Documenting an IV insertion?

[iluvivt, BSN, RN]

According to the INS guidelines all of these things need to be included. Gauge and length of catheter and name of product,exact anatomical location (name of vein) including right or left side # of attempts...flush you used...any extension tubing you added and how the patient tolerated the procedure. This is the minimum. I find most nurses leave out the length and how patient tolerated the procedure. If I follow the hospital protocol (ie secure with TSM dressing etc) I can say I followed the protocol so it is not too long...... For example. IV start per protocol with 20 ga 1 1/4 in insyte into the R accessory cephalic vein with attempt....2 ml NS flush with ease ...saline loc...pt tol well. i do not chart how I dressed it if I followed the protocol. If there is anything unusual I also chart that. PS when you DC a cannula always chart that you DCed it intact.

[TigerGalLE, BSN, RN]

20g IV gelco placed in right hand on 1st attempt.

Or

22g IV gelco placed in right hand on 2nd attempt X 2 nurses.

I'm sure someone has something more by the book but this is what I say.

[Ivanna_Nurse, BSN, RN]

Same as above...

plus I document the dressing, and the date due for the site to be rotated out. ~Ivanna

[bsrn0523]

22g angiocath to rfa, inserted on 1st attempt. dated and signed. Jenn

[icyounurse, BSN, RN]

I agree with previous posts, the only thing I could add is you can also say "good blood return, flushes well."

[ICRN2008, BSN, RN]

We had stickers printed out on our unit because of a new IV initiative. It includes date, time, number of attempts, 22 ga or whatever, how IV was secured (statlock, tegaderm, etc), flushes easily and good blood return check, and RN signature. Sticker gets put into the progress notes.

[kmoonshine, RN]

18g CIV placed in the R FA without difficulty on first attempt, blood cultures x 1 and labs drawn from IV start. Pt tolerated procedure well, site c/d/i without redness or irritation.

20g PIV placed in the L FA on second attempt - pt is a difficult IV start. Pt tolerated procedure well, 500ml 0.9% NS hung w/o per MD order. IV site is without swelling or redness, will continue to monitor.

[Roy Fokker, BSN, RN]

I love ibex! ?

We just click click about 5-8 boxes and here's what it read on the chart: the words in black are already present, the words in red vary based on what choice boxes we click. Example:

"patient's id verified by hospital id bracelet. Reason for procedure is medication administration. Procedure performed at 0900 hrs. Site was cleaned and prepared with appropriate topical cleansing agent. Size of catheter is 20g placed in the right forearm in 1 attempt. Catheter was flushed with 10 ml of normal saline post placement. No redness, no swelling, no adverse reaction noted. Sterile dressing applied to site. Labs were drawn at time of placement, catheter flushed post access. Emotional support was needed and was provided. 1 additional staff was required due to pt's. Age. Pt. Tolerated procedure well. Procedure performed by person documenting."

10 clicks and all that gets charted. The more you click, the more it charts (like using anesthetics or collecting blood cultures for example.)

Cheers

[Daytonite, BSN, RN]

From these guidelines a charting template can be put together for your own use that incorporates your writing style to refer to when charting each IV access.

This is the INS Standard (2006 Infusion Nursing Standards of Practice?

• "Standard 14.1 - Nursing documentation shall contain complete information regarding infusion therapy and vascular access in the patient's permanent medical record.
  • Practice Criteria B - Documentation should include, but not be limited to, the following
    • 2. Type, brand, length, and size of vascular device.
    • 3. Date and time of insertion, number and location of attempts, type of catheter stabilization and dressing, patient's response to the insertion, and identification of the person inserting the device.
    • 4. Use of visualization and guidance technologies.
    • 5. Identification of insertion site by anatomical descriptors, landmarks, or appropriately marked drawings.
    • 10. Specific site preparation, infection control, and safety precautions taken.
    • 11. Communication among the healthcare team members responsible for patient care and monitoring,
    • 17. ....indicate what fluids and medications are being infused...."

[Inquisitive one]

In my note, I always include tourniquet removed. This is a double check for me to ensure that I did remove it.

[RazorbackRN, BSN, RN]

22ga PIV placed in L hand x 1 attempt, + blood return and flushes without resistance. Secured with tegaderm and tape, protective tent applied. Heplocked per protocol. Pt tolerated s complication. Will con't to monitor.

[me143]

very informative