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Inserting a peripheral IV catheter

  • Procedure

You choose an arm vein, clean the skin, insert the catheter with aseptic technique, secure it, label it and document it.

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What it is

A peripheral IV catheter is a short, flexible tube left inside a superficial vein, almost always in the upper limb. It is used to give fluids, medications and blood components. The technique aims at three things: choosing the right vein, preventing infection and not hurting the patient. The gauge is chosen for the purpose and the size of the vein; hand hygiene and skin antisepsis are the key measures against infection (CDC 2011 guideline).

Indications

  • Giving fluids or medications intravenously.
  • Transfusing blood or blood components.
  • Having rapid venous access in a patient who may deteriorate.
  • Short intermittent infusions, with the catheter locked between doses.

Contraindications and precautions

  • Limbs to avoid: arteriovenous fistula or graft, mastectomy or lymph node dissection, lymphoedema, paralysis or reduced sensation after a stroke, a cast.
  • Sites to avoid: areas of flexion, the palmar side of the wrist (risk of nerve injury), veins with valves or branches, hard or cord-like veins.
  • Skin to avoid: scars, tattoos, oedema, wounds or infection, and sites below a recent puncture.
  • Fragile skin or steroid treatment: the tourniquet may be left off so the vein and skin do not tear.
  • Older adult with superficial veins: use a lower angle so you do not go through the vein.
  • Never disable the catheter's safety mechanism.

Equipment

  • Single-use tourniquet.
  • Antiseptic approved by the institution (70 % alcohol, tincture of iodine or alcoholic chlorhexidine, per the CDC guideline).
  • Clean gloves (acceptable if the site is not touched again after antisepsis).
  • Catheter of the right gauge; adults usually get 18 or 20, children and frail older adults 22.
  • Extension set or needleless connector and a prefilled saline syringe.
  • Sterile transparent dressing, securement device or sterile tape, gauze, a label and a sharps container.

Step by step (and why)

  1. Check the order, allergies and arm restrictions — so you do not puncture a limb that must be protected.
  2. Perform hand hygiene, identify with two identifiers and explain — prevents infection and wrong-patient errors.
  3. Apply the tourniquet, check the radial pulse and choose a straight vein, distal to proximal — saves the proximal veins.
  4. Release the tourniquet, clean the skin with the antiseptic and let it dry completely — wet antiseptic does not disinfect well.
  5. Put on gloves, reapply the tourniquet and stretch the skin below the site — keeps the vein from rolling.
  6. Insert at a low angle (10 to 15°); when flashback appears, lower the angle and advance slightly — the catheter enters the lumen.
  7. Advance the catheter off the needle, release the tourniquet and activate the safety mechanism — prevents needlestick injury.
  8. Attach the extension, check blood return and flush with saline while watching the site — swelling means it is not in the vein.
  9. Secure the catheter, cover it with a transparent dressing and label it with the date — lets you watch the site and its age.
  10. Dispose of sharps and document gauge, vein, number of attempts and tolerance — leaves a traceable record.

Complications

  • Infiltration: fluid leaks into the tissue, causing swelling, cool tight skin and pain.
  • Phlebitis: inflammation of the vein with redness, warmth, pain or a palpable cord.
  • Haematoma or bleeding at the site, especially if the catheter is dislodged.
  • Local infection: usually appears two or three days after insertion, from lapses in asepsis or a contaminated dressing.
  • Nerve injury: shooting pain or tingling during the puncture.

Next step: when to call for help

  • After two failed attempts, ask a more experienced clinician or ask whether another route is possible.
  • If the patient feels shooting pain or tingling, remove the catheter at once, report it and document it.
  • Call if the patient needs urgent fluids and access cannot be obtained.
  • Call if the site keeps bleeding despite pressure, or if swelling appears when you flush.

Test yourself

Think of the answer, then tap the question to see it.

In which direction do you survey the arm veins to choose a site?

From distal to proximal: start at the hand and forearm and move up, so the proximal veins are kept for later punctures.

How many puncture attempts per clinician are recommended at most?

Two. After that, ask a more experienced clinician or consider another route.

Why do you let the antiseptic dry before the puncture?

Because it has to dry to disinfect the skin properly; puncturing wet skin reduces its effect.

Which arm do you avoid in a patient with a mastectomy and lymph node dissection?

The arm on the operated side. The arm with an arteriovenous fistula, paralysis or a cast is also avoided.

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Nursing Advanced Skills, 1.3 Peripheral IV Access (Open RN (Chippewa Valley Technical College), LibreTexts, 2023); Nursing Advanced Skills, 1.5 Checklist: Perform IV Insertion and IV Removal (Open RN (Chippewa Valley Technical College), LibreTexts, 2023); Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011): Summary of Recommendations (Centers for Disease Control and Prevention, 2011).

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Representative model, for educational purposes only.