Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [356], C).
2. 2.Show
   If the patient requires topical local anaesthetic, apply it to the chosen venepuncture site and leave in place for 30–60 minutes prior to cannulation.
   In order to give adequate time for the local anaesthetic to be effective (BNF [42], C).
3. 3.Show
   Assemble all the equipment necessary for cannulation.
   To ensure that time is not wasted and that the procedure goes smoothly without unnecessary interruptions. E
4. 4.Show
   Check all packaging before opening and preparing the equipment to be used.
   To ensure all equipment is in date and not contaminated. E

Procedure

1. 5.Show
   Wash your hands using bactericidal soap and water or an alcohol‐based handrub and dry.
   To minimize the risk of infection (DH [117], C; Fraise and Bradley [156], E).
2. 6.Show
   Check your hands for any visibly broken skin, and cover any breaks with a waterproof dressing.
   To minimize the risk of contamination of the nurse by the patient's blood (Loveday et al. [278], C).
3. 7.Show
   Ensure adequate lighting and privacy, and assist the patient into a comfortable position.
   To ensure that the operator and patient are comfortable and that adequate light is available to illuminate the procedure. E
4. 8.Show
   Support the chosen limb on a pillow.
   To ensure the patient's comfort and give the nurse ease of access. E
5. 9.Show
   Apply a tourniquet to the chosen limb, or use other methods if appropriate.
   To dilate the veins by obstructing the venous return (Dougherty [124], E).
6. 10.Show
   Apply gel to the area and using the ultrasound probe assess and select the vein (Action figure 10).
   To select a vein (Alexandrou et al. [4], E; Gorski et al. [181], C; Moureau [329], E).
7. 11.Show
   Release the tourniquet and wipe off the gel.
   To ensure that the patient does not feel discomfort while the device is selected and equipment is prepared (Dougherty [124], E).
8. 12.Show
   Select a device based on the vein size and depth.
   To reduce damage or trauma to the vein. To reduce the risk of phlebitis (Dougherty [124], E; Moureau [329], E; RCN [381], C).
9. 13.Show
   Wash hands with soap and water, or an alcohol‐based handrub, and dry.
   To minimize risk of infection (DH [117], C; Fraise and Bradley [156], E).
10. 14.Show
    Open a pack, empty all equipment onto the pack and place a sterile dressing towel under the patient's arm
    To create a clean working area. E
11. 15.Show
    Prime the extension set with a syringe of 0.9% sodium chloride (unless taking blood samples immediately after cannulation). Note: when using a closed system integrated peripheral intravenous cannula, there is no need to prime the system.
    To remove air from the set prior to connection. If taking blood then the sodium chloride will contaminate the sample (Dougherty [124], E).

    To reduce the manipulation of components and minimize the risk of contamination. E
12. 16.Show
    Reapply the tourniquet.
    To promote venous filling (Dougherty [124], E).
13. 17.Show
    Clean the patient's skin over the selected vein for at least 30 seconds using 2% chlorhexidine using back‐and‐forth strokes with friction and allow to dry (see Figure 17.18). Do not re‐touch the skin.
    To maintain asepsis and remove skin flora (DH [117], C; Dougherty [124], E; Loveday et al. [278], C; RCN [381], C).
14. 18.Show
    Put on gloves.
    To prevent contamination of the nurse from any blood spill (DH [117], C).
15. 19.Show
    Using an aseptic non‐touch technique, apply sterile gel to the transducer on the ultrasound probe and cover it with a sterile semi‐permeable transparent IV film dressing (Action figure 19)
    To maintain asepsis and minimize the risk of infection (DH [117], C; Loveday et al. [278], C).
16. 20.Show
    Remove the needle guard and inspect the device for any faults.
    To detect faulty equipment, for example bent or barbed needles. If these are present, do not use and report to the manufacturer as faulty equipment (MHRA [313], C; RCN [381], C).
17. 21.Show
    Apply sterile gel and, using the non‐dominant hand, position the ultrasound probe 0.5–1.0 cm above the proposed site of insertion (Action figure 21).
    To visualize the vein and facilitate a smooth needle entry (Moureau [329], E).
18. 22.Show
    Holding the cannula in the dominant hand, ensure that it is in the bevel‐up position, and puncture through the skin, 0.5–1.0 cm below the probe, at the selected angle (normally 45°). Adapt the puncture angle according to the depth of the vein (Action figure 22).
    To ensure optimum visualization of the echogenic needle tip during cannulation. E
19. 23.Show
    Visualizing the vein under ultrasound, slowly slide the probe upwards using the non‐dominant hand, while the dominant hand slowly advances the cannula tip towards the top of the vein wall.
    To allow clear visualization of the echogenic needle tip. E
20. 24.Show
    While continuing to visualize with ultrasound, advance the cannula tip and puncture the vein wall. At this point there will be a first blood flashback into the stylet chamber of the cannula (Action figure 24).
    To continue to clearly visualize the echogenic needle tip. E

    To ensure that the needle has entered the vein. E
21. 25.Show
    Level the cannula by decreasing the angle between the cannula and the skin. While continuing to visualize with ultrasound, advance the cannula slightly to ensure entry into the lumen of the vein (Action figure 25).
    To avoid advancing too far and causing damage to the vein wall. To stabilize the device (Alexandrou et al. [4], E; Dougherty [124], E; Moureau [329], E).
22. 26.Show
    Withdraw the stylet slightly with the dominant hand and a second flashback of blood will be seen along the shaft of the cannula (Action figure 26).
    To ensure that the cannula is still in a patent vein. This is called the ‘hooded technique’ (Dougherty [124], E).
23. 27.Show
    Using the dominant hand, continue to slowly advance the cannula off the stylet and into the vein (Action figure 26).
    To ensure the vein remains immobilized, thus reducing the risk of a through‐puncture (Dougherty [124], E).
24. 28.Show
    Release the tourniquet and remove the ultrasound probe from the skin.
    To decrease the pressure within the vein. E
25. 29.Show
    Apply digital pressure to the vein above the cannula tip and completely remove the stylet. Note: when using an integrated closed system peripheral intravenous cannula, there is no need for digital pressure as blood is contained within the system by a vent plug (Action figure 26).
    To prevent blood spillage. E

    To minimize exposure to blood. E
26. 30.Show
    Immediately dispose of the stylet into an appropriate sharps container.
    To reduce the risk of accidental needle stick injury (NHS Employers [346], [347], C).
27. 31.Show
    Attach a primed extension set, needleless injection cap or administration set. Note: if using an integrated closed system peripheral intravenous cannula, there is no need to attach an extension set as it is integrated.
    To enable flushing of the cannula (Dougherty [124], E).

    To minimize the risk of infection through manipulating the system (Bitmead and Oliver [39], E).
28. 32.Show
    Using the sterile tape provided in the dressing package, secure the cannula using, for example, the method illustrated in Action figure 32, always allowing visualization of the insertion site.
    To ensure the device will remain stable and secure (Dougherty [124], E).

    To visualize and monitor phlebitis score (RCN [381], C).
29. 33.Show
    Aspirate to check for blood flashback then flush the cannula with 0.9% sodium chloride using a pulsatile flush ending with positive pressure.
    To ascertain and maintain patency (Goode et al. [174], R; RCN [381], C).
30. 34.Show
    Observe the site for signs of swelling or leakage and ask the patient whether they are experiencing any discomfort or pain.
    To check that the device is positioned correctly and is stable and secure (Dougherty [124], E).
31. 35.Show
    Cover with semi‐permeable transparent IV film dressing (unless contraindicated) and apply a date and time label (Action figure 35).
    To ensure patient comfort and security of the device. To enable all staff to know when the dressing was applied (Loveday et al. [278]; C; RCN [381], C).

Post‐procedure

1. 36.Show
   Remove gloves and discard waste, making sure it is placed in the appropriate containers.
   To ensure safe disposal in the correct containers and avoid laceration or injury of other staff. To prevent reuse of equipment (NHS Employers [346], [347], C).

   To prevent sharps injury (HSE [217], C).
2. 37.Show
   Clean and decontaminate the ultrasound equipment as per infection control guidelines. Label as cleaned.
   To minimize the risk of cross‐infection (Loveday et al. [278], C).
3. 38.Show
   Document date and time of insertion, site, size of cannula, number of attempts, and volume and type of flushing solution, and sign in the patient's notes or care plan.
   To ensure adequate records are maintained and to enable continued care of the patient and device (DH [118], C; NMC [356], C).