IV Cannulation and Venepuncture

Intravenous (IV) cannulation and venepuncture are core nursing skills required for delivering fluid therapy, medications, blood products, and for obtaining blood samples in UAE clinical practice. The DOH (UAE) licensure examination tests both the technical competence and the clinical decision-making aspects of these procedures. Given that IV therapy is among the most common interventions in any UAE hospital — from emergency departments to medical-surgical units and ICUs — mastery of peripheral IV access is essential for safe practice.

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🟢 Lite — Quick Review (1h–1d)

Rapid summary for last-minute revision before your exam.

IV Cannula Sizes — When to Use Which:

Gauge (G)	Colour	Use
24G	Yellow	Paediatrics; fragile veins; elderly
22G	Blue	Small veins; elderly; IV medication
20G	Pink	Most adults; general purpose; blood products
18G	Green	Major trauma; surgery; rapid infusion
16G	Grey	Major surgery; rapid volume expansion
14G	Orange	Trauma; surgical; rapid transfusion

Key Principles:

• Use the smallest gauge that will accommodate the therapy (minimises vein trauma)
• Use the distal veins first (preserves proximal sites for future access)
• Never insert in an area of flexion if avoidable
• Maximum insertion time: 2 attempts before calling for assistance (UAE hospital policy)

⚡ Exam Tip: Never use veins that are sclerosed (hard, cord-like), thrombosed (occluded), or in an arm with a functioning AV fistula or shunt. Avoid veins in the arm on the same side as a mastectomy or lymph node dissection.

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🟡 Standard — Regular Study (2d–2mo)

Standard content for students with a few days to months.

1. Common Venepuncture Sites

A. Upper Limb Veins (most common)

• Median cubital vein — preferred for blood draws and IV access; lies in the antecubital fossa between biceps and brachioradialis; least likely to roll
• Cephalic vein — lateral side of forearm; good for IV access
• Basilic vein — medial side of forearm; more fragile, more painful to cannulate
• Dorsal hand veins — used when forearm veins are exhausted; more painful, higher infiltration risk

B. Lower Limb Veins

• Generally AVOID for IV access in adults (risk of thromboembolism, especially in immobile patients)
• Only used when upper limb sites are unavailable and the situation is life-threatening

C. External Jugular Vein

• Rarely used; reserved for emergency situations when no peripheral access is obtainable
• High infection risk; difficult to secure dressing

2. Venepuncture Procedure

Equipment needed:

• Tourniquet (non-latex if patient has latex allergy — ask all patients)
• Sterile gauze
• Antiseptic wipe (70% isopropyl alcohol or chlorhexidine 2%)
• Appropriate blood collection tubes (order of draw: blood cultures first, then citrate tubes, then serum tubes, then EDTA/purple top, then heparin, then glucose — always check facility protocol)
• Needle and syringe OR vacutainer system
• Label tubes at bedside immediately
• Lab request form
• Sharps container

Procedure:

1. Identify patient (full name + DOB + MRN)
2. Explain procedure and obtain verbal consent
3. Apply tourniquet 5–10 cm above site; check pulse distal to tourniquet
4. Allow veins to engorge (up to 1 minute); have patient make a fist (do NOT pump hand — can alter some lab values)
5. Palpate vein (feel for bounce/elasticity)
6. Perform hand hygiene; don gloves
7. Clean site with antiseptic wipe using concentric circles from centre outward (30 seconds for chlorhexidine; 60 seconds for alcohol); allow to dry completely
8. Anchor vein by pulling taut below the intended puncture site
9. Insert needle at 15–30° angle (bevel up) with smooth, confident motion
10. Observe for blood return (syringe) or blood flashback (vacutainer)
11. Release tourniquet BEFORE removing needle (prevents haematoma and reduces patient discomfort)
12. Apply gauze; apply gentle pressure until bleeding stops (2–5 minutes)
13. Label tubes at bedside; complete lab form
14. Document: date, time, site, number of attempts, tests ordered

3. IV Cannulation Procedure

Additional equipment:

• IV cannula of appropriate size
• IV administration set (primary line)
• Securing dressing (semi-permeable transparent dressing)
• IV fluid/bag (if applicable)

Procedure highlights: 1–7. Same as venepuncture steps above 8. Insert cannula (cannula-over-needle technique): advance at 15–30° until blood flashback; lower angle; advance cannula only (not needle) slightly further; remove needle while holding cannula steady 9. Connect administration set; open clamp; check for free flow 10. Secure with transparent semi-permeable dressing (Tegaderm-style); date and time the dressing 11. Document: date, time, site, gauge, type of fluid/line, batch number

4. Complications of IV Cannulation

Complication	Signs/Symptoms	Action
Phlebitis	Redness, warmth, tenderness along vein; palpable cord	Remove cannula; warm compress; elevate limb
Infiltration	Swelling, cool skin, slowing infusion; no blood return	Remove cannula; elevate; cold compress if extravasation of irritant
Extravasation	Pain, burning, swelling; blanching; no blood return	Stop infusion immediately; follow extravasation protocol
Haematoma	Bruising at site	Remove needle; apply pressure; choose new site
Nerve injury	Tingling, numbness, shooting pain during insertion	Stop immediately; withdraw; assess neurology; notify physician
Air embolism	Sudden dyspnoea, chest pain, tachycardia, hypotension	Position patient on left side, head down (Durant’s manoeuvre); give oxygen; call physician
Catheter-related bloodstream infection (CRBSI)	Fever, chills, erythema at site, purulent discharge	Remove cannula; send tip for culture; start antibiotics as ordered

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🔴 Extended — Deep Study (3mo+)

Comprehensive coverage for students on a longer study timeline.

5. IV Fluids — Classification and UAE Practice

A. Crystalloids Solutions of dissolved ions that can pass through semipermeable membranes. They distribute throughout the extracellular compartment.

Fluid	Na⁺ (mEq/L)	K⁺ (mEq/L)	Use
Normal Saline (0.9% NS)	154	0	Hypovolaemia; resuscitation; compatible with blood
Ringer’s Lactate (Hartmann’s)	130	4	Preferred for burns, trauma, surgery; DO NOT give with liver disease (impaired lactate metabolism) or hyperkalaemia
Half-strength NS (0.45%)	77	0	Maintenance; diabetic patients
5% Dextrose (D5W)	0	0	Free water; hypoglycaemia; isotonic in bag but hypotonic in vivo (dextrose metabolised)
D5 0.9% NS	154	0	Maintenance in surgical patients

B. Colloids Contain large molecules that remain in the intravascular space. Used for acute volume expansion:

• Albumin (5%, 20%) — hypoalbuminaemia, burns
• Hydroxyethyl starch (HES)/Voluven — restricted in many UAE facilities due to safety concerns
• Fresh Frozen Plasma (FFP) — coagulation factor deficiencies; requires blood bank compatibility

C. Blood and Blood Products

• Packed Red Blood Cells (PRBCs) — anaemia, blood loss; must be ABO and Rh compatible
• Platelets — thrombocytopenia with bleeding
• Whole blood — massive haemorrhage
• Cryoprecipitate — fibrinogen deficiency (DIC, massive transfusion)

Blood Transfusion Process:

1. Verbal consent (written in UAE for first transfusion)
2. Two qualified nurses must verify: Patient name/MRN, blood group, Rh, donor unit number, expiry date
3. Check vital signs before, during (15 min), and after transfusion
4. Use blood administration set with filter (170–260 micron filter)
5. Infuse each unit over 2–4 hours (longer if patient at risk of fluid overload)
6. If reaction occurs: Stop immediately; keep IV open with saline; notify physician; return blood and tubing to blood bank
7. Document every step

Transfusion Reactions — Know the Difference:

Reaction	Timing	Signs	Priority Action
Febrile non-haemolytic	During/after	Fever >1°C rise, chills	Stop; antipyretics; may restart slowly after physician review
Allergic	During	Urticaria, itching, anaphylaxis	Stop; antihistamine; adrenaline if severe
Acute haemolytic	During (minutes)	Back pain, fever, hypotension, haemoglobinuria	STOP immediately; aggressive IV fluids; inform blood bank
TRALI (lung injury)	During	Acute respiratory distress, hypoxaemia, bilateral infiltrates	STOP; oxygen; supportive care; most improve with steroids
TACO (circulatory overload)	During/after	Dyspnoea, orthopnoea, raised JVP, pulmonary oedema	STOP; position upright; diuretics

6. IV Medication Administration

IV Push:

• Administer over time specified (e.g., morphine 2–4 mg IV over 1–2 min; fentanyl 25–100 mcg IV over 1–2 min)
• Use appropriate dilution (check medication guide — some must be diluted before IV push)
• Flush with 10–20 mL normal saline after administration

IV Infusion via pump:

• Use volumetric pump or syringe pump
• Set rate per physician order
• Monitor for alarms (occlusion, air in line, empty bag)
• Change tubing per UAE MOHAP policy (every 72 hours for standard IV tubing; every 24 hours for blood/ lipid infusions; every 12 hours for TPN)

Exam Watch: A common DOH exam question involves a patient receiving IV antibiotics who develops dyspnoea and urticaria during the infusion. The correct action is ALWAYS: Stop the infusion immediately, keep the IV patent with saline, assess the patient, notify the physician, and document. Never restart without physician orders.

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