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Shaun D Bowden has been involved with nursing education and organisational wide training for over a decade in hospitals and tertiary institutes of education. He currently works as Head of Nursing Education at Mafraq Hospital in Abu Dhabi, UAE and as the Programme Director for CME activities for the Dept of Nursing GAHS Abu Dhabi. In 1997 he was conferred his Masters of Nursing degree in Advanced Practice in Australia, and holds further qualifications in teaching and management.

Peripheral intravenous (IV) insertion is a challenging clinical skill performed by either professional nurses or doctors. The key to successful IV insertion are assessing patient's needs, distending the patient's veins, and selecting an appropriate site and device. This knowledge will assist the professional nurse or doctor to make some important decisions as to where to site the IV, what type of IV accessed is best used and care for the patient receiving intravenous therapy. Knowing what the nurse might need ask you and some of the signs of complications, will help you alleviate any concerns you may have and help you to concentrate on more important things like getting well.

Peripheral intravenous insertion

The first barrier to successful peripheral intravenous insertion is the skin. The skin acts as a barrier between the outside environment and internal organs. The risk for infection increases whenever the skin is broken. An infusion access device perforates the skin, interrupts the integrity of the barrier and increases the risk for infection. Strict aseptic or sterile technique for peripheral intravenous insertion, care and maintenance of the site is important.

Epidermis: Composed of squamous cells that are less sensitive than underlying structures, the epidermis is the first line of defence against infection.

Dermis: Much thicker than and directly below the epidermis, the dermis layer consists of blood vessels, hair follicles, sweat glands, sebaceous glands, collagen and nerves. The dermis reacts quickly to painful stimuli as well as to temperature changes and pressure sensation. The dermis is the most painful layer during a peripheral intravenous insertion for the patient.

The fascia lies below the dermis and epidermis and provides a covering for blood vessels. The vascular system is made up of blood vessels, which include arteries, arterioles, capillaries and veins. These vessels vary in size and function.

Arteries carry oxygenated blood away from the heart. Veins carry deoxygenated blood back to the heart. Capillaries provide nutrients to the tissue and take wastes away. The vein, the second barrier to successful peripheral intravenous insertion, consists of three layers and in the inner layer are the semi-lunar valves, which are directed toward the heart and prevent blood from flowing toward the extremities. Therefore, the direction of the IV needle should always be toward the heart with the flow of the circulation.

Systemic veins are in two sets: deep and superficial. Deep veins accompany the corresponding arteries. The superficial veins commence as a network of small veins just under the skin. Superficial veins in the hand and forearm are generally utilized for the initiation of IV therapy; however, upper arm veins can be and frequently are accessed as peripheral intravenous insertion sites.

When selecting a vein to perform a peripheral intravenous insertion, doctors and professional nurses consider the following factors for patients:

Your age--Infants have fewer accessible sites than older children and adults. Hands, feet and the antecubital region are generally the most accessible sites. The elderly may have fragile veins. The tourniquet may need to be loose or not used at all.

Your preference--Use the non-dominant side whenever possible. Advise the patient of the optimal sites and ask which site they prefer.

Your activity-- Avoid lower extremities. Consider allowing hands to be free, particularly if the patient uses a walker, crutches or a wheel chair.

Your previous medical history--Avoid the affected side, i.e., paralysis, mastectomy, burns, scars. Do not place in close proximity to an infected wound.

If you have a shunt or graft--NEVER use the side that has a shunt or graft used for haemodialysis.

How long-When prolonged therapy is required, the distal portion of the vein should initially be used with subsequent re-sites above. If possible, alternate arms and remember to begin distally and work proximally.

The type of solution--Hypertonic solutions and various medications can be chemically irritating to the vein. If the solution is a known irritant, the nurse or doctor would select a large vein in the lower forearm.

Condition of your vein-Previously used veins can become sensitive. If the vein has been recently used for an infusion, is bruised, red, swollen, sore, or is near a previously affected site; another vein would be selected.

The Cannula size--The cannula should be as small as possible and yet be able to effectively deliver the therapy.

Potential complications of peripheral intravenous access

The possibility that a patient may develop a complication from having a peripheral intravenous access insitu increases proportionally with the time the access is required, so the longer you have a drip the more risk of there being a complication. The nurse and yourself should be aware of these complications to ensure prevention and early detection if a complication arises.

Signs for the patient can include; Coolness of skin around site, skin feeling tight, swelling, slowing of the flow of the drip

Signs for the patient can include; Changes in patient colour, cyanosis, difficulty breathing, cough, increase in heart rate, changes in blood pressure and even dizziness.

Signs for the patient can include; the site is sore, hard, cordlike and warm; red line above site, oedema, and sluggish or stopped IV

Signs for the patient can include; Discomfort along the vein, decrease in blood pressure, weak rapid pulse, cyanosis and unconsciousness

Signs for the patient can include; Discoloration of tissue at IV site and swelling

Signs for the patient can include; Site red and sore, swelling and discharge may be present

If you develop any symptom related to your cannula, you should contact your nurse immediately.

In order to prevent infection and complications it is important to care for the cannula and the site, here a few tips:

Handle with care: don't contaminate the equipment, the connections should be handled as little as possible, so don't play with a drip.

Inspect the site: the insertion site should be checked regularly for any signs of infection or complications, if you notice anything changed you should tell your nurse.

Securing the cannula: the cannula should be fixed securely, preferably clear tape/dressing where you can see the cannula itself.

Change the cannula: A new cannula is usually inserted every two to three days. Don't forget that lines these need changing too. Don't leave a cannula in, the longer you leave it the more risk of complications.

Flush: A cannula needs to be flushed regularly, before and after any medication is given into them.

Flushing a cannula

Finally

Further information on intravenous Cannulation for medical and nursing professionals can be accessed on:

Williams, Penny and Hadaway, Lynn C. 2003. Essentials of IV Therapy: MODULE 1: Peripheral IV Catheter Insertion, Care and Maintenance. Baxter Healthcare Corporation. Accessed on the World Wide Web on June 26th via

Special thanks to Nawal Ahmed, Nurse Educator at Mafraq Hospital for her assistance.

Your Drip! - Peripheral Intravenous Cannula

Peripheral intravenous insertion

Potential complications of peripheral intravenous access

Flushing a cannula

Finally