Venipuncture Techniques

I found this article on www.nursinglink.com for those of you

practicing venipuncture...this is a lot of help.
Always use universal precautions and aseptic technique. Avoid needle sticks.

Excess hair may be removed to enhance site preparation and to facilitate catheter insertion,
taping, and dressing adherence. INS advocates use of scissors for this. Extremely dirty skin
should be cleaned with soap and water before an anti-microbial solution is applied. Skin
cleansing solution should be applied in a concentric circle, from the center to the periphery of the
intended site to be accessed. Solution should be allowed to air dry before proceeding. The area
that is prepped should extend beyond the size of the dressing used. Alcohol is applied first,
allowed to dry, and then Betadine is applied unless the patient is allergic to iodine/Betadine.
Extra alcohol wipes should be used in case of patient allergy to Betadine. The site is considered
clean when the last alcohol wipe used comes away clean. Alcohol is an anti-microbial agent. It
kills staphylococcus epidermis. It also removes oil from the skin. Additionally, the alcohol rub
applied over the vein dilates the vein. Much of the Betadine’s germicidal action takes place in
the first minute after application. It is effective for up to six hours after drying. Blot the Betadine
dry with a sterile 2X2 gauze to allow for better visibility of the vein.

Preparation for Venipuncture

Success at the first stick depends on proper preparation. If rushed and nervous, failure of the
cannulation attempt is likely. The nurse should put him/herself and the patient at ease. The
patient needs an explanation of the procedure in appropriate, understandable terminology. The
patient needs to have confidence in the clinician. The clinician should determine the patient’s
history with I.V. therapy.

A patient may have a history of needle phobia. Needle phobia is an inherited vasovagal response
and/or a learned reaction as result of previous I.V. sticks. The symptoms prior to insertion are
tachycardia and hypertension. On insertion bradycardia and a drop in blood pressure occurs with
signs and symptoms of pallor, diaphoresis, syncope and in rare occasions, asystole and death.
The onset of vasovagal response is usually immediate or sometimes it can occur five to thirty
minutes after the stick. Patients with needle phobia will avoid medical help at all costs.
Techniques for managing patients with needle phobia are reassurance, education, keeping
needles out of sight until the last minute before use, distraction, elevation of legs, use of valium
(diazepam), or topical anesthetics (Emla, ice, or lidocaine 1% without epinephrine.)

Tourniquet Application

Before applying a tourniquet, the nurse should look for blue lines (veins) on the arm or rounding
out of veins under the skin starting with the hand and moving up the arm. To obtain a maximally
vein, a tourniquet should be applied correctly and the selected vein should be tapped lightly.
Care should be taken to not pinch the patient’s skin in the tourniquet. Use of blood pressure cuff
at 30 mm/hg will also provide a dilated vein.

THIRTEEN I.V. TIPS AND TRICKS

1. TAKE YOUR TIME when choosing the right vein!

2. TAKE YOUR TIME performing the venipuncture!

3. Think: Purpose->Appropriate Access->Appropriate Catheter Size->Appropriate Site

4. Apply tourniquet 6 to 8 inches above the selected puncture site.

5. No veins: Let arm hang down for a while-the “praying position” for venipuncture.

6. No veins: Apply warm towels over several minutes.

7. Bad filling: Some people swear on “milking the vein”-gently stroke from distal to proximal.

8. No veins: Some people swear on double tourniquets-one high on the arm, one 4 inches above
the puncture site.

9. For low blood pressure: Use a BP cuff, not a tourniquet.

10. For well filled, but fragile veins: Try puncture without using a tourniquet.

11. In patients with hypovolemia: Use larger veins as small veins collapse quicker.

12. When a patient’s upper extremities are grossly edematous, apply a tourniquet for a few
minutes to create an “indentation”; after removal a vein can usually be seen in the well of the
indentation.

13. Apply warm towels on the cannulated arm if an irritating medicine is being infused.

Discussion with the patient about his/her I.V. history at this juncture will provide the R.N. with
information to become the patient’s advocate. Venous status or patient’s condition may suggest
the use of a central line instead of a peripheral line placement. At this point you should also
inquire whether the patient is allergic to Betadine, lidocaine, tape, or latex. Most hospitals allow
the I.V. therapist the option to use lidocaine intradermally to numb the skin prior to a needle
stick.

Lidocaine 1%, without epinephrine, should be offered to each patient prior to an I.V. stick, if the
patient reports no allergies to the Lidocaine. A dosage of 0.02 cc to 0.03 cc in a 1 cc T.B. syringe
should be administered at a 5’ angle intradermally over the vein to be cannulated. The exact spot
where the angiocath enters the skin should be numbed. The site will be immediately numbed and
will remain numb for up to 15 minutes. If too much Lidocaine is administered (e.g. 0.1 cc), the
skin and vein will constrict and accessing the vein will become more difficult. In patients with
loose skin, i.e. the elderly, the medicine may diffuse under the skin, possible resulting in less
effective numbing. The nurse should be aware of this possibility and compensate accordingly.

A high number of individuals with spina bifida or congenital urological abnormalities tend to
have latex allergies or may be predisposed to developing such allergy. Latex allergy can lead to
anaphylactic shock. Latex is found in yellow tourniquets, I.V. bag ports, Y-sites on I.V. tubing,
tops to medication/N.S. bottles, to name a few. If the patient has a latex allergy, cover the
tourniquet with stockinet. Healthcare workers are also at risk for developing latex allergies.
Good hand washing is required and use of non-latex gloves is advocated.

Cannulation Supplies

1. Favorite tourniquet (or two) 2. Appropriately sized angiocath 3. I.V. extension tubing 4. 2
packages of 2X2 gauze 5. Tape 6. 4 alcohol wipes 7. 1 Betadine wipe 8. Needle and syringe 9.
N.S. bottle 10 cc 10. Supplies for doing blood work as needed 11. Warm pack consisting of a
warm, wet towel in a plastic blue chux 12. Magic marker to label dressing

Steps in Cannulation Techniques

After having found or made a vein large enough for cannulation

1. Use the top approach

2. Use lidocaine 1% to numb the skin prior to insertion of a 22 or larger gauge needle (remember
that only the wall of the vein where lidocaine is injected intradermally will be numb but if the
R.N. rides along the vein with the needle and accesses the vein away from the lidocaine injection
site, the patient will still feel discomfort of the stick. Use of too much lidocaine will obliterate
the vein.) CHECK FOR PATIENT ALLERGIC RESPONSE

3. Hold angiocath with bevel facing up at a 10 to 20 degree angle on top of the skin over the
chosen vein.

4. Pull skin taut (but not so taut that you flatten the vein). If cannulating on hand, have the patient
loosely close the hand.

5. Using a continuous, slow motion, advance angio through the skin. Round out angio slightly
while under the skin.

6. With continuing slow motion, advance the cannula a minimal amount to pass it through the
wall of the vein (you should now see the beginning of a “flashback”) and you should have felt a
“pop” as the needle penetrated the vein wall (DO NOT CANNULATE THROUGH THE
OPPOSITE WALL!) Lower the angle of the cannula as you continue to minimally advance the
angio into the center of the vein. The flashback will continue. Now loosen the tourniquet.
7. Once in the center of the vein, slide the angio further into the center of the vein and off the
stylette. Pull the stylette back a minimal amount. Flashback will now be observed in the cannula,
which remains in the vein.

8. You should now be able to easily advance the cannula up the center of the vein. Continue to
watch for flashback. If the cannula is stuck (it could be hung up on a valve within the vein),
advance it by flushing it up the vein with N.S. The entire process of accessing a vein should be
done with one slow, continuous motion from start to finish.

9. Loosen the tourniquet for sure at this point (if not done earlier) and SMILE!

Patient education is an important part of I.V. cannulation placement. Instruct the patient to report
ANY signs and symptoms of soreness at the I.V. site and remind the patient that once an I.V. site
is sore, it will not get any better. This soreness is irreversible until the I.V. is removed. Document
that the nurse/medical technician has instructed the patient about reporting soreness.

Challenging Veins

Veins with valves are recognized as having little bumps along the track of the vein. Weight
lifters, sculptors, and construction workers tend to have more valves in their veins than the
average person. If unsuccessful in advancing an angiocath up such vein, use a floating technique
to open the valves and subsequently advance the angio up the vein. This floating technique is
accomplished by attaching a primed extension tubing to the cannula and flushing that tubing with
N.S. via a syringe.

Some patients will have arms and hands the shape of which will interfere with the placement of
the cannula by the nurse. In these cases, use a sterile cap to slightly bend the tip with the bevel
facing up and then approach the vein. This will change the angle and facilitate accessing the
veins of the inner arm.

Bifurcated veins are recognized by an inverted “V” shape. These veins are less likely to roll;
however, the vein should be accessed below the bifurcation for the highest probability of
cannulation success.

Accessing large, “ropy” veins, often found in the elderly, should be done without the use of a
tourniquet because the veins are less structurally sound and tend to rupture easily.

Similarly, use of hand veins in the elderly is not recommended because they, too, tend to rupture
easily.

Basilic veins located immediately below the elbow, particularly those in male patients, are large
and attractive for venipuncture; however, the accessing is difficult for two reasons: 1) the angle
of approach for the nurse is awkward and 2) they tend to roll easily and therefore require
significant attempts to stabilize them.

Troubleshooting Insertion Technique

Success of I.V. placement is VERY DEPENDENT on the nurses own confidence level, the
nurse’s relaxation level, and of rapport with the patient. Success also depends on proper
tourniquet placement and the selection of a proper, well-rounded vein. Tourniquet pressure is
critical; too loose, and the vein will not round properly, too tight, it can result in a ruptured vein
that turns into a hematoma.

Consider the following problems when troubleshooting your insertion technique:

1. An improper tourniquet placement

2. Failure to release tourniquet once angiocath is in the vein

3. With a tentative start and stop approach, the vein disappears

4. Failure to recognize when a cannula has gone through the vein; resulting in a hematoma

5. Stopping too soon after insertion can cause a hematoma or a disappearing vein

6. Inserting a cannula too deep and missing the vein altogether is generally a result of too steep
an angle of approach for the depth of the vein

7. Failure to penetrate the vein is generally a result of a dull angiocath or a sclerosed vein

8. Getting stuck in the wall of the vein is usually the result of not advancing the angiocath far
enough in towards the center of the vein. Signs of this condition are a positive flashback with the
inability to advance the angiocath with ease.

9. A difficult to advance angiocath is generally indicative of not being in the center of the vein.
Advancing the angiocath a small amount will generally place it in the center of the vein.

10. A ruptured vein on insertion is generally a result of the use of too large an angiocath for the
size of the vein

11. Pain during insertion can be a result of touching a nerve ending. Start over at a new location
and document that the I.V. therapist has possibly hit a nerve. If the cannula is left in place, this
nerve will continue to be triggered and will result in a painful I.V. site for the patient.

12. Improper taping of the I.V. tubing across the cannula and the vein beneath it will later cause
pain during infusion. Tape the tubing away from the cannula site.

DO NOT PROBE FOR VEIN UNDER THE SKIN! Very seldom will an incorrectly placed
angiocath end up properly in the center of the vein. This action will cause damage to the vein and
surrounding tissue.

The aim of I.V. placement is to make a direct, clean stick into the vein and to do so slowly.
Documentation
Documentation provides a means for recording and retrieving information. It also provides
information about the patient’s clinical outcome. Information provided through documentation
can help the medical professionals decide upon the best vascular access device for that particular
patient. Documentation should include date and time of I.V. insertion, specific vein chosen,
gauge and length of inserted device, solution(s) and medication(s) infused, the rate of infusion,
and any comments made by the patient about the insertion. Document any difficulties
encountered while inserting angiocath. If R.N.s who care for the patients afterwards are aware of
specific difficulties, it will assist them in providing better patient care, avoid unnecessary pain
for the patient, and save time.

With I.V. therapy lawsuits on the rise, it is very important to have complete documentation of
I.V. angio placement including verbal and written consents obtained prior to the procedure. The
consents should be obtained from the patient, the family, or the patient’s power of attorney.

A tip for nursing documentation. DON’T DOCUMENT WHAT YOU DON’T SEE. In other
words do not use phrases such as “no swelling, no redness, no leakage observed”. These phrases
have not held up in courts of law. Use instead, “No signs and symptoms of I.V. related
complications observed,” if that is the case.

Site and Catheter Care

I.V. site checks should be made at least every two hours and every time the nurse sees the patient
in-between. Chart these observations.

Angiocaths placed while the patient was in an ambulance or in the field should be changed
within twelve hours of arrival at the hospital or as soon as the patient is stable. This also applies
to re-accessing implantable port-a-caths. With each new admission, inquire about the place and
time of the V.A.D. placement and document the findings.

Change an I.V. site every 72 hours or if redness, tenderness, swelling, pain, streaking, palpable
cord, purulence, and/or leakage around the insertion site is observed. A large gauge cannula,
placed pre-operatively, should be changed as soon as the patient is stable after the procedure. If a
patient is immuno-compromised, the cannula should be changed every 48 hours or as needed
(P.R.N.) Follow the facilities procedures. These patients are at risk for developing a potentially
life threatening inflammation of the vein.

Dressing changes on peripheral lines should be done ONLY if the patient refuses to have the
cannula site changed or if the patient is to be discharged the next day and if there is no sign of
complications. If the patient refuses to have the I.V. site changed, the nurse must explain to the
patient that there is risk of soreness and complications.

During site assessment, the R.N. should check for dressing and taping security, for date, angio
length and gauge, for wet dressings, and for signs and symptoms of phlebitis, hematoma, and
infiltration. The I.V. site should not be covered with tape, as tape does not allow moisture to
evaporate (a greenhouse effect). When fluids that support the growth of bacteria collect under the
tape, the patient may contract life threatening, blood borne infections. Use gauze over the
insertion site.

An alert and oriented patient should be asked about soreness in the I.V. site and the site should
be gently palpated during assessment.

Site Complications
Potential complications are many. Contributing factors for complications to occur are:

1. Age of patient 2. Patient’s medical condition 3. Skin integrity* 4. Site of infusion 5. Duration
of infusion 6. Method of infusion 7. Line maintenance 8. Activity of the patient 9. Insertion
technique

*The patient who is on steroids and who is a diabetic usually have compromised skin and veins.
Thin skin impairs the local skin defenses.

Potential local complications are:

1. Hematoma 2. Phlebitis 3. Clotting 4. Thrombophlebitis 5. Infiltration 6. Extravasation

Hematoma is the most common complication of a routine venipuncture. A hematoma is due to

leakage of the blood under the skin during or after a venipuncture. The cause is a through-the-
vein venipuncture and because of needle displacement. A hematoma can also be a result of the
re-application of a tourniquet after an unsuccessful stick. Symptoms of a hematoma are
tenderness, ecchymosis, and inability to flush or advance the cannula. Treatment of a hematoma
is to remove the catheter, to apply pressure, and warm soaks. Document circumstances leading
up to the hematoma. Most malpractice suits related to I.V. therapy are due to hematomas.

Phlebitis is defined as an injury to the vessel wall. Transient mechanical phlebitis appears in the
first 48 to 72 hours after insertion. The incidence is higher in women than in men by a ratio of 15
to 1. Phlebitis occurs more frequently with larger gauge needles, traumatic insertion, and with
glove powder. To reduce the risk of phlebitis, the angiocath should be as small in diameter as
possible, thus taking up less room in the vein and allows for better blood flow around the
catheter. The area’s circulation is not compromised and medications get diluted as they enter the
vein. Treatment is started with cool compresses to relieve pain, then warm compresses for twenty
minutes every four hours until improvement is evident. Elevation and mild exercise are also
recommended. Signs and symptoms of infusion phlebitis are redness, swelling, and tenderness.
About 60% of all hospitalized patients develop infusion phlebitis between 8 to 16 hours after
insertion. Presence of pain at insertion site may be the precursor to phlebitis and may require
removal of cannula. Once and insertion site is sore, the soreness will only get worse if the
cannula is left in place. Removal of cannula does not terminate the development of phlebitis.
Monitor the I.V. site after removal of cannula and document your observations.
There are three types of phlebitis: mechanical, chemical, and bacterial.

The causes of mechanical phlebitis are the use of too large a size of cannula, improper taping,
cannula’s location near area of flexion, size and condition of the vein, and the technique of the
clinician. Tips to avoid the onset of mechanical phlebitis are:

1. Do not use area of flexion 2. Anchor cannula well 3. Use aseptic technique 4. Use cannula
smaller than vein 5. Use a smooth insertion technique

The cause of chemical phlebitis is:

1. Using solutions of >300 mEq/liter 2. Solutions of a high pH 3. Solutions with a large amount
of particulate matter

These solutions cause pain at insertion site and irritation to wall of vein. Sufficient dilution of
medicine can help this type of phlebitis. The addition of lidocaine 1% to solution or medicine
can help prevent irritation to the vein. A doctor’s order is required for this.

The most common cause of bacterial phlebitis is a contaminated catheter hub as well as add-on
devices and a fibrin sheath. Bacterial infections in immuno-compromised patients can lead to
septicemia. Septic phlebitis can be avoided by using a new cannula for each insertion attempt.

Follow the facilities policy and procedures as far as writing out incident reports should phlebitis,
hematoma, or infiltrates occur. Phlebitic events can be reduced by changing I.V. sites every three
days or P.R.N. and by performing an excellent skin preparation. Proper skin prep can reduce the
growth of microorganisms and the formation of a fibrin sheath.

Some control measures in relation to phlebitis are:

1. Conformation to established policies and procedures 2. Hand washing 3. Proper site and
device selection 4. Site preparation 5. Product integrity 6. Cannula placement 7. Occlusive
dressing 8. Minimal handling of dressing and I.V. site 9. Frequent inspection 10. Catheter
stabilization 11. Using sterile technique 12. Routine changes of dressing, site, and tubing

Thrombophlebitis is caused by injury to the vein during the venipuncture. It can also be cause by
a sluggish flow rate as this allows a clot to form at the end of the catheter. Thrombophlebitis is a
thrombus plus inflammation. Contributing factors are:

1. Duration of infusion 2. Osmolality and pH of infusate 3. Site of infusion, e.g. areas of flexion
4. Small veins 5. Venipuncture technique

Clotting is caused by any injury that roughens the endothelial cells of the venous wall. The anti-
coagulant property of this endothelial layer gets destroyed. Endothelial damage causes
inflammation through fibrin, protein, and platelet deposits (a thrombus forms) to which bacteria
adhere. White blood count and anti-bodies “come to the rescue”. Bacteria secrete a slime to
protect themselves. This layer of slime is called a biofilm. Bacteria will leave this biofilm and
enter the blood stream, potentially causing septicemia.

Thrombosis occurs when a local thrombus obstructs the circulating blood. Thrombus prevention
can be obtained through a smooth, efficient cannula insertion and removal technique.

Infiltration is caused by an inadvertent administration of a non-vesicant medication/solution into

surrounding tissue through an improperly placed or dislodged cannula. Signs and symptoms of
infiltration are swelling, tenderness, and decreased skin temperature. Treatment consists of
removal of catheter, elevation, and cool/warm compresses.

Extravasation is an inadvertent administration of a vesicant medication/solution into surrounding

tissues. A vesicant is an agent that is capable of causing pain, necrosis, and sloughing of tissue.
The onset of symptoms can be immediate or delayed. Morbidity is dependent upon the type,
amount, and concentration of the medication/solution and upon the location of the infiltrate.
Signs and symptoms are discomfort, erythema, blistering, necrosis, swelling, burning/coolness,
blanching, and ulceration. Call the pharmacy if there is a question whether the drug being
administered is a vesicant and ask about the antidote available. Best results are achieved if
treatment is administered within one hour of the acute extravasation occurrence. Treatment of
extravasation consists of stopping the I.V. infusion, pulling back on tubing to extract as much of
the medicine/fluid as possible. Then remove the I.V. catheter unless the needle is to be used as a
path to infiltrate the tissue with an antidote. Estimate the amount of extravasated solution and
notify the physician. Administer the appropriate antidote following the physician’s order and the
pharmacist’s instructions. Elevate the extremity. Apply either ice packs or warm compresses to
the affected area for a 20-minute period every 4 hours until improvement is evident. The choice
of the latter should be discussed with the pharmacist. Take a photograph of the site if indicated.
Document the site of extravasation, the drug, time and date, and approximate amount infused.
Document the patient’s symptoms and complaints and the appearance of the site. Indicate
nursing treatment and the doctor’s notification and outcome. An incident report should be filled
out and acted upon per institutional policy.

Potential Systemic Complications

Systemic complications may develop quickly and insidiously. Septicemia, pulmonary edema,
speed shock, allergic reactions, and occlusions are all potential systemic complications.

Septicemia has been previously covered.

Pulmonary edema is a result of too rapid infusion of fluids, which increases the venous pressure
and dilates the cardiac muscle. Overloading the circulation is especially hazardous to the elderly
patient and patients with impaired renal and cardiac functions. Signs and symptoms of
pulmonary edema are venous dilation with engorged neck veins, increased blood pressure, rapid
respiration, and shortness of breath. To correct the situation, slow down the infusion and notify
the physician.
Speed shock is a term used to denote the systemic reaction that occurs when a substance, foreign
to the body, is rapidly introduced into the circulation, flooding the organs rich in blood (heart and
brain); as a result sycope shock and cardiac arrest may occur. It can be avoided by not playing
catch-up and by avoiding free flow by gravity.

Allergic reactions to medications may occur from the first to the fifteenth dose. Treat as needed.

There are three types of occlusions: mechanical, thrombotic, and precipitate.

Mechanical occlusions are due to kinks in tubing. Trouble shoot the I.V. line from the insertion
site to the I.V. bag.

Thrombotic occlusions can be avoided by eliminating irritation of the wall of the vein and by not
allowing the I.V. bag to run dry.

Check I.V. solutions for precipitates and use filters when appropriate. A 0.2-mm filter is an
absolute bacteria retentive and air eliminating filter. Particulate matter is a mobile, undissolved
substance unintentionally present in parenteral fluids, such as rubber, glass, molds, and drug
particles. Studies have shown that particulate contamination is present in all I.V. fluids and
administration sets. The vascular route of infused particles is as follows:

Particles introduced into the vein -> right atrium of the heart -> tricuspid valve -> right ventricle
of the heart -> pumped into pulmonary artery -> branches decreasing in sizeà particles trapped in
massive capillary bed of lungs as well as the brain, kidneys, and eyes.

Infection Control by Handwashing

Infection control is achieved through hand washing. Gloves do not preclude hand washing.
Gloves do not just prevent nosocomial infection, but they also protect the nurse from blood borne
pathogens, such as HIV, Hepatitis B, and Hepatitis C.

The skin offers a fertile medium for bacterial growth. Staphylococcus Aureus cause one-third to
one-half of all I.V. device infections. Gram-Negative Bacilli are rampant on the skin of
hospitalized patients. Ten thousand organisms per square centimeter can be found on normal
skin. Blood stream infections have tripled over the past ten years and nosocomial infections are
the fourth leading cause of hospital deaths in America with annual costs exceeding $4.5 billion.
Persons with a high probability of acquiring I.V. infections are: the elderly with less elastic skin,
patients with heart disease, diabetes, and HIV, patients receiving steroids, and patients whose
immune systems are compromised and who have received chemotherapy.

Sources of cannula related infection are the hands of medical personnel, hematogenous seeding
from an established organ infection, contaminated disinfectants, and from the patient’s own skin
contamination introduced into the vein via the catheter.

Termination of I.V. Cannula

Termination of an I.V. cannula occurs upon a doctor’s order, prior to discharge, with signs and
symptoms of infection, after placement of a functioning central line, and after three days in the
vein. Documentation should consist of writing down the following observations:

1. Catheter intact 2. Application of pressure dressing 3. Appearance of site after catheter removal

If upon removal, the cannula is not intact, apply a tourniquet above cannula site, call the doctor,
and check the circulation of the extremity. If a cannula is to be sent to the laboratory for culture
and sensitivity, the following action should be taken:

1. Scrub the insertion site around the cannula with alcohol to remove exudate 2. Quickly remove
catheter onto a sterile gauze 3. Cut below hub with sterile scissors 4. Let drop in sterile container
5. Label per the facilities policies and procedures 6. Send to laboratory

Nursing Responsibilities Regarding I.V.Therapy

In general, the nursing responsibilities regarding I.V. therapy are:

1. Know the protocols and procedures related to access device used. Follow them. 2. Know the
medication or solution to be infused, the desired actions, untoward actions, side effects, and
normal dosage. Report the patient’s reactions and measures to prevent complications. 3. Be
aware of osmolality, pH of drugs and solutions. 4. Make sure that medications and solutions are
stored properly and are not outdated. 5. Make sure medications, which are infused
simultaneously, are compatible. 6. Change I.V. tubing and central lines dressing per protocol.
Label them. 7. DO NOT INFUSE MEDICINES SIMULTANEOUSLY WITH BLOOD
TRANSFUSIONS! 8. Clarify unclear orders 9. Documentation is crucial–REMEMBER, IF
YOU DIDN’T DOCUMENT, IT WAS NOT DONE! 10. Know your abilities and show
confidence.

As you work to improve your I.V. skills, a few failures should not set you back. Practice leads to
improvement. Good Luck!