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Initiating a Peripheral Intravenous (PIV) Line and PIV Therapy in UWHC Clinics - Pediatric and Adult (12.02)

Initiating a Peripheral Intravenous (PIV) Line and PIV Therapy in UWHC Clinics - Pediatric and Adult (12.02) - Policies, Clinical, UWHC Clinical, Department Specific, Ambulatory, Clinic Specific

12.02

12.02 Initiating a Peripheral Intravenous (PIV) Line and PIV Therapy in UWHC Clinics ‐ Pediatric and Adult  
Category:  UWHC Departmental Policy   
Policy Number:  12.02    
Effective Date:  February 26, 2014   
Version:  Revised    
Manual:  Ambulatory    
Section:  Clinic Specific (Ambulatory) 
 
 
I. POLICY

To provide UWHC health care providers in pediatric and adult primary and specialty care the steps of procedure for
the safe insertion of a peripheral intravenous (PIV) access device and initiation of PIV for bolus rehydration without
an infusion pump after attempt at oral rehydration has failed or oral hydration is not possible.

II. POLICY
A. IV catheters of 4 inches or less can be inserted by a Registered Nurse (RN) or Licensed Practice Nurse
(LPN). Please refer to UWHC Hospital Administrative Policy 8.18 - Vascular Access (Venous and Arterial).
RN placement of catheters greater than 4 inches requires additional training and qualification. (See UWHC
Nursing Patient Care Policies 1.26 - Peripherally Inserted Midline Venous Catheters and 1.27 - Peripherally
Inserted Central Catheters.)
B. A qualified RN or LPN may place, discontinue and/or cap off a peripherally inserted venous catheter.
C. Hand hygiene should be performed when indicated according to UWHC Hospital Administrative Policy
13.08 - Hand Hygiene.
D. Exam gloves are to be worn by all personnel manipulating vascular devices and apparatus. Refer to
Nursing Patient Care Policy 1.21 - Central Venous Catheter, Adult and Pediatric.
E. PIV catheter sites are inspected frequently during infusion of bolus rehydration to monitor for
infiltration. Assess PIV site for signs of infiltration and swelling of the site.
F. This policy is intended for pediatric and adult patients requiring rehydration related to acute causes such
as hyperemesis or gastroenteritis. Patients with conditions such as but not limited to infants < 40 weeks
gestation, heart disease and diabetes should be assessed for referral to an emergency department or
specialist.
III. EQUIPMENT
A. Gloves (to be worn by all personnel starting or discontinuing IVs)
B. Intradermal or topical anesthetic (4% lidocaine ointment L.M.X.4 or 1% injectable lidocaine)
C. Bacteriostatic 0.9% sodium chloride
D. 18, 20, 22, 24 gauge safety syringe as appropriate to age and size of patient
E. Intravenous administration set
F. Intravenous solution as prescribed
G. 10 mL normal saline syringe
H. Extension set with needleless connector
I. Appropriate choice of safety catheter and gauge
J. IV start kit with chlorhexidine sponge (ChloraPrep®)
K. Sterile alcohol prep swabs
L. Tape or securement device
M. Optional equipment:
1. Arm board

2. Underpad
3. Needleless connector (microclave)
4. Securement device (StatLock®) or other manufacturer

IV. PROCEDURE

A. Preparation
1. Prepare patient/family for IV placement.
2. Obtain order via smart set for IV fluids.
B. May pre-medicate for Analgesia per UWHC Protocol 29 –
Analgesic Ordering Prior to Needle Insertion – Adult – Inpatient/Outpatient and HFFY #6835 (pediatrics) -
Non Drug Pain Control for Kids.
C. Determine if patient has any allergies to lidocaine before proceeding.
D. First line medication choice is L.M.X.4. Situations for use include stable patient condition, no allergies to
lidocaine, able to wait at least 20 minutes prior to starting IV.
a. When using topical anesthetic L.M.X.4, premedicate at least 20 minutes prior to IV
attempt. Consider premedicating on two sites to prevent delay in IV access.
E. A second line anesthetic technique should be selected when the IV start cannot wait 30 minutes due to
patient condition or medication delivery*. Second line medication choices include intradermal lidocaine or
bacteriostatic normal saline.
. Lidocaine is more painful to inject, but may provide superior anesthetic during venipuncture.
a. Both lidocaine and bacteriostatic normal saline provide some relief during venipuncture. Choice
of medication should be based on patient’s previous experience/preference, history of lidocaine
allergy and ease of access. See policy appendix "Starting an IV Doesn't Have to Hurt!" for
specific administration directions.
* This technique may be beneficial in younger pediatric patients but injecting the patient twice
may cause more distress than benefit; therefore, use of distraction, relaxation and other non-
drug techniques may be less anxiety producing in this population if topical anesthetic cannot be
used.
F. Site Selection
0. Examine upper extremities for most appropriate location for IV access. In general, do not use
lower extremities for peripheral venous access.
a. Start peripheral routine IV therapy in distal areas of the upper extremities; hands and
lower arms are preferred sites for IV access.
b. Always assess distal to proximal and use the most distal vein appropriate for therapy
required. Subsequent venipunctures may be made in areas proximal to previous IV
sites, as necessary.
c. Avoid the antecubital fossa unless there are no other sites since this is the preferred site
for venipuncture for drawing blood tests and has a higher incidence of mechanical
complications (occlusion/phlebitis).
d. If access is poor in arms, consider referral to urgent care or emergency department.
G. Prepare Infusion
0. Check the provider's order for prescribed solution, volume, additives, and rate of flow.
1. Determine if patient has any allergies or sensitivities to tape, or transparent dressing.
2. Obtain prescribed solution and check against provider’s order.
3. Connect administration set to solution container. Remove protective cap from end of tubing
assembly, open clamp and flush tubing with solution according to manufacturer's instruction;
clamp tubing and replace with the protective cap.
4. Affix appropriate date label to tubing.
H. Prepare for Venipuncture
0. Choose appropriate catheter gauge.
a. Choose the smallest gauge catheter possible to achieve the ordered therapy taking into
account patient age, weight and size of vein.
1. Assemble equipment.
2. Place underpad under selected extremity.
3. Pediatric Considerations
a. The nurse should have a knowledge and understanding of growth and development,
including the psychological and behavioral development relative to the patient's age
group and cognitive level.

b. Offer the use of some type of premedication and distraction to start IV standardly for all
pediatric patients.
c. Observe IV site frequently. The pediatric patient may be at greater risk for potential
complications related to infusion therapy and thus requires more frequent monitoring.
d. If the IV attempt is unsuccessful, consult provider regarding status and need for patient
to be referred to emergency department for rehydration.
I. Skin Preparation
0. Prepare the skin using ChloraPrep® (2% CHG/70% isopropyl alcohol). Use povidone iodine
solution for skin disinfection for patients with a chlorhexidine allergy.
a. Perform friction scrub for 30 seconds. Allow to dry 30 seconds.
b. Avoid touching the actual puncture site after disinfecting the area unless wearing sterile
gloves. Palpation of the vessel should be done before prepping and only above the
puncture site after prepping.
J. Catheter Insertion
0. Distend vein by applying tourniquet or blood pressure cuff 4-6 inches above site selected.
a. Tourniquet may not be necessary for distended veins or for elderly patients.
b. Additional measures utilized to distend veins include:
i. Have the patient open and close the fist repeatedly.
ii. Lightly stroke directly over a vein in an upward direction toward the tourniquet.
iii. Lower the extremity for 5 minutes before applying tourniquet.
iv. Wrap the entire extremity in warm, moist towel, or have patient put arm under
warm running water before applying tourniquet.
v. With difficult peripheral venous access, a blood pressure cuff inflated to just
below the diastolic pressure may help to distend the vein.
vi. If additional methods have contaminated puncture site, re-cleanse skin area
before venipuncture.
1. Directions for Insertion using BD InsyteTM AutoguardTM IV Catheter
a. Remove needle cover in a straight outward motion and inspect catheter unit. Rotate
catheter to loosen seal.
b. Perform venipuncture with bevel up. Approach vein slowly at a low angle. Observe
flashback.
c. Lower and observe catheter until 1/8 inch advanced to ensure full vein entry.
d. Holding the flash chamber stationary, advance the catheter off the needle into the vein
while maintaining skin traction.
e. Release tourniquet, apply digital pressure beyond catheter tip, and depress button to
retract needle.
f. Attach primed extension set with needleless connector valve to BD InsyteTM
AutoguardTM IV catheter.
2. Directions for Insertion using BD Saf-T-IntimaTM IV Catheter
a. Remove needle cover and inspect unit. Grasp pebbled side of wings, pinching firmly
(pebbles to fingertips).
b. Approach vein slowly at a low angle with bevel up.
c. Observe flashback in tubing behind wings.
d. Upon flashback visualization, lower catheter almost parallel to the skin. Thread entire
unit an additional 1/8 inch to ensure catheter tip is in the vein.
e. Release wings and stabilize.
f. Hold 1 wing on top and bottom. Grasp white shield by pebbles and pull straight back
until needle is safely shielded. Do not stop until needle is all the way into the safety
shield. Shield will come off, exposing the adapter.
g. Thread catheter into vein while maintaining skin traction.
h. Remove tourniquet.
i. Attach needleless connector. Flush using 10 mL normal saline syringe to ensure
patency. If flushes well and has blood return, attach fluid bolus in preparation for
infusion.
K. Catheter Securement and Dressing
0. Anchor IV site with tape or Statlock®, as applicable.
1. If applicable, apply StatLock® anchor tape as follows: (NOTE: statlocks are not typically used in
our outpatient clinic due to the short duration of the PIV).
a. For BD InsyteTM AutoguardTM IV Catheter:
i. Press the StatLock® over the catheter hub to capture the push tab.
ii. Peel StatLock® paper backing 1 side at a time and gently press into place.
b. For BD Saf-T-IntimaTM IV Catheter:
i. Remove transparent adhesive shield from wing securement side of StatLock®
pad.

ii. Lift the wings of the Saf-T-IntimaTM Catheter and carefully position the
StatLock® pad at targeted securement site and firmly place wings over
designated adhesive area of pad.
iii. If using, Peel StatLock® paper backing 1 side at a time and gently press into
place.
c. If using securement device other than StatLock®, apply according to manufacturer’s
instructions.
2. Apply transparent dressing and document date and time.
3. Do NOT use Coban to secure catheter extension or tubing proximal to the insertion site.
L. Documentation
0. Document in patient’s electronic medical record using LDA Doc Flowsheet or smart phrase .npivst
in progress note section for location, size of catheter and fluids used.
1. Document patient's response to therapy in the clinical record.
M. Initiate Infusion or Saline Lock
0. Continuous Infusions
a. Connect administration tubing assembly to catheter/extension and open the
clamp. Solution should drip rapidly if device is in the vein. Check skin to verify that
solution is dripping into the vein and not subcutaneously.
b. RN or LPN is responsible for monitoring PIV site frequently, regulating and maintaining
the rate of fluids and total volume as ordered.
c. After infusion is complete, provider should reassess or give parameters for
discontinuation (such as patient is able to void). Repeat bolus infusion may be ordered
and RN or LPN should follow policy steps again as needed.
N. Discontinue Infusion
0. Per provider reassessment or parameters for discontinuation parameters, RN or LPN may
discontinue PIV therapy.
1. Clinics that transport patients with PIV in place should complete SBAR including documentation
regarding PIV.
2. If PIV therapy is being discontinued, stop infusion by closing clamp.
3. Remove dressing or Stat Lock device and remove catheter, applying pressure to site until
bleeding stops, apply secure dressing.
4. Document in progress note using smart phrase .npivdc

V. RESOURCES

Hospital Administrative Policy 8.18 - Vascular Access (Venous and Arterial)
Hospital Administratie Policy 13.08 - Hand Hygiene
Nursing Patient Care Policy 1.21 - Central Venous Catheter, Adult and Pediatric
Nursing Patient Care Policy 1.23 – Continuous Peripheral Intravenous Therapy
Nursing Patient Care Policy 1.26 - Peripherally Inserted Midline Venous Cathers
Nursing Patient Care Policy 1.27 - Peripherally Inserted Central Catheters
UWHC Protocol 29 – Analgesic Ordering Prior to Needle Insertion – Adult – Inpatient/Outpatient and HFFY #6835
(pediatrics) - Non Drug Pain Control for Kids

VI. WRITTEN BY

Pediatric Clinics CNS

VII. REVIEWED AND APPROVED BY

CNS, Pediatric Clinics
CNS, Adult Specialty Clinics
Ambulatory Nursing Education Specialist
Clinic Manager, Internal Medicine
Ambulatory Policy and Procedure Committee
Clinics Administration

SIGNED BY

Deborah D. Tinker, MSN RN CENP, Director, Ambulatory Nursing