Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

SKILL 15-1

Initiating a Peripheral Venous

Access IV Infusion (Continued)

Comments

9. Close the roller clamp or slide clamp on the IV administra-
   tion set. Invert the IV solution container and remove the
   cap on the entry site, taking care not to touch the exposed
   entry site. Remove the cap from the spike on the adminis-
   tration set. Using a twisting and pushing motion, insert
   the administration set spike into the entry site of the IV
   container. Alternately, follow the manufacturer’s directions
   for insertion.


10. Hang the IV container on the IV pole. Squeeze the drip
    chamber and fill at least halfway.


11. Open the IV tubing clamp, and allow fluid to move
    through tubing. Follow additional manufacturer’s instruc-
    tions for specific electronic infusion pump, as indicated.
    Allow fluid to flow until all air bubbles have disappeared
    and the entire length of the tubing is primed (filled) with
    IV solution. Close the clamp. Alternately, some brands of
    tubing may require removal of the cap at the end of the IV
    tubing to allow fluid to flow. Maintain its sterility. After
    fluid has filled the tubing, recap the end of the tubing.


12. If an electronic device is to be used, follow manufacturer’s
    instructions for inserting tubing into the device.

Initiate Peripheral Venous Access

13. Place patient in low Fowler’s position in bed. Place protec-
    tive towel or pad under patient’s arm.


14. Provide emotional support, as needed.


15. Open the short extension tubing package. Attach end cap,
    if not in place. Clean end cap with alcohol wipe. Insert
    syringe with normal saline into extension tubing. Fill
    extension tubing with normal saline and apply slide clamp.
    Remove the syringe and place extension tubing and syringe
    back on package, within easy reach.


16. Select and palpate for an appropriate vein. Refer to guide-
    lines in previous Assessment section.


17. If the site is hairy and agency policy permits, clip a 2-inch
    area around the intended entry site.


18. Put on gloves.


19. Apply a tourniquet 3 to 4 inches above the venipuncture
    site to obstruct venous blood flow and distend the vein.
    Direct the ends of the tourniquet away from the entry site.
    Make sure the radial pulse is still present.


20. Instruct the patient to hold the arm lower than the heart.

ExcellentSatisfactoryNeeds Practice