LPN-C
Unit Five
Peripheral Intravenous Therapy
Nursing Interventions R/T Anxiety &
Discomfort with IV Infusion

Individuals typically experience anxiety
related to intravenous therapy
◦ Illness
◦ Unfamiliar environment
◦ Need for complex services and procedures

Extreme anxiety can have physiological
effects
◦ Spasm or constriction of veins due to the
sympathetic response
 Blood shunted from peripheral circulation to vital
organs
 Inhibits venous access
◦ Syncope related to the vasovagal response
Anxiety & Discomfort (cont’d)

Psychological preparation increases coping
ability
◦ Relaxes the client
◦ Facilitates initiation of IV therapy for the nurse

Client teaching
◦ Time
 Building rapport and relaying caring
 Allowing time for questions
◦ Explanations
 Overcoming communication barriers
◦ Honesty
 How long the IV may be in place
 Why IV access is needed
 Acknowledge associated pain and discomfort
Anxiety & Discomfort (cont’d)

Pain reduction
◦ Advise patient of measures that may decrease
distress
◦ Assure patient that you will be as efficient as
possible
◦ Employ appropriate physical, pharmacological,
and psychological measures to minimize
discomfort

Professionalism
◦ Express confidence and expertise
◦ Reinforce positive aspects of the procedure
Latex Allergy Precautions

Patients at risk for latex-related reactions –
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Women constitute 75% of all reported cases
Asthma
Allergy history
Occupational exposure to latex
Fruit and vegetable allergies
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Avocados
Bananas
Chestnuts
Kiwis and other tropical fruits
◦ Intermittent catheterization
◦ Chronic genitourinary or abdominal conditions
requiring multiple surgeries
Latex Allergy Precautions (cont’d)
Report incidents of adverse reactions to
latex or other materials used in medical
devices to the FDA
 FDA recommendations to health
professionals -
◦ Assess latex sensitivity while obtaining history
for all patients
◦ Use devices made with alternative materials
◦ Be alert for an allergic reaction whenever latexcontaining devices are used, especially when in
contact with mucus membranes
◦ Alert clients with suspected allergic reaction to
latex to possible latex sensitivity, and advise
them to consider immunologic evaluation
Latex Allergy Precautions (cont’d)

FDA recommendations to health
professionals (cont’d) -◦ Advise clients to tell health professionals and
emergency personnel about latex sensitivity
◦ Consider advising clients with a latex allergy to
wear a medical identification bracelet

Other allergies
◦ Must assess for allergies to foods, animals and
insect matter, and environmental substances
◦ Iodine
 Often used in skin antisepsis
 Client may only recognize this as a shellfish allergy
◦ Adhesive
 Used in dressing tape
Caring for an IV at Home

Many clients receive IV therapy at home
◦ Limitations by 3rd party payers
◦ Personal preference

Several types of IV therapy can be
maintained outside of the hospital
◦
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Antibiotics
Chemotherapy
Hydration and hyperalimentation
Pain control
HIV-related therapies
Growth hormone and immunoglobulins
Dobutamine (for severe CHF)
Tocolytic therapy (to ↓ premature contractions)
Caring for an IV at Home (cont’d)
Arm/hand movement may be limited, so
client may need to relearn ADLs
 Ambulation with infusion equipment
 Instruct client against tampering with IV
tubing, clamp, or dressing
 Advise client to keep the IV dry to minimize
risk of infection

◦ Staphylococcus epidermis
◦ Staphylococcus aureus
Teach client how to assess IV site for signs
and symptoms of infection
 Provide list of symptoms or conditions for
which client would need to call the doctor

IV Preparation
*Physical preparation of the client for
initiation of intravenous therapy includes
safety, comfort, and positioning
 Safety
◦ Verify IV order
◦ Verify correct patient identification
◦ Validate that the ordered infusion is
appropriate for the patient
◦ Confirm that the patient is not allergic to
anything that is to be administered
◦ Review documentation of significant laboratory
and diagnostic reports
◦ Maintain strict asepsis when preparing all
products to be used for venipuncture/infusion

IV Preparation (cont’d)
Safety (cont’d) --
◦ Ensure that all supplies and equipment for
venipuncture are sterile
◦ Check expiration dates
◦ Provide a safe environment for the patient
during infusion therapy
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Bedrails
Restraints
Movement
Ambulation
◦ Assess/select the vessel that is appropriate for
the type of infusion ordered
◦ Instruct the client about what to report in terms
of activity, discomfort, or signs/symptoms
associated with a reaction

Comfort
IV Preparation (cont’d)
◦ Restrictions in mobility and sustaining ADLs
 Prevent dislodgement of the cannula
 Avoid disconnection of any part of the infusion setup
 If any portion of the closed IV system were disrupted,
contamination and infection could occur
◦ Use nondominant hand for IV access
◦ Avoid using veins in areas of flexion unless
immobilized
◦ Allow completion of ADLs prior to IV insertion
◦ Provide loose-fitting clothing/hospital gown
 Allows for less restricted movement
 Does not impede fluid flow
 Easily removed for changing
◦ Provide for privacy

IV Preparation (cont’d)
Correct positioning
◦ Fowler’s position
◦ Maintain intended venipuncture site below
heart level to promote venous filling
◦ Follow institutional protocol with regards to
armboards, restraints, or stabilization devices
 Can cause nerve and muscle damage
 Must be removed at frequent intervals to assess
circulatory status
◦ Protect insertion site from moisture and
contamination
◦ Hair may need to be removed prior to initiating
IV therapy if it impedes vessel visualization, site
disinfection, cannula insertion, or dressing
adherence
IV Preparation (cont’d)

Correct positioning (cont’d) –
◦ Hair removal (cont’d) –
 Hair is to be removed by gently clipping it close to the
skin
 Do not scratch the skin
 Do not shave the hair because of the potential for
microabrasion and the introduction of contaminants
 Do not apply depilatories due to the possibility for
skin irritation or allergic reactions
 An electric shaver may be used
 Check your institutional policy
 If the shaver does not belong to the patient, the shaving heads
would need to be changed or disinfected between patient use
IV Preparation (cont’d)
*IV preparation involves using the correct
site preparation/maintenance materials
 Obtain the appropriate dressing materials
◦ Sterile gauze
◦ Sterile transparent, semipermeable dressing

Cleanse the skin
◦ Use an antimicrobial barrier
 2% chlorhexidine or per institutional policy
 Available in the form of swab sticks, prep pads, or
plastic, cotton-tipped squeezable vials
 These are one-time use only!
◦ Allow barrier to air dry
Vein Selection
*Intravascular access refers to entrance into
arteries, veins, or capillaries
 The selected access site should provide the
most appropriate access to the vessel
◦ Needs to be appropriate for intended therapy
◦ Must accommodate administration of the
prescribed infusion
◦ Endeavor to minimize associated risks or
complications

Factors to consider with vein/site selection
◦ Patient’s age, health status, and diagnosis
◦ Condition of the site to be accessed
◦ Purpose, duration, and possible side effects of
therapy
Vein Selection (cont’d)
*Peripheral intravenous routes should be
achieved in an upper extremity
 Venous cannulation should begin at the
distal-most area of the upper extremity
and proceed proximally
 Examine the upper extremities
◦ Predict the ease or difficulty of venous access
◦ Predetermine measures to facilitate successful
venipuncture

Inspect the patient’s skin
◦ Assess for damaged areas
◦ Apply a tourniquet
◦ Use a flashlight for enhanced visualization
Vein Selection (cont’d)
*Peripheral intravenous routes (cont’d) –
 Palpate the patient’s veins
◦ Determine condition of the vessel
◦ Locate deeper, larger veins that are stronger
and more suitable for initiation of IV therapy
*The nurse needs to know which veins to
avoid when preparing to perform
venipuncture for purposes of peripheral
intravenous therapy
 Do not use veins in an area with a recent
infiltration
 Do not use veins in an area that has
sustained 3rd degree burns
Vein Selection (cont’d)
*Veins to avoid (cont’d) –
 Avoid veins in the antecubital fossa
 Do not use veins that are irritated or
sclerosed from previous use
◦ For a vein to be viable, it must be able to be
blanched
◦ To check for blanching, apply downward
pressure over, or on each side of, a vein
◦ If the vein disappears with the pressure, then
reappears when the pressure is removed, the
vein is viable
◦ A sclerotic vein will not blanch

Avoid veins in an extremity that is partially
amputated
Vein Selection (cont’d)
*Veins to avoid (cont’d) –
 Do not use veins in the lower extremities in
ambulatory adults and children
◦ Use lower extremity sites only in an emergency
◦ Must have a written order
◦ Ensure agency has policy in place that upholds
this procedure

Never access an arteriovenous fistula,
graft, or shunt that has been surgically
placed for hemodialysis
◦ Do not use the affected arm itself for IV therapy

Do not use veins in an extremity that is
impaired as a result of a CVA
Vein Selection (cont’d)
*Veins to avoid (cont’d) –
 Do not use veins on the side of the body
where a radical mastectomy with lymph
node dissection/stripping has been
performed
 Bypass veins in an extremity that has
undergone reconstructive or orthopedic
surgery
 Avoid edematous extremities
Cannula Selection
*Types of peripheral venous devices
 Steel needles
 Winged needles
 Catheters
*Steel needles are very rarely used anymore
*Winged needles, referred to as butterflies,
have one or two “wings”
 Connect with a needle on one side and a
segment of infusion tubing that ends in a
hub and protective cap on the other
◦ Tubing varies in length from 3½ to 12 inches
◦ Tubing is primed with NS prior to insertion to
prevent entry of air into the circulation
Cannula Selection (cont’d)
*Butterflies (cont’d) –
 Wings are held upright during insertion to
facilitate movement into the vein
 Once the needle is in the vein, the wings
are taped to the skin to secure the device
 If secured properly, winged needles stay in
the vein well
 Good means of venous access under
certain circumstances
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Short-term infusions (24 hours or less)
Seldom used for adult infusion therapy
Can be used for one-time IV push medications
May be used to draw blood
Cannula Selection (cont’d)
*Peripheral venous access catheters are the
most commonly used IV device
 Used to enter superficial or deep veins
◦ Extremity
◦ Neck
◦ Head

Two-part flexible cannula in tandem with a
rigid needle or stylet
◦ Stylet is used to puncture and insert the
catheter into the vein
◦ Connects with a clear chamber
 Allows for visualization of blood return
 Indicates successful venipuncture
 Facilitates removal of the needle
Cannula Selection (cont’d)
*Catheters (cont’d) - Color-coded plastic cannula hub
◦ Indicates length and gauge of catheter
Length ranges from ¼ inches to 12 inches
 Catheter is radiopaque

◦ Easily detected by radiology in case of embolus
*Types of catheters include the over-theneedle peripheral catheter (ONC) and the
through-the-needle peripheral catheter
(TNC)
 The ONC is a flexible cannula that encases
a steel needle or stylet device
◦ Most commonly used peripheral IV device
Cannula Selection (cont’d)
*Types of catheters (cont’d) - ONC (cont’d) –
◦ Once the vein is accessed, the catheter is
threaded into the vessel and the stylet is
withdrawn

The TNC is the opposite of the ONC, as the
flexible cannula is encircled by the steel
needle
◦ Infrequently used
◦ The needle is withdrawn once venous access is
achieved
◦ Secured in a protective shield outside the body
on the skin
Cannula Selection (cont’d)
*Factors to consider when selecting a
cannula –
 Use the smallest cannula that will deliver
the prescribed infusate
◦ Adequate blood flow and hemodilution
◦ Causes minimal discomfort

Delivery rate
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24 gauge cannula → approx 15-25mL/min
22 gauge cannula → approx 26-36mL/min
20 gauge cannula → approx 50-65mL/min
18 gauge cannula → approx 85-105mL/min
Achieving Venous Distention

Apply a tourniquet
◦ A tourniquet is an encircling device consisting
of a segment of rubber tubing that temporarily
arrests blood flow to or from a distal vessel
◦ Apply tightly enough that venous blood flow is
suppressed, but not so tight that it obstructs
arterial flow
 Should be able to palpate pulse distal to the
tourniquet
◦ Do not leave a tourniquet in place longer than
four to six minutes
 Tourniquet paralysis from injury to a nerve can occur
if the tourniquet is applied too tightly or left for too
long a period

Apply warm compresses for 10-15 minutes
Achieving Venous Distention (cont’d)
Place the extremity intended for
venipuncture below the level of the
patient’s heart for several minutes
 Have the patient open and close his or her
fist, or squeeze and release the lowered
bedrail
 Use an alcohol pad to gently rub the skin
over the vein intended for venipuncture

◦ Alcohol and friction creates heat
◦ Enhances venous distention

Pat the area of skin over the intended vein
using light to moderate force to engorge
the vein with blood
IV Equipment and Supplies
*Infusate containers and IV administration
sets
 Infusate containers –
◦ Flexible plastic
◦ Semirigid plastic
◦ Glass
IV administration set = tubing that delivers
fluid/medication from the infusate
container to the patient
*All administration sets have a spike insert
that fits into the administration set port of
the infusate container, as well as a drip
chamber, clamps, and an adapter

IV Administration Sets
On an administration set, the drip chamber
is where the solution flows after leaving
the infusate container and before entering
the tubing
 A screw and roller clamp allows for flow
regulation
 A slide clamp functions as an on-off clasp
 A cannula hub can be attached to the
sterile adapter at the end of the tubing

◦ The adapter can be straight, fitting directly into
the cannula hub with a push ~OR~
◦ The adapter can be screwed on to the cannula
hub, providing a firm attachment (Luer-Lok)
IV Administration Sets (cont’d)
The administration set determines the rate
at which fluid can be delivered to the
patient (i.e. the drop factor)
 Specialized tubings are used in specific
settings and circumstances

◦ Extra large (macrobore) tubings
 Used in emergency surgical and trauma situations
 Rapid infusion of large volumes of blood or fluid
◦ Extra small (microbore) tubings
 Used for the delivery of small amounts of precisely
controlled fluid or medication
 Special volume restriction (neonatal care, epidural
infusions)
IV Administration Sets (cont’d)

Types of administration sets:
◦ Vented systems
 Used for vacuum infusate containers that don’t have
their own built-in mechanisms for air displacement
 Glass and some semirigid bottles
◦ Nonvented systems
 Used with flexible plastic bags and other nonvacuum
receptacles
◦ Primary administration sets
◦ Secondary administration sets
*Primary administration sets are also
known as basic, or standard, sets
 Carries fluid directly to the patient through
one tube
IV Administration Sets (cont’d)
*Primary administration sets (cont’d) - Spiked into one (single line) or two (Y-type)
main infusate container(s)
 May terminate in straight, flashtube, or
Luer-Lok male adapters
 Available in macrodrip or microdrip in
varying lengths
 Available with or without check valves,
which prevent retrograde blood flow
 May contain one or several injection ports
 Can accept attachments
◦ Secondary administration tubings, extension
tubings, flow control devices, filters, adapters
IV Administration Sets (cont’d)
*Single line primary administration sets
have one spike that is inserted into one
infusate container; the tubing terminates
with an adapter that connects to the
cannula hub at the IV access site
*Y-type primary administration sets have
two equal-length tubings that can each
access an infusate container
 Access can be simultaneous or alternately
◦ Each tubing has its own roller clamp
◦ Each tubing may or may not have its own drip
chamber

Frequently used in emergency, surgical,
and critical care situations
IV Administration Sets (cont’d)
*Y-type administration sets (cont’d) –
 The solution reaches the patient via one
common tubing
◦ Necessitates compatibility between the
infusates
Blood administration tubings are Y-type
sets, but differ from standard Y-type
primary administration sets
 Should be used only with nonvacuum,
flexible infusion containers where venting
is unnecessary

◦ If vented containers are used, air can be drawn
into the circulatory system, resulting in an air
embolism
IV Administration Sets (cont’d)
*Secondary administration sets are referred
to as piggyback sets
 Used to deliver continuous or intermittent
doses of fluid or medication
 Widely used because they negate the need
for additional venipunctures and
interruption of the primary infusion
 Usually connected with a needle or
needleless adapter into an injection port
immediately distal to the back-check valve
of the primary tubing
 Some primary administration sets have a
closed-system connection to a second line
IV Administration Sets (cont’d)
*Whenever an infusion line is breached, the
possibility for introduction of contaminants
exists
 IV line should not be broken to add
accessory equipment unless absolutely
necessary
 Refer to your institution’s policy for adding
equipment such as filters, extension sets,
adapters, and connectors to infusion lines
*Needleless systems and needlestick safety
systems are state-of-the-art in IV therapy
 Used to connect IV devices, administer
fluids and medications, and sample blood
IV Administration Sets (cont’d)
*Needleless systems (cont’d) –
 Eliminates up to 80% of needles
◦ Other than the initial stick to insert the cannula
into the patient’s vein, there is no need for
needles during IV therapy
*Blood exposure protocol –
◦ Wash needlestick punctures with soap & water
◦ Flush splashes to the nose, mouth, or skin with
water
◦ Irrigate splashes to the eyes with clean water,
NS, or sterile ophthalmic irrigants
◦ Report the incident to the department
responsible for managing exposures
◦ Start post-exposure treatment ASAP
Mechanical Gravity Control Devices
*Mechanical gravity control devices are flowregulating mechanisms that attach to the
primary infusion administration set
 Manually set to deliver specified volumes
of fluid per hour
 Available as dials or cylindrical controls
 Includes approximate flow markings that
must be verified (i.e. counting gtt/min)
 Accuracy varies
◦ Discrepancies can be up to ± 25%
◦ Dependent upon patient’s condition, activity
level, positioning, and venous pressure
Mechanical Gravity Control (cont’d)

Should generally be used for only short
periods, such as transporting the patient
◦ IV tubing kinking/obstruction can restrict fluid
flow
◦ Must be checked frequently for infusion
accuracy
Electronic Infusion Control Devices (EID)
*EIDs are state-of-the-art infusion-regulating
mechanisms that deliver fluids and medications
 Powered by electricity and/or battery
 Safe and accurate (± 5%)
 Programmable for several infusates at different
rates and volumes at the same time
 Sensors detect air in the line and pressure
changes
 Signals infusion termination
 Alerts the nurse to problems via readouts, alarms,
and flashing lights
EIDs (cont’d)

Most newer EID models have built-in safety
flow mechanisms
◦ Prevents unintended free flow of infusate into
the patient if the administration set were to be
removed from the machine

NOTE: No EID is a substitute for regular
patient observation and evaluation
Initiation of Infusion Therapy
*Gather the necessary equipment/supplies
to be optimally prepared for venipuncture
 Check the order
◦ Identify that the order is for the right patient

Read the label on the infusate container to
verify correct medication and dose
◦ Container should be compared directly with the
physician’s order to be sure it is correct
◦ Verify pharmacy admixtures
Verify infusate compatibility
 Check the expiration date of the infusate
 Evaluate the infusate container to ensure
seals are intact

Initiation of Infusion Therapy (cont’d)
*Gather equipment/supplies (cont’d) –
 Check the infusate fluid for clarity and
presence of particulate matter
*Equipment preparation and setup should
be completed away from the patient’s
room in an environment that minimizes
the chance for contamination
 Prior to starting an infusion, the correct
infusate should be set up with a primary
administration set
 If secondary infusions are ordered or
anticipated, choose a primary set with a
check valve and injection ports
Initiation of Infusion Therapy (cont’d)
*Equipment preparation(cont’d) –
 The interior of the tubing, both ends of the
tubing, and the infusate must be kept
sterile
 NOTE: The nurse must obtain permission
from the adult patient before performing
venipuncture or it may constitute assault
and battery
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7
Step 8
Venipuncture
Introduce yourself to the patient
Ask the patient to state his/her
full name, verifying identity with
chart and ID bracelet
Provide privacy
Explain proposed procedure in
terms the patient can understand
Elevate the bed to prevent strain
Place the patient in a semiFowler’s or Fowler’s position
Protect clothing/bedding with a
pad or towel
Wash your hands
Venipuncture (cont’d)
Step 9
Step 10
Step 11
Step 12
Step 13
Step 14
Set up all necessary supplies near
the bed in the order they will be
used
Select an appropriate vein based
on the type of therapy and
anticipated duration
Apply a tourniquet 2-3 inches
below the antecubital fossa for
venous access in the arm or hand
Prepare the site
Apply gloves while the final
antiseptic is drying
Cannulate the vein
Catheter Immobilization

Once in place, the IV device must be
secured
◦ Must allow for regular site assessment
◦ Need to prevent cannula movement or
dislodgement
◦ Maintain asepsis
◦ Prevent catheter-related infection

Transparent, semipermeable dressings are
most common
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Secures the vascular access device
Allows for continuous visual inspection of site
Allows bathing without saturating the dressing
Requires less frequent changes than others
Special Considerations

Patients with altered skin and vessels
◦ Burns, fragile veins
◦ Do not use a tourniquet
◦ Use alternative measures per institutional
policy for skin antisepsis to prevent further
irritation and discomfort

Patients with peripheral edema
◦ May need to use landmarks to identify a vein
◦ Client is at risk for unidentified infiltration due
to edema
◦ Vein may collapse due to pressure from excess
fluid

Obese patients
◦ May have deeply imbedded vessels
Special Considerations (cont’d)

Obese Patients (cont’d) -◦ May need to use landmarks to identify a vein
◦ May need to employ a longer cannula to reach
an appropriate vein

Patients receiving anticoagulant therapy
◦ Avoid using a tourniquet, or, if necessary, apply
as loosely as possible
◦ Avoid excess pressure when applying the skin
preparation
◦ Use the smallest cannula that will
accommodate the vein and deliver the ordered
infusate
◦ Remove dressings gently and use an adhesive
solvent
Converting a Peripheral IV

Converting a peripheral IV to an
intermittent access device is necessary
when discontinuing peripheral infusions
while retaining venous patency
◦ IV access remains available in case it is needed
◦ Administration of intermittent medications

Conversion is completed by attaching an
intermittent infusion plug to the hub of the
cannula
◦ Also called a male adapter plug
◦ Formerly referred to as a heparin lock
 Heparin is no longer recommended for intermittent
flushing because bacterial growth on the catheter
may be intensified in its presence
Converting a Peripheral IV (cont’d)
Intermittent line maintenance is achieved
by assessing the IV site, checking for
cannula patency, and flushing with 2cc NS
every 8-12 hours
 Check for patency of the intermittent line
by attaching the syringe to the intermittent
plug and pulling back the plunger to elicit
blood return

◦ If there is no blood return, gently inject the
saline while palpating the infusion site
 If the cannula is out of the vein, the saline will
infiltrate the surrounding tissue, causing it to rise and
be cool to the touch
 If the cannula is placed correctly, the saline will enter
the cannula and vein, maintaining patency
Converting a Peripheral IV (cont’d)

When any medication is administered into
an intermittent infusion device, the
protocol to be followed is the S-A-S method
◦ Slowly instill 2mL NS to clear the lock (S)
◦ Administer the prescribed medication (A)
◦ Flush with NS to clear the lock (S)

Prior to implementing the S-A-S method –
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◦
◦
◦
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Wash your hands
Assess the IV access site
Don gloves
Disinfect the cannula port
Verify cannula and venous patency
 If resistance is met, do not exert pressure on the
syringe plunger to restore patency
Converting a Peripheral IV (cont’d)

Multiple medication orders –
◦ Instill NS between the administration of each
medication
◦ Always flush with NS after all medications are
injected in order to clear the cannula and
maintain patency

Maintain positive pressure during and after
saline flushes
◦ Achieved by withdrawing the blunt cannula or
needle as the last 0.5mL of NS is flushed
inward
◦ Prevents the reflux of blood
Adding a Fluid/Medication
*During infusion therapy, fluids or
medications can be added in the following
ways –
 Added to the primary infusate container
 Via secondary administration set
 Through an injection port in the primary
administration tubing
 By direct injection into a vein that is not
concurrently receiving infusates (bolus)
 NOTE: For all but the last method, the
nurse must check for chemical, physical,
and therapeutic compatibility between the
medications and delivery systems
Adding a Fluid/Medication (cont’d)

Adding fluid/medication to the primary
infusate container –
◦ This is usually done as an admixture by the
pharmacy under asepsis
◦ If the nurse would need to add a medication,
you would need to check for compatibility,
additive concentration, and stability of the new
solution
◦ Never add a medication to an existing infusion
container while it is hanging and infusing
 Drug would be delivered to the base of the container
 Bolus dose would be infused to the patient
 May result in serious complications, or even death
Adding a Fluid/Medication (cont’d)

Adding fluid/medication via secondary
administration set (piggyback) –
◦ This method involves administering a
medication or fluid that is initiated after the
primary infusion is already in progress
◦ This is the most common means to administer
intravenous medications concurrently with the
primary infusion
◦ The piggyback line is coupled to the primary
infusion line at the first injection port below the
check valve
◦ The secondary infusion is able to function
concurrently with the primary infusion only
when suspended higher than the primary line
Adding a Fluid/Medication (cont’d)

Adding fluid/medication via piggyback
(cont’d) –
◦ The primary line must have a back-check valve
◦ By opening the clamp on the secondary line,
the primary infusion temporarily stops flowing
◦ When the piggyback infusion is complete and
the infusate in its tubing falls below the level of
the primary line drip chamber, the back-check
valve opens and the primary infusion resumes
Adding a Fluid/Medication (cont’d)

Adding fluid/medication through an
injection port in the primary administration
tubing –
◦ This is termed an IV push medication
◦ Intravenous medications that would normally
be delivered directly into the vein by bolus
injection can be delivered through an injection
port in the primary administration set if the
patient already has a running IV
◦ The nurse must check for compatibility
between the product already and the drug to be
administered by IV push
 Failure to do so could cause a precipitate to form
 Precipitate could obstruct the infusion line, damage
the vein, or embolize
Nonfunctioning IV Lines
*Checklist for determining the cause of a
nonfunctioning peripheral IV line –
 Check IV site for infiltration, patency
 Check the infusate container
◦ Fluid level
◦ Height
Check the tubing for kinking
 Check the air vent and filter
 Ensure the clamp is open
 Check the positioning of the patient
 Check the temperature of the solution
 Ensure the tubing is correct for the infusate

Documentation
*IV documentation includes labeling
 The main purpose for labeling is to denote
IV start, stop, and discontinuation times
 Labels must be affixed to infusate
containers, administration set tubing, and
dressing sites
 Placement of labels
◦ IV site
 Place next to the dressing
 Include the date and time of cannulation
 Indicate the type of device used
 Length
 Gauge
 Identification (nurse’s initials)
Documentation (cont’d)

Placement of labels (cont’d) -◦ Allergy labels
 On and in the patient’s chart
 In the patient’s room and on the patient’s bed
 All communication with other personnel and
departments regarding allergies and drug reactions
 Attach appropriate identification bracelet to the
patient
◦ Administration set tubing
 Include date and time of initiation/change
◦ Infusate container(s)




Start date and time
Flow level strips
Added medications
Never write directly on an IV bag (use label instead)
Documentation (cont’d)
*Accurate charting for intravenous infusions
should include these components –
 Date and time of insertion
 Which vein was cannulated
◦ Be specific (know your peripheral venous
anatomy!)
◦ Document why you chose a particular vein if
necessary
◦ Document the condition of the vein in terms of
its softness or hardness and resiliency

Device used
◦ Brand name and style
◦ Gauge and length
Documentation (cont’d)
What to include in your charting (cont’d) –
 Infusate administered
◦ Name of medication/fluid
◦ Rate of infusion

Method of infusion
◦ Gravity
◦ EID
 Controller or pump mode
 Name brand and model number
Type of dressing applied
 Remedial information

◦ Number/location of attempted cannulations
◦ Condition of the failed site(s)
Documentation (cont’d)
What to include in your charting (cont’d) –
 Patient’s response to the procedure
◦ Reaction/comments
*Be sure to document in these areas - MAR
 Nurse’s notes
 Infusion and equipment flow sheets
 Nursing care plan
 Intake and output records
 Laboratory, radiology, and other ancillary
department requisitions
Local and Systemic
Complications
of IV Therapy
Local Complications of IV Therapy
Local complications = adverse reactions that
occur at or close to the IV insertion site
◦ Constitutes the majority of complications in IV
therapy
◦ Usually less serious than systemic problems
*Types of localized infusion-related
complications include infiltration,
thrombosis, phlebitis, thrombophlebitis,
and allergic reaction to the IV catheter
*Infiltration refers to the inadvertent
administration of nonvesicant solution into
the surrounding tissue
Local Complications (cont’d)

Causes of infiltration
◦
◦
◦
◦
◦

Dislodgement of the cannula from the vein
Puncture of the vein wall during venipuncture
Friction of the catheter against the vein wall
Use of a high pressure infusion device
Irritating infusate that weakens the veins
Signs and symptoms of infiltration
◦
◦
◦
◦
◦
Skin is taut and/or cool to the touch
Dependent edema
Absence of blood backflow
Pinkish blood return
Slowing of the infusion rate
Local Complications (cont’d)

Infiltration complications
◦ Ulceration may appear after days/weeks
◦ Compartment syndrome





Fluid builds up inside an inflexible compartment
Pressure on nerves, muscles, and vessels
Functional muscle changes occur within 4-12 hours
Ischemic nerve damage occurs within 24 hours
Preventing infiltration
◦
◦
◦
◦
Assess IV site (blood return is not an indicator)
Pain may or may not be present
Extremity comparison
Infusion should stop running if pressure is
applied 3 inches above the catheter site
Local Complications (cont’d)

Treatment of infiltration
◦ Infuse antidote through the IV if applicable,
then remove the IV
◦ Apply warm compresses for antineoplastic
agents, and cool compresses for most other
medications
◦ Notify the physician
◦ Elevate the extremity if this promotes comfort
for the patient
*Extravasation is the inadvertent
administration of vesicant medication or
solution into the surrounding tissue
 Requires an incident report
Local Complications (cont’d)

Treatment of extravasation
◦ Dependent on a variety of factors
 Pharmaceutical manufacturer’s labeled uses and
directions
 Properties and severity of extravasated agent
◦ Treatment determined before IV removed
◦ Do no apply excessive pressure to the site to
avoid establishment of perfusion
◦ Ongoing observation and assessment of site
(i.e. motion, sensation, circulation)
◦ Do not use extremity for subsequent IV
placement
◦ Notify the physician
Local Complications (cont’d)

Infiltration documentation
◦ Use the INS Infiltration Scale
 Extravasation always graded at 4
◦ Document written and verbal communication
◦ Chart nursing and medical interventions
◦ Document patient’s response to incident and
treatment

Drugs associated with extravasation
necrosis include –
Calcium chloride
Dopamine
Vincristine
Calcium gluconate
Vancomycin
Streptozocin
Infusion Nurses Society Infiltration Scale
Criteria
Grade
0
No symptoms
1
Skin blanched and cool to touch
1 inch edema
Pain may or may not be present
2
Skin blanched and cool to touch
1 - 6 inch edema
Pain may or may not be present
3
Skin blanched, translucent, and cool to touch
Gross edema (>6 inches)
Mild-to-moderate pain; possible numbness
4
Skin blanched, translucent, tight, discolored, and bruised
Gross, deep, pitting edema
*May have circulatory impairment and severe pain with
infiltration of blood product, irritant, or vesicant
Local Complications (cont’d)
*Thrombosis occurs when blood flow
through the vein is obstructed by a local
thrombus
◦ If thrombosis is IV-related, it has resulted from
injury to the endothelial cells of the venous wall
◦ Injury leads to platelet aggregation at the site
of injury, which forms the thrombus
◦ Major complication of central venous catheters

Signs and symptoms of thrombosis
◦ Earache or jaw pain
◦ Edema, redness at insertion site
◦ Tachycardia, tachypnea
Local Complications (cont’d)

S/S of thrombosis (cont’d) –
◦
◦
◦
◦

Malaise
Unilateral arm or neck pain
Absence of pulse distal to the obstruction
Digital coldness, cyanosis, and/or necrosis
Treatment of thrombosis
◦ Never flush with force to remove an occlusion
◦ Discontinue IV and restart with a new catheter
at a different site
◦ Notify the physician for assessment of
circulatory status
Local Complications (cont’d)
*Phlebitis = inflammation of the vein
◦ Endothelial cells in the venous wall become
irritated and rough, allowing platelets to adhere
◦ Capillary permeability increases, and protein
leaks out into the interstitial space
◦ Area more susceptible to mechanical or
chemical irritation

Signs and symptoms of phlebitis
◦
◦
◦
◦
◦
Localized redness and swelling
Warm and tender to the touch
Palpable “cord” along the vein
Sluggish infusion rate
Increased temperature
Local Complications (cont’d)

Prevention of phlebitis
◦ Use of larger veins for hypertonic solution
infusions
◦ Use of central line for long-term IV therapy
◦ Use of the smallest IV cannula appropriate for
the ordered infusate
◦ Rotation of IV sites per agency protocol
◦ Change IV bag per agency protocol
◦ Appropriate stabilization of the catheter
◦ Correct venipuncture technique
◦ Good handwashing
*Phlebitis is graded according to INS scale
Infusion Nurses Society Phlebitis Scale
Criteria
Grade
0
No symptoms
1
Erythema (redness of the skin due to capillary congestion)
Pain may or may not be present
2
Pain at access site
Erythema and/or edema
3
Pain at access site
Erythema and/or edema
Streak formation
Palpable venous cord
4
Pain at access site
Erythema and/or edema
Streak formation
Palpable venous cord >1 inch in length
Purulent drainage
Local Complications (cont’d)
*INS practice criteria for phlebitis requires
established guidelines for treatment in
Policy and Procedures Manual
◦ All vascular access sites should be routinely
assessed for signs or symptoms of phlebitis
◦ Discontinue IV at first sign of phlebitis and
remove the intravenous device
◦ Grade ≥2 report to physician and file incident
report
◦ Observe peripheral catheter site for 48 hours
after device has been removed
◦ Document incident, intervention, treatment,
corrective action, and patient education
Local Complications (cont’d)

Types of phlebitis
◦ Mechanical
◦ Chemical
◦ Bacterial

Causes of mechanical phlebitis
◦ Insertion of a cannula that is too small for the
vein
◦ Improper taping of the cannula hub so that the
catheter tip rubs the vein wall
◦ Manipulation of the catheter during infusion

Causes of chemical phlebitis
◦ Excessively rapid infusion
Local Complications (cont’d)

Causes of chemical phlebitis (cont’d) –
◦ Infusion of irritating substances
 Acidic solutions (Dextrose, KCL, antibiotics)
 pH level falls the longer the solution is stored
◦ Improperly mixed medications
◦ Presence of particulate matter in the solution

Causes of bacterial phlebitis
◦
◦
◦
◦
Poor aseptic technique
Incorrect cannula insertion procedure
Inadequate stabilization of cannula hub
Lengthy catheter dwell time
Local Complications (cont’d)
*Thrombophlebitis occurs when thrombosis
is accompanied by inflammation
◦ May become obstructive if IV not discontinued

Complications of thrombophlebitis
◦ Embolism
◦ Septicemia
◦ Acute bacterial endocarditis

Causes of thrombophlebitis
◦ Use of leg veins for venipuncture
◦ Use of hypertonic or highly acidic infusates

Signs and symptoms of thrombophlebitis
◦ Local tenderness and warmth
Local Complications (cont’d)

S/S of thrombophlebitis (cont’d) –
◦
◦
◦
◦
◦
◦

Appearance of a red line above the IV site
Hardening of the vessel
Sluggish flow rate
Edema in the limbs
Diminished arterial pulses
Mottling or cyanosis of the extremities
Treatment of thrombophlebitis
◦ Notify the physician, remove IV catheter and
restart in opposite extremity using new
equipment
◦ Apply warm, moist compresses to the area for
20 minutes for comfort
Local Complications (cont’d)

Documentation of thrombophlebitis
◦
◦
◦
◦
Chart all observable symptoms
Document patient’s complaints/reactions
Chart nurse’s actions
Document information regarding new
venipuncture
*Allergic reaction to the IV catheter
 Symptoms include red streak over the vein
 Treatment of a localized allergic reaction
◦ Discontinue the IV
◦ Notify the physician
◦ Use different material for new IV in another site
Systemic Complications of IV Therapy
Septicemia
 Embolism

◦ Pulmonary
◦ Air
◦ Catheter
Pulmonary Edema
 Speed Shock
 Allergic Reaction
*Septicemia = a febrile disease caused by
microorganisms in the circulatory system

◦ Major complication that occurs from cannula or
infusate contamination
Systemic Complications (cont’d)

Signs and symptoms of septicemia
◦
◦
◦
◦

Fever, flushing, profuse diaphoresis
Altered mental status
Nausea/vomiting, abdominal pain
Tachycardia, hypotension
Treatment of septicemia
◦
◦
◦
◦
◦
◦
Monitor patient
Culture IV catheter per order/agency protocol
Administer antimicrobial therapy as ordered
Administer oxygen if needed
Administer IV fluids
Observe for bleeding (all body orifices)
Systemic Complications (cont’d)

Prevention of septicemia
◦
◦
◦
◦
Good handwashing
Careful inspection of IV solutions
Appropriate infusion site dressing
Rotate IV sites
*Pulmonary embolism is associated with IVrelated thrombus
◦ Dislodged from the wall of the vein
◦ Carried by the venous circulation through the
right side of the heart to the pulmonary artery

Signs and symptoms include shortness of
breath, cyanosis, chest pain, tachypnea
Systemic Complications (cont’d)

Prevention of a pulmonary embolism
◦
◦
◦
◦

Manage local complications immediately
Do not apply pressure to regain IV patency
Inspect medication/fluid for particulate matter
Avoid venipuncture in lower extremities
Treatment of a pulmonary embolism
◦ Position patient on the left side, trendelenburg
◦ Administer oxygen
◦ Transfer to ICU
*Air embolism is most frequent in central
lines, and results from small amounts of
air in the circulatory system
Systemic Complications (cont’d)

Causes of an air embolism
◦ Incorrect IV insertion
◦ Excessive catheter manipulation
◦ Loose connections in the IV tubing

Complications of an air embolism
◦ Accumulation of small bubbles forms larger
bubbles that can block pulmonary capillaries
◦ Blockage may be fatal due to sudden vascular
collapse

Symptoms of an air embolism
◦ Cyanosis, hypotension, ↑ venous pressure
◦ Rapid loss of consciousness
Systemic Complications (cont’d)

Treatment of air embolism
◦ Immediately place the client on the left side
with head down
 Air becomes trapped in the right atrium
 Prevents air from entering the pulmonary artery
◦ Administer oxygen
◦ Notify the physician ASAP
◦ May need to administer CPR
*Catheter embolism can occur during
catheter insertion if appropriate placement
technique is not observed
◦ Catheter tip can shear off and become a freefloating embolus
◦ Can occur in both OTC and TNC
Systemic Complications (cont’d)

Treatment of catheter embolism
◦ Apply a tourniquet high on the extremity to
impede venous flow
◦ Cardiac catheterization may be needed to
remove the tip
◦ Notify the physician and radiologist
◦ Start an IV in the opposite arm to prepare for
angiography for visualization

Symptoms of catheter embolism
◦
◦
◦
◦
Hypotension
Tachycardia, chest pain
Cyanosis
Loss of consciousness
Systemic Complications (cont’d)

Prevention of a catheter embolism
◦ Never place an IV over a joint
 Flexing may cause the catheter to break
 If unavoidable, use splint to prevent bending

Documentation of catheter embolism
◦ Vital signs, symptoms, level of consciousness
◦ Appearance of catheter upon removal
*Pulmonary edema is caused by rapid
administration of large volumes of fluid
that leads to circulatory overload
 Prevention of pulmonary edema includes
monitoring the patient frequently and
using an EID for IV therapy
Systemic Complications (cont’d)

Symptoms of pulmonary edema
◦
◦
◦
◦
Increased blood pressure
Distended neck veins
Shortness of breath, rales
Orthopnea (sensation of breathlessness in the
recumbent position)
◦ Copious frothy sputum
*Speed shock = systemic reaction to rapid
or excessive infusion that overloads the
system; may result in cardiac arrest
 Symptoms of speed shock
◦ Flushing of the head and neck
◦ Severe headache, chest pain

Systemic Complications (cont’d)
Causes of speed shock
◦ Leaving the flow clamp open on the IV tubing
◦ IV pump programming error
◦ Incorrect drip rate calculation

Prevention of speed shock
◦ Always dilute IV push medications to the
appropriate concentration
◦ Always administer IV push medications over
the amount of time recommended per agency
protocol
*Allergic reaction at the systemic level is
considered a hypersensitivity reaction that
can be mild or severe
Systemic Complications (cont’d)

Symptoms of an allergic reaction
◦
◦
◦
◦
◦
◦

Localized pain, edema, and/or redness
Wheezing, bronchospasm
Headache
Palpitations, agitation, confusion
Intestinal cramping, nausea/vomiting
Development may vary from rapid to delayed
Treatment of an allergic reaction
◦
◦
◦
◦
Stop the infusion
Keep the vein open with NS
Administer oxygen if needed
Ensure emergency equipment is available
Systemic Complications (cont’d)

Complications of an allergic reaction
◦ Severe hypersensitivity to IV therapy
 Profound physiological response to an antigen
 Abnormal immune response to an allergen
◦ May include anaphylaxis
*Anaphylaxis = severe allergic reaction
◦ Immune response to allergen
◦ Large quantities of histamine released
◦ Massive peripheral dilation occurs
 Decreased blood flow to vital organs
◦ May lead to shock and death within minutes if
untreated
Medication/Fluid Interactions
*Incompatibility = unintended effects from
mixing fluids and/or medications
◦ Action may be neutralized, intensified, or
weakened
◦ Precipitation may occur
 Crystallization of particles
 Occlusion of the IV line
 Vessel injury
*Significant drug-drug interactions involve
medications that are incompatible with
other products
◦ Sodium bicarbonate
◦ Phenytoin (Dilantin)
Medication/Fluid Interactions (cont’d)
*Drug-drug interactions (cont’d) –
◦ Aminoglycosides (gentamicin, neomycin)
◦ Digitalis glycoside
◦ Barbiturates
 Secobarbital (Seconal)
 Pentobarbital (Nembutal)
 Phenobarbital (Luminal)
◦ Chlordiazepoxide (Librium)
◦ Diazepam (Valium)
◦ Theophylline
Infection
Control
◦ 500,000 patients develop IV-related infections
every year; of these, 30,000 individuals die as a
result
◦ It is critically important to understand the ways in
which IV-related infection can occur, and take
action to prevent it
◦ The three interacting factors in infection control
are 1) prevention, 2) control, and 3) eradication
of the microbe
◦ The goal of infection control is to break the chain
of infection
◦ If infection does occur, practitioner must identify
the microbe, determine causative circumstances,
use efficient means to eradicate it, and identify
factors to prevent recurrence
Agencies and organizations that set
guidelines for infection control:

Center for Disease Control and Prevention
(CDC) in Atlanta, Georgia
◦ Investigates, develops, recommends, and sets
standards for infection control practices
◦ Division of the Department of Health and
Human Services (DHHS)

Occupational Safety and Health
Administration (OSHA)
◦ Enforcing agency that provides mandates to
protect employees in all fields
◦ Policies regarding health care personnel are
closely aligned with CDC guidelines
Infection Control –
Agencies and Organizations (cont’d)
Infusion Nurses Society (INS)
 National Association of Vascular Access
Network (NAVAN)
 The Association of Practitioners in
Infection Control and Epidemiology, Inc.
(APIC)
 The CDC Hospital Infection Control
Practices Advisory Committee (HICPAC)

◦ New committee that meets annually
◦ Updates information for health care personnel
in IV therapy and hand hygiene procedures
Terms Related to Infection Process
Infection = process in which a host is
invaded by microbes that grow, reproduce,
and cause injury
 Pathology = a substance capable of
producing disease
 Disease = usually a result of infection
 Colonize = if disease doesn’t occur, the
invading microbes could colonize (or
reside in) the host, and the host becomes
a carrier of the organism without clinical
signs or symptoms


Terms (cont’d)
Virulence = the microorganism’s strength
and ability to produce disease; the
occurrence of infection depends the
virulence of the microorganism and the
ability of the host to defend itself against
the invader; factors that affect the virulence
of the microbe include:
◦ The ability to adhere to and/or penetrate skin
and mucus membranes
◦ The ability to adhere to and/or proliferate on
inanimate objects
◦ Ability to exude toxic substances
◦ Ability to resist phagocytosis
◦ Ability to mutate and multiply within the host
◦ Ability to grow and multiply in the presence of
antibiotics and other medications
Epidemiologic Triangle
Host
Living organism that
allows the
microorganism to live
Interacting conditions,
surroundings, and/or
influences in which the
host and agent co-exist
Agent
Environment
The microorganism that
is capable of disease
The Chain of Infection
For an infection to occur, the 3
components of the epidemiologic triangle
must be present
 An interacting chain of events must occur
before infection will be transmitted
 There are 6 links of the infection chain:

1.
2.
3.
4.
5.
6.
A causative agent
Its reservoir
Its portal of exit
A method of transmission
A portal of entry
A susceptible host
The Chain of Infection (cont’d)
The causative agent is the microorganism
present in the environment
 The reservoir is the source of infection

◦ Human individuals or groups
◦ Environmental fomites or contaminants (i.e.
food, water, soil, air)
◦ Animals (i.e. ticks, fleas, mosquitos, bats)

The portal of exit is the site where a
pathogen leaves the reservoir
◦
◦
◦
◦
Gastrointestinal
Respiratory
Blood
Urinary
The Chain of Infection (cont’d)

The mode of transmission is the
mechanism of transfer for the agent
◦ Contact transmission (direct, indirect contact)
◦ Airborne or droplet
◦ Vector (flies, mosquitos)
The portal of entry is the location by which
the agent enters; the agent gains entry by
permeating the first level of defense (i.e.
skin, mucus membranes)
 The susceptible host has little resistance
to the invader and is capable of
supporting growth

Normal Flora
Normal flora is the mixture of organisms found at
any anatomical site at any given time
 Complex mixture (>200 species of bacteria)
 The make-up of normal flora depends on
genetics, age, sex, stress, nutrition, diet, etc
 The nature of associations between humans and
their normal flora is thought to be mutualistic
(beneficial to each other)

◦ Humans benefit normal flora by supplying nutrients, a
stable environment, constant temperature, protection,
and transport
◦ Normal flora benefits humans by stimulating the
immune system and keeping potential pathogens away
through colonization, competing for nutrients, and
contributing to a low (acidic) pH
Normal Flora (cont’d)

Normal flora has tissue tropism, or tissue
preference
◦ Certain bacteria may be found at one location
on/in the body, but not another
◦ This may be due to the presence of an
essential growth factor needed by the bacteria

Density and composition of normal flora
depend on location
◦ High moisture content of the axilla, groin, and
areas between the toes have higher counts of
normal flora than other skin sites; bacteria on
the skin surface near any body orifice may be
similar to the bacterial count within that orifice
Normal Flora (cont’d)

The majority of skin organisms are found
in the superficial layer of epidermis and
upper parts of hair follicles
◦ Staphylococcus epidermidis
 Remains benign until conditions arise that allow it to
cause disease
 Especially life-threatening in hospital patients with
any type of catheter
 This bacteria can form antibiotic-resistant biofilms
along the catheter and enter the bloodstream
causing systemic infection
 Can be fatal
 Catheters that prevent biofilm are in production
◦ Corynebacteria
Normal Flora (cont’d)

Throat organisms
◦ Corynebacterium diphtheriae

Urogenital epithelium
◦ Neisseria gonorrhoeae

Surfaces of the tongue and teeth
◦ Streptococcus mutans
◦ Streptococcus salivarius

Epithelium of the small intestine
◦ Vibrio cholerae
◦ Escherichia coli (E. coli)

Nasal membranes
◦ Staphylococcus aureus
Normal Flora (cont’d)

Respiratory tract
◦
◦
◦
◦
Nares are always heavily colonized
Staphylococcus epidermidis
Corynebacteria
Staphylococcus aureus
 The nares are the main carrier site for this pathogen
 Can be found on the face and hands of individuals
that are nasal carriers
 Pathogenic
 A major cause of surgical wound and systemic
infection
 Often resistant to antibiotics; this type of S. aureus
can be fatal for the aged individual, burn and trauma
patients, and the immunocompromised
Normal Flora (cont’d)

Methicillin-resistant staphylococcus
aureus
◦ Has become resistant to most antibiotics,
including methicillin and vancomycin
◦ Often carried in the nares of health care
workers, and transmitted from patient to
patient
◦ Has been found to survive on nurses’ hands for
up to 3 hours
◦ Can result in skin and wound infection,
septicemia, endocarditis, and pneumonia
◦ Why some people are carriers while others are
not remains unknown
◦ Prevent spread through effective handwashing
Nosocomial Infections
Develop in individuals during hospitalization
 Preventable
 Three main influences include:

◦ Overuse of antibiotics
◦ Failure to follow basic infection control practices
◦ Increase in immunocompromised patients
200,000 nosocomial infections occur each year
 Most are related to the use of IV therapy
 Rates are highest in the ICU
 Hand hygiene is most important in preventing
the spread of dangerous microbes; gloves do not
replace adequate hand hygiene; long natural
and artificial nails harbor significant bacteria

Factors that could weaken the host and
allow the infection process:
Age
 Integrity of the mucus membrane
 Body weight
 Body system function
 State of nutrition and hydration
 Mental outlook
 Coexisting disease process
 Social and psychological health
 Ability to adapt to the external environment
 Stress
 Immune incompetence
 Length and amount of exposure to microbes
 Medications (antibiotics, chemotherapy)
 Skin integrity
 Equipment (indwelling catheter, IV line)

Who is at risk for infection?

Diabetes
◦ Foot and lower leg ulcers
◦ Candida infections (vulvovaginal or thrush)
◦ UTI (more common and more severe)

Alcoholism
◦ Decreased effectiveness of neutrophils, impaired
neuro function, and organ damage
◦ Pneumonia more likely than in general population
◦ Bacterial peritonitis (co-occurs with ascites)

Injected drug use
◦
◦
◦
◦
◦
Unsterile techniques
Bacterial endocarditis on tricuspid valve
Superficial skin infections
Tetanus
Transmission via needle-sharing (hepatitis, HIV)
Infection risk (cont’d)

Internal prosthesis
◦ Potential for infection at site of insertion
◦ Immune response to foreign material
◦ Inoculation at time of insertion (sepsis may occur years
after insertion)

Indwelling catheter
◦ Provides communication between external
environment and sterile internal environment
◦ The two major factors that determine the likelihood of
catheter-related infections are duration of
catheterization and degree of cleanliness maintained
during catheterization

Neurologic deficits
◦ Predisposes individual to infection
◦ Loss of gag reflex can lead to aspiration of gastric or
oral secretion (pneumonia)
◦ Diabetic neuropathy
◦ Long-term catheterization with neurogenic bladder
Infection risk (cont’d)

Granulocytopenia
◦ Absence of adequate number of circulating
neutrophils
◦ Hematologic malignancy
◦ One becomes infected with one’s own normal flora
◦ Causes fever

Immunosuppressive agents
◦ Used to prevent rejection of transplanted organ or
tissue
◦ Used to control autoimmune disorders
◦ Steroids
◦ Injectable tumor necrosis factor (TNF)
◦ Inhibiting drugs (rheumatoid arthritis, inflammatory
bowel disease)

Occupational exposure
◦ Legionnaire’s Disease (form of pneumonia from the
spread of water droplets through an air-conditioning
system)
Infection risk (cont’d)

Age
◦ Diminished immune response in the elderly
◦ Nosocomial infection from residence in
hospital/nursing home
◦ Various tube insertions
◦ Failure to follow infection control procedures
◦ Environmental factors

IV therapy
◦ Most common invasive procedure
◦ At least 90% of hospitalized patients require IV
◦ CDC reports lower infection rate in peripheral than
central venous lines
◦ Tunneled central catheters have lower infection rate
than non-tunneled catheters
Lines of defense for the prevention
of infection:
First line of defense –
 Skin and mucus membranes
◦ Act as protective coating
◦ Secrete substances to inhibit the growth of
microbes
◦ Sweat glands secrete lysozyme, which is an
antimicrobial enzyme
◦ Sebaceous glands secrete sebum, which has
antimicrobial and antifungal properties
◦ Acidic secretions of the skin inhibit the growth
of microbes
Lines of defense (cont’d)

Skin and mucus membranes
◦ Colonized with normal flora, which prevents the
entrance of pathogens
Second line of defense –
 Phagocytosis
◦ Leukocytes have the ability to ingest bacteria;
measurement indicates severity of infection
◦ Neutrophils fight bacteria; first responders;
release lysozyme that destroys bacteria;
phagocytosis

Complement system
◦ 17 different proteins that attach to the
infectious agent and promote ingestion by the
phagocyte
Stages of the Infection Process

Incubation Stage
◦ Presence and reproduction of pathogen
◦ Host remains asymptomatic
◦ This stage could last hours to years

Prodromal Stage
◦ Initial symptoms appear, which are usually mild
◦ Symptoms may be nonspecific

Acute Stage
◦ Presence of pronounced symptoms
◦ Results from toxic by-products of the metabolic
processes of microbes and from tissue damage
caused by the inflammatory process
Stages of Infection (cont’d)

Convalescent Stage
◦ Diminished symptoms
◦ Infection is contained

Resolution Stage
◦ Elimination of the pathogen
Classification of Infection

Local infection
◦ Microbes penetrate tissues at a specific area of
the body
◦ Microbes grow, multiply, exert effects within
that specific area
◦ Microbes do not migrate to other areas of the
body
◦ A localized infection can become systemic if
conditions are right in the host
Classification of Infection (cont’d)

Systemic infection
◦ Microbes travel freely and exert effects on
several, or all, body systems

Sepsis
◦ Describes a pathologic condition that results
from the spread of microbes or their toxins
through the circulatory and/or lymphatic
system
◦ This is the leading cause of death in the ICU
◦ 65 – 70% of sepsis is caused by gram negative
E. Coli (diarrhea, UTI, pneumonia),
pseudomonas (pneumonia, bacteremia),
klebsiella (pneumonia, UTI, bronchitis)
◦ Sepsis is on the rise since more pathogens are
becoming antibiotic resistant
Updated CDC Guidelines for
Preventing Infusion Device-Related
Infections
-- Major Recommendations -
Prepping the skin
◦ Use 2% chlorhexidine, which is more effective
in lowering catheter-related bloodstream
infection rates than 10% povidone-iodine and
70% isopropyl alcohol
◦ Chlorhexidine persists on the skin longer, which
is important because it kills organisms that
could repopulate the insertion site from deeper
skin layers
Major Recommendations (cont’d)

Prepping the skin
◦ The CDC recommends “back and forth” scrub
rather than outwardly radiating concentric
circles
◦ Allow solution to dry
◦ It has not been determined if chlorhexidine
should be used on infants less than 2 months
of age

Routine central venous catheter
replacement has now been changed to
dwell time as long as needed, (remove
immediately when no longer needed)
Major Recommendations (cont’d)
Peripheral IV site recommended for only
72 to 96 hours to prevent phlebitis
 Maintain peripheral IV in place in pediatric
patients as long as needed

◦ Ensure site is free from complications
◦ If catheter was placed in an emergency
situation, replace within 48 hours
Follow hand antisepsis protocols (i.e.
handwashing and alcohol-based hand
rubs)
 Use aseptic technique
 Wear clean gloves

Major Recommendations (cont’d)

For central line insertions, use maximum
sterile barrier technique (i.e. cap, mask,
sterile gown, sterile gloves, large sterile
drapes)
◦ This also applies to peripherally inserted
central lines
◦ Facilities must comply with these
recommendations by having the necessary
equipment available

Change short-term central catheter
dressings every 48 hours or every 7 days
depending on the dressing
Major Recommendations (cont’d)

The CDC does not recommend transparent
dressing over tape-and-gauze dressing, but
gauze does not allow access to viewing
insertion site
◦ Gauze is adequate for a site that is bleeding
(i.e. the first day or so after insertion)
◦ If using a transparent dressing, visually inspect
IV site
◦ If using a gauze dressing, palpate to assess for
pain or tenderness to site
◦ Remove dressing if any symptoms of infection
occur in order to inspect directly
◦ Educate patient to inform the nurse of any
discomfort or changes at the IV site
Major Recommendations (cont’d)
Replace a gauze dressing every 48 hours
and a transparent dressing every 7 days
(except in pediatric patients in which the
risk of dislodging the catheter outweighs
the benefits of changing the dressing)
 Change either dressing if it becomes
contaminated, damp, or nonadherent
 It is not recommended to routinely use
antimicrobial ointment to the insertion
site, as this promotes fungal infections and
antimicrobial resistance

Major Recommendations (cont’d)
The Infusion Nurses Society recommends
use of sterile wound closure strips under a
dressing if needed to secure the catheter;
the sterile strips are to be changed along
with dressing changes
 The IV tubing is to be routinely changed no
more than every 72 hours, including the
piggyback, or secondary, tubing that
remains attached to the primary tubing
continuously

◦ Exceptions include 24-hour use of tubing for
blood, blood products, lipids, and TPN
Major Recommendations (cont’d)
Add-on adaptors used with needleless
systems should be changed as frequently
the tubing
 Stopcocks have a high contamination rate
(50%), so closed, modified stopcocks and
piggyback connections should be used
instead
 Use of central catheters coated or
impregnated with antimicrobial/aseptic
agents is not recommended due to
increased cost and risk for antimicrobial
resistance

Major Recommendations (cont’d)
Coated central catheters can be used if
chlorhexidine site preparation results in
infection and catheter will remain in place
longer than 5 days
 Only remove central catheters when they
are no longer needed; don’t replace them
for the sole purpose of reducing the
incidence of infection
 Intravascular catheter infections may be
localized or systemic

Major Recommendations (cont’d)
The CDC defines localized infection as the
significant growth of a microorganism
from the catheter tip, subcutaneous
segment of the catheter or catheter hub
 The CDC defines systemic infection as per
the above definition, in addition to growth
from a peripheral blood culture (in other
words, a mild local infection to the IV site
could progress to full-blown systemic
bacteremia)
 The CDC does not recommend taking
routine cultures of catheter tips

Major Recommendations (cont’d)

Watch for localized and systemic signs and
symptoms associated with catheter-related
infection
◦
◦
◦
◦
Redness, swelling, and tenderness at insert site
Cellulitis and purulent drainage
Altered mental status
Diaphoresis, fatigue, muscle aches, weakness,
fever, and chills
◦ Glucose intolerance
◦ Abdominal pain, nausea and vomiting, and
diarrhea
◦ Hypotension, tachycardia, and hyperventilation
Major Recommendations (cont’d)

Resistant pathogens that can cause
catheter-related bloodstream infections
include
◦ Coagulase-negative staphylococcus
◦ Enterococcus
◦ Staphylococcus aureau
These are commonly resistant to multiple
antibiotics, which makes treatment difficult
 Catheter-related infections occur by
contamination of device by skin flora on
insertion (i.e. migration down the cannula
tract from the skin) or contamination of the
hub during manipulation

Major Recommendations (cont’d)
Use clean gloves to insert a peripheral
catheter; do not touch access site after skin
prep has been applied
 Wash hands with antiseptic soap and
water, or an alcohol-based gel or foam
 Observe hand hygiene before and after
palpating catheter insertion sites; before
and after inserting an IV; and before and
after replacing, accessing, repairing, or
dressing an IV site
 When inserting a peripheral catheter, use a
“no touch” procedure, wear gloves that fit,
do not repalpate after prepping, and do not
touch the prepped area with nonsterile
gloves to stabilize the vein


Occupational HIV Exposure
Preventing exposures to blood and body
fluids is the primary means of preventing
occupationally acquired human
immunodeficiency virus (HIV) infection
◦ Universal precautions
◦ Handwashing
◦ Proper use of safety equipment


Follow institutional policy/procedures
Recommendations for post-exposure
prophylaxis (PEP) include urgent medical
treatment to ensure timely initiation
◦ Prompt reporting of exposure
◦ 4-week regimen of two antiretroviral
medications to prevent seroconversion of HIV
infection in health care workers
◦ Counseling
IV Calculation
Introduction to IV Calculation
IV’s are fluids, sometimes infused with
medications, blood, nutrients, electrolytes, etc.
 The fluids are generally normal saline (NS), or
salt water, and dextrose water (DW), or sugar
water
 The IV flow rate is the speed at which the IV
fluid infuses into the body

◦ Often measured in drops per minute (abbreviated
“gtt/min”)

Factors affecting the flow rate include:
◦ The amount of fluid to be infused
◦ The time over which it is to be infused
◦ The size of the tubing
IV Calculation (cont’d)
The number of drops required to deliver 1 ml
of fluid varies with the type of IV
administration set (tubing) used; the size of
the tubing is called the drop factor
 There are 2 types of IV administration sets:

◦ Macrodrip = 10, 15, or 20 gtt/ml
◦ Microdrip = 60 gtt/ml
In calculating the flow rate, ratio/proportion
cannot be used because there are more than
two components to calculate
 The dosage calculation formula cannot be
used because a dosage is not being calculated
 When calculating the flow rate, all rates should
be rounded to the nearest whole number

IV Flow Rate Formula
volume of infusion (in mL) x drop factor
time of infusion (in minutes)
= Flow rate
(in gtt/min)
• Note that time must be converted to minutes, and that
the drop factor is in gtt/mL
IV Calculation Examples
Administer D5 ½ NS at 30 mL/h. The drop factor
is a microdrip.
30mL x 60gtt/mL = 30gtt/min
60min
An IV medication in 60 mL of 0.9% NS is to be
administered in 45 minutes. The drop factor is a
microdrip.
60mL x 60gtt/mL = 80gtt/min
45min
Examples (cont’d)
Administer 3,000 mL D5 ½ NS in 24 hours. The
drop factor is 10 gtt/mL.
3000mL x 10gtt/mL = 21gtt/min
1440min
Administer Lactated Ringer’s at 125 ml/h. The
drop factor is 15 gtt/mL.
125mL x 15gtt/mL = 31gtt/min
60min
Examples (cont’d)
1,000 mL of Lactated Ringer’s solution is to infuse
in 16 hours. The drop factor is 15 gtt/mL.
1000mL x 15gtt/mL = 16gtt/min
960min
Infuse 2,000 mL D5W in 12 hours. The drop factor
is 15 gtt/mL.
2000mL x 15gtt/mL = 42gtt/min
720min
Electronic Flow Rate
When using an electronic infusion device (IV
pump), the flow rate is calculated in milliliters
per hour (mL/h)
 To find mL/h, you must divide the total
milliliters by the total hours
 You would then round your final answer to the
nearest whole
 Examples -
◦ 1000 mL in 8 hours = 1000/8 = 125mL/h
◦ 500 mL in 24 hours = 500/24 = 21mL/h

If an order is given without total milliliters, this
becomes a dose calculation; you would use
ratio-proportion, dimensional analysis, or the
Formula
Recalculating the Flow Rate
Sometimes the IV infusion rate changes due to
a change in the patient’s position
 If you notice that the flow rate needs to be
adjusted, assess the client and determine the
percentage of change needed to correct the
infusion
 Please note that you can adjust the infusion
flow rate by no more than 25% without
consulting the physician or practitioner
 In order to determine the percentage of
increase or decrease of the flow rate:

◦ Determine the actual change in the flow rate
◦ Divide by the original flow rate
◦ Multiply by 100
Examples of IV Recalculation
Original infusion order : 1000mL D5W IV to infuse
over the next 10 hours.
Infusion start time: 1300 hours. Drop factor = 10.
Hourly rate = 100mL/h. Flow rate = 17gtt/min.
At 1430 hours, the infusate level is at 900mL.
150mL should have already infused, leaving
850mL remaining to infuse over the next 8 ½
hours.
The IV would be recalculated as follows:
900mL = 106mL/h – 100mL/h = 6mL/h
8.5h
6mL/h = 0.06 x 100 = 6% increase
100mL/h
Recalculation Examples (cont’d)
Original infusion order : 1000mL D5W IV to infuse
over the next 8 hours.
Infusion start time: 0900 hours. Drop factor = 15.
Hourly rate = 125mL/h. Flow rate = 31gtt/min.
At 1200 hours, the infusate level is at 850mL.
375mL should have already infused, leaving
625mL remaining to infuse over the next 5 hours.
The IV would be recalculated as follows:
850mL = 170mL/h – 125mL/h = 45mL/h
5h
45mL/h = 0.36 x 100 = 36% increase
125mL/h
Titrating Medications
Titrating means to adjust the medication
until it brings about the desired effect
 Always start with the low end of “safe” and
increase dosage from there
 Follow institutional protocol for titrating
medications
 Titrated medications are calculated in the
same way as non-titrated drugs
 An example of a titration order would be:

◦ A client weighing 50 kg is to receive a
Dobutrex solution of 250 mg in 500 mL D5W
ordered to titrate between 2.5–5 mcg/kg/min
Titration Calculation Examples
In the previous order, the initial dose would be set
at the low end of safe. Therefore, the client will
receive 2.5mcg/kg/min of the ordered medication,
and will receive no more than 5mcg/kg/min.
The client’s weight is 50kg.
50 x 2.5 = 125mcg/min
safe range of drug
50 x 5 = 250mcg/min
Per IV pump, the client would receive the minimum
dosage of 7500mcg/h, or 7.5mg/h:
250mg = 500mL = 250 X mg/mL = 7.5mg(500mL)
7.5mg
X mL
X = 3750mg/mL = 15mL (initial dose is 15mL/h)
250mg
Heparin
Heparin is an anticoagulant for the
prevention of clot formation; ensure
correct calculation to avoid complications
 Heparin is measured in USP units
 IV Heparin is often ordered in units per
hour (units/h), and should be administered
per IV infusion device
 Heparin infusions would be calculated like
other medications via IV pump, in
milliliters per hour (mL/h)
 The normal adult dosage of Heparin is
20,000 – 40,000 U every 24 hours
