• Introduction to Intravenous Infusion • Spike

Administering IV Therapy
- a common form of therapy for handling fluid
disturbances
- ordered by a physician
- nurse: responsible for initiating, monitoring,
and discontinuing the therapy
- understand the patient’s need for IV therapy,
the type of solution being used, its desired
effect, and untoward reactions that may occur
Drip Chamber
• Examples of NIC: IV Therapy
• maintain strict aseptic technique
• examine the solution for type, amount,
expiration date, character of the solution, and
lack of damage to container
• select and prepare an IV infusion pump, as
indicated
• administer IV fluids at room temperature
• Examples of NIC: IV Therapy
• monitor for IV patency before administration
Roller Clamp
of IV medication
• maintain occlusive dressing
• flush IV lines between administration of
incompatible solutions
• Equipment
• sterile technique
• disposable infusion tubing and needles
• varies according to the manufacturer
– flexible or rigid plastic containers
• collapse and do not require
Checking Drip Chamber and Time Drops
a vent for air to enter to
replace fluid flowing from
the container
– glass bottles
• required for certain
medications
• require a vent to allow air to
enter the bottle as the fluid
leaves the bottle
• Basic Administration Set
• Guidelines for Nursing Care: Regulating IV
for IV Therapy
Flow Rate
• Follow agency's guidelines to determine if
infusion should be administered by electronic
pump or by gravity.
• Check physician's order for IV solution.
• Check patency of IV line and needle.
• Verify drop factor (number of drops in 1 mL)
of the equipment in use.
• Regulation and Monitoring
• maintain proper flow rate
 • ensure comfort and safety
• macrodrip (10, 15, 20 drops per mL)
– used for rates greater than 75 mL per
hour
• microdrip (60 drops per mL)
• blood adminitration (10 drops per mL)
• Volume-controlled Set
• Regulation and Monitoring
• a time tape can be placed on the container of
solution to provide a quick reference for the
nurse to monitor the rate at which the solution
is entering the patient
• factors: height of the container, BP, patient’s
position, patency of the IV catheter,
infiltration, knot or kink
• check the infusion every hour or more
frequently, if indicated
• Calculate the flow rate:
EXAMPLE—Administer 1000 mL D5W over
8 hours (set delivers 60 gtt/1 mL).
a. Standard formula
gtt/min = volume (mL) x drop factor (gtt/mL)
time (minutes)
gtt/min = ?
b. Short formula using milliliters per hour
gtt/min = mL per hour x drop factor (gtt/mL)
time (60 min)
Find milliliters per hour by dividing 1000mL by 8
hours: 1000mL / 8 = 125 mL/hr
gtt/min = 125 mL/hr x 60 gtt/mL
60 min/hr
c. Dimensional Analysis
gtt/min = gtt x mL x hr
mL hr min
gtt/min = 60gtt x 1000mL x 1 hr
1mL 8 hr 60 min
gtt/min = 125gtt/min
• Count drops per minute in drip chamber
(number of gtt/15 sec interval x 4). Hold watch
beside drip chamber.
• Adjust IV clamp as needed and recount drops
per minute
• Mark IV container according to agency policy
and manufacturer’s recommendations. Use a
time tape or label if indicated to measure
amount to be infused at timed intervals.
• Monitor IV flow rate at frequent intervals.
Document patient’s response to infusion at
prescribed rate.
• Infusion Pump
Selected IV Solutions
Isotonic Solution
5% dextrose in water (D5W)
Supplies about 170 cal/L and contains 50 g of glucose
Should not be used in excessive volumes because it does
not contain any sodium; thus the fluid dilutes the
amount of sodium in the serum. Brain swelling, or
hyponatremic encephalopathy, can develop rapidly and
cause death unless it is promptly recognized and treated.
0.9% NaCl (normal saline)
Not desirable as routine maintenance solution because it
provides only Na+ and Cl-, which are provided in
excessive amounts.
May be used to expand temporarily the extracellular
compartment if circulatory insufficiency is a problem;
also used to treat diabetic ketoacidosis.
Lactated Ringer’s Solution
A roughly isotonic solution that contains multiple
electrolytes in about the same concentrations as found in
plasma (note that this solution is lacking in Mg2+ and
PO43-)
Used in the treatment of hypovolemia, burns, and fluid
lost as bile or diarrhea
Useful in treating mild metabolic acidosis
Hypotonic Solution
0.33% NaCl 1/3-strength saline)
A hypotonic solution that provides Na+, Cl-, and free
water Na+ and Cl- allows kidneys to select and retain
needed amounts
Free water desirable as aid to kidneys in elimination of
solutes
0.45% NaCl ½-strength saline)
A hypotonic solution that provides Na+, Cl- and free
water
Often used to treat hypernatremia (because this solution
contains a small amount of Na+, it dilutes the plasma
sodium while not allowing it to drop too rapidly)
Hypertonic Solution
5% dextrose in 0.45% NaCl
A common hypertonic solution used to treat
hypovolemia; used to maintain fluid intake
10% dextrose in water (D10W)
Supplies 340 cal/L
Used for peripheral parenteral nutrition (PPN)
5% dextrose in 0.9% NaCl (normal saline)
Replaces nutrients and electrolytes
Can temporarily be used to treat hypovolemia if plasma
expander is not available
Vascular Access Devices
• Factors
• length of time the infusion therapy is needed
• type of medication or product that will be
delivered intravenously
• patient's health status and needs determine
which option is used
• what will pose the least risk for IV
complications
• Peripheral Venous Catheters
• Over-the-needle catheters - the most common
type of peripheral vascular catheter used.
• infusion therapy will be brief, a short (<3
inches) peripheral catheter
• insertion site should be rotated at least every
72 to 96 hours for an adult
• child - the site can remain in place until the IV
intervention is completed unless a
complication develops
• smallest-gauge device is usually selected to
minimize trauma to the vein
• Midline Peripheral Catheter
• inserted peripherally, normally through the
antecubital fossa into the proximal basilica or
cephalic veins
• longer (>3 inches) than peripheral venous
catheters
• not considered to be central lines
• should not be used to infuse vesicants or
hyperosmolar or irritating solutions
• length of time - median of 7 days, but possibly
as long as 49 days. Follow agency policy for
rotation of midline catheter insertion site.
• Central Venous Access Devices
• (CVADs) are now an integral component of
patient care in acute, ambulatory, and subacute
care settings, as well as in the home and long-
term care facilities.
• provide access for a variety of IV fluids,
medications, blood products, and TPN
solutions
• allow a means for hemodynamic monitoring
and blood sampling
• CVAD
• usually introduced into the subclavian or
internal jugular vein and passed to the superior
vena cava just above the right atrium
• require radiographic confirmation of position
Types of CVADS
• Peripherally Inserted Central Catheters
(PICCs)
• Nontunneled percutaneous central venous
catheters
• Tunneled central venous catheters
• Implanted ports
• PICCs
• >20 cm depending on patient size, that can be
introduced into a peripheral vein
– basilic, brachial, or cephalic veins
• advanced as far as the superior vena cava
• specially trained registered nurse or physician
can insert this type of catheter
• radiographic verification
• single or multiple lumens
• PICCs
• for long-term IV therapy, from 6 weeks to 6
months
• normally replaced as needed
– catheter is no longer patent
– site looks infected.
• Indications for PICCs
• administration of IV antibiotics for an
extended period (2–6 weeks)
• infusion of parenteral nutrition
• chemotherapy
• continuous narcotic infusions
• vesicants, hyperosmolar solutions
• blood components
• other specific medications (eg, vasopressors,
anticoagulants)
• long-term rehydration
• Advantages of PICC
• less risk of complications because the catheter
is inserted peripherally
– infection
– pneumothorax
• cost effective
• provide adequate hemodilution for medications
• Nontunneled Percutaneous Central Venous
Catheters
• have a shorter dwell time (3–10 days)
 • introduced through the skin into the internal
jugular, subclavian, or femoral veins and
sutured into place
• can have double, triple, or quadruple lumens
• >8 cm, depending on patient size
• Nontunneled Percutaneous Central Venous
Catheters
• tip rests in the superior vena cava
• may be inserted at the bedside or in outpatient
settings
• associated with a high risk for complications ,
accounting for most catheter-related
bloodstream infections
– infection
– pneumothorax the catheter is placed
– in the subclavian vein.
triple-lumen nontunneled percutaneous central venous
catheter
• Tunneled Central Venous Catheter
• intended for long-term use
• implanted into the internal jugular subclavian,
or femoral vein
• length of this catheter is >8 cm, depending on
patient size
• tunneled in subcutaneous tissue under the skin
(usually the midchest area) for 3 to 6 inches to
its exit site
• Tunneled central venous catheter
• initially sutured into place, but after 7 to 14
days, the sutures are removed.
• subcutaneous tissue attaches to a Dacron
polyester cuff around the catheter, helping to
stabilize the catheter and minimize the risk for
infection
• associated with a lower incidence of infection
than is the nontunneled central venous catheter
• Tunneled Central Venous Catheter
• Implanted Port
• >8 cm, depending on patient size
• tip is placed in the subclavian or internal
jugular vein, but the proximal end or port is
usually implanted in a subcutaneous pocket of
the upper chest wall, and no external parts of
the system are visible
• placed in the antecubital area of the arm
(peripheral access system ports)
• initially used for chemotherapy
• Implanted Port
• now used for any patient requiring long-term
intermittent infusions
• a special angled noncoring needle is inserted
through the skin and rubber septum and into
the port reservoir
• require minimal care, but the discomfort of
accessing the port may be a disadvantage for
some patients
• Implanted Port
• numbing cream can be applied to the site
before needle insertion (ensure that all of the
cream is removed and the skin adequately
cleaned before accessing the port)
• associated with the lowest risk for catheter-
related bloodstream infections
• patients report improved self-image
• surgery is required for catheter removal.
•
•
• STARTING AN
INTRAVENOUS INFUSION
• Equipment
• IV solution
Towel or disposable pad
Nonallergenic tape
IV infusion set
Gauze or transparent dressing (according to
agency policy)
Electronic infusion device (if ordered)
 IV tubing Tourniquet
Time tape or label (for IV container)
• Equipment
• Armboard (if needed)
Cleansing swabs (chlorhexidine preferred,
alcohol, povidone-iodine)
Site protector or tube-shaped elastic netting
(optional) Clean gloves
IV pole
Anesthetic (numbing) cream (if ordered)
Lidocaine 1% injection (if ordered)
1-mL syringe (for lidocaine)
IV catheter (over the needle, Angiocath) or
butterfly needle
• Butterfly
• Angiocath
• Neoflon
Venflon
Actions
1. Verify the IV order against the physician order.
Clarify any inconsistencies. Check the patient's chart
for allergies. Check for color, clarity, expiration
date, etc.
Rationale
This ensures that the correct IV solution and rate of
infusion, and/or medication will be administered.
2. Know the techniques for IV insertion, precautions,
purpose of the IV administration and medications if
ordered.
This knowledge and skill is essential for safe and
accurate IV and medication administration.
3. Gather all equipment and bring to the bedside.
Having equipment available saves time and facilitates
accomplishment of the task.
4. Identify the patient. Ask the patient if he/she is
allergic to any medication, iodine, or tape, as
appropriate. If considering using an anesthetic
(numbing) cream or 1% lidocaine injection, check
for allergies for these substances as well.
Identi fication of the patient ensures that the right
patient receives the correct IV administration and
medication as ordered.
Possible allergies may exist related to medications,
iodine, tape, anesthetic cream or lidocaine injection.
Injectable anesthetic can result in allergic reactions,
tissue damage, and inadvertent injection into the
vascular system.
5. Explain the need for the IV and procedure to the
patient
Explanation allays anxiety.
6. Perform hand hygiene. If using an anesthetic cream,
apply the anesthetic cream to a few potential insertion
sites.
Hand hygiene deters the spread of microorganisms.
Anesthetic (numbing) cream decreases the amount of
pain felt at the insertion site. Some of the numbing
creams take as long as an hour to become effective.
7. Prepare IV solution and tubing:
a. Maintain strict aseptic technique when opening
sterile packages and IV solution.
Asepsis is essential for preventing the spread of
microorganisms
b. Clamp IV tubing, uncap spike on the administration
set, and insert into the entry site on the IV bag or bottle
as the manufacturer directs.
This punctures the seal in the IV bag or bottle.
Clamping the IV tubing prevents air and fluid from
entering the IV tubing at this time
c. Squeeze the drip chamber and allow it to fill at least
halfway
Suction causes fluid to move into the drip chamber and
prevents air from moving down the tubing.
d. Remove the cap at end of the IV tubing and while
maintaining its sterility, open the IV tubing clamp, and
allow fluid to move through tubing. Allow fluid to flow
until all air bubbles have disappeared and the entire
length of the tubing is primed (filled) with IV
solution. Close the clamp and recap the end of tubing,
maintaining sterility of the setup.
This technique prepares for IV fluid administration and
removes air from tubing. In large amounts, air in the
tubing can act as an embolus.
e. If an electronic device is to be used, follow the
manufacturer's instructions for inserting the tubing and
setting the infusion rate.
This ensures correct flow rate and proper use of
equipment.
f. Apply the label if medication was added to container
(pharmacy may have added medication and applied the
label). Label the tubing with the date and time that
tubing was hung.
This provides for administration of correct solution with
prescribed medication or additive. Labeling the tubing
alerts nursing staff of the need for IV tube changes.
Consult hospital policy. In general, IV tubing is changed
every 72 hours.
g. Place time-tape on the container and hang the IV on
the pole.
This permits immediate evaluation of the IV according
to the time-tape schedule.
8. Place the patient in low Fowler's position in bed.
Place protective towel or pad under the patient's arm.
Close the door to the room or pull the bedside curtain.
The supine position permits either arm to be used and
allows for good body alignment.
Closing the door provides for patient privacy.
9. Provide emotional support as needed.
The patient may experience anxiety because he/she may
fear needle stick or IV infusion in general.
10. Select and palpate for an appropriate vein. Avoid
an arm that has been compromised, such as with the
presence of arteriovenous fistula.
The use of an appropriate vein decreases discomfort for
the patient and reduces the risk for damage to body
tissues.
11. If the site is hairy and agency policy permits, clip a
2-inch area around the intended site of entry.
Hair can harbor microorganisms.
12. Apply a tourniquet 3 to 4 inches above the
venipuncture site to obstruct venous blood flow and
distend the vein. Direct the ends of the tourniquet away
from the site of entry. Make sure the radial pulse is still
present.
Interrupting the blood flow to the heart causes the vein
to distend. Distended veins are easy to see, palpate, and
enter. The end of the tourniquet could contaminate the
area of injection if directed toward the site of entry.
The tourniquet may be applied too tightly, so
assessment for the radial pulse is important.
13. Instruct the patient to hold the arm lower than the
heart.
Lowering the arm below the heart level helps distend
the veins by filling them.
14. Ask the patient to open and close the fist. Observe
and palpate for a suitable vein. Try the following
techniques if a vein cannot be felt:
Contracting the muscles of the forearm forces blood into
the veins, thereby distending them further.
a. Massage the patient's arm from proximal to distal
end and gently tap over the intended vein.
Massaging and tapping the vein help distend veins by
filling them with blood.
b. Remove the tourniquet and place warm moist
compresses over the intended vein for 10 to 15 minutes.
Warm moist compresses help dilate veins.
15. Put on clean gloves.
Gloves protect against transmission of HIV, hepatitis,
and other blood-borne infections.
16. If using intradermal lidocaine, cleanse the insertion
site with alcohol using a circular motion. Inject a small
amount (0.2 to 0.3 mL) of lidocaine into the area. If
numbing cream was used, wipe cream off the insertion
site. Cleanse the site with an antiseptic solution such
as chlorhexidine or according to agency policy. Use a
circular motion to move from the center outward for
several inches.
The lidocaine numbs the skin and makes the insertion
less painful. Cleansing that begins at the site of entry
and moves outward in a circular motion carries
organisms away from the site of entry. Organisms on the
skin can be introduced into the tissues or the
bloodstream with the needle. Chlorhexidine is the
preferred antiseptic solution but iodine, iodophor, and
70% alcohol are considered acceptable alternatives. If
there is difficulty visualizing or palpating the intended
vein for IV insertion, a tourniquet may be left in place.
17. Use the nondominant hand, placed about 1 or 2
inches below the entry site, to hold the skin taut against
the vein. Avoid touching the prepared site. Ask the
patient to remain still while the venipuncture is
performed.
Pressure on the vein and surrounding tissues helps
prevent movement of the vein as the needle or catheter
is being inserted. The needle entry site and catheter must
remain free of contamination from unsterile hands.
Patient movement may prevent proper technique for IV
insertion.
18. Enter the skin gently, holding the catheter by the hub
in your dominant hand, bevel side up, at a 10- to 15-
degree angle. The catheter may be inserted from directly
over the vein or the side of the vein. While following the
course of the vein, advance the needle or catheter into
the vein. A sensation of “give” can be felt when the
needle enters the vein.
This allows the needle or catheter to enter the vein with
minimal trauma and deters passage of the needle
through the vein.
19. When blood returns through the lumen of the needle
or the flashback chamber of the catheter, advance either
device 1/8 to ¼ inch farther into the vein. A catheter
needs to be advanced until the hub is at the venipuncture
site, but the exact technique depends on the type of
device used.
The tourniquet causes increased venous pressure,
resulting in automatic backflow. Placing the catheter
well into the vein helps to prevent dislodgement.
20. Release the tourniquet as soon as possible. Quickly
remove the protective cap from the IV tubing and attach
the tubing to the catheter or needle. Stabilize the
catheter or needle with your nondominant hand
Bleeding is minimized and the patency of the vein is
maintained if the connection is made smoothly between
the catheter and tubing
21. Start the flow of solution promptly by releasing the
clamp on the tubing. Examine the tissue around the
entry site for signs of infiltration
Blood clots form readily if IV flow is not maintained. If
the catheter accidentally slips out of the vein, the
solution will accumulate (infiltrate) into the surrounding
tissue.
22. Secure the catheter with narrow nonallergenic tape
(½ inch) placed with the sticky side up under the hub
and crossed over the top of the hub.
The weight of the tubing is sufficient to pull it out of the
vein if it is not well anchored. Nonallergenic tape is less
likely to tear fragile skin.
23. Place sterile dressing over the venipuncture site.
Agency policy may direct nurse to use gauze dressing or
transparent dressing. Apply tape to dressing if
necessary. Loop the tubing near the site of entry, and
anchor to dressing.
Transparent dressing allows easy visualization. Gauze
dressings are capable of absorbing drainage.
Securing the Catheter
24. Label the IV dressing with the date, time, site, and
type and size of catheter used for the infusion on the
tape anchoring the tubing.
Other personnel working with the infusion will know
what type of device is being used, the site, and when it
was inserted. IV insertion sites are changed every 48 to
72 hours or according to agency policy (Lavery, 2005).
25. Remove all equipment and dispose of properly.
Remove gloves and perform hand hygiene.
Hand hygiene deters the spread of microorganisms.
26. Anchor arm to an armboard for support if necessary,
or apply a site protector or tube-shaped mesh netting
over the insertion site. Explain to the patient the purpose
of the armboard and the importance of safeguarding the
site when using the extremity.
An armboard or site protector helps to prevent the
position of the catheter in the vein from changing.
27. Adjust the rate of solution flow according to the
amount prescribed, or follow manufacturer's directions
for adjusting flow rate on infusion pump.
The physician prescribes the rate of flow.
28. Document the procedure and the patient's response.
Chart the time, site, device used, and solution.
This provides accurate documentation and ensures
continuity of care.
29. Return to check the flow rate and observe the IV site
for infiltration 30 minutes after starting the infusion.
Ask the patient if he/she is experiencing any pain or
discomfort related to the IV infusion.
This documents the patient's response to infusion.
Pain is a symptom often associated with IV
complications such as infiltration and phlebitis.
• Sources of Catheter Contamination
• Hands of the caregiver
• Skin bacteria that contaminate the catheter
during insertion
• Disconnection of the tubing or injection cap
from the catheter hub, allowing bacteria to
enter the closed system or multiple-lumen
catheters
• Poor insertion technique
• An IV solution that becomes contaminated
when solutions are changed, a medication is
added, or the solution is allowed to infuse for
too long a period
• Complications Associated With Intravenous
Infusions
*Complication/Cause
Infiltration: the escape of fluid into the
subcutaneous tissue Dislodged needle Penetrated
vessel wall
>Sign and Symptoms
Swelling, pallor, coldness, or pain around the
infusion site; significant decrease in the flow rate
^Nursing Considerations
Check the infusion site several times per shift for
symptoms.
Discontinue the infusion if symptoms occur.
Restart the infusion at a different site.
Limit the movement of the extremity with the IV.
* Sepsis: microorganisms invade the bloodstream
through the catheter insertion site
Poor insertion technique Multilumen catheters
Long-term catheter insertion
Frequent dressing changes
> Red and tender insertion site Fever, malaise,
other vital sign changes
^ Assess catheter site daily.
Notify physician immediately if any signs of
infection.
Follow agency protocol for culture of drainage.
Use scrupulous aseptic technique when starting an
infusion.
* Phlebitis: an inflammation of a vein
Mechanical trauma from needle or catheter
Chemical trauma from solution
Septic (due to contamination)
> Local, acute tenderness; redness, warmth, and
slight edema of the vein above the insertion site
^ Discontinue the infusion immediately.
Apply warm, moist compresses to the affected site.
Avoid further use of the vein.
Restart the infusion in another vein.
* Thrombus: a blood clot Tissue trauma from
needle or catheter
> Symptoms similar to phlebitis IV fluid flow may
cease if clot obstructs needle
^ Stop the infusion immediately.
Apply warm compresses as ordered by the
physician.
Restart the IV at another site.
Do not rub or massage the affected area.
* Speed shock: the body's reaction to a substance
that is injected into the circulatory system too
rapidly
Too rapid a rate of fluid infusion into circulation
> Pounding headache, fainting, rapid pulse rate,
apprehension, chills, back pains, and dyspnea
^ If symptoms develop, discontinue the infusion
immediately.
Report symptoms of speed shock to the physician
immediately.
Monitor vital signs if symptoms develop.
Use the proper IV tubing.
Carefully monitor the rate of fluid flow.
Check the rate frequently for accuracy. A time tape
is useful for this purpose.
* Fluid overload: the condition caused when too
large a volume of fluid infuses into the circulatory
system
Too large a volume of fluid infused into circulation
> Engorged neck veins, increased blood pressure,
and difficulty in breathing (dyspnea)
^ If symptoms develop, slow the rate of infusion.
Notify the physician immediately.
Monitor vital signs.
Carefully monitor the rate of fluid flow.
Check the rate frequently for accuracy.
* Air embolus: air in the circulatory system
Break in the IV system above the heart level
allowing air in the circulatory system as a bolus
> Respiratory distress
Increased heart rate
Cyanosis
Decreased blood pressure
Change in level of consciousness
^ Pinch off catheter or secure system to prevent
entry of air.
Place patient on left side in Trendelenburg position.
Call for immediate assistance.
Monitor vital signs and pulse oximetry.