Independent study was required before nurses spent 4 hours working with an IV Team nurse to learn how to start peripheral IVs.

1. Study Guide
This Study Guide is for the following article:
Milliam, D. A. & Hadaway, L. C. (2000). On the Road to Successful IV Starts.
Nursing 2000 30(4):34-48.
Article Index
Words of wisdom on learning the skill .................................................................................... 34
Selecting a Vein ...................................................................................................................... 36
Exploring the options .................................................................................................. 36
Evaluating the vein you choose .............................................................................. 36, 38
Avoiding arteries ......................................................................................................... 38
Mapping it out: diagram of upper extremity veins .................................................................. 37
Selecting a Cannula ............................................................................................................... 38)
Intermediate and long-term therapy options ........................................................................... 38
From container to cannula: trends in IV therapy .................................................................... 39
Getting Started ....................................................................................................................... 40
Applying a Tourniquet ............................................................................................ 40-41
Preparing the Site ........................................................................................................ 41
Troubleshooting tips: Common reasons for problems ........................................................ 41-42
Immobilizing the Vein ............................................................................................................. 42
Using a Local Anesthetic .................................................................................................... 42-43
How to Approach the Vein ....................................................................................................... 43
Inserting the Cannula Into a Hand Vein ................................................................................. 44
Advancing the Cannula: Four Options .................................................................................... 45
Troubleshooting tips: if blood backflow stops when you remove the stylet ............................. 46
Special Consideration for Deep Veins ..................................................................................... 46
Applying a Transparent Dressing Over a Winged Catheter ..................................................... 47
SKIP THIS Taping With the Chevron Method .......................................................................... 48
Removing the Dressing and Cannula ...................................................................................... 48

2. Learning Guide: “On the Road to Successful IV Starts”
VAT message. Remember that your IV start technique can affect whether your patient will
experience complications. Complications arise when the vein intima has been damaged, if the
catheter is too large for the vein, and when poor aseptic and sterile technique are used.
Learning good principles of IV therapy and practicing skills correctly until they become
automatic will better enable you to focus on getting the cannula in without compromising your
patient.
Learning the Skill
1) Describe three (3) ways that you can develop your IV skills.
a) Practice on rubber arms
b) Observe a preceptor perform several venipunctures
c) Try a few (IV starts) under the supervision of an experienced nurse
2) How many times should you try to start the IV before calling the VAT? ____2
Selecting a Vein (p. 36)
3) When selecting a vein, what are six (6) general factors to consider?
a) medical history
b) age, size, and general condition
c) condition of patient veins
d) type of IV fluid or medication to be infused
e) expected duration of therapy
f) skill of nurse starting the IV
4) Match the vascular access device with the therapy. Your choices are SPC (Short Peripheral
Catheter), PICC (Peripherally Inserted Central Catheter); and MLC (Midline Catheter).
a) Therapy lasting 5-7 days, fluids/meds with pH between 5 and 9; osmolality less than
500mOsm/liter. _________SPC
b) Planned therapy beyond one week. __________ or __________.
5) Catheter placement should start in the most ______________ location and _____________
between extremities.
6) Why should you think out cannula placement ahead of time?
You can head off problems during therapy.
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3. Learning Guide: “On the Road to Successful IV Starts”
7) More about vein selection. Match the following.
f___ Veins in non dominant hand a) Should be avoided. Site limits range of
motion and ability to sample blood. Save for
g___ Veins in fingers and thumb midlines or PIICs.
b___ Veins in both sides of forearm b) Good option for short-term therapy. Permit
mobility. Good for home care or for patients
a___ Veins in the antecubital fossa
using walker or crutches.
d___ Most distal veins
c) Avoid these.
e___ Veins in palm or volar aspect
d) Always start with these. Cannot start an IV
of wrist.
more distal if there has been phlebitis or
infiltration.
h___ Veins in legs, feet, and ankles.
e) Last resort veins. High incidence of
c___ Veins below a previous
complications. Thin walled and close to
infiltration or phlebitis. Sclerosed or
superficial nerves. Vein damage can cause
thrombosed veins. Areas of skin
severe pain.
inflammation, disease, bruising, or
breakdown. Affected arm after
f) Good for most adults. May not be good for
radical mastectomy, edema, blood
elderly who have lost subcutaneous tissue
clot, or infection. Arm with AV shunt
surrounding the veins. Contraindicated for
or fistula.
vesicant solutions.
g) May look good when tourniquet is applied,
but are very small. Small size will permit
little blood flow around catheter. Motion
can predispose patient to infiltration.
h) Avoid these. Experienced Vascular Access
Team nurses will start these and only with
physician’s approval.
Evaluating the vein you choose (p. 36,38)
8) Describe a vein for venipuncture should and should not look.
Should feel round, firm, elastic, and engorged.
Not hard, bumpy, or flat.
9) Describe how you would palpate a vein after you place the tourniquet. What should you do
to acquire a highly developed sense of touch.
Place one or two fingertips (not the thumb) over the vein and press lightly. Release the
pressure to evaluate the vein’s elasticity and rebound filling. To acquire a highly developed
sense of touch, palpate before every venipuncture. Try to visualize the vein lying beneath
the skin. You can also outline the vein with betadine or a pen.
10) How can you tell a vein from an artery?
Arteries pulsate; veins do not. Arteries do not look bluish, veins do.
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4. Learning Guide: “On the Road to Successful IV Starts”
Selecting a Cannula (p. 38)
11) Which two types of devices are good for the hand or forearm? Describe them.
a) Over the needle catheter; ¾ - 1 ¼ inches long; 16-24 gauge; has a steel needle that you
withdraw.
b) Winged butterfly cannula with attached tubing; ¾ - 1 inch long; 16 – 24 gauge; has a
steel needle thatdraw.
Intermediate and long-term therapy options (p. 38)
12) Select a type of cannula for each of these situations.
b__ midline cannula a) Therapy will last 1-12 months. Therapy has extreme
osmolality and pH.
a__ PIIC
b) Therapy will last 1-4 weeks. Osmolality of therapy is less
than 500mOsm/liter and pH range is 5-9.
Mapping out a plan (p. 37)
Compare the diagram below to the
one in the article. Label each of the
veins indicated above and note which
size catheter they usually can
accommodate. Which veins are you
less likely to cannulate?
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5. Learning Guide: “On the Road to Successful IV Starts”
Choosing the right size (p. 38)
13) Why should the cannula be as small as possible?
To reduce the risk of phlebitis. The catheter should take the least space in the vein as
possible. This better allows flow of blood around the catheter.
14) A good rule of thumb is the use the ___________ size catheter, possible, in ___________ size
vein.
15) Name two factors that will influence the size of peripheral catheter.
patient’s condition, type of solution
16) Select the size of cannula for each of these situations.
c___ Trauma patients and those requiring rapid large amounts of a) 24-22 gauge
fluid volume
b) 18 gauge
a___ Medical patients and post operative surgical patients
c) 16 gauge
a___ Children and elderly patients
b___ Surgical patients and for rapid blood administration
From container to cannula: Trends in IV therapy (p. 39)
17) Using extention tubing and tubing loops are advantageous for two reasons. What are they?
a) They allow for tubing changes away from the puncture site.
b)
The side clamp on the tubing facilitates positive pressure flushing technique and
controls backflow of blood into the tubing.
Getting Started (p. 40)
18) If you patient is nervous, chilly, hypotensive, or experiencing vasomotor changes, what can
you do to help the vein dilate and distend?
a) Position arm below level of heart to encourage capillary filling.
b) Gently rub or stroke arm to warm the skin.
c) Cover entire arm with warm packs for 5-10 minutes to trigger vasodilation.
d)
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6. Learning Guide: “On the Road to Successful IV Starts”
Applying a Tourniquet (p. 40-41)
VAT message. At FSH all of the blue tourniquets on the rolls and in the IV start kits are
non latex.
19) Where should you apply the tourniquet if you have chosen a hand or lower arm vein?
Where should it be for an obese patient?
2-3 inches below the antecubital fossa. For obese patients, place it a few inches lower for
better capillary filling.
20) You can use the tourniquet to help stabilize veins and this will be very good to practice
before you have your Hands-on Training with the VAT nurse. Once the tourniquet is on, lift
the tied tourniquet and stretch the underlying skin away from the venipuncture site. Then
gently lower the tourniquet. You may be able to retract several inches of skin and tissue
away from the site. This is an especially good technique for which kinds of patients?
Older patients who have less collagen and elastin (skin turgor) than younger patients.
21) When the tourniquet is in place, the objective is to change the vein shape from elliptical to
turgid and round. The vein should be as engorged as possible to provide a good target.
List four to six ways from the article to do this.
a)
b)
c)
d)
e)
f)
g)
See the Practice Exercises.
VAT message. If you apply a warm pack, be sure to cover the hands and fingers completely.
22) When you palpate the vein, you check to see if it has rebound resiliency. First it must
be filled with blood and engorged (so you may first need to take the steps above to promote
engorgement). Then, when you depress and release the engorged vein, what should
happen?
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7. Learning Guide: “On the Road to Successful IV Starts”
Preparing the Site
VAT message. At FSH, you can choose from three (3) antimicrobial solutions for skin prep: (a)
alcohol, (b) 10% providone-iodine, and (c) Chloraprep. It is important to use only one, not to
use one after another. It is also important to let the antimicrobial solution air dry. That’s when
it does the most work.
23) The Intravenous Nurses Society recommends that excessive hair be removed by what
method? clipping
24) If the IV insertion site is visibly dirty should you clean it first with soap and water or just
use alcohol swabs until they wipe clear? use soap and water
VAT message. Iodophors are released when betadine (10% providone-iodine) solution
dries on the skin. Iodophores are what penetrate the cell wall of microorganisms to
kill them. Wiping betadine off with a dry sponge prevents the release of iodophores.
Iodophores bind with alcohol when isopropyl alcohol wipes are used.
25) How should you apply alcohol or betadine solution for site preparation?
Start with the intended site and work outward in a circular motion. Depending on the size
of the extremity, prepping an area of 2-4 inches in diameter is usually acceptable.
VAT message. Compared to alcohol or betadine, Chloraprep is applied differently. You
should apply friction in side-side and up-down motions for 2 minutes. Then, let the
Chloraprep air dry for 30 seconds.
Troubleshooting tips (p. 41-42)
26) The article lists seven (7) common reasons for problems during venipuncture. List them
here.
1.
2.
3.
4.
5.
6.
7.
8. Cannula then rides on top or below the vein.
27) If you have a good blood return after stylet insertion, but it disappears when the stylet is
withdrawn, what is the problem?
Only the stylet was in the lumen of the vein, not the cannula.
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8. Learning Guide: “On the Road to Successful IV Starts”
Immobilizing the Vein (p. 42)
VAT message. In the section titled “Immobilizing the Vein” on page 42, the author gives the
impression that superficial veins are only hand and cephalic. On page 46, the author discusses
“Special Considerations for Deep Veins.” This is where the author discusses arm veins. Do not
let the article give you the impression that all arm veins are deep. Some lower arm veins are also
superficial, particularly the basilic.
See the Practice Exercises.
Using a Local Anesthetic (p. 42-43)
VAT message. The information in the article about local anesthetic is not entirely accurate. And
practices at FSH are somewhat different.
Injection of bacteriostatic 0.9% NS is not recommended by the INS. We don’t use it at
•
FSH.
Iontophoresis is not an option at FSH.
•
Lidocaine is a good local anesthetic, but can cause vasoconstriction – so use it
•
cautiously in patients who have poorly filling veins. Use lidocaine without epinephrine.
The article states that use of buffered lidocaine helps to eliminate the sting when the
drug is injected. At your request, pharmacy will prefill syringes with lidocaine and
buffered solution. They will come with expiration dates on them and must be stored in
the refrigerator.
Most of the units at FSH have Emla cream on the floor in the refrigerator. If you use
•
the Emla cream, you must apply it 60 minutes prior to the insertion procedure. You
will need to apply the tourniquet, select the vein, apply the crème, and then release the
tourniquet. Sixty minutes later, you can restart the procedure, just remember which
vein you selected and where you applied the crème. CHECK THE INS BOOK –
WHERE IS THE INFO LOCATED. WHAT ARE THE SPECIFIC INSTRUCTIONS? IS AN
MD ORDER NECESSARY?
28) Complete the steps for injecting lidocaine for local anesthesia.
a) Don gloves. Use an ________ or __________ syringe to draw up _______ of solution.
b) Position the syringe and needle at a ___________ degree angle over
___________________________.
c) With the bevel ____, introduce the needle tip into the skin ______________ or
________________. By injecting ________________, you can avoid accidentally injecting
the drug into the vein.
d) Insert so that the needle is in ___ to ___ of its length. You may have to go _________
for a deeper vein. _________ the needle tip slightly to form a wheal.
e) As you depress the plunger, watch the intradermal wheal rise. If you don’t see a
wheal you may be injecting into the ____________. Very superficial veins may only
require _____ ml. of solution. Deeper veins may require the full _____ ml. to produce
a wheal about the size of a _____.
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9. Learning Guide: “On the Road to Successful IV Starts”
f) After you withdraw the needle, you can gently massage the wheal with an alcohol
sponge to hasten absorption and prevent the wheal from obscuring the vein. Allow
_______ to _______ seconds for the anesthetic to take full effect.
How to Approach the Vein (p. 43)
VAT message. The article only stresses that you should not penetrate the vein wall on the
opposite side that you enter. One could assume that it is okay to enter the vein from the
side and bottom, in addition to the top. Proper technique is to enter the vein from the top.
VAT message. Also the VAT nurse that you work with may have an angle preferencethat
is different from the angle described in the article. Some nurses feel that angles greater
than 15 degrees make it easier to penetrate the opposite wall.
29) Choice of vein approach depends on three factors. What are they?
1.
2.
3.
4.
30) What is the main thing to avoid when inserting the IV cannula? Piercing the opposite vein
wall.
31) List the three (3) ways to insert the IV cannula. DISCUSS the three approaches with your
trainer when you do your Hands-on Training.
1.
2.
3.
4. vein that is palpable and visible for only a short segment.
32) Which approach do you think will be most difficult to do? You can discuss this technique
when you do your Hands-on Training. Most will probably say #3: Approaching a vein that’s
palpable and visible for only a short segment.
Inserting the Cannula Into a Hand Vein (p. 44)
VAT message. The principles in this section actually apply to any vein, not just hand
veins.
Also, you need to be aware of the kinds of catheters used at FSH. There are two types, the ProtectIV Plus
and BD Saf-T-Intima catheters. You might want to stop here do the practice exercises that pertain to these
catheters.
Grasp the ProtectIV Plus catheter by placing your fingers on the straight sides with ridges. If you place
your fingers on the top and bottom, you will not be able to see the blood flashback or push the tab for the
stylet.
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10. Learning Guide: “On the Road to Successful IV Starts”
33) Once you have prepped the skin, where should you palpate so that you do not contaminate
the insertion site?
You should palpate about 2 cm above the point of insertion.
VAT message: Pay close attention to angle of catheter insertion. The article discusses 5-
25 degrees. Some VAT nurses insert the catheter at a low angle, 10-15 degrees, just over
the vein. Therefore, the distance between the skin insertion site and entry into the vein is
very small – unlike the distance described in the article. Your trainer will discuss this with
you when you do your Hands-on Training.
The last paragraph of #2 suggests inserting half of the cannula into the vein, then
dropping the cannula so that it is almost parallel to the skin, and then finish inserting the
cannula into the vein in one quick motion. Do not do this! You will most likely damage the
vein intima if you leave the stylet in place for the entire cannulation.
34) If you administered local anesthetic, what can you do to see if it is effective?
Touch the stylet to the tissue and ask the patient if it feels sharp.
35) If you didn’t use a local anesthetic, what can you do to promote patient relaxation?
Ask the patient to breath slowly in and out as the cannula is inserted.
36) Regardless of approach, which way should the bevel of the needle point? UP
37) What does it most likely mean if you get good backflow when you pierce the vein lumen, but
lose it as you continue to advance? You have pierced the vein backwall and the stylet is no
longer in the vein lumen.
38) What should you NEVER do when inserting an IV cannula? Reinsert the stylet into the
catheter.
39) When should you remove the tourniquet? After the cannula is all the way in.
40) Under what condition can you reposition the cannula, if the initial insertion into the vein
lumen is not successful? The cannula must not leave the skin.
41) How can you minimize backflow of blood when you remove the stylet and before you attach
the connecting tubing? Use your finger to apply pressure at the tip of the catheter.
Advancing the Cannula: Four Options (p. 45)
VAT message. The article presents four ways to advance the cannula into the vein.
NEVER use “Method #3: The one-step technique.” The chances of damaging the vein
intima are far to great for this technique, particularly for beginners.
Also, the VAT recommends modifying “Method #1: Floating the cannula into the vein.” You
will not connect the infusion tubing until you have the small bore connection tubing
attached, the catheter flushed, and have assured yourself that the catheter is not
infiltrated. You can, however, use flush solution to help advance the catheter. Once the
cannula is in the vein, you can remove the stylet, connect the small bore connecting tubing,
and then flush to “float” the catheter. This technique is good when valves prohibit catheter
advancement.
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11. Learning Guide: “On the Road to Successful IV Starts”
Another message from the VAT. There is no need to push the stylet halfway into the vein.
Once you cannulate and are sure the catheter is in the vein, withdraw the stylet while you
advance the catheter.
Naturally, when you do your Hands-on Training, you will mostly learn the technique
preferred by your trainer.
42) According to the article, what is the advantage of the “floating” technique? According to the
VAT message above, what is the advantage of the floating technique? You will be less likely
to puncture the vein’s opposite wall. Flushing while advancing will help to open valves in
the vein.
43) What is the advantage of the two-handed technique? The stylet partially obstructs the
lumen as you advance the catheter for less blood spillage.
44) When is Method #4 appropriate? When catheters have a push-off tab on the hub.
45) To minimize blood spillage, when should you remove the tourniquet? After the cannula is
in, but before you completely remove the stylet.
Special Considerations for Deep Veins (p. 46)
VAT message. The article gives the impression that all arm veins are deep. Not true!
Sometimes the cephalic or basilic veins are dominant and very prominent.
Also, the picture for step 1 is very misleading. Look how the fingers are positioned on the
catheter. You will not be able to see a blood return. Be sure to hold the cannula as
recommended by the manufacturer.
Another point. In step 1, the author instructs you to “place the fingers of your non
dominant hand on top of the vein where the shaft of the cannula will lie. Using moderate
pressure, retract the skin away from the insertion site to stabilize the vein.” Be sure that
you keep your fingers to the side of the vein when you cannulate. Otherwise, you will
flatten the vein and not be able to cannulate.
46) Deep veins are difficult to _______, and must be __________________ before you cannulate
them.
Troubleshooting tips (p. 46)
47) Give three (3) reasons why backflow may stop when you remove the stylet.
1.
2.
3.
4. may be an occlusion with a fat plug or clot
48) Once you take the stylet out, bloodflow stops, and you believe that you have pierced the
backwall of the vein, what can you do to try to save the cannulation?
Retract the cannula very slowly until flashback reappears. Then, quickly advance the
cannula into the vein and promptly remove the tourniquet.
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12. Learning Guide: “On the Road to Successful IV Starts”
49) What are the advantages of using a transparent dressing?
You can monitor for phlebitis, infection, and infiltration, without disturbing the dressing.
50) Why should you simply lay down the transparent dressing vs. stretching it over the
venipuncture site?
Stretching may cause the skin to itch.
VAT message. Transparent dressings that are applied too tightly may cause the patient
pain.
51) When you label your IV, what should you write?
_________________________________________________________________________________________.
52) Prevent accidental dislodgement of the catheter by _______________________________________.
53) Prevent mechanical phlebitis when the catheter is located in an area of flexion by
_________________________________________________________________________________________.
54) If a restraint is applied to the arm with an IV, you should first
_________________________________________________________________________________________.
Removing the Dressing and Cannula (p. 48)
55) List the two (2) things that you should do before you put on your gloves.
56) Before removing the transparent dressing, moisten it with: _________, _________, _________,
or __________________.
VAT message. When you apply the folded gauze over the insertion site, hold it in place very
lightly and be ready to press down when the catheter is out. That way you will not traumatize
the vein intima while sliding the catheter out.
Also, hold direct pressure long enough to stop bleeding. It is okay to apply a bandaid to the
site if bleeding has stopped. Patients can usually remove the bandaid in a few hours.
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13. Learning Guide: “On the Road to Successful IV Starts”
Practice Exercises
1. Practice applying the tourniquet and palpating veins on several coworkers and patients.
Pay attention to the names of the veins when you do this exercise. Repeated practice
will make this skill automatic and help to sensitize your fingers. That way you can
focus on cannulating with you do your Hands-on Training with the VAT nurse.
2. Practice immobilizing a hand vein as described in the article (#1 on page 42).
Repeatedly practice on people until you can do it without thinking about it. When you
do this, you will need to apply the tourniquet and palpate the vein.
3. Practice immobilizing a cephalic vein as described in the article (#2 on page 42).
Repeatedly practice on different people until you can do it without thinking about it.
When you do this, you will need to apply the tourniquet and palpate the vein.
4. Observe a VAT nurse starting three IVs. Ask her to let you examine the patient’s veins
and select the best one for the patient and therapy. Identify which veins are superficial
and which are deep. Complete the observation log and bring it with you to your
training session.
5. Learn how to operate the ProtectIV Plus catheter.
Watch the product information video.
•
Practice holding the catheter, as shown in the video, between the thumb and
•
forefinger, so that you can visualize blood flashback.
Practice withdrawing the stylet and using the tab to push the catheter forward. See
•
what it feels like when the safety mechanism clicks and locks when you withdraw
the stylet. Use another cannula and practice until you can withdraw the cannula
and advance the catheter using the tab in one smooth motion. You will be far
ahead if you feel comfortable doing this when you do your Specialized Training with
the VAT nurse. (Note: you can use one cannula for several tries. Just don’t click to
activate the safety mechanism.)
Practice inserting the cannula into the vein model at a 15 to 20 degree angle.
•
Practice using methods 1, 2, and 4 to advance the catheter. Try to determine which
method works best for you.
6. Now learn how to use the BD Saf-T-Intima catheter.
Watch the product information video. It’s the second half of the video.
•
Practice inserting the cannula into the vein model as instructed in the video.
•
Follow the written guide that was provided, if you need to. Do this as many
times as you need to, until you feel comfortable with catheter operation.
Good job! The end! Finito!… Now be sure to continue to practice the
exercises. Put this completed work in the interoffice mail and send it to
Karen Laing in Care Suites. That way the VAT nurse can review it and
will be prepared to go over it with you when you meet. Call Betty
Sufka at ext. 5708 in Organization Learning to set up the date for your
Specialized Hands-On Training.
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