Guide — IV Therapy
Peripheral IV Insertion Basics
Peripheral intravenous catheter insertion is one of the most frequently performed nursing procedures. Proper site selection, technique, and post-insertion care directly reduce complication rates and patient discomfort.
10 min read · IV Therapy
Educational use only. Peripheral IV insertion requires competency validation. Follow facility-specific policies and procedures for IV insertion, site care, and complication management. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Catheter Gauge Selection
| Gauge | Flow Rate | Best Use |
|---|---|---|
| 14–16 G | Rapid (250–400 mL/min) | Trauma, surgery, massive transfusion, rapid fluid resuscitation |
| 18 G | Moderate–Fast (90–100 mL/min) | Surgery, blood transfusions, IV contrast for CT, routine adult care |
| 20 G | Moderate (60–65 mL/min) | Most general adult use — maintenance fluids, medications, routine access |
| 22 G | Slower (35–40 mL/min) | Elderly patients, small or fragile veins, children over 1 year, most medications |
| 24–26 G | Slow (14–25 mL/min) | Neonates, infants, very small or fragile veins, heparin flushes only |
Larger gauge = smaller number = larger lumen. Use the smallest gauge catheter that meets the clinical need to reduce vein irritation and complication risk.
Site Selection
Site selection affects insertion success, patient comfort, complication risk, and function of the IV. Work distal to proximal — start at the most distal appropriate site and move proximally if reattempts are needed.
| Site (Preferred Order) | Considerations |
|---|---|
| Forearm (cephalic, basilic, median) | Preferred — lower risk of accidental dislodgement, better tolerated, allows arm mobility |
| Hand (dorsal metacarpal veins) | Acceptable — good visualization, but more painful insertion and limits hand function |
| Antecubital fossa | Avoid for continuous infusions — arm must remain extended; use only for difficult access or as last resort |
| Foot / ankle (adults) | Avoid — risk of thrombus formation; use only when no upper extremity sites available, with physician order |
Sites to Avoid
- Affected arm post-mastectomy or lymph node dissection
- Arm on side of AV fistula or graft (dialysis access)
- Arm affected by hemiplegia or neurological deficit
- Bruised, infected, or edematous areas
- Over a joint (increases infiltration and dislodgement risk)
- Dominant hand when non-dominant arm is available
Equipment
Gather all equipment before starting to prevent interruptions during insertion:
Insertion Steps
Verify order and patient identity
Confirm provider order for IV access. Use two patient identifiers (name + DOB or MRN) to confirm identity per facility protocol.
Gather supplies and perform hand hygiene
Perform hand hygiene with ABHR before gathering and before donning gloves. Prepare all equipment within reach.
Position patient and assess veins
Position arm in dependent position or apply warm compresses for 5–10 minutes to dilate veins. Palpate veins before applying tourniquet — do not rely on visualization alone.
Apply tourniquet
Apply tourniquet 4–6 inches proximal to the selected insertion site. Tourniquet should occlude venous flow but allow arterial flow — verify a radial pulse is present.
Select vein and cleanse site
Identify the target vein. Clean insertion site with chlorhexidine gluconate (CHG) using a back-and-forth scrubbing motion for at least 30 seconds. Allow to dry completely — do not fan or blow. (Alcohol: 70% isopropyl, 30-second scrub, full dry.)
Don gloves and stabilize the vein
Don non-sterile gloves. Use your non-dominant hand to anchor the skin distal to the insertion site, pulling the skin taut.
Insert catheter
Hold catheter at 15–30° angle, bevel up. Insert through the skin and advance until flashback (blood in flash chamber) is seen. Lower angle to nearly flat and advance catheter 1–2 mm further into the vein, then thread the catheter off the needle. Never reinsert the needle into the catheter.
Release tourniquet and apply pressure
Release tourniquet. Apply gentle digital pressure proximal to catheter tip to prevent blood spillage. Activate safety mechanism on needle and discard in sharps container.
Connect and flush
Connect extension set or needleless connector. Flush with 5–10 mL normal saline using a push-pause technique to assess patency. Observe for resistance, swelling, or patient-reported pain — any of these indicates non-patent placement.
Secure and dress
Apply TSM dressing over insertion site. Apply catheter stabilization device if used. Label dressing with date, time, catheter gauge, and inserter initials.
Document and educate
Document insertion per facility policy. Educate patient on purpose of IV, signs of complications to report, and activity restrictions.
Troubleshooting
| Problem | Possible Cause | Action |
|---|---|---|
| No flashback on insertion | Missed vein, vein collapsed, or bevel against wall | Withdraw slightly and redirect; do not reinsert needle through catheter |
| Flashback stops before catheter advanced | Bevel pierced posterior wall of vein | Withdraw catheter 1–2 mm, reattempt threading |
| Resistance on flushing / slow drip | Positional occlusion, kinking, fibrin clot | Reposition arm, check for kinking; if no improvement, remove and resite |
| Swelling at site on flushing | Infiltration — catheter not in vein | Stop infusion immediately; remove catheter; assess and document |
| Sluggish drip without swelling | Fibrin sheath, partial occlusion, positional | Try repositioning; flush with normal saline; if persistent, resite |
| Burning/stinging at insertion | Phlebitis beginning, irritating medication | Assess site; stop infusion; cold or warm compress; resite if phlebitis present |
Infection Prevention
- Hand hygiene before and after every IV-related procedure
- Chlorhexidine gluconate (CHG) skin antisepsis — allow to dry completely before insertion
- Maintain aseptic technique throughout insertion
- Apply and maintain intact transparent dressing — change when soiled, loosened, or at scheduled interval
- Scrub needleless connectors for ≥15 seconds with CHG or 70% alcohol before each access
- Change peripheral IV site every 72–96 hours per facility policy
- Remove peripheral IV as soon as clinically no longer needed
- Use single-dose medication vials when possible; discard after opening
- Inspect IV solution bags for clarity, particulates, and expiration before hanging
NCLEX Pearls
- ✦Work distal to proximal — always start with the most distal appropriate vein and work toward the body.
- ✦Larger gauge = smaller number — 14G flows faster than 22G.
- ✦Never reinsert the needle back into the catheter — this can shear the catheter and cause catheter embolism.
- ✦Bevel up at 15–30° for insertion — lower the angle after flashback before threading the catheter.
- ✦Avoid antecubital for continuous infusions — the patient's arm must remain extended, limiting mobility.
- ✦For blood transfusion: minimum 18G is recommended; LR cannot be used as compatible tubing diluent.
- ✦Peripheral IVs should be changed every 72–96 hours or per facility policy — or sooner if complications develop.
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with Infusion Nurses Society (INS) Standards of Practice · CDC (CLABSI prevention) · Institute for Safe Medication Practices (ISMP). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →