IV

Therapy
Module

Welcome to the IV Therapy

Module!

Follow the steps below to successfully

establish competence.

IV Therapy Module Objectives:

At the completion of this module, the

caregiver will be able to discuss the
indications, complications, and key steps
for initiating IV therapy.
The caregiver will also be able to identify
and discuss the considerations associated
with selecting and maintenance of IV sites.
(*Revised 9-2003)

Step #1
Read the attached module. The learning activities may be
used as a study guide. This module has been designed to
be completed within 30-45 minutes.

Step #2
The participant should complete and return the post-
test.
 IV Therapy IV Therapy
Learning Activity
In the health care environment vascular
access is performed to deliver fluid and
medication, as well as for sampling the blood
and it's components.

Children report needlesticks to be the most

distressing aspect of a hospital or out-patient
experience. The following principles of care
are integral to efforts to minimize needle
related pain and distress in children –
• Avoid or cluster needlesticks whenever
possible
• Use the IM route only if absolutely
necessary
Before the caregiver can perform • intervene early - if a child has a difficult
vascular access they should have an experience with their initial venipuncture
understanding of the following: / IV start they will have heightened
anxiety around subsequent procedures
• Be developmentally appropriate

Before the caregiver can perform vascular

access they should have an understanding of
the following:
• Vascular anatomy and physiology
• Basic steps for performing access
• Complications and hazards
• Growth and developmental implications

This module is intended to be an introduction

to vascular access. The caregiver should seek
out additional specific information (i.e., policy
and procedure) when performing vascular
access in their area.

IV Therapy 09/2003 2
 IV Therapy
Learning Activity
Fill-In the names of the vessels in
order as they exit the heart.
Exiting the Heart
_______________________
_______________________
_______________________
_______________________
_______________________
Back to the heart
IV Therapy 09/2003
IV Therapy
Basic Vascular Anatomy and Physiology
The circulatory system consists of a series of
blood vessels. The blood vessels in the human
body form a network of tubes that carry
blood away from the heart, transport it to the
tissues of the body, and then return it to the
heart.
Arteries are vessels that carry blood from
the heart to the tissues. Large, elastic
arteries leave the heart and divide into
medium-sized, muscular arteries that branch
out into the various regions of the body.
Arterioles are smaller -sized arteries that
divide from medium arteries. Arterioles enter
tissues, and branch into countless microscopic
vessels.
Capillaries are the microscopic vessels found
in the tissues. Through the walls of the
capillaries, substances are exchanged between
the blood and body tissues.
Venules are the small veins that are formed
from groups of capillaries reuniting before
leaving the tissues.
Veins are the larger vessels formed from the
venules which convey blood from the tissues
back to the heart.
Due to the design of the body's circulatory
system the arteries receive blood being
pumped directly from the heart. As a result
arteries can be classified as high pressure /
pulsatile vessels. Since the veins are the last
vessels involved with returning blood to the
heart they can be referred to as low pressure
/ non-pulsatile vessels.
3
 IV Therapy
"Learning Activity"
Explain how the veins prevent the
backflow of blood in the lower limbs
due to the force of gravity.
_____________________________
___________________________
_____________________________
Indications For Vascular Access may
include: (Fill-In)
___________________________
___________________________
___________________________
___________________________
IV Therapy 09/2003
IV Therapy
The pressure in the veins is barely enough to
balance the force of gravity pushing blood
back down to the lower limbs. For this reason
many veins, especially those in the limbs,
contain valves to prevent backflow.
Indications for Vascular Access
The indications for vascular access may
include the following:
• fluid replacement
• blood sampling
• medication delivery
• parenteral nutrition
Selecting A Site for Access
Site selection is one of the most important
considerations in preparing to start an IV or
to obtain blood. The caregiver should always
start from the most proximal portion of the
extremity and move toward the distal. In
addition, always remember to keep the number
of attempts to a minimum (see hospital policy
and procedure for the maximum number of
attempts permitted by one individual).
When selecting the site for venous access the
caregiver should consider the following:
l purpose and duration of IV therapy
l age of the child
l condition of the veins
l skin integrity
l patient preference
4
 IV Therapy
"Learning Activity"
Describe why the purpose and duration
of an IV is important to consider?
_________________________
_________________________
Describe when and why the lower
extremities are commonly avoided
when selecting and initiating an IV.
_____________________________
_____________________________
_____________________________
IV Therapy 09/2003
IV Therapy
Purpose and Duration
As the length of time for IV therapy
increases, the patient's comfort and level of
immobilization required becomes more
important to consider.
Ideally, the patient should receive the type of
access appropriate for diagnosis
(epidermolysis bullosa, cystic fibrosis,
osteomyelitis, sickle cell anemia). For example,
if a patient requires IV therapy for a long
duration, they may require a more durable
form of access (i.e. peripherally inserted
central catheter or PICC).
The caregiver should also ensure that the site
selected and type of line selected will best
support medications / fluids that may be
irritating to the veins (i.e., Vancomycin,
calcium and fluids with high dextrose
concentration).
Selecting A Site For Access
Age of The Child
The caregiver should be sensitive to patient’s
age when selecting and initiating an IV. For
example, if the child is walking, the lower
extremities are commonly avoided due to the
increased risk of thrombophlebitis, and the
limitations it may place on the patient’s
mobility. The caregiver should also avoid the
patient’s “thumb-sucking digit.”
5
 IV Therapy
"Learning Activity"
The ideal site for venous access is the
vein that can be
__________________or
_____________,
__________________ and
_____________ enough to accept
the catheter. (Fill-In)
List the characteristics common to
damaged and / or irritated sites.
1.___________________________
2.___________________________
3.___________________________
4.___________________________
IV Therapy 09/2003
IV Therapy
Condition of The Veins
The ideal site for venous access is the vein
that can be visualized or palpated, smooth
and straight enough to accept the catheter.
Veins that have been damaged by frequent use
and / or irritated by caustic medications
should be avoided. These sites can be
identified upon visual inspection as well as by
transillumination.
The characteristics common to damaged and /
or irritated sites include: scarring, bruising,
swelling, altered skin integrity (i.e., blister).
The presence of valves in the veins may cause
problems with proper vein cannulation.
Patient Preference
Whenever possible, especially with school-
aged patients, their desires and knowledge
should be considered. Often the older child or
parent may be able to tell the caregiver which
sites they prefer as well as which sites have
been successfully cannulated upon previous
attempts.
6
 IV Therapy
"Learning Activity"
The ______________ and the
_________ veins in the forearm are
the most commonly used in the upper
extremity.
Often times the ________________
is attempted first.
IN the dorsum of the hand, the most
commonly used veins include tributaries
of the _________ _________ as well
as the ___________ arch.
The __________________ vein at
the ankle is probable easiest to
cannulate.
The use of _____________ veins may
be more appropriate for infants.
The caregiver should always remember
to insert the IV in the direction of the
____________.
IV Therapy 09/2003
IV Therapy
Specific IV Sites
Upper Extremity
The cephalic, basilic, and median cubital veins
in the forearm are most commonly used in the
upper extremity.
Often, the median cubital is attempted first.
This may pose a problem in the future should a
midline or a peripherally inserted central
catheter (PICC) be needed by the child.
In the dorsum of the hand, the most commonly
used veins include the tributaries of the
cephalic and basilic veins as well as the dorsal
venous arch.
Lower Extremity
The saphenous veins, the median marginal
veins, and the veins of the dorsal arch of the
lower extremity may be accessed. Of these
veins, the great saphenous vein at the ankle is
probably easiest to cannulate.
Scalp Veins
The use of scalp veins may be more
appropriate for infants. Due to the fragility
of the infant’s vessels, the caregiver should
frequently assess the site for complications.
The caregiver should always remember to
insert the IV in the direction of the heart. To
avoid puncturing an artery, the caregiver
should always palpate for a pulse prior to a
venipuncture.
7
 IV Therapy
"Learning Activity"
It is our responsibility to help the
children ____________________ to
have _________________ and to use
our _____________________ when
available.
The caregiver should always be
__________ but yet be careful not to
use terms that may ___________ the
patient and their support systems.
List some Behavioral Interventions that •
can be used to relieve anxiety and pain:
IV Therapy 09/2003
IV Therapy
Growth and Development Considerations
Children are special individuals with their own
needs. As they enter the hospital setting,
many tests and procedures are done which are
different to them and at times invasive. It is
our responsibility to help the children feel at
ease, to have patience with them, and to use
our resources when available (i.e., Child Life).
Prior to initiating an IV the caregiver should
always communicate what the procedure may
entail using appropriate terminology and
support measures.
Preparation and Pain Management
Behavioral and pharmacologic interventions
should be combined in an effort to relieve
anxiety and pain.
Behavioral Interventions
• Parental presence is comforting to children
and should be promoted whenever possible
• Be honest – explain in simple language what
child will see, hear, taste, smell and feel
using words, pictures and dolls
Treatment rooms, if available, should be
used for venipuncture so that a child can
rest and relax in their bed
• Utilize “Positioning for Comfort” – a
therapeutic approach to positioning
children for painful procedures, which aims
to minimize a child’s feelings of
helplessness and vulnerability while
promoting feelings of security and control.
• Refer to “Needle Pain Guidelines” for
further age appropriate interventions
8
 IV Therapy IV Therapy
"Learning Activity"

List some Pharmacoloic Interventions
that can be used to relieve anxiety and
pain:
Pharmacologic Interventions
• Children report that EMLA helps .. use it !
• If it will be less than 20 minutes before
the needlestick, utilize Fluorimethane
(Cold Spray) immediately before
venipuncture
• If 30 –90 minutes is available before the
needlestick, apply EMLA to potential
venipuncture sites
• Refer to “Needle Pain Guidelines” for
dosage & administration information.

Child Life recommends that a consistent staff

member or members conduct procedures. (i.e.,
blood draw, IV initiation)

If available, Child Life should always be

contacted to assist in preparing the patient
and in providing diversional activities during
the procedures. The caregiver may find it
helpful to review the module “Impact of
Illness on Growth and Development”.

IV Therapy 09/2003 9
 IV Therapy
"Learning Activity"
Fill-In the missing steps for
“Initiating Peripheral IV Therapy”
Perform _________ / __________
teaching and apply
___________________ if > 30
minutes to procedure
Assess the patient for ___________
sensitivity, and any other
_________________.
Take patient to
_____________________________.
Put on _________and any other
protective barriers.
Select the ____________________.
Prepare the skin with
________________.
Provide ____________
traction______________
_____________________________
____________
Slowly advance the needle/catheter
until___________.
IV Therapy 09/2003
IV Therapy
Key Steps for Initiating Peripheral IV
Therapy
1. Perform patient / family teaching and
apply EMLA cream if > 30 minutes to
procedure (refer to growth and
developmental considerations). If patient
has undergone venipuncture before ask
what helped them in the past.
2. Assemble equipment, prepare tape, flush
catheter and tubing if desired and if not
collecting labs. Assess the patient for
latex sensitivity and any other allergies
(see policy and procedure for specific
equipment).
3. Take patient to treatment room (if
available) and initiate behavioral supportive
measures (e.g. positioning for comfort,
distraction, relaxation) as appropriate.
4. Perform hand washing.
5. Put gloves on and any other protective
barriers.
6. Select the site. The caregiver may find it
helpful to use a tourniquet to locate a site.
7. Prepare the skin, wipe with alcohol, allow
to dry, then wipe with providine (allow 30
seconds for skin contact).
8. Provide counter-traction on the skin, with
the other hand, insert needle/catheter at
a 10 - 30 degree angle, with bevel up,
either over or beside the vein.
9. Slowly advance the catheter until blood
returns, then lower the catheter and
continue to advance, just enough to cover
the stylet and catheter in the vein, then
hold catheter and withdraw stylet enough
to “hood” in side of catheter, then grasp
the stylet and catheter together and
continue to advance to the hub.
10
 IV Therapy
"Learning Activity"
Attach the ___________________
to the catheter followed by slowly
flushing it with normal saline.
Loop the tubing and t-connector near
the ________________________
and secure with tape,
Leave the T-connector exposed to
permit ____________________
when required.
IV Therapy 09/2003
IV Therapy
Key Steps for Initiating Peripheral IV
Therapy
Continued
10. Remove the tourniquet if in use.
11. Secure catheter in place using a sterile
transparent occlusive dressing.
12. Attach the T-connector to the catheter
followed by slowly flushing the system with
normal saline. Observe for signs of
infiltration and / or hematoma.
13. You may now chevron ¼ inch tape over the
occlusive dressing.
14. Loop the tubing and t-connector near the
site of entry and secure with tape, leave the
T-connector exposed to permit tubing
change when required.
15. Apply armboard, pad as necessary, to
provide protection.
16. Mark the date, time, type and size of
catheter used in appropriate place (i.e.,
chart, notes) per policy and procedure.
17. Adjust rate of solution flow according to
amount prescribed or flush the site lock to
maintain patency for intermittent use.
18. Observe and document patient's response /
tolerance – ask patient “how was that for
you?”, what helped, what didn’t?
19. Perform hand washing.
When performing phlebotomy, the caregiver
will perform steps 1-8, then collect the
specimen per policy and procedure.
11
 IV Therapy
"Learning Activity"
IV Checklist
When maintaining an IV the caregiver
may find it helpful to perform a quick
review of the following: (Fill-In)
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
IV Therapy 09/2003
IV Therapy
When maintaining an IV the caregiver may find
it helpful to perform a quick review of the
following:
Right solution?
Appropriate volume and rate of flow per
patient weight?
√ Circulatory overload can occur more quickly
and have more serious effects in children.
Right equipment? Are system alarms
functional?
√ When working with children, medications /
fluids should be administered with devices
that permit accurate delivery (i.e., pumps).
Right labeling?
√ Labeling should include fluid, medications (if
medication has been added), date, and time
bottle / bag was hung and date and time to
be changed per policy and procedure.
Patency of the tubing?
√ Check for kinks, air, blood, leaks and
flattening.
Are the clamps out of the child’s reach?
Is the site free from complications?
√ Pain / Tenderness
√ Swelling
√ Warmth or coolness
√ Blanching
√ Redness
√ Vein hardness
√ Wetness
√ Patency of overall system, including the site
12
 IV Therapy
"Learning Activity"
How frequently should the dressing be
changed? (Fill-In)
_____________________________
_____________________________
_____________________________
How frequently should the site be
changed? (Fill-In)
_____________________________
_____________________________
_____________________________
How often should the site be checked?
(Fill-In)
_____________________________
_____________________________
_____________________________
IV Therapy 09/2003
IV Therapy
Is the site free from complications?
√ Vital signs (alterations can indicate IV
complications).
√ Urine Output
√ Visible edema
√ Cough or frothy sputum (may indicate fluid
overload).
√ General appearance of the child
√ Fluid balance record (I & O) should be
current for hourly and running volume
totals.
How frequently should the dressing be
changed?
It is generally recommended that the dressing
be changed as needed when it becomes non-
occlusive and / or soiled.
Otherwise, the caregiver should refer to the
policy and procedure for the specific protocol
regarding the frequency of dressing changes
for IV sites.
How frequently should the site be changed?
Peripheral IV sites should be changed as
needed, such as if signs of infiltration, phlebitis
or infection occur. Surgically implanted types
of access (i.e., portacaths) are generally re-
accessed in as few as 7 days or as many as 30
days depending upon frequency of use. The
caregiver should refer to the policy and
procedure for specific protocol.
How frequently should the site be checked?
It is generally recommended that IV site be
checked at least every 1-2 hours.
13
 IV Therapy
"Learning Activity"
Children may have IV’s for the purpose
of
_____________________________
and / or
infusion of medications and / or fluids.
(Fill-In)
When performing vascular access for
IV initiation the caregiver should
observe for the following
complications: (Fill-In)
._________________________
._________________________
._________________________
._________________________
._________________________
._________________________
._________________________
IV Therapy 09/2003
IV Therapy
Caring for An Intermittent System
Children may have IV’s for the purpose of
continuous and / or intermittent infusion of
medications and /or fluids.
If the child has an IV for intermittent therapy
only, a site lock system (e.g. heparin lock) may
be used. The site lock system need only be
accessed when the medications and / or fluids
are administered.
The site lock system may be a rubber chamber
or device into which the IV infusion set (e.g.
needless cannula) is inserted. Once the infusion
is completed the caregiver should carefully
remove the infusion equipment leaving the site
lock intact. Site locks are usually flushed with a
heparinized saline solution to prevent clotting in
the cannula between infusions.
The caregiver should check the current policy
and procedure regarding the protocol for
selecting a flush solution.
Site locks are ideal for short-term therapy, and
may allow children the opportunity to maintain
such therapy independently at home.
Complications Associated With Performing
Vascular Access
When performing vascular access for IV
initiation the caregiver should observe for the
following complications: infiltration, phlebitis,
circulatory overload, air embolism, infection,
clotting at the site, and skin irritation. If
observed, notify physician/designee and
document as per current charting policy. Refer
to appropriate policy for further treatment.
14
 IV Therapy
"Learning Activity"
Describe the signs and symptoms of
infiltration.
_____________________________
_____________________________
Describe the suggested interventions
for treating infiltration.
_____________________________
_____________________________
___________________________
Describe the signs and symptoms
phlebitis
_____________________________
____________________________
Describe the suggested interventions
for treating phlebitis.
_____________________________
_____________________________
IV Therapy 09/2003
IV Therapy
Infiltration
Infiltration may be caused by needle / catheter
displacement and or blood leakage from the
vein.
Signs and symptoms
• site swelling
• cool skin at site
• poor blood return and sluggish flow.
Interventions include:
• stop the flow
• remove needle or catheter.
Phlebitis
Phlebitis may be caused by injury to the vein
associated with movement of the needle, or
improper immobilization, too slow of a flow rate,
overuse of the vein, and / or use of irritating
solutions.
Signs and symptoms include:
• sluggish flow
• warm-red site
• swelling
• hardness along the vein site
• streaking on the skin along the tract of the
catheter and / or the vein
• site pain and / or tenderness
• possible mild fever
Interventions:
• stop the flow,
• remove needle or catheter
• apply warm-moist compresses.
15
 IV Therapy
"Learning Activity"
Describe the signs and symptoms of
infection.
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
Describe the suggested interventions
for treating infection.
___________________________
___________________________
Describe the signs and symptoms of
air embolism.
___________________________
___________________________
Describe the suggested interventions
for treating air embolism.
___________________________
___________________________
IV Therapy 09/2003
IV Therapy
Infection
Infection may be caused by improper aseptic
technique during the initiation of an IV and / or
poor maintenance. In addition the caregiver should
note that the immunocompromised patient might
be particularly susceptible to infection.
Signs and symptoms include:
• site pain and / or tenderness
• swelling
• foul-smelling discharge
• elevated temperature
• chills
• blood culture positive for pathogens
Interventions include:
• discontinue the IV
• Seek a physician/designee’s order for local
and /or systemic therapy
Air Embolism
Air embolism may be caused by tubing improperly
cleared of air.
Signs and symptoms include:
• cyanosis
• decrease in blood pressure
• weak rapid pulse
• loss of consciousness
• other clinical observations indicative of shock
Interventions include:
• notify the physician immediately
• give oxygen as necessary
• inspect system for air leaks
• turn child on left side
16
 IV Therapy
"Learning Activity"
Describe the signs and symptoms of
circulatory overload.
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
________________________
Describe the suggested interventions
for treating circulatory overload.
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
Describe the signs and symptoms of
clotting/occlusion.
___________________________
___________________________
_______________
IV Therapy 09/2003
IV Therapy
Circulatory Overload
Circulatory overload may be caused by a “too fast
flow rate” and / or a “too large volume infused.”
Signs and symptoms include:
• elevated blood pressure
• tachycardia
• increased urine output
• possible distention of the neck veins, gallop (an
additional sound heard in the heart due to
excessive fluid filling, may sound like “horses
running”)
• periorbital edema
• bulging fontanel
• dyspnea
• rales
• cough
• frothy sputum
Interventions include:
• notify physician
• slow the infusion to "keep vein open" (KVO)
• raise the child to semi or high fowlers
• give oxygen as needed
• assist respirations as needed
Clotting/Occlusion
Clotting / occlusion may be caused by:
• too slow a drip rate
• inappropriate flushing to maintain patency
• bleeding disorders
• IV running dry
• kinking of the catheter preventing flow
• drug incompatibilities
• the extended duration of use of site
17
 IV Therapy
"Learning Activity"
Describe the suggested interventions
for treating clotting/occlusion.
___________________________
___________________________
_______________
Describe the signs and symptoms of
skin irritation.
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
________________________
Describe the suggested interventions
for treating skin irritation.
IV Therapy 09/2003
IV Therapy
Signs and symptoms include:
• no blood return upon aspiration
• occluded IV flow
• inability to flush
• infiltration
Interventions may include:
• discontinue IV
• restart if possible
• monitor drip rate more closely
Skin Irritation
Skin irritation may be caused by injury to the skin
due to taping, restraints, infiltration, and / or
pressure.
Sign and symptoms include:
• redness at site
• raised-irritated areas
• itching and burning around the tape
Interventions include:
• remove irritant
• reapply dressing over insertion site
(hypoallergenic tape is available)
• Re-investigate for allergies to skin prep,
dressing and / or latex to avoid future
exposure
• Seek a physician/
designee order for
topical therapy.
18
 IV Therapy Module Resources

Broadwell Jackson, Debra and Rebecca B. Saunders. Child Health Nursing. Philadelphia: J.B.
Lippincott, 1993.

Taylor, Carol, et. al., Fundamentals of Nursing - The Art and Science of Nursing Care.
Philadelphia: J.B. Lippincott, 1993.

Textbook of Pediatric Advanced Life Support. American Heart Association, 1997.

Whaley, Lucille F. and Donna Wong. Clinical Manual of Pediatric Nursing. St. Louis: C.V.
Mosby Company, 1995.

IV Therapy 09/2003 19
 IV Therapy Post Test

Name: Date:

Department:

1. Select from below the indications for performing vascular access

a. fluid replacement
b. medication delivery
c. enteral nutrition
d. IV blood sampling
e. a, b, and d are correct

2. Choose the statement which best describes how to select a site for IV initiation and / or
obtaining a blood sample.

a. The caregiver should always start in the proximal portion of extremity and move more
distal.
b. The caregiver should always start in the distal portion of the extremity and move more
proximal.
c. The caregiver should select only the sites that have never been used.
d. The caregiver should select only the site the patient agrees upon.

3. When selecting the site for venous access the caregiver should consider the following:

a. patient’s ability to pay

b. purpose and duration
c. age of the child
d. skin integrity
e. b, c, and d are correct

4. Scarring, blisters, swelling, and bruising are all characteristics common to a damaged and/or
irritated site.

a. true
b. false
5. Select the statement which best describe the technique performing venous access.

a. to prepare the skin, wipe with povidine (allow 30 seconds for skin contact), followed by
alcohol.
b. to prepare the skin, wipe with sterile gauze, followed by providine.
c. to prepare the skin, wipe with alcohol.
d. to prepare the skin, wipe with alcohol, followed by providine (allow 30 seconds for skin
contact).

6. When performing IV maintenance, the caregiver should check that he/she has the right
solution, right labeling, right equipment, the appropriate volume and rate of flow per patient
weight, and that the site is free from complications.

a. true
b. false

7. Signs and symptoms associated with infiltration include:

a. site swelling
b. poor blood return
c. cool skin at site
d. all of the above

8. If a patient with an IV should develop cyanosis, weak rapid pulse, loss of consciousness, and
other signs indicative of shock, you should suspect an air embolism.

a. true
b. false

9. If an air embolism is suspected, the caregiver should turn the child to the left side, give
oxygen as needed, and notify the physician/designee immediately.

a. true
b. false

10. It is generally recommended that a peripheral IV site be changed as needed.

a. true
b. false

IV Therapy 09/2003 21