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Intravenous Cannulation Education Program___________________________________________________
IV
CANNULATION
LEARNING
PACKAGE
Revised February 2008
Feb 2009
May 2012
Intravenous Cannulation Education Program
1.
NAME OF COURSE
Intravenous (IV) Cannulation.
2.
RATIONALE
This education package has been designed to facilitate the achievement of
competency in the procedure of intravenous cannulation in an adult
patient.
This procedure may be performed by a Registered Nurse (Division 1):



3.
To replace fluids/administer blood transfusion
To administer medications
To provide circulatory access for emergencies
OBJECTIVES
Participants will demonstrate the ability to:

Describe and differentiate arterial and venous anatomy.

Identify the principles of asepsis in relation to intravenous therapy.

Discuss risk factors that may contribute to IV related infections

Outline important factors in appropriate vein selection.

Outline the important factors in appropriate cannula selection

Discuss correct documentation of IV cannula insertion

State complications
cannulation.

Discuss the implications of intravenous cannulation in relation to
competency assessment and the scope of professional practice.

Complete three successful supervised insertions of a peripheral
intravenous cannula in an adult patient.
2
that
may occur
during/following
IV
4.
COURSE OUTLINE
The course comprises a self-directed theoretical learning component, a
practical component and a supervised clinical component.

1 hour self-directed theoretical learning component in the form of an IV
cannulation learning package, to be completed prior to practical and clinical
component. Accessed via the SWH Intranet site.

1 hour practical tutorial (see Appendix I) utilising model/patient conducted by one
of the following:
Specialist Anaesthetist/Physician/Director of Emergency
Department/Senior Registrar/Registered Nurse (Division 1)
appointed by Clinical Facilitator , Clinical Facilitator
(Emergency Department/Critical Care), Clinical Support
Nurse or Clinical Nurse Educator. Note: above must be
deemed competent in IV cannulation.

Supervision of Intravenous Cannulation Insertion (see Appendix II)
To achieve competency:
The procedure must be performed successfully on three (3) occasions, under the
direct supervision of a Specialist Anaesthetist/Director of the Emergency
Department/Physician/ Senior Registrar/Clinical Facilitator (Emergency
Department / Critical Care), Clinical Support Nurse or a CNS/ above Emergency
Department / Critical Care/ Chemotherapy/ Clinical Nurse Educator. Note:
above must be deemed competent in IV cannulation.
5.
PARTICIPANT ASSESSMENT

Clinical assessment of competency in performing intravenous insertion must be
achieved.

To maintain proficiency in this technique, the participant may gain additional
clinical practice in the Peri-operative or Endoscopy Unit. This must be under the
supervision of an Anaesthetist / Physician / Clinical Facilitator.
3
6.

MAINTENANCE OF COMPETENCY
The participant must take responsibility for maintaining their own competency in
this procedure. If the participant has not inserted at least one (1) intravenous
cannula in a six month period they must undertake the supervised intravenous
cannula component of this competency annually.
Annual competency in this procedure will be assessed by one of
the following:
i)
ii)
iii)
iv)
v)
vi)
vii)

Specialist Anaesthetist
Director of Emergency Department
Physician
Clinical Facilitator (Emergency Department/Critical
Care / Appointee)
Senior Registrar
Clinical Support Nurses/Clinical Nurse Educators
CNS or above Emergency Department / Critical
care / Chemotherapy
It is the participant’s responsibility to provide documentation of competency
assessment to the Unit Manager/Education Service, to ensure maintenance of
Records.
Ashley Zanker
(Education Department/Critical Care)
Updated February 2009
Updated May 2012
Shannon Graham
(Clinical Nurse Educator)
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IV CANNULATION
SELF DIRECTED
LEARNING
PACKAGE
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Anatomy and Physiology of Veins
Veins have three layers:
a) tunica intima (inner layer)
An elastic, endothelial lining which also forms the valves. Valves are semilunar folds of
endothelium and their function is to keep the blood flowing towards the heart. They occur
more frequently at junctions and can be observed as a small bulge in the veins. Valves can
interfere with the withdrawal of blood as well as the advancement of a cannula.
(Dougherty, 1996)
b) tunica media (middle layer)
Muscular and elastic tissue, as well as nerve fibres. These keep the vessels in a state of
tonus and stimulate the vein to contract and relax. Stimulation by a change in temperature
or by mechanical or chemical irritation may produce venospasm, which impedes the flow
of blood and causes pain. (Dougherty, 1996)
c) tunica adventita (outer layer).
Comprises the epidermis and the areolar connective tissue which surrounds and
supports the vessel. (Dougherty, 1996)
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ACTIVITY ONE
Locate and name the landmarks indicated on the following diagram:
7
Sites of selection for the insertion of intravenous needles for the parenteral administration of
fluids, medication or for blood transfusion.
Brunner, Suddarth (1988), Textbook of Medical - Surgical Nursing. Chpt. 9, p
127, 6th Ed, JB Lippincott Co, Philadelphia.
The superficial veins of the arms should be used for the placement of intravenous cannula in
adults.

easily accessed

allow patients to perform activities of daily living with minimal impairment to function.
(Dougherty, 1996).
1. Digital veins/Metacarpal veins
 Easily visualised and palpated
 Leaves proximal sites on the limb for cannulation
 Use with caution in elderly people and where skin turgor and subcutaneous tissue
is diminished.
2. Cephalic vein
 Large vein, which is easily stabilised and accessible. Its size and position make it
an excellent choice for intravenous therapy
 Good vein for large bore cannula, and useful for rapid infusions, including blood
 More comfortable for patient, as hand is free
3. Basilic vein
 Large easily palpable vein but may be difficult to access and stabilise due to its
location.
4. Median Cephalic and Basilic veins
 Usually used for venipuncture. Their size and superficial location make them easy
to palpate and visualise and they are well supported by connecting tissue
 Can be difficult to stabilise (in joint)
 Risk of dislodgment , infiltration, extravasion and mechanical phlebitis
 Median cephalic vein crosses in front of the brachial artery and care must
be taken to avoid puncturing the artery. (Dougherty, 1996)
8
General principles when choosing a vein for cannulation
Veins to use
Veins to avoid
Distal veins first:
This enables proximal veins to be used when
the catheter requires resiting
Veins in lower extremities:
Veins in the feet, for example, are only used if
there is no other venous access or there is a
clinical requirement e.g. Patients with a
mastectomy.
Easily palpable with good capillary refill:
If the vein feels bouncy or springy to touch,
this infers a healthy, full vein with good venous
flow.
Points of flexion:
Cannulation near a joint may increase the risk
of mechanical phlebitis because of continual
movement in the vein.
Opposite limb to surgical procedures:
If the patient is to undergo a procedure on one
arm, it is advisable to cannulate the opposite
arm to ensure easy access during the
procedure.
Obvious valves:
A vein with visible valves (notches along the
vein) should be avoided as the valve may
prevent smooth entrance of the catheter into
the vein.
Veins with the largest diameter:
Although not always possible because of
patient’s vein quality, the aim is to insert the
smallest possible gauge catheter for intended
use into the largest diameter vein (RCN, 2003;
Dychter et al, 2012) to maximise blood flow
and minimise risk of thrombus or venous
stasis.
Infected sites or broken skin:
The risk of phlebitis and infection are much
greater and the catheter will cause the patient
discomfort if the site is infected or the skin is
broken
9
Prevention of Intravascular Device-Related Infections
DEVICES USED FOR SHORT TERM VASCULAR ACCESS
Short peripheral venous catheters, usually inserted into the veins of the forearm or
hand, remain the most commonly used intravascular device. Phlebitis, largely a
physicochemical mechanical, rather than infectious, phenomenon, remains the most
important complication associated with the use of peripheral venous catheters. When
phlebitis does occur, the risk of local catheter-related infection may be increased.
Factors associated with infusion-related
Phlebitis among patients with peripheral venous catheters
Factors causing phlebitis:
Type of phlebitis
Causes
Mechanical
If the cannula is not secure, the catheter will ‘move’
in the vein, causing irritation, pain and phlebitis.
Physical
A poor cannulation technique can initiate the
phlebitis process by causing irritation and damage to
the vein. If the catheter is left in too long or is
placed inappropriately, e.g. by a joint, these factors
may cause phlebitis.
Chemical
The type of medication administered via the catheter
may cause phlebitis. For example, an acid pH or high
osmolality may irritate the vein.
Other
The cannula: size and material
The patient’s age, health, nutritional status, presence
of disease
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PATHOGENESIS
The pathogenesis of catheter-related infections is multifactorial and complex, but
available scientific data show that most catheter-related infections appear to result
from migration of skin organisms at the insertion site into the cutaneous catheter tract
with eventual colonisation of the catheter tip. There is a smaller, but growing body of
data to suggest that contamination of the catheter hub also is an important contributor
to intraluminal colonisation of catheters, particularly long-term catheters.
11
STRATEGIES FOR PREVENTION OF CATHETER-RELATED
INFECTIONS
Strict adherence to hand washing and aseptic non touch techniques remain the
cornerstone of prevention of catheter-related infections. Other measures may confer
additional protection and must be considered when formulating preventive strategies:
selection of an appropriate site of catheter insertion and type of catheter material, use
of barrier precautions during catheter insertion, replacement of catheters,
administration sets and IV fluids at appropriate intervals, appropriate catheter-site
care, use of filters, flush solutions, prophylactic antimicrobials.
Site of Catheter Placement
Several factors should be assessed when determining the site of catheter placement,
including patient-specific factors, pre-existing catheters, anatomic deformity, bleeding
diathesis, relative risk of mechanical complications (eg. bleeding) and the risk of
infection. The site at which a catheter is placed has been shown to influence the
subsequent risk of catheter-related infection. For peripheral venous catheters, lower
extremity insertions pose a greater risk of phlebitis than do those inserted in the upper
extremity (Dychter et al, 2012), and upper extremity sites differ in their risk for
phlebitis, in adults, hand vein insertions have a lower risk of phlebitis than do upper
arm or wrist vein insertions.
Barrier Precautions During Catheter Insertion
For
short
Possible contamination points





Pts own skin flora if skin disinfection not adequate.
HCW’s hands if effective hand hygiene not performed.
Contaminated device. ( inappropriate storage and handling)
From the patient if they already have an infection the bacteria
can travel to the foreign object.
During drug administration, the hub can become contaminated
by HCW’s hands.
peripheral catheters, good hand washing before catheter insertion or maintenance,
combined with proper non touch aseptic technique during catheter manipulation
provides protection against infection (Dychter et al, 2012).
12
Refer also Guidelines for prevention of intravascular device related infections from the
Public Health Service, U.S. Department of Health and Human Services, Centres for
Disease Control and Prevention, Atlanta, Georgia. (Complete guidelines can be found
at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm)
ACTIVITY TWO
INTRAVENOUS CANNULATION WORKSHEET
(Additional reading may be required –see references and SWH Intravenous insertion and infusion policy)
1. List four factors to consider when assessing the patient for intravenous cannulation.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2.
List two groups of patients who should be approached cautiously with regards to intravenous
cannulation.
______________________________________________________________________________
____________________________________________________________________________
3. List contraindications for arm choice for IV cannula placement.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4. List two characteristics of an ideal vein choice.
______________________________________________________________________________
5. List 3 things to avoid when selecting a vein.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
6. How far above the intended puncture site should the tourniquet be placed?
______________________________________________________________________________
7. List actions to help raise a vein not dilated after tourniquet application.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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8. What is the nursing responsibility when the procedure is complete?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
9. What are the risk factors for developing a peripheral line infection?
______________________________________________________________________________
______________________________________________________________________________
10. List three signs/symptoms of a peripheral line infection
___________________________________________________________________________
___________________________________________________________________________
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APPENDIX I
IV CANNULATION
PRACTICAL
TUTORIAL
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1.
SITES

Hand – metacarpal vein, cephalic vein, basilic vein.

Arm – cephalic vein, accessory cephalic vein, median cubital vein, median
antebrachial.
Factors to consider:
Location
•
Sites in order of preference are lower arm, hand, and antecubital
fossa (the lower extremities are undesirable because they are
prone to thrombophlebitis and embolism and should be resited
ASAP).
•
If possible use the distal end of the vein therefore; recannulation
of the same vein may be possible later.
•
Generally, use distal veins first, preserving more proximal ones
for future sites. To reduce the risk of phlebitis and trauma, the
gauge of the cannula inserted should be appreciably smaller than
the lumen of the vein. When viscous or large volumes of fluid are
to be infused, a large bore cannula will need to be sited to ensure
adequate flow rates.
•
Ante-cubital fossa – ideal for quick access but is not
recommended routinely. This area requires splinting which
decreases direct viewing of the site. Cannula mobility is also
increased, thus increasing the risk of vein damage. The cannula is
liable to kink in this area.
•
The median nerve and brachial artery lie in close proximity –
special care must be taken to avoid them. Minimise striking the
artery by first locating pulse before venipuncture.
•
Avoid joints, (such as at the wrist or elbow) infected or injured
areas.
•
Registered nurses must not attempt to cannulate:
- veins in lower extremities
- veins in upper arm
- the last visible vein.
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Condition
•
•
The vein must be full, soft and unobstructed.
Avoid crooked, hard, scarred on inflamed veins.
Reasons for selection of specific sites
2.
•
Time factor eg. emergency cannulation – antecubital route.
•
Type of intravenous solution – highly acidic/alkaline or hypertonic
solution can irritate a small peripheral vein, a larger vein will dilute
the infusion better.
•
Rapid infusions require larger veins.
CANNULA SIZE
It has been shown that the incidence of vascular complications increases as the ratio of cannula
external diameter to vessel lumen increases. Therefore most literature recommends the smallest,
shortest gauge cannula in any given situation (Dychter et al, 2012; RCN,2003).
GUIDE ONLY:
 24g Medications, short term infusions, fragile veins, children
 22g Blood Transfusions, most medications and fluids
 20g Blood Transfusions, large volumes of fluids
 18g Blood Transfusions, parenteral nutrition, large volumes of fluid
 16g as per 14g
 14g used in theatres or emergencies for rapid transfusion of blood or viscous
fluids.
(Dougherty & Lister, 2004)
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3.
PROCEDURE
(To practice on IV simulation arms)
a. Equipment
Standard precautions apply
Cleanse area appropriately
Disposable dressing tray/ IV starter pack
Chlorhexidine 2% and alcohol 70% solution prep (Solu-IV)
Clippers if required
Tourniquet
IV cannula 18 – 22g (appropriate for patient)
Primed giving set / IV bung / extension tubing with 3 way tap
Protective covering &/ Splint p.r.n.
Tegaderm & tape
I.V. labels and stand
Waste disposable bag & sharps container
Personal Protective Equipment (PPE) Gloves, Glasses
Normal saline ampoule (for flushing)
Vacutainer (when collecting blood sample)














b. Cannula Insertion
Decontaminate hands with soap and water or alcoholic based hand rub
Clean trolley/tray/surface with soap and water (or detergent wipes) and dry
with a paper towel
Gather equipment required, if using a trolley place on bottom shelf of trolley
Take trolley/tray to the patient or ensure the prepared surface is close to
patient
Hand hygiene performed before contact with the patient
Assess appropriate site for insertion, apply tourniquet, palpate vein
Assess if hair removal is required, clippers to be used for hair removal
Appropriate PPE is selected and worn. Safety glasses or shield, gloves.
Open dressing pack/IV pack using only the corners of the paper, taking care
not to touch any of the sterile equipment.
Decontaminate hands with alcoholic based hand rub or use clinical wash (2
minutes)
Prepare skin- prep with (Chlorhexidine 2%and alcohol 70%), allow to
dry – approx 45sec. (Palpation of the vein should not be performed after the
skin prep is applied
Apply gloves, clean correct fitting. Non sterile.
Drape insertion site with sterile drape
Stabilise vein with thumb, and stretch skin gently downward and
maintain position until cannula is inserted properly
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With bevel up, approach vein slowly at a low angle (about 45°)
Advance needle forward at 20-30° angle to vein’
‘Pop” into vein, observe flashback, initially seen along cannula
Upon flashback visualisation, lower cannula almost parallel to skin
Advance entire unit about 2-3mm before threading cannula, to ensure cannula
is located in vein (Advancing whole assembly gently up vein, without
excessive force).
Slight twisting may assist passage.
Using the push off tab, thread cannula into vein while maintaining skin
traction
For needle removal, release the tourniquet, place middle finger over vein
distal to catheter tip (to interrupt blood flow) and stabilise catheter hub with
index finger (“V technique), then withdraw needle (a protective shield will
automatically clasp over the bevel upon removal of the needle, making the
sharp safe)and put immediately into the sharps container.
Connect IV/bung and secure with Tegaderm. Ensure dressing is
applied appropriately to minimise movement and thus reduce irritation
on the vein. Any spillage is cleaned up and insertion site is clean and dry
prior to dressing application
Flush with Normal Saline
Sharps are disposed of at point of use
Dispose of contaminated swabs etc in the clinical waste stream
Dispose of all packaging in the domestic waste stream
Dispose of aprons and gloves in the appropriate waste stream as per policy.
Decontaminate hands
Clean the trolley/tray/surface with soap and water or detergent wipes and dry
with a paper towel
Document time and date of insertion on appropriate area of dressing
and on Clinical Management Plan, also document type and length of cannula
and person inserting device
If cannulation is unsuccessful following 2 attempts, a more experienced person must
perform the procedure.
Caution Reminders:
 Needle should be retracted prior to disposal in a puncture resistant, leak
proof sharps container.
 Never reinsert the needle into the cannula as this could shear the cannula
RECOMMENDATIONS




Wash hands/ cleanse with antimicrobial gel before and after clinical procedure
Maintain an aseptic technique and utilise standard precautions
Clip hair, do not shave
Air-dry all preps.
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APPENDIX II:
SUPERVISION OF
INTRAVENOUS (IV)
CANNULATION
20
SUPERVISION OF
INTRAVENOUS (IV) CANNULATION
COMPETENCY STATEMENT
Demonstrates the ability to perform IV Cannulation.
Performance Criteria
The participant must achieve the following:
1.
Identify four (4) indications for IV Therapy
2.
Name possible insertion sites
3.
Identify correct solution, additives, selects appropriate size needle, prime tubing,
set administration rate and prep insertion site appropriately.
4.
Clean trolley/tray/surface with soap and water (or detergent wipes) and dry with a
paper towel. Collect equipment for IV cannulation
5.
Safely and effectively perform cannulation using aseptic technique/standard
precautions.
6. Cannula Insertion:•
Explain procedure to patient and ensure privacy.
•
Position patient appropriately and provide adequate lighting.
 Ensure the trolley/tray or prepared surface is close to the patient
 Assess appropriate site for insertion:
Non dominant hand
Avoid areas of bony prominence and flexion
The antecubital fossa veins should only be used in emergency situations
Select appropriate sized cannula
 Assess if hair removal is required, clippers to be used for hair removal
 Appropriate PPE is selected and worn. Safety shield or glasses, gloves
 The dressing pack/IV pack is opened using only the corners, taking care not to
touch any of the sterile equipment
•
Apply tourniquet.
•
Palpate vein.
•
Decontaminate hands with alcoholic based hand rub or use clinical hand
wash (2 minutes)
•
Prepare skin with Chlorhexidine 2% and alcohol 70% prep
Allow skin to dry.
Palpation of vein should not be performed after the skin prep is applied
 Apply gloves, non sterile, clean, correct fitting
•
•
Stabilise vein with thumb, and stretch skin gently downward and maintain
until cannula is in properly
With bevel up, approaches skin slowly at a low angle (about 45°)
•
Advance needle forward at 20-30° angle to vein
21
1.
2.
INSTRUCTIONAL
STRATEGIES
Policy and Procedure
IV Cannulation education
program
Clinical Performance
Competent Unsuccessful
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•
"Pop" into vein, observe flashback along the cannula

Competent
·
Upon flashback visualisation, lower cannula almost parallel to skin
•
Advance entire unit about 2-3mm before threading cannula, to ensure
cannula is located in vein
Advance whole assembly gently up vein, without excessive force.
Slight twisting may assist passage.
Take blood for Pathology if required.
•
•

•
•
Releases tourniquet, applies digital pressure beyond cannula tip, gently
stabilises hub (“V technique”).
Dispose of needle into sharps container.
Connect IV/Bung and secure with Tegaderm
Any spillage is cleaned up and insertion site is clean and dry prior to
dressing application
Flush with normal saline
 Gloves are removed and hand hygiene is performed
 Dispose of waste appropriately
7.
 Clean the trolley/tray/surface with soap and water or detergent wipes and dry with
a paper towel
Verbalise 4 signs and symptoms of phlebitis.
8.
State 3 ways to decrease the risk of developing IV-related infections.
9.
Identify 2 ways to help prevent vascular irritation.
10.
Identify 3 complications associated with IV therapy noting with each
complication:
•
Cause
11.
•
Prevention
•
Symptoms
•
Treatment
Demonstrate correct documentation:
•
Date and time of IV insertion / gauge & length of cannula
•
Type and volume of solution
•
Rate of administration
•
RN's signature
22
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EVALUATION
Competent
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Unsuccessful
Date/Signatures: 1 .
............................................................
..............................................................
2.
............................................................
..............................................................
............................................................
(Assessor)
...............................................................................
(Participant)
......................................................... .....
(Designation)
3.

Comments:........................................................................................................................................
............................................................................................................................................................
If the participant has not inserted at least one (1) intravenous cannula over a six month time interval they
must undertake a supervised intravenous cannula competency assessment annually.
D. Clapham
Clinical Facilitator (ED/Critical Care)
December 1993
Revised May 1994
Revised 1996
Revised August 1998
Revised Feb 2001
Revised September 2003
Revised July 2005
Feb 2008
Feb 2009
Revised Shannon Graham Clinical Nurse Educator
May 2012
23
APPENDIX III
24
25
ANSWER ACTIVITY TWO
Question 1
(any 4)
patient’s medical history
size, age and general condition
condition of veins
previous experience of patient with IV cannulation
type of fluid/medication to be administered
expected duration of therapy
Question 2
(any 2)
Patients with:
blood clotting disorders
on anticoagulant therapy
extreme needle phobia
fragile veins
a history of prolonged/multiple IV access
Question 3
Avoid:
arms with existing arterial line
arm that has had a brachial angiogram performed less than three days before
arms with veins that have been surgically compromised; e.g. mastectomy or axillary/arm
surgery
limb with Arterio Venous fistula
arms with burns/sclerosis
if possible, avoid the dominant arm
Question 4
Select most distal vein
Easily palpable, bouncy, anchored, springy to touch, straight.
Question 5
Avoid veins in lower extremities
Avoid point of flexion
Avoid obvious valves
Avoid broken skin or infected sites
Question 6
10 - 20 cm
26
Question 7
Tap finger gently over vein
Position arm below heart level to encourage capillary filling
Apply a warm pack/cloth over vein
Release and reapply tourniquet. Veins may refill better on the rebound
Question 8
Patient comfort
Safe disposal of sharps
Cleaning of equipment
Hand hygiene
Documentation.
Question 9
Inadequately prepared site
Poor technique
Leaving the line insitu > 72-96 hrs
Question 10
Redness
Swelling/oedema
Warm to touch
Tracking up vein
Patient febrile
Pain
Pus/purulent drainage
27
References
Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010)
Section B 1-7
Brunner, Suddarth (1988), Textbook of Medical - Surgical Nursing. Chpt. 9, p
127, 6th Ed, JB Lippincott Co, Philadelphia.
Centre for Disease Control and Prevention (2002) Guidelines for the prevention of
intravascular catheter – related infections, MMWR Morb Mortal Wkly Rep, 51(RR-10),
11-12.
CHRISP Peripheral Intravenous Catheter (PIVC) Recommended Practices Version 4 –
January 2010
Corrigan, AM, Pelletier G & Alexander M. (2000) Core Curriculum for Intravenous
Nursing Intravenous Nurses Society 2nd edition, Lippincott, Massachusetts.
Dougherty, L. & Lister, S. (2004). The Royal Marsden Hospital manual of Clinical
Nursing Procedures, 6th edition. Blackwell publishing, Oxford.
Dougherty, L., (1999) Obtaining peripheral vascular access, Intravenous Therapy in
Nursing Practice, Churchill Livingstone, Edinburgh.
Dychter, S.S., Gold, D.A., Carson, D. & Haller, M. (2012). Intravenous Therapy.
Journal of Infusion Nursing, 35 (2).
Evans, P et al, (1998), Emergency Department-Intravenous Cannulation For Registered
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