
vein wall).2
○​ Prevention: Adhere to strict flushing protocols (correct
solution, volume, frequency, technique – especially
push-pause and positive pressure).2 Ensure compatibility of
all medications and solutions administered through the line.
Avoid kinking tubing during securement. Use appropriate
catheter size and secure well. Address pump alarms
promptly.
○​ Management: First, assess for and correct any obvious
mechanical causes: check for clamps being closed, kinks in
the tubing or under the dressing, ensure the patient's
position isn't obstructing flow.2 Attempt to gently flush with
normal saline using a 10 mL syringe.22 Never forcefully flush
against resistance, as this could dislodge a clot
(embolization risk) or rupture the catheter.22 If gentle flushing
meets resistance or fails to restore patency, the catheter is
likely occluded and must be removed. For CVCs, specific
protocols involving thrombolytic agents (like alteplase) may
be used for suspected thrombotic occlusions, but this is not
typically done for PIVCs.22
6.​ Catheter Dislodgement: The unintentional partial or complete
 removal of the catheter from the vein.
○​ Signs/Symptoms: Catheter is visibly pulled back from the
insertion site, infusion may have stopped or infiltrated, pain
may be present, bleeding at the site.2
○​ Causes: Inadequate securement of the catheter hub and/or
tubing, patient confusion or agitation leading to pulling at the
line, catching the tubing on furniture or equipment during
movement.2
○​ Prevention: Use robust securement techniques (appropriate
dressing, tape/ESD, J-loop for tubing), educate cooperative
patients about protecting the site, use splints or protective
coverings (like Surgifix or bandaging) for at-risk patients
(pediatrics, confused elderly).2
○​ Management: Stop the infusion immediately. Assess the site.
If partially dislodged, do not attempt to re-advance; remove
the catheter completely. Apply direct pressure with sterile
gauze to control any bleeding.2 Assess the need for
continued IV access and restart at a new site if required.
7.​ Local Site Infection: Bacterial contamination and infection
localized to the catheter insertion site.
○​ Signs/Symptoms: Erythema (redness), warmth, swelling,
and tenderness specifically at the insertion site, often
accompanied by purulent drainage (pus).3 These signs
typically appear 2-3 days after insertion.33
○​ Causes: Primarily due to breaks in aseptic technique during
insertion or subsequent site care/access, use of
contaminated equipment or solutions, or the dressing
becoming wet, soiled, or losing its seal, allowing
microorganisms to enter.5
○​ Prevention: Strict adherence to ANTT and hand hygiene
during all phases of IV therapy. Proper skin antisepsis before
insertion. Use of sterile dressings and equipment. Regular
site assessment and prompt changing of compromised
dressings. Thoroughly scrubbing the hub before each
access.5
○​ Management: Stop any infusions. Remove the IV catheter.5
Cleanse the site gently with sterile saline or antiseptic. Obtain
a culture specimen from any purulent drainage, and
potentially culture the catheter tip according to institutional
 policy.22 Apply a dry sterile dressing. Monitor the site for
resolution and the patient for signs of systemic infection
(fever, chills, malaise). Notify the healthcare provider.
Document findings and actions. Topical or systemic
antibiotics may be required based on severity and culture
results.
8.​ Nerve Injury: Accidental damage to a peripheral nerve during
venipuncture or from the indwelling catheter.
○​ Signs/Symptoms: Patient reports immediate, sharp,
shooting, or "electric shock-like" pain radiating along the
nerve distribution during needle insertion; persistent
paresthesia (tingling, numbness, "pins and needles"),
burning, or pain after insertion or during infusion.33
○​ Causes: Direct trauma from the needle hitting a nerve,
compression of a nerve by a hematoma or infiltrated fluid,
chemical irritation from extravasated medication near a
nerve.
○​ Prevention: Thorough knowledge of anatomy to avoid known
nerve pathways (especially at the wrist). Careful site
selection. Gentle insertion technique. Stabilizing the vein
properly to prevent sudden movements. Immediate cessation
of advancement if the patient reports characteristic nerve
pain.9
○​ Management: If the patient reports sharp, radiating pain or
paresthesia during insertion, stop advancing immediately
and withdraw the needle/catheter.33 Do not proceed at
that site. Assess the patient's neurological status (sensation,
motor function) distal to the site. Report the event to the
healthcare provider immediately. Document the patient's
symptoms, the location, the actions taken, and the
assessment findings.33 If symptoms persist after removal,
further investigation may be needed.

The ability to differentiate between these local complications is

crucial for appropriate management. Careful assessment considering
the constellation of signs and symptoms (e.g., coolness points to
infiltration, warmth to phlebitis, blistering to extravasation, purulence
to infection), along with knowledge of the infusate's properties
(vesicant vs. non-vesicant), guides the correct diagnosis and
intervention.5 Relying on a single symptom like swelling or redness
can be misleading, as these are common to multiple complications.

B. Systemic Complications
While less common with peripheral IVs than central lines, systemic
complications can occur and may be life-threatening.
1.​ Catheter-Related Bloodstream Infection (CRBSI/BSI): The
presence of bacteria or fungi in the bloodstream originating from
the IV catheter. While often associated with central lines
(CLABSI), PIVCs can also be a source.4 Staphylococcus aureus is
a common pathogen associated with PIVC-BSI.12
○​ Signs/Symptoms: Systemic signs include fever, chills,
tachycardia, hypotension, malaise, altered mental status,
elevated white blood cell count.4 Local signs of infection at
the insertion site may or may not be present.22
○​ Prevention: Primarily through meticulous adherence to
infection prevention bundles: strict hand hygiene, optimal
aseptic technique during insertion and maintenance, proper
skin antisepsis (CHG/alcohol), use of sterile dressings and
devices, routine site care, scrubbing the hub before access,
appropriate site selection, removing catheters promptly when
no longer needed, staff education and competency
validation, and potentially use of technologies like sutureless
securement devices or antiseptic caps.5
○​ Management: Suspected CRBSI is a medical emergency.
Notify the provider immediately. Obtain blood cultures
(typically two sets from peripheral sites, plus potentially a
culture drawn through the suspected line if it's a CVC).22
Remove the suspected catheter promptly; the tip may be
sent for culture per institutional policy.22 Administer
broad-spectrum antibiotics as ordered, pending culture
results. Monitor vital signs and patient status closely.
2.​ Air Embolism: The entry of air into the venous circulation, which
can obstruct blood flow, particularly in the pulmonary circulation
or heart.
○​ Signs/Symptoms: Sudden onset of dyspnea (shortness of
breath), tachypnea, cyanosis, chest pain, hypotension,
tachycardia, altered mental status (anxiety, confusion, loss of
 consciousness), churning "mill wheel" murmur heard over the
precordium.22 A significant air embolism (often cited as >50
mL, but smaller amounts can be dangerous, especially in
pediatrics or those with cardiac shunts) can be rapidly fatal.87
○​ Causes: Failure to adequately prime air out of IV tubing
before connection, air entering through disconnected tubing
or loose connections, air infused from an empty IV bag when
using a pump without adequate air detection, air entry during
CVC insertion or removal.6
○​ Prevention: Meticulously prime all air from IV tubing and
add-on devices before connecting to the patient. Ensure the
drip chamber is appropriately filled (usually 1/3 to 1/2 full).87
Use Luer-lock connections and ensure they are securely
tightened.22 Clamp tubing appropriately during bag changes
or disconnections. Utilize infusion pumps with functioning
air-in-line detectors.22 Take specific precautions during CVC
insertion and removal (e.g., Trendelenburg positioning,
Valsalva maneuver).22
○​ Management: This is a critical emergency. Immediately
clamp the catheter/tubing to prevent further air entry.22
Position the patient in the left lateral Trendelenburg
position (head down, lying on the left side).22 This position
helps trap air in the apex of the right ventricle, preventing it
from entering the pulmonary artery. Administer 100% oxygen
via non-rebreather mask to help reduce the size of the air
bubble.22 Call for immediate medical assistance (Rapid
Response Team or code team). Monitor vital signs
continuously. Notify the provider urgently.
3.​ Fluid Overload (Circulatory Overload): Administration of a
larger volume of IV fluid than the patient's circulatory system can
tolerate.
○​ Signs/Symptoms: Respiratory distress (dyspnea, orthopnea,
tachypnea, cough), adventitious lung sounds (crackles/rales),
hypertension, tachycardia, bounding pulse, jugular vein
distention (JVD), peripheral edema, rapid weight gain, dilute
urine.5
○​ Causes: Infusion rate set too high, incorrect fluid volume
prescribed or administered, rapid infusion of fluid boluses, or
underlying patient conditions impairing fluid tolerance (e.g.,
 heart failure, renal insufficiency, elderly).5
○​ Prevention: Always verify IV fluid orders (type, rate, volume).
Use an infusion pump for accurate delivery, especially for
high-risk patients or medications.5 Monitor infusion rates
closely. Maintain accurate intake and output records.
Regularly assess patient's respiratory status (lung sounds,
work of breathing), cardiovascular status (vital signs, JVD,
edema), and weight.5 Exercise particular caution in patients
with cardiac or renal disease, the elderly, and pediatric
populations.5
○​ Management: If fluid overload is suspected, slow the
infusion rate immediately to a minimum keep-open rate (or
stop it if ordered/policy allows).22 Raise the head of the bed
to ease breathing. Administer supplemental oxygen as
needed. Notify the healthcare provider promptly. Monitor
vital signs, oxygen saturation, and respiratory status
frequently. Anticipate orders for diuretics (e.g., furosemide).22
Continue close monitoring of fluid balance.
4.​ Electrolyte Imbalance: Can occur as a result of the type or
volume of IV fluids administered (e.g., hyponatremia from
excessive hypotonic fluids, hyperkalemia from
potassium-containing solutions).18 Prevention involves
appropriate fluid selection based on patient needs and careful
monitoring of serum electrolyte levels and clinical signs of
imbalance. Management involves adjusting fluid therapy and
specific electrolyte correction as ordered by the provider.
5.​ Speed Shock: A sudden adverse systemic reaction caused by
the rapid infusion of a medication, leading to toxic plasma levels.
○​ Signs/Symptoms: Dizziness, facial flushing, headache,
tightness in the chest, irregular pulse, hypotension, syncope,
potentially progressing to shock and cardiac arrest.22
○​ Causes: IV medication (especially bolus doses) administered
too quickly, exceeding the recommended rate of infusion.22
○​ Prevention: Strict adherence to recommended
administration rates for all IV medications, as specified in
drug references or institutional protocols. Use an infusion
pump for medications requiring precise rate control. Dilute
medications appropriately. Never "push" medications rapidly
unless specifically indicated (e.g., adenosine in
 emergencies).
○​ Management: Stop the infusion immediately. Call for
help/activate emergency response system. Monitor vital signs
closely. Provide supportive care (e.g., oxygen, fluids) as
needed. Notify the provider. Document the event.

VII. Special Patient Populations: Tailoring Techniques

While the fundamental principles of IV cannulation apply universally,
certain patient populations present unique challenges requiring
adapted techniques and heightened awareness.

A. Pediatric Patients (Infants and Children)

Establishing IV access in pediatric patients can be particularly
challenging due to smaller, more fragile veins, limited cooperation,
and heightened anxiety.
●​ Challenges: Smaller vein size, less subcutaneous tissue support
making veins mobile, difficulty visualizing/palpating veins, limited
sites (scalp veins used in infants), fear and anxiety leading to lack
of cooperation, difficulty securing the catheter adequately.13
Failed first attempts are common (up to 69%).13
●​ Site Selection: Common sites include hands, forearms, feet
(infants/toddlers), and scalp (neonates/young infants).3 Avoid
ACF if possible.
●​ Catheter Size: Typically smaller gauges (22G, 24G, sometimes
25G/26G in neonates) are used.4 Choose the smallest
appropriate size.76
●​ Pain/Anxiety Management: Crucial for success.
○​ Preparation: Perform procedures away from the bedside
("safe space") if possible, in a treatment room.41 Have all
equipment ready beforehand.41
○​ Pharmacologic: Apply topical anesthetics (EMLA, LMX,
AnGel) well in advance (check age restrictions/timing).39
Vapocoolant spray can be used for older children.74 Oral
sucrose is effective analgesia for infants <12 months.29
Consider nitrous oxide for anxious children if available.41
Local anesthetic infiltration may be used for USG access.41
○​ Non-Pharmacologic: Explain procedure using
age-appropriate language.41 Utilize Child Life specialists if
 available. Employ distraction techniques (bubbles, toys,
tablets, VR), relaxation, comfort holds (allow parent/carer
involvement), swaddling for infants.15
●​ Vein Visualization/Dilation: Transillumination devices can be
helpful.26 Gentle warming, gravity. Tourniquet application requires
care to avoid pinching skin; often an assistant's grasp can serve
as a tourniquet in infants.41 Ultrasound guidance is increasingly
used for difficult pediatric access.14
●​ Insertion Technique: Requires skilled assistance for
holding/stabilization.41 Stabilize vein well.41 Use a very shallow
insertion angle (e.g., 10-15 degrees, or lower).41 Advance slowly;
flashback may be minimal or absent.41 Once flashback seen (or
entry felt), advance unit only 1-2mm before threading catheter.41
●​ Securement: Meticulous securement is vital to prevent
dislodgement. Use sterile tapes (e.g., Steri-Strips™ in specific
patterns like "awareness ribbon" or over wings), transparent
dressing (ensure site visible), and often a splint/armboard shaped
to the limb.41 Consider placing cotton/gauze under hub.41 Cover
entire dressing/limb with tubular netting (e.g., Surgifix) or
bandage, ensuring digits/nailbeds remain visible for
assessment.41 Consider bandaging the opposite hand in young
children to prevent tampering.41
●​ Monitoring: Assess site at least hourly due to higher risk of
infiltration/complications.2 Educate parents/caregivers on signs to
report.2
●​ DIVA in Pediatrics: Difficult access is common. Use DIVA
assessment tools (pediatric versions exist, e.g., based on vein
visibility/palpability, age, history) to identify at-risk children
early.11 Escalate to experienced clinicians or use ultrasound after
limited attempts (e.g., 2 per clinician, max 4 total).13

B. Geriatric Patients
Elderly patients often present challenges related to age-related
physiological changes affecting skin and veins.
●​ Challenges: Veins become more fragile, less elastic, and prone
to rolling due to loss of subcutaneous fat and collagen integrity.32
Skin is thinner, tears easily, and bruising (hematoma) is more
common, especially if on anticoagulants.29 Veins may be tortuous
 or sclerosed from previous procedures.78 Dehydration is
common, making veins harder to find.36 Higher risk of fluid
overload.5
●​ Site Selection: Forearm veins are often preferred over hand
veins, which may have very thin skin and be more prone to rolling
or infiltration. Avoid areas with bruising or skin tears.
●​ Catheter Size: Smaller gauges (e.g., 22G or 24G) are often
necessary due to vein size and fragility.9
●​ Vein Dilation: Use gentle techniques. Apply tourniquet lightly or
consider using a blood pressure cuff inflated just enough to
impede venous return (~40-60 mmHg) to avoid over-distending
fragile veins.29 Warm compresses are effective.27 Avoid vigorous
tapping.77 Gravity positioning helps.27
●​ Insertion Technique:
○​ Stabilization: Excellent skin traction below the insertion site is
crucial to anchor rolling veins.32
○​ Angle: Use a lower angle of insertion (e.g., 10-15 degrees)
due to superficial vein location and thin skin.29
○​ Advancement: Advance the catheter slowly and smoothly
after entering the vein to minimize trauma.32 Be prepared for
veins to "blow" easily; if this happens, release the tourniquet
immediately and apply pressure.32
●​ Securement: Use caution with tape removal to prevent skin
tears. Consider using skin barrier wipes before applying
tape/dressing. Use non-adhesive securement devices or gentle
adhesive tapes. Ensure dressing provides adequate stabilization
without excessive pressure.
●​ Monitoring: Assess site frequently for infiltration, phlebitis, and
hematoma. Monitor closely for signs of fluid overload.5

C. Obese Patients
Obesity presents significant challenges due to increased
subcutaneous adipose tissue obscuring veins.
●​ Challenges: Difficulty visualizing and palpating veins due to
overlying adipose tissue.30 Veins may be deeper than usual.30
Traditional landmarks may be obscured.83 Higher risk of difficult
intubation and altered pharmacokinetics if sedation/anesthesia
involved.82 Increased risk of catheter complications, potentially
 including CRBSI.82 Difficulty securing catheters and maintaining
dressing integrity in skin folds.84
●​ Site Selection: Standard sites (hand, forearm, ACF) may be
inaccessible. May need to explore deeper veins in the upper arm
(cephalic, basilic, brachial – use caution near artery).9 The
cephalic vein in the deltopectoral groove may be an option.37
Volar (inner) wrist veins might be palpable when dorsal veins are
not.37 External jugular vein access is possible but difficult in short,
thick necks.37 Avoid inserting within skin folds.84
●​ Vein Dilation/Visualization: Tourniquet may need to be longer
or require assistance to apply effectively. Standard dilation
techniques (warmth, gravity) can be attempted.36 Ultrasound
guidance is strongly recommended and often essential for
successful access in obese patients, especially those with BMI >
40.26 Vein visualization devices (NIR) may also be beneficial.36
●​ Catheter Selection: Longer catheters (e.g., 1.88 inches or longer
peripheral catheters, or midline catheters) are often necessary to
ensure adequate catheter length resides within the deeper vein
lumen.30 Standard length PIVCs may be too short.30
●​ Insertion Technique: Ultrasound guidance requires specific
skills (see Section VIII). A steeper insertion angle (e.g., 45-60
degrees) may be needed to reach deeper veins.38 Careful
landmarking (if not using USG) or precise USG targeting is
critical.
●​ Securement: Achieving secure dressing adherence can be
difficult due to skin folds and moisture. Thoroughly dry skin, use
skin barrier prep, and consider specialized dressings or
additional securement methods.

D. Patients with Difficult Intravenous Access (DIVA)

DIVA refers to patients in whom establishing peripheral IV access is
challenging using standard techniques. It's not limited to specific
populations but can result from various factors.
●​ Definition: Commonly defined by having ≥2 failed insertion
attempts, non-visible/non-palpable veins on physical exam, or a
patient history of difficult access.10 Prevalence estimates vary
widely (6-87%) depending on definition and population.10
●​ Predictive Factors/Risk Assessment: Factors associated with
 DIVA include history of DIVA, non-visible veins, non-palpable
veins, obesity (BMI>30), dehydration, edema, chronic illness (e.g.,
diabetes, renal failure, sickle cell), chemotherapy, IV drug abuse
history, advanced age, very young age, dark skin tone, certain
emergency conditions (hypovolemia, shock).11 Standardized
assessment tools (e.g., A-DIVA scale, C-DIVA tool) can help
prospectively identify patients at risk.28 These tools typically
score factors like vein visibility, palpability, history, and clinical
condition to stratify risk (e.g., low, moderate, high).31
●​ Consequences: Multiple failed attempts lead to patient pain,
anxiety, fear, distress, treatment delays, increased costs, vessel
damage, and potential need for more invasive access (e.g.,
CVC).10
●​ Management Algorithm/Strategies:
○​ Early Identification: Use assessment tools and risk factor
analysis upon admission or before planned IV start.26
○​ Limit Attempts: Strictly adhere to the "two attempts per
clinician, maximum 3-4 total" rule.9
○​ Escalate Appropriately: If initial attempts fail or DIVA is
predicted, escalate promptly to a more experienced clinician,
a dedicated vascular access team/specialist, or utilize
advanced techniques.14 DIVA assessment tools often include
specific escalation pathways based on the score.31
○​ Utilize Technology: Employ vascular visualization aids.
Ultrasound guidance is the most recommended technology
for DIVA, significantly increasing first-attempt success rates
when used by trained clinicians.14 Near-infrared (NIR) devices
can also be helpful.14
○​ Optimize Conditions: Ensure patient is warm, hydrated (if
possible), positioned comfortably, and utilize appropriate
pain/anxiety management techniques.27 Use standard vein
dilation methods (tourniquet, gravity, warmth, gentle
tapping).27
○​ Consider Alternatives: If peripheral access remains
unsuccessful despite escalation and technology use,
consider alternative routes (e.g., intraosseous access in
emergencies) or more definitive vascular access (midline,
PICC, CVC) if appropriate for the therapy duration and type.25
VIII. Advanced Techniques: Ultrasound-Guided
Peripheral IV Cannulation
Ultrasound guidance (USG) has emerged as a highly effective
technique for establishing peripheral IV access, particularly in
patients with DIVA where traditional methods fail. It allows
visualization of veins that are not palpable or visible on the surface.
●​ Indications: Primarily used for patients with known or suspected
DIVA (e.g., obese, edematous, history of difficult access, IV drug
use, chemotherapy patients, shock/hypovolemia) after failed
traditional attempts or when DIVA is predicted.14
●​ Benefits: Significantly increases first-attempt success rates,
reduces the total number of attempts, decreases procedure time
compared to multiple failed attempts, improves patient
satisfaction, reduces pain and anxiety, potentially lowers costs by
avoiding CVC placement, and allows access to deeper, larger
veins.26
●​ Equipment: Requires a portable ultrasound machine with a
high-frequency linear transducer (probe), sterile ultrasound gel,
a sterile probe cover (e.g., Tegaderm, dedicated cover, sterile
glove), appropriate length IV catheter (often longer, e.g., 1.88
inches or more), and standard IV start supplies.30
●​ Training and Competency: USGPIV requires specific training
and demonstrated competency beyond standard PIV insertion
skills.25 Training typically involves didactic learning (ultrasound
basics, anatomy identification, technique) and hands-on practice
with simulation, followed by supervised insertions.85 Many
institutions have dedicated vascular access teams or specially
trained nurses/providers who perform USGPIV.25
●​ Procedure Steps:
1.​ Preparation: Gather supplies, position patient comfortably,
place ultrasound machine for optimal line of sight (operator
between patient arm and machine).38 Set machine to vascular
preset, optimize depth/gain.54 Perform hand hygiene, don
gloves.54
2.​ Site Assessment (Pre-scan): Apply tourniquet high on the
arm.54 Use non-sterile gel initially to scan the arm (typically
upper arm for deeper veins like basilic, brachial, cephalic).38
 Identify a suitable target vein: assess its depth (ideally <1.5
cm, preferably <1.2 cm), diameter (>0.4 cm associated with
higher success), compressibility (to confirm it's a vein and
patent), and trajectory (look for a straight segment).38
Identify and avoid nearby arteries (non-compressible,
pulsatile) and nerves (often appear as hyperechoic,
honeycomb structures).38 Trace the vein proximally and
distally.38
3.​ Site Preparation: Once a target vein is selected, remove
non-sterile gel. Cleanse the skin thoroughly with CHG/alcohol
(30 sec scrub, 30 sec dry).54
4.​ Aseptic Setup: Apply sterile probe cover (e.g., TSM) to the
transducer.54 Apply sterile ultrasound gel over the covered
probe and/or the prepared skin site.54 Reapply tourniquet if
removed.54
5.​ Cannulation (Two Main Approaches):
■​ Short-Axis (Transverse / Out-of-Plane): The probe is
held perpendicular to the vein, visualizing it as a circle in
cross-section.38 Center the vein on the screen. Insert the
needle adjacent to the middle of the probe, aiming
towards the vein.38 Visualize the needle tip as a
hyperechoic (bright) dot entering the screen.38 Crucially,
as the needle advances, the probe must also be
advanced slightly ("walk down" or "slide") just ahead of
the needle tip to continuously track the tip and avoid
mistaking the needle shaft for the tip, which can lead to
posterior wall puncture.38 Follow the tip until it is seen
entering the center of the anechoic vein lumen.92
■​ Long-Axis (Longitudinal / In-Plane): The probe is held
parallel to the vein, visualizing it as a longitudinal tube.38
The needle is inserted at the end of the probe and
advanced in the same plane as the ultrasound beam,
allowing visualization of the entire needle shaft and tip as
it enters the vein.38 This approach provides better
visualization of the needle's trajectory and depth but can
be technically more challenging to keep the needle,
probe, and vein all aligned in the same plane.38
6.​ Catheter Advancement: Once the needle tip is confirmed
within the vein lumen (visualized on US, +/- flashback), lower
 the insertion angle, advance the unit slightly (2-3mm), then
thread the catheter off the needle into the vein, similar to the
traditional technique, potentially visualizing catheter entry on
US.54
7.​ Completion: Release tourniquet, apply proximal pressure,
remove needle (dispose safely), connect primed extension
set, aspirate/flush to confirm patency (can sometimes
visualize saline flush turbulence within the vein on US - "swirl
sign"), wipe off gel, secure catheter with dressing, label,
document use of USG.54
8.​ Cleaning: Thoroughly clean and disinfect the ultrasound
probe and machine after use according to manufacturer
guidelines and institutional policy.54
●​ Tips for Success: Maintain stable probe position, use adequate
gel, optimize image (depth/gain), choose appropriate catheter
length for vein depth, practice hand-eye coordination, know both
short-axis and long-axis approaches.38

IX. Equipment Overview: Catheters and Infusion

Devices
Selecting and understanding the equipment used in IV therapy is
crucial for safe and effective administration.

A. Types of Peripheral IV Catheters

1.​ Short Peripheral IV Catheters (PIVCs):
○​ Description: Thin, flexible plastic tubes (typically
polyurethane 4), 0.75 to 1.88 inches (approx. 2-5 cm) long,
inserted into superficial peripheral veins.2 Come pre-loaded
over a removable introducer needle (stylet).60
○​ Indications: Most common type for short-term therapy
(typically < 6 days), administration of fluids, non-irritant
medications, blood products (with appropriate gauge), and
obtaining blood samples.2 Suitable for solutions that are
iso-osmotic or near iso-osmotic.4
○​ Advantages: Relatively easy and quick to insert at the
bedside, less invasive than central lines, lower cost, easy to
monitor site.3
○​ Disadvantages: Prone to complications like phlebitis,
 infiltration, occlusion, dislodgement (high failure rates
reported, 35-50%).4 Limited dwell time (often recommended
replacement q 72-96h, though practice moving towards
removal only when clinically indicated).5 Not suitable for
continuous vesicants, highly irritating solutions, or parenteral
nutrition with high osmolarity (>900 mOsm/L).4 Difficult to
insert in patients with DIVA.3
○​ Variations: Can be winged or non-winged, ported or
non-ported, open or closed systems (with integrated
extension tubing/connectors).4 Safety catheters with needle
protection features are standard.32
2.​ Midline Catheters:
○​ Description: A type of peripheral catheter, but longer than a
standard PIVC, typically 3-8 inches (approx. 8-20 cm) long.2
Inserted via the basilic, cephalic, or brachial veins in the
upper arm (often using ultrasound guidance), with the tip
terminating in the peripheral vasculature distal to the
shoulder (axillary vein or below) – it does not enter central
veins.2 Requires specialized training for insertion.2 Managed
similarly to PIVCs.2
○​ Indications: For IV therapy lasting longer than 6 days but
typically less than 4 weeks, when peripheral access is
difficult, or when forearm/hand sites are unsuitable.4 Suitable
for medications and solutions appropriate for peripheral
administration (pH 5-9, osmolarity <600-900 mOsm/L
depending on source).4 Can reduce the need for repeated
PIVC insertions.85
○​ Advantages: Longer dwell time than PIVCs, provides more
reliable access, lower risk of infiltration compared to PIVCs in
ACF, avoids risks associated with central lines.
○​ Disadvantages: Still considered peripheral access, so not
suitable for continuous vesicants, TPN, or highly
irritant/hyperosmolar solutions requiring central dilution.4
Requires specialized insertion. Potential complications
include phlebitis, thrombosis, occlusion, infection (though
generally lower risk than CVCs).
3.​ Extended Dwell Peripheral Catheters (LPCs): Similar to
midlines, these are longer PIVCs (e.g., 6-15 cm) inserted usually
with ultrasound guidance into deeper arm veins, offering longer
 dwell times than standard PIVCs but still terminating
peripherally.2 Used increasingly for patients with DIVA or needing
therapy for 1-4 weeks.30
4.​ Steel Winged Needles ("Butterfly Needles"):
○​ Description: Short, rigid steel needle with plastic wings for
handling/securement and attached tubing.
○​ Indications: Primarily used for short-term, single-dose
medication administration or blood collection.
○​ Disadvantages: High risk of infiltration and vein damage due
to needle rigidity if left indwelling for infusions. Should be
avoided for continuous or intermittent infusions, especially
of potentially irritating or vesicant substances.24

B. Infusion Pumps and Flow Control Devices

Infusion devices are used to deliver IV fluids and medications at a
controlled rate.
1.​ Manual Flow Control Devices:
○​ Gravity Drip: The traditional method where fluid flows via
gravity from a bag hung above the patient. Flow rate is
regulated manually by adjusting a roller clamp on the IV
tubing and counting the number of drops per minute falling in
the drip chamber.9 Requires calculation based on prescribed
volume/time and the tubing's drop factor (gtts/mL -
macro-drip 10, 15, 20 gtts/mL; micro-drip 60 gtts/mL).9
○​ Advantages: Simple, low cost, no electricity needed.
○​ Disadvantages: Less precise, flow rate affected by patient
position, venous pressure, tubing kinks, fluid viscosity.
Requires frequent monitoring and readjustment by the nurse.
Higher risk of free-flow or inaccurate dosing.22 Not suitable
for medications requiring high accuracy or low flow rates.
2.​ Electronic Infusion Devices (EIDs) / Infusion Pumps: Devices
that mechanically control the infusion rate. Offer greater
accuracy and safety features.6
○​ Volumetric Pumps (Large Volume Pumps - LVPs): Deliver
fluids from bags or bottles at programmed rates (mL/hr)
using mechanisms like linear peristalsis (rollers compressing
tubing) or piston-driven cassettes.22 Used for general
fluid/medication administration, blood products, PN.124 Can
 handle larger volumes and higher flow rates (e.g., 0.1-1000
mL/hr).126 Often require specific administration sets designed
for the pump.129
■​ Pros: Accurate for wide range of rates/volumes,
programmable, safety alarms (occlusion, air-in-line, low
battery).8 "Smart pumps" have dose error reduction
software (DERS) with drug libraries and dose limits.8
■​ Cons: More complex, require power source (though have
battery backup), higher cost, potential for programming
errors, can generate pressure that may worsen infiltration
if site compromised.124
○​ Syringe Pumps (Syringe Drivers): Deliver small volumes of
fluid or medication from a syringe at precise, often very low,
flow rates.22 A motor drives the syringe plunger at a
controlled speed.125 Ideal for potent medications requiring
high accuracy (e.g., vasoactive drugs, anesthetics, neonatal
infusions, insulin), typically <60 mL volume.126
■​ Pros: High precision, especially at low flow rates (micro,
nano, pico ranges possible in research models),
compact.126
■​ Cons: Limited volume capacity, requires frequent syringe
changes for longer infusions, potential for flow
inaccuracies at start-up or with very low rates/large
syringes due to mechanical slack/compliance
("stiction").126 Requires careful selection of syringe size
and concentration to optimize flow rate.132
○​ Patient-Controlled Analgesia (PCA) Pumps: Specialized
pumps (often syringe-based) allowing patients to
self-administer doses of analgesics (typically opioids) within
programmed limits (dose, lockout interval, hourly limits) set
by the provider.8 Empowers patients in pain management but
requires careful monitoring for respiratory
depression/over-sedation.126
○​ Ambulatory Pumps: Small, lightweight pumps (volumetric,
syringe, or elastomeric) designed for portability, allowing
patients to receive therapy outside of a hospital setting (e.g.,
home infusion, chemotherapy).8
○​ Elastomeric Pumps ("Balloon" or "Ball" Pumps):
Disposable devices using pressure from a contracting
 elastomeric reservoir to deliver fluid at a fixed,
predetermined rate over hours or days. Simple, portable, no
electricity needed. Used for antibiotics, chemotherapy, local
anesthetic infusions.8 Rate can be affected by temperature
and fill volume.
3.​ Add-on Devices:
○​ Extension Sets: Short lengths of tubing added between the
catheter hub and the main administration set. Provide
flexibility, allow easier taping/securement away from the
insertion site, and can incorporate needleless connectors.22
Must be primed and considered in flush volume
calculations.106
○​ Needleless Connectors: Allow access to the IV line without
needles, reducing needlestick risk. Require meticulous
disinfection before each access ("scrub the hub").2 Different
types exist (split septum, mechanical valve) with varying
reflux characteristics (positive, negative, neutral
displacement) influencing clamping sequence during
flushing/disconnection.24
○​ Filters: In-line filters (e.g., 0.22 micron for non-lipid solutions,
1.2 micron for lipids/PN) remove particulate matter and
microorganisms.22 Primarily used for PN, certain medications,
and sometimes CVCs to prevent complications like
pulmonary emboli from particulates.59 Recommendations
(e.g., from INS/ASPEN) guide appropriate use.59

X. Patient Education: Empowering Participation in

Care
Effective patient and caregiver education is a crucial component of
safe and successful IV therapy. Informed patients are better
equipped to participate in their care, recognize potential problems
early, and adhere to necessary precautions.
●​ Rationale and Procedure Explanation:
○​ Explain why the IV therapy is needed (e.g., fluids for
hydration, antibiotics for infection, medication for pain) using
clear, simple language.15
○​ Describe the basic steps of the insertion procedure, including
site preparation, the sensation of the needle stick ("sharp
 scratch"), and how the catheter will be secured.16
○​ Explain the expected duration of therapy and how long the IV
might need to stay in place.5
○​ Address any patient concerns or questions about previous
experiences.16
●​ Cannula Care and Precautions:
○​ Instruct the patient to keep the IV site and dressing clean and
dry at all times.16
○​ Explain how to protect the site during bathing (e.g., covering
with an impermeable barrier like plastic wrap secured with
tape, or using commercially available shower covers).16
Emphasize not to submerge the site in water.23
○​ Advise the patient on how to move carefully to avoid pulling
or kinking the tubing or dislodging the catheter.27 Explain the
purpose of an armboard if used.16
○​ Teach the patient (and caregivers) to avoid lying on or
compressing the tubing.91
○​ Reinforce the importance of hand hygiene, especially before
touching the IV site or equipment (though patients should
generally avoid manipulating the system).16
●​ Monitoring and Reporting Signs of Complications: This is
perhaps the most critical area of patient education. Empower
patients and caregivers to be active monitors of the IV site.
○​ Teach them to report immediately any of the following signs
or symptoms to the nurse:
■​ Pain, tenderness, burning, or stinging at the insertion site
or along the vein.2
■​ Swelling, puffiness, tightness, or coolness at or around
the site (potential infiltration/extravasation).2
■​ Redness or warmth at the site (potential
phlebitis/infection).2
■​ Any leakage of fluid or blood from the site or dressing.5
■​ The dressing becoming loose, wet, or soiled.16
■​ Blood visible in the IV tubing.91
■​ The infusion pump alarming frequently.5
■​ Any signs of adverse reaction to infused medications.15
■​ Fever or chills (potential systemic infection).45
○​ Explain that nurses will also be checking the site frequently
(e.g., hourly or every few hours) by touching, looking, and
 comparing it to the other limb.2
●​ Infusion Pump Alarms: Briefly explain that the infusion pump
has alarms to signal potential issues (e.g., occlusion, air, low
battery, infusion complete) and instruct the patient to call the
nurse if an alarm sounds.91
●​ Reinforcement and Assessment of Understanding:
○​ Provide information in an age-appropriate and culturally
sensitive manner.15
○​ Use teach-back methods or ask the patient/caregiver to
verbalize the key points (e.g., "What signs would you tell me
about right away?") to assess understanding.
○​ Provide written materials or diagrams if available and
appropriate.
○​ Reinforce education throughout the course of therapy.
Document the education provided and the
patient's/caregiver's understanding.34

By actively involving patients and their families through education,

nurses can foster a partnership that enhances safety, promotes early
detection of complications, and improves the overall patient
experience with IV therapy.15

XI. Visual Resources and Further Learning

While this report provides comprehensive textual guidance, visual
aids are invaluable for learning and mastering the psychomotor skills
involved in IV cannulation.
●​ Diagrams: Anatomical diagrams illustrating the veins of the
upper extremities are essential for understanding site selection.9
Procedural diagrams showing insertion angles, catheter
advancement steps, and securement techniques can clarify
complex maneuvers.2 Diagrams illustrating complications like
infiltration or phlebitis can aid recognition.
●​ Videos: Video demonstrations provide dynamic visualization of
the entire process, from preparation to insertion and
securement. Numerous online resources offer video guides for
standard PIVC insertion, pediatric techniques, ultrasound-guided
insertion, and troubleshooting.34 Watching experienced clinicians
perform the skill can highlight subtle nuances of technique.
●​ Simulation: Hands-on practice using simulation manikins or task
trainers is crucial for developing initial dexterity and confidence
before performing the procedure on patients.75 Simulation allows
for repeated practice in a safe environment.
●​ Formal Training Programs: Structured educational programs,
such as the INS Fundamentals of Infusion Therapy (FIT) program
or competency validation programs (INS CCVP, RCN IV Therapy
Passport), offer comprehensive learning modules often
incorporating visual aids and practical assessments.19 Ultrasound
guidance requires dedicated training courses.85
●​ Organizational Resources: Healthcare institutions should
provide access to up-to-date policies, procedures, and
educational materials, potentially including visual aids and
competency checklists.20

Integrating visual learning resources with theoretical knowledge and

supervised clinical practice is the most effective pathway to
achieving and maintaining proficiency in IV cannulation.

XII. Conclusion
Peripheral intravenous cannulation is an indispensable nursing skill,
fundamental to the delivery of modern healthcare. Its successful and
safe execution demands not only technical proficiency but also a
deep understanding of underlying principles, adherence to
evidence-based standards, meticulous attention to detail, and a
patient-centered approach.

This report has synthesized recommendations from leading

organizations like the CDC, INS, and RCN, alongside insights from
clinical research and practice guidelines. Key takeaways emphasize
the critical importance of:
1.​ Asepsis and Infection Prevention: Strict hand hygiene, proper
skin antisepsis (preferably with CHG/alcohol), ANTT, and
appropriate use of PPE are non-negotiable elements in
preventing local and systemic infections.
2.​ Comprehensive Assessment: Evaluating the patient
holistically—considering medical history, allergies, vein condition,
therapy needs, and psychosocial factors—before selecting a site
and initiating the procedure is crucial for success and safety.
 3.​ Evidence-Based Technique: Adhering to best practices for vein
selection (distal to proximal, avoiding high-risk areas), catheter
choice (smallest appropriate gauge), insertion (correct angle,
confirming flashback, careful advancement), and securement
(preventing micro- and macro-movement) minimizes
complications.
4.​ Diligent Maintenance: Frequent site assessment using
systematic methods (TLC), adherence to correct flushing
protocols (solution, volume, technique), and timely changes of
dressings and administration sets are vital for maintaining
catheter function and detecting issues early.
5.​ Prompt Complication Management: Rapid recognition of
complications like phlebitis, infiltration, extravasation, occlusion,
or infection, coupled with immediate and appropriate
intervention based on established protocols, is essential to
mitigate patient harm.
6.​ Adaptation for Special Populations: Recognizing and
addressing the unique challenges presented by pediatric,
geriatric, obese patients, and those with DIVA through tailored
techniques and the use of technology (like ultrasound) improves
outcomes.
7.​ Patient Empowerment: Educating patients and caregivers
about the IV therapy process, necessary precautions, and signs
of complications fosters partnership and facilitates early
reporting of problems.
8.​ Continuous Learning and Competency: IV therapy is a
dynamic field; ongoing education, staying abreast of updated
guidelines, and participation in competency validation programs
are necessary to maintain proficiency and ensure patient safety.

Mastering peripheral IV cannulation is an ongoing journey that

combines knowledge, skill, critical thinking, and a commitment to
patient well-being. By consistently applying the evidence-based
principles and practices outlined in this guide, nurses can
significantly enhance their proficiency, reduce complication rates,
improve patient outcomes, and contribute to a safer healthcare
environment.

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