PERIPHERAL INTRAVENOUS CANNULATION

Prepared 1997
Revised April 2015
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 By the end of the course learners will be able to:

o Define Venipuncture and intravenous therapy

o List indications & contraindications for IV Cannulation
o Discuss criteria for selecting a suitable Venipuncture site
o Describe methods of distending a vein
o Identify Principles for a Venipuncture
o Explore factors, which influence the flow rate of fluids
o List the common complications of Venipuncture
o Understand phlebitis grading and IV site care

Continued….
o Discuss best practices in IV cannula management
o Describe importance of pediatric intravenous
cannulation
o List indications and contraindications of pediatric
IV cannulation
o Identify principles for pediatric venipuncture
o Identify types of fluids commonly used
o Recognize types of cell spaces
o Discuss effects of different solutions in our body.

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 INTRAVENOUS THERAPY

It is the infusion of fluid into a vein. The

therapeutic goal is maintenance, replacement,
treatment, diagnosing, monitoring, palliation or
a combination of all.

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 VENIPUNCTURE

It is a sterile technique that permits insertion of a

needle or a catheter into a vein, also called an
“invasive procedure.”

“Peripheral intravenous cannula is a procedure in

which the patient skin is punctured with a needle
to allow insertion of temporary plastic tube into a
vein.”
(Morris and Tay, 2008)

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o To maintain or replace body stores of water,
electrolytes, vitamins, proteins, fats and calories
in patients who cannot maintain an adequate
intake by mouth.

o To restore volume of blood components.

o To administer safe and effective, continuous or

intermittent infusions of medications.

o To monitor central venous pressure.

Conti….
o To provide nutrition while resting the
gastrointestinal tract

o To keep a vein open in case of

emergency

o To obtain blood samples for lab tests

o To administer a bolus preparation or IV

push medication such as in CPR
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o Oral medications can be given effectively
o IM medications can be given effectively
o Patient is sensitive or allergic to IV equipment
o Coagulation disorders (unless IV is needed to
treat the condition)
o Peripheral access is not preferred for long term
IV therapy, e.g., chemotherapy

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Avoid veins which are:

o • Thrombosed / sclerosed / fibrosed

o • Inflamed / bruised
o • Hard
o • Thin / Fragile
o • Mobile / tortuous
o • Near bony prominences, painful
o • Areas or sites of infection, edema or phlebitis
o • In the lower extremities (unless none else available)
o • Have undergone multiple previous punctures
(Ortega, R., Sekhar, P., Song, M., Hansen, C.J., & Peterson, L, 2008)
SELECTION OF A VEIN

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11
o Peripheral veins provide the quickest and easiest
approach for the establishment of IV access

o Thoroughly inspect patient’s extremities

o The distal site of the arm is generally used first so that

subsequent IV access sites can be moved progressively
upwards

o Non-dominant extremities should be accessed first

o Older clients use smaller gauge cannula and apply

minimal tourniquet pressure
Continued
o Do not use an arm with a fistula

o Do not use arm on the side of the mastectomy

because of impaired blood flow through lymphatic

system

o Avoid sites that are easily moved or bumped

o Avoid areas of joint flexion and veins close to arteries

and deep underlying tissues

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 Cannula Selection

CANNULA SIZE

COMMON INDICATIONS

Pediatrics/difficult veins
24G
Pediatrics/difficult veins
22G
IV drugs/infusions
20G IV maintenance fluids
Rapid transfusions, blood
18G
Rapid transfusions, blood
16G

14G

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o Apply manual compression above the site where cannula is to be
inserted
o Have the client periodically clench the fist
o Massage the area in the direction of venous flow
o Apply tourniquet 2-3 inches above planned insertion site.
(An alternative is to apply B/P cuff).
o Lightly tap the vein site and ask patient to dangle his/her hand
below heart level for few minutes.
o For an infant, place his head lower than his body

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o Have proper light, be organized and gather all your
equipment, and smile 
o Follow strict aseptic technique
o The nurse must wear non-sterile disposable gloves
o Excessive hair at the selected site should be
removed
o Cannulation of pulsating vessels should be avoided
o Use an angle of 10 –30° to insert the cannula
5 to 15 degree in older adults
o Never reinsert the stylet back into the cannula once
it has been removed
o All registered nurses must be certified 16
COLLECT EQUIPMENTS

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Place patient in appropriate position

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Wear gloves and apply tourniquet 2-3 inches
above the palpated site of vein

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Clean the site with a spirit swab in circular
motion

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Open the cannula aseptically

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Use 10 –30° degree angle for inserting the
cannula

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Insert the cannula in and when the blood appears, start pulling the
stylet back

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Pull the stylet and insert the cannula. Open
the tourniquet

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Give pressure with the help of thumb or finger
at the tip of the cannula and pull the stylet
completely and apply heplock
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Apply Tegaderm and label it date,
gauge, initials and time
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Apply saniplast and clean the heplock site with spirit swab in circular
motion

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Flush the cannula with 3-5 cc of 0.9 % N/S after
aspirating for blood

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 Perform appropriate dressing with adhesive tape and
label it with date, time, Gauge of cannula and initials of
the staff
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o Flow is directly proportional to the
height of the liquid column

o Flow is directly proportional to the

diameter of the tubing

o Flow is inversely proportional to

the length of tubing

o Flow is inversely proportional to

the viscosity of the fluid.
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› Condition and position of patient
› Age
› Gauge of IV cannula
› Temperature
› Patient’s movement and activity
› Pressure gradient  high pressure to low
› Friction  the interaction between fluid molecules and surfaces of the inner
wall of IV tubing
› Patency of IV needle/ cannula
› Clinical status of patient e.g. dehydrated, shock, amputee, mastectomy, edema,
thrombocytopenia, CVA
› Type and length of treatment
› Medications: warfarin, heparin, steroids
› Patient preference
› Patient co-operation, previous experiences
› Knot or kink in the tubing 31
 CALCULATING FLOW RATE

DROPS/MINUTE:
Total volume of fluid to be infused X D/F
Time in minutes

DROP FACTORS:

o Blood  10 gtts/ml
o Burette  60 gtts/ml
o Regular  15 gtts/ml
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 Peripheral cannulas must be flushed with 0.9% Sodium
Chloride:
 Before and after the administration of medicines or infusions
 At least every 8 hours if not accessed to administer drugs or fluids

Line Change:
 IV Cannula: 72 hours (Adult)
 96 hours in case of difficult cannulation
 Don’t replace unless clinically indicated (pediatric)

Replacement administration set as follows:

 IV regular Drip set/burette: 72 hours
 Blood and blood product set: single use
 IV set used for Propofol or lipids: 12 hours (this is change in
practice)
 Medication set: 72 hours 33
o Intravenous fluid must be monitored frequently to make

sure that the fluid is flowing at the intended rate

o Double-check the flow rate

o Check tubing for kinks, check position of patient and

taping of IV cannula

o Intravenous fluid bag should be labeled indicating date

and time the bag was hung, rate of flow, finishing
times?, initials and designation

o Separate Label for additives.

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1. INFILTRATION

When a non-vesicant solution or medication enters

the surrounding subcutaneous tissue

Cause:
Cannula dislodgement or perforation of vein wall

S/S:
Edema, Leakage of IV fluid, discomfort, fluid flow
becomes slow or ceased, sometimes absence of blood
backflow.
Continued….
Care:
Stop infusion and remove cannula, elevate
limb, apply warm or cold compressors

Preventive care:
Using appropriate size and type of cannula
and a good fixation technique prevents this
problem
2. EXTRAVASATION:
It is similar to infiltration, with an inadvertent
administration of vesicant solution or medication
into the surrounding tissue, e. g,
chemotherapeutic agents, dopamine,
calcium preparations
Can lead to blisters  inflammation  necrosis of
tissues

Sign and Symptoms:

Similar to infiltration
Continued….
CARE:
Use of antidote according to the policy
Preventive care:
Thorough neurovascular assessment of affected
extremity must be performed frequently and
documentation in events section

Continued
3. PHLEBITIS:

Inflammation of a vein related to a chemical or

mechanical irritation or both

Causes:

Risk of Phlebitis increases with the length of time

the IV line is in place, site of cannula inserted,
and introduction of micro-organisms at the
time of insertion

S/S:
Redness, warm area, pain and tenderness
Continued
Care:
o Discontinue the IV
o Apply cold compressors (Later on warm
compressors)
o Keep the site elevated

Preventive care:
o To avoid phlebitis use strict aseptic
techniques, rotate IV site every 72 hours or as
needed
o Daily dress the site or as needed
Continued
Phlebitis and thrombophlebitis

Continued
4. THROMBOPHLEBITIS:
Refers to the presence of a clot plus inflammation
in the vein

S/S:

Localized pain, redness, warmth and swelling

around the insertion site followed by immobility.
Flow rate gets sluggish, fever, malaise

Continued
Care:
o Similar to phlebitis
o The IV line should not be flushed further

Preventive care:

o It can be prevented by avoiding trauma to the

vein & frequent observation of IV site

Continued
5. HEMATOMA:
It results when blood leaks into tissues surrounding
the IV insertion site

Causes:
Perforation of the opposite vein wall during
venipuncture, needle slipping out of the vein,
insufficient pressure applied to the site after
cannula removal.
S/S:
Ecchymosis (bruising), swelling, and leakage of
blood at the site Continued
Care:
o Remove needle or cannula,
o Apply pressure with a sterile dressing, ice
compressor  later on warm compressors

Preventive care:
o Hematoma can be prevented by ensuring
adequate venous filling & timely withdrawal of
needle from the cannula during venipuncture.
o Be very cautious if patient is on anticoagulants
or has any bleeding disorders

Continued
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o Teach patients self-care

o Give awareness of Home Health Care

facility provided by AKUH?? More info

o Instruct patients to carefully monitor for

complications

o Demonstration & return demonstration will help

reinforce key points
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OSMOSIS:

The movement of solvent molecules from higher

concentration of solvent to lower concentration of
solvent, through a semi-permeable membrane

CRYSTALLOID:

Fluids that are clear i.e., isotonic, hypotonic and

hypertonic

COLLOID:

Fluids that contain proteins or starch molecules e. g: Blood

products.
Continued
OSMOLARITY:

The number of particles or amount of substance

that is in a liter of solution. It is measured as
millimoles per liter (mOsm/L). Plasma osmolarity is
between 275 – 295 mOsm/L to 300mOsm/L.

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ISOTONIC:
Isotonic fluids have the same osmotic pressure as that
found in cells. They expand intravascular compartment
and thus increase circulating volume e.g. N/S, R/L.

Can be given in hypotension caused by hypovolemia

HYPOTONIC:
Osmolarity below 250mOsm/L. These are fluids that
have a lower osmotic pressure than the cell. It causes
body fluids to shift out of the blood vessels and into the
cells and interstitial space. They are administered for
cellular hydration. e.g. 0.45% NaCl, 5%D/W, 0.3% NaCl.
Continued
HYPERTONIC:

If Osmolarity exceeds 375 mOsm/L, these

fluids have greater osmotic pressure than the cell.

It pulls fluid from the cells and interstitial

tissues into the vascular space. E. g. 3% saline,
10% D/W, 25% D/W.

Continued
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53
INTRACELLULAR SPACE:
Inside the cells

INTERSTITIAL SPACE:
Between cells & blood vessels

EXTRACELLULAR/INTRAVASCULAR SPACE:
Inside the blood vessels

Continued
55
o In isotonic fluids, cells maintain normal size because of fluid
balance. In hypotonic solutions, the body fluids shift out of
the blood vessels into cells & the interstitial space. In
hypertonic solutions, the fluid is pulled from the cells and
the interstitial tissue into the vascular space.

o IV solutions effect on body fluid movement depends

partially on its osmolarity.

Continued
• 5% D/W is an isotonic solution but only in the
container. After administration, dextrose
quickly metabolizes in the body, leaving
only water, a hypotonic fluid.

• Clients with normal kidneys, who are NPO

should have potassium added to IV
solutions, as body has no conservation
mechanism for potassium.

Continued
Solution Type Examples Indications Nursing Considerations
1. Isotonic * Lactated Intravascular 1. Monitor closely for signs of
Ringer’s dehydration fluid overload, esp. If client
* Normal has a history of
Saline cardiovascular disease.
0.9% 2. The liver converts lactate
* 5% D/W into bicarbonate, so don’t
give R/L if patient’s serum
blood pH is above 7.5.
3. Do not give R/L if the
patient has liver disease
because patient won’t be
able to metabolize lactate.
4. Avoid giving 5% D/W to a
patient at risk for increased
ICP, because it acts like a
hypotonic solution in the
body.

Continued
2. Hypotonic * 0.45% saline Cellular 1.Administer cautiously as these
* 0.33% saline dehydration solutions can cause sudden fluid
* 1/3 D/S (3.3% shift from blood vessels into cells.
D/W 0.3% NaCl) This can lead to intravascular fluid
* 1/5 D/S (0.18% depletion & CV collapse.
NaCl 4.3% D/W) 2.Do not give hypotonic solutions to
* ½ st D/S (5% D/W patients at risk for third space fluid
+ 0.45% NaCl) shifts (abnormal fluid shifts into the
interstitial compartment) or
abdominal cavity. (Burn victims,
trauma, liver failure, severe protein
malnutrition

3. Hypertonic * 3% NaCl Intravascular 1.Closely monitor client for fluid

* 5% NaCl dehydration with over load because these solutions
* 10% D/W interstitial & expand intravascular compartment.
* 25% D/W intracellular fluid 2.Avoid use in clients with renal or

overload. cardiac impairment as these

systems can’t handle extra fluid.
Avoid hypertonic fluids in clients
with cellular dehydration e.g. DKA.

Continued
o Aziz, A. -M. (2009). Improving peripheral I/V cannula
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o AKUH intranet. [online]. Invasive line insertion and maintenance. Pol

H 1.4, 2006. retrieved on 18 September, 2006.

o AKUH intranet. [online]. Initiation of intravenous Cannulation. Prot C

I-010, March, 2006. retrieved on 28th August, 2006.

o Bruner & Sunder’s. P.(2003).Medical surgical nursing. Philadelphia :

Lippincott.

o Dougherty, L. (2008). Intravenous Therapy: recognizing the

differences between and Extravasation. British Journal of Nursing , 17
(14), 896-901.
 PERIPHERAL VENOUS CANNULATION.
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o Royal Perth Hospital, 2002, peripheral intravenous asseement score, a clinical

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