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Intravenous (IV) Cannula Nursing Care Plan
Assessment
Patient identifiers: age, diagnosis, allergies, skin integrity, peripheral circulation, level of consciousness, orientation, mobility, and ability to report discomfort.
IV site: location, date/time of insertion, gauge and type of cannula, number of attempts, securing method, dressing type, presence of pain, swelling, erythema, warmth, drainage, leakage, blood return, and patency (flush response).
Infusion: solution/medication name, concentration, rate, pump settings, compatibility, and indication.
Vascular access history: presence of previous phlebitis, thrombosis, lymphedema, dialysis fistula, mastectomy, or other limitations.
Vital signs and neurovascular status of the limb (capillary refill, pulses, sensation, movement).
Patient education needs, cultural considerations, and psychosocial factors (anxiety, understanding, preferences).
Nursing Diagnoses (common)
Risk for infection related to break in skin integrity from IV cannula.
Risk for impaired skin integrity related to prolonged IV placement and tape/dressing use.
Risk for ineffective peripheral tissue perfusion related to infiltration/extravasation or thrombophlebitis.
Risk for injury related to dislodgement of cannula.
Acute pain (or discomfort) related to IV insertion/complications.
Knowledge deficit regarding care of IV site and signs/symptoms of complications.
Goals/Outcomes (examples)
IV site remains free from signs of infection or phlebitis for duration of therapy.
IV infusion continues at prescribed rate with no evidence of infiltration, extravasation, or occlusion.
Patient demonstrates correct understanding and self-care measures for IV line prior to discharge.
Pain at IV site is maintained at acceptable level (patient-defined) or decreased within 1 hour after interventions.
Interventions and Rationales
Perform hand hygiene before and after all IV-related care to reduce infection risk.
Inspect IV site at least every 1–2 hours when infusing vasoactive or irritant medications; at least every 4 hours for continuous infusions and before/after intermittent therapy. Rationale: early detection of phlebitis, infiltration, or infection.
Assess for signs of phlebitis using a standardized scale (e.g., redness, pain, swelling, palpable cord). Rationale: objective monitoring guides timely removal/replacement.
Palpate gently along catheter tract for tenderness or cord formation. Rationale: detects thrombophlebitis early.
Verify patency by checking for blood return (if appropriate for device) and gentle saline flush per facility policy before administering meds. Rationale: confirms lumen patency and catheter position.
Secure cannula with appropriate dressing (transparent semipermeable dressing or sterile gauze per policy) and stabilization device; ensure site is visible. Rationale: reduces movement, contamination, and allows inspection.
Replace dressings that are damp, loosened, soiled, or no longer intact per facility guidelines. Rationale: compromised dressings increase infection risk.
Change peripheral IV site per facility protocol (commonly every 72–96 hours) or sooner if signs of complication. Rationale: limits risk of phlebitis and infection.
Use aseptic technique when accessing ports and tubing connections (scrub the hub with appropriate antiseptic for recommended time). Rationale: prevents catheter-related bloodstream infections.
Monitor infusion pump alarms and flow rate frequently; ensure tubing clamps are open and tubing is not kinked. Rationale: maintains prescribed therapy and prevents pressure-related complications.
Flush catheter with normal saline per policy using push-pause technique to maintain patency between intermittent infusions. Rationale: prevents occlusion and reduces thrombus formation.
Administer medications and solutions compatible with the catheter gauge and infusion site; dilute and infuse irritants slowly or use central access when indicated. Rationale: reduces risk of extravasation and phlebitis.
Educate patient and family about signs of complications (redness, swelling, pain, leaking, numbness, coolness, slowed infusion) and instruct them to report immediately. Rationale: timely reporting improves outcomes.
Elevate limb and apply warm compress for infiltration or phlebitis as indicated (unless contraindicated). Rationale: promotes circulation and reduces inflammation.
If extravasation of vesicant occurs, stop infusion immediately, leave cannula in place per protocol for possible antidote administration, aspirate residual drug, and follow facility extravasation protocol. Rationale: reduces tissue injury and allows antidote delivery.
Remove and re-site peripheral IV when signs of infection, phlebitis (moderate to severe), infiltration, occlusion that cannot be corrected, or as per protocol.
Intravenous (IV) Cannula Nursing Care Plan
Assessment
Patient identifiers: age, diagnosis, allergies, skin integrity, peripheral circulation, level of consciousness, orientation, mobility, and ability to report discomfort.
IV site: location, date/time of insertion, gauge and type of cannula, number of attempts, securing method, dressing type, presence of pain, swelling, erythema, warmth, drainage, leakage, blood return, and patency (flush response).
Infusion: solution/medication name, concentration, rate, pump settings, compatibility, and indication.
Vascular access history: presence of previous phlebitis, thrombosis, lymphedema, dialysis fistula, mastectomy, or other limitations.
Vital signs and neurovascular status of the limb (capillary refill, pulses, sensation, movement).
Patient education needs, cultural considerations, and psychosocial factors (anxiety, understanding, preferences).
Nursing Diagnoses (common)
Risk for infection related to break in skin integrity from IV cannula.
Risk for impaired skin integrity related to prolonged IV placement and tape/dressing use.
Risk for ineffective peripheral tissue perfusion related to infiltration/extravasation or thrombophlebitis.
Risk for injury related to dislodgement of cannula.
Acute pain (or discomfort) related to IV insertion/complications.
Knowledge deficit regarding care of IV site and signs/symptoms of complications.
Goals/Outcomes (examples)
IV site remains free from signs of infection or phlebitis for duration of therapy.
IV infusion continues at prescribed rate with no evidence of infiltration, extravasation, or occlusion.
Patient demonstrates correct understanding and self-care measures for IV line prior to discharge.
Pain at IV site is maintained at acceptable level (patient-defined) or decreased within 1 hour after interventions.
Interventions and Rationales
Perform hand hygiene before and after all IV-related care to reduce infection risk.
Inspect IV site at least every 1–2 hours when infusing vasoactive or irritant medications; at least every 4 hours for continuous infusions and before/after intermittent therapy. Rationale: early detection of phlebitis, infiltration, or infection.
Assess for signs of phlebitis using a standardized scale (e.g., redness, pain, swelling, palpable cord). Rationale: objective monitoring guides timely removal/replacement.
Palpate gently along catheter tract for tenderness or cord formation. Rationale: detects thrombophlebitis early.
Verify patency by checking for blood return (if appropriate for device) and gentle saline flush per facility policy before administering meds. Rationale: confirms lumen patency and catheter position.
Secure cannula with appropriate dressing (transparent semipermeable dressing or sterile gauze per policy) and stabilization device; ensure site is visible. Rationale: reduces movement, contamination, and allows inspection.
Replace dressings that are damp, loosened, soiled, or no longer intact per facility guidelines. Rationale: compromised dressings increase infection risk.
Change peripheral IV site per facility protocol (commonly every 72–96 hours) or sooner if signs of complication. Rationale: limits risk of phlebitis and infection.
Use aseptic technique when accessing ports and tubing connections (scrub the hub with appropriate antiseptic for recommended time). Rationale: prevents catheter-related bloodstream infections.
Monitor infusion pump alarms and flow rate frequently; ensure tubing clamps are open and tubing is not kinked. Rationale: maintains prescribed therapy and prevents pressure-related complications.
Flush catheter with normal saline per policy using push-pause technique to maintain patency between intermittent infusions. Rationale: prevents occlusion and reduces thrombus formation.
Administer medications and solutions compatible with the catheter gauge and infusion site; dilute and infuse irritants slowly or use central access when indicated. Rationale: reduces risk of extravasation and phlebitis.
Educate patient and family about signs of complications (redness, swelling, pain, leaking, numbness, coolness, slowed infusion) and instruct them to report immediately. Rationale: timely reporting improves outcomes.
Elevate limb and apply warm compress for infiltration or phlebitis as indicated (unless contraindicated). Rationale: promotes circulation and reduces inflammation.
If extravasation of vesicant occurs, stop infusion immediately, leave cannula in place per protocol for possible antidote administration, aspirate residual drug, and follow facility extravasation protocol. Rationale: reduces tissue injury and allows antidote delivery.
Remove and re-site peripheral IV when signs of infection, phlebitis (moderate to severe), infiltration, occlusion that cannot be corrected, or as per protocol.
