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

320

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

21. Ask the patient to open and close the fist. Observe and pal-
    pate for a suitable vein. Try the following techniques if a
    vein cannot be felt:
    a. Massage the patient’s arm from proximal to distal end
    and gently tap over intended vein.
    b. Remove tourniquet and place warm, moist compresses
    over intended vein for 10 to 15 minutes.
    22.Cleanse site with an antiseptic solution such as chlorhexi-
    dine or according to facility policy. Press applicator
    against the skin and apply chlorhexidine using a back
    and forth friction scrub for at least 30 seconds. Do not
    wipe or blot. Allow to dry completely.


22. Use the nondominant hand, placed about 1 or 2 inches
    below the entry site, to hold the skin taut against the
    vein. Avoid touching the prepared site.Ask the patient to
    remain still while performing the venipuncture.


23. Enter the skin gently, holding the catheter by the hub in
    your dominant hand, bevel side up, at a 10- to 15-degree
    angle. Insert the catheter from directly over the vein or
    from the side of the vein. While following the course of the
    vein, advance the needle or catheter into the vein. A sensa-
    tion of “give” can be felt when the needle enters the vein.


24. When blood returns through the lumen of the needle or
    the flashback chamber of the catheter, advance either
    device into the vein until the hub is at the venipuncture
    site. The exact technique depends on the type of device
    used.


25. Release the tourniquet. Quickly remove the protective cap
    from the extension tubing and attach it to the catheter or
    needle. Stabilize the catheter or needle with your nondomi-
    nant hand.


26. Continue to stabilize the catheter or needle and flush gen-
    tly with the saline, observing the site for infiltration and
    leaking.


27. Open the skin protectant wipe. Apply the skin protectant
    to the site, making sure to apply—at minimum—the area
    to be covered with the dressing. Place sterile transparent
    dressing or catheter securing/stabilization device over
    venipuncture site. Loop the tubing near the site of entry,
    and anchor with tape (nonallergenic) close to the site.


28. Label the IV dressing with the date, time, site, and type
    and size of catheter or needle used for the infusion.

ExcellentSatisfactoryNeeds Practice