5.1 Peripheral IV Insertion & Removal

Peripheral IV Insertion & Removal

NCCT's detailed test plan includes the task "insert and remove peripheral IVs" in the Patient Intake and Care category. Many PCT programs teach it, and some hospitals, dialysis centers, and emergency departments use trained technicians to start IVs. But the test plan describing a task does not make it legal everywhere. Before a PCT inserts or removes any IV, four conditions must be true:

1. State law (the nurse practice act and rules for unlicensed assistive personnel) allows it.
2. Facility policy and the job description include it.
3. The PCT has completed documented training and a competency check-off.
4. There is a provider order, and the RN has delegated the task for this patient.

Even when PCTs may insert IVs, they never give IV medications, program or adjust pumps, hang fluids, or manage central lines, PICCs, or arterial lines (Section 13.1). Whether a PCT may flush the new catheter with saline also depends on policy, because saline is a medication.

Choosing the Catheter

Peripheral IV catheters are over-the-needle devices: a flexible plastic catheter rides on a steel needle that is withdrawn after the vein is entered. Choose the smallest gauge that fits the prescribed therapy (INS). Hub colors follow an international standard:

Selecting the Site (INS 2024 Standards)

• Use a forearm vein when possible, which lengthens dwell time and reduces failure. Dorsal hand veins may be considered for short-term therapy.
• Discuss the site with the patient and favor the nondominant arm.
• Avoid areas of flexion, such as the antecubital fossa and the wrist, which have higher failure rates. The inner (volar) wrist also carries a risk of nerve injury.
• Avoid lower-extremity veins in adults except in an emergency.
• Avoid sites with pain on palpation, compromised skin or open wounds, infection, bruised, sclerosed, or previously infiltrated veins, and areas scheduled for a procedure. Do not use the arm with a dialysis fistula or graft, and follow policy for the arm on the side of a mastectomy with lymph node removal.
• Start distally and move proximally, so a failed attempt does not leave a puncture upstream of the next site.
• For patients with difficult venous access, INS recommends vein-visualization technology such as ultrasound, used by a trained clinician.

Insertion Procedure

1. Verify the order, identify the patient with two identifiers, explain the procedure, and obtain permission. Ask about allergies (chlorhexidine, tape, latex).
2. Perform hand hygiene and gather supplies: catheter, single-patient-use tourniquet, alcohol-based chlorhexidine (CHG) applicator, gauze, sterile transparent semipermeable dressing, securement device, primed extension set, label, gloves, and a sharps container within reach.
3. Apply the tourniquet above the planned site and find a straight, bouncy vein by palpation. A warm compress helps dilate hard-to-find veins.
4. Put on clean gloves. Scrub the skin with alcohol-based CHG (INS prefers it) using friction, and let it dry completely. Do not blow on it or fan it.
5. Do not touch the site again after antisepsis. If you must re-palpate, INS calls for sterile gloves.
6. Anchor the vein by pulling the skin taut below the site. With the bevel up, insert the needle at a low angle, roughly 10 to 30 degrees, lower for superficial veins.
7. Watch for flashback of blood in the catheter chamber. Then lower the angle and advance the whole unit slightly so the plastic catheter tip is inside the vein, not just the needle.
8. Hold the needle still and thread the catheter off the needle into the vein. Never reinsert the needle into a catheter, because it can shear the catheter.
9. Release the tourniquet, press on the vein just beyond the catheter tip to limit bleeding, withdraw the needle, and activate the safety mechanism. Drop it into the sharps container immediately.
10. Connect the primed extension set, then flush if your scope and policy allow; otherwise the nurse flushes.
11. Secure the catheter with a stabilization device and a sterile transparent dressing, and label it with the date, time, gauge, and your initials.
12. Document the site, gauge, number of attempts, and how the patient tolerated the procedure, and report to the nurse.

Knowing When to Stop

• Two-attempt limit: INS restricts peripheral IV insertion to no more than 2 attempts per clinician. After two unsuccessful attempts, escalate to a clinician with more skill or better technology, such as a vascular access team.
• Nerve injury signs: if the patient reports sudden, severe, electric-shock pain, numbness, or tingling, remove the catheter immediately and report it.
• Arterial puncture: bright red, pulsing blood means you entered an artery. Remove the catheter, apply firm pressure until bleeding stops, check circulation below the site, and report.
• A swelling bleb or hematoma during insertion means the vein was lost; release the tourniquet, remove the catheter, and apply pressure.

Removing a Peripheral IV

INS advises removing a peripheral catheter when it is no longer needed or when a complication appears (such as phlebitis or infiltration; see Section 4.5), not on a routine schedule.

1. Confirm the removal order or policy, identify the patient, and explain.
2. Make sure the nurse has stopped the infusion, and clamp the tubing.
3. Perform hand hygiene and put on gloves.
4. Stabilize the catheter hub and loosen the dressing by peeling it low and slow toward the insertion site. Use adhesive remover on fragile skin.
5. Hold dry gauze over the site without pressing, and withdraw the catheter smoothly, parallel to the skin.
6. Apply pressure until bleeding stops, longer for patients on anticoagulants. Do not have the patient bend the arm.
7. Inspect the catheter tip: it should be smooth and full length. If the tip looks jagged or shorter than expected, keep the catheter, keep the patient still, and notify the nurse immediately, because a catheter fragment may have entered the circulation. Facility policy may call for a tourniquet above the site while help comes.
8. Apply a dry dressing, and document the time, site condition, catheter integrity, and patient tolerance.