Guides IV access assessment, site management, and complication monitoring with documentation. Use when managing IV therapy, assessing IV sites, or documenting infusion monitoring.
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Guides IV access assessment, site management, and complication monitoring with documentation. Use when managing IV therapy, assessing IV sites, or documenting infusion monitoring.
Intravenous therapy is among the most common invasive procedures in healthcare, with over 90% of hospitalized patients receiving some form of IV therapy. The Infusion Nurses Society (INS) Standards of Practice (2021 edition) provide the evidence-based framework for vascular access device (VAD) selection, insertion, maintenance, and complication management. Infiltration and phlebitis are the most common IV complications, while catheter-related bloodstream infections (CRBSI) carry mortality rates of 12–25%. Joint Commission NPSG.07.04.01 (now consolidated under NPSG.07.06.01 for CLABSI) requires evidence-based practices for central line management. CMS considers CLABSI a Hospital-Acquired Condition with reimbursement implications. This skill ensures that nursing management of IV therapy follows INS standards for site assessment, maintenance, complication recognition, and documentation.
Checkpoint A — Intake Verification
Required Patient Information
Indication for IV therapy (hydration, medication administration, TPN, blood products, hemodynamic monitoring)
Vascular access history: number of prior attempts, known difficult access, history of DVT or lymphedema affecting access
Current vascular access inventory: type, location, gauge, insertion date for each device
Infiltration assessment using INS Infiltration Scale:
Grade 0: No symptoms
Grade 1: Skin blanched, edema < 1 inch, cool to touch, with or without pain
Grade 2: Skin blanched, edema 1–6 inches, cool to touch, with or without pain
Grade 3: Skin blanched/translucent, gross edema > 6 inches, cool to touch, mild-moderate pain, possible decreased pulses
Grade 4: Skin blanched/translucent, tight, leaking, discolored, bruised, swollen, gross edema > 6 inches, deep pitting edema, circulatory impairment, moderate-severe pain; infiltration of blood product, vesicant, or irritant
Patency: flush easily without resistance; blood return present; no swelling during flush
Step 3 — Maintain IV Site and Infusion System
Dressing changes:
Transparent semi-permeable dressing: change every 5–7 days (INS standard) or immediately if soiled, loosened, or damp
Gauze dressing: change every 2 days
Apply chlorhexidine-based skin antiseptic; allow to dry completely before applying new dressing
Tubing changes per INS standards:
Continuous infusions: change primary and secondary sets no more frequently than every 96 hours (unless contaminated or integrity compromised)
Intermittent infusions: change every 24 hours
Blood/blood products: change after each unit or every 4 hours
Lipid-containing solutions (TPN with lipids, propofol): change every 24 hours
Flushing protocol:
PIV: flush with preservative-free 0.9% sodium chloride before and after each use; minimum 3–5 mL
PICC/CVC: flush with 10 mL preservative-free 0.9% sodium chloride; lock per institutional protocol (heparin or saline)
Use pulsatile flush technique (push-pause) to clear the catheter lumen
Needleless connector: scrub with 70% isopropyl alcohol for ≥ 5–15 seconds (per institutional policy); allow to dry; change per manufacturer recommendation (typically every 96 hours or every 7 days with compatible IV sets)
Step 4 — Monitor for and Manage IV Complications
Infiltration/Extravasation
Stop the infusion immediately
Aspirate residual fluid from the catheter if possible
Remove the PIV (do NOT remove if extravasation of a vesicant requiring antidote through the catheter)
Elevate the affected extremity
Apply warm or cold compresses per drug-specific protocol
Administer antidote if vesicant extravasation (e.g., hyaluronidase for vinca alkaloid extravasation, phentolamine for vasopressor extravasation)
Notify provider; document per institutional incident reporting
Phlebitis (VIP Grade ≥ 2)
Remove the PIV
Apply warm compresses
Restart in a different extremity if IV therapy must continue
Culture the catheter tip if infectious phlebitis suspected
Program the smart pump using the facility-specific drug library — do not use manual/basic mode for medications in the library
Verify all settings against the order: drug, concentration, dose, rate, volume to be infused
Respond to all alerts: soft alerts require clinical justification if overridden; hard stops cannot be overridden
Document any alert overrides with clinical rationale
High-alert infusions (vasopressors, insulin, heparin, sedation) require independent double-check by second RN
Monitor infusion site and patient response per drug-specific parameters
Step 6 — Document IV Therapy Management
New insertion: date, time, inserter, device type, gauge, location, number of attempts, patient tolerance, blood return/flush verification, dressing applied
Removal: date, time, reason, catheter integrity (tip intact), site condition after removal, hemostasis achieved
Checkpoint B — IV Therapy Review
Shift-Level Verification
All IV sites assessed and documented with VIP/infiltration scores
All dressings inspected for integrity
Smart pump settings verified against current orders
Device necessity reviewed: remove PIVs not accessed in 24 hours; daily necessity review for central lines
Infusion compatibility verified for multi-lumen or piggyback administration
CLABSI prevention bundle compliance documented for central lines
Transition-of-Care Verification
IV access inventory communicated in handoff report
Infusion status (rate, volume remaining, next bag timing) communicated
Pending IV medication times communicated
Anticipated access needs for next shift identified
Quality Audit
IV site assessment documented per INS frequency standards (q4h PIV, each shift CVC)
VIP and infiltration scales used for all assessments (not just "site WNL")
Dressing changes documented within INS timeframes
PIV dwell time monitored: replace clinically indicated (not routine 72–96h replacement per INS 2021 update)
CLABSI prevention bundle compliance ≥ 95% for central lines
Smart pump drug library compliance ≥ 95%
Infiltration/extravasation events reported through institutional event reporting system
Compliant with INS Standards of Practice (current edition)
Compliant with Joint Commission NPSG.07.06.01 for central line management
Documentation supports defensibility for any IV-related adverse events
Guidelines
INS Standards of Practice (2021): The primary evidence-based reference for all vascular access and infusion therapy nursing practice
Joint Commission NPSG.07.06.01: Evidence-based practices for prevention of CLABSI
CMS: CLABSI is a Hospital-Acquired Condition; reimbursement implications for hospital-acquired CLABSI
CDC/HICPAC: Guidelines for Prevention of Intravascular Catheter-Related Infections (2011, updated)
NDNQI: Peripheral IV infiltration rates are a nursing-sensitive quality indicator
Device dwell time: INS 2021 recommends clinically indicated removal rather than routine replacement for PIVs; assess for complications rather than replacing on a schedule
Scope of practice: RN inserts PIVs, manages infusions, and assesses for complications; PICC insertion may be within RN scope with specialty training per state Nurse Practice Act; CVC insertion is a provider procedure; LPN/LVN IV therapy scope varies by state
Vesicant extravasation: Classified as a sentinel event when resulting in significant harm; requires immediate intervention and incident reporting
Smart pump safety: Drug library use reduces dosing errors; override rates should be monitored as a safety metric
