NURSING MANAGEMENT
OF A PATIENT RECEIVING
INTRAVENOUS THERAPY
Loreiyne Grace Aballe, RN
Ophelia Mae Odtojan, RN
OBJECTIVES: AT THE END OF THIS LECTURE, YOU WILL BE ABLE TO:
◦ DESCRIBE INTRAVENOUS THERAPY
◦ UDERSTAND THE FACTORS AND CONSIDERATIONS IN
CHOOSING AN IV SITE
◦ ENUMERATE THE STEPS IN PREPARING INTRAVENOUS
THERAPY
◦ KNOW HOW TO REGULATE THE INTRAVENOUS FLUID
AT DESIRED RATE
◦ IDENTIFY SYSTEMIC AND LOCAL COMPLICATIONS
◦ ENUMERATE THE PROCEDURE IN DISCONTINUING
INTRAVENOUS THERAPY
◦ LEARN THE PROPER DOCUMENTATION OF
INTRAVENOUS THERAPY.
INTRAVENOUS
THERAPY
A VENIPUNCTURE (AN EXPECTED NURSING SKILL)
TO GAIN ACCESS TO THE VENOUS SYSTEM FOR
ADMINISTERING FLUIDS AND MEDICATION
PREPARING TO
ADMINISTER IV
THERAPY
◦ NURSES MUST:
◦ Check doctor's order (ex. Start
venoclysis of D5LR 1L at 120mL per
hour)
◦ Perform hand hygiene
◦ Apply gloves
◦ Informs patient of procedure
CHOOSING AN
INTRAVENOUS SITE
◦ Peripheral sites
◦ mostly arm veins like
metacarpal, cephalic, basilic,
and median veins) are
ordinarily used and are the safe
and easy sites
◦ Legs are used rarely because of
the high risk of
thromboembolism
VEIN FEELS FIRM,
ELASTIC, ENGORGED,
AND ROUND NOT HARD,
FLAT OR BUMPY
SITES TO BE AVOIDED
◦ Veins distal to a previous IV infiltration or phlebitic area
◦ sclerosed or thrombosed veins
◦ Arm with arteriovenous shunt or fistula
◦ Arm affected by edema, infection, blood clot, deformity, severe
scarring or skin breakdown
◦ Arm on the side of mastectomy (impaired lymphatic flow)
* antecubital fossa is avoided, except last resort (most distal first
for subsequent IV access progressively upward)
FACTORS TO CONSIDER IN CHOOSING A SITE
Condition of the
vein
Type of fluid or
medication to be
infused
Whether the
patient is lefthanded or righthanded
Duration of the
therapy
Patient's
medical history
and current
health status
Patient's age and
size
Skill of the
person
performing the
venipuncture
GENRAL GUIDELINES
FOR SELECTING A
CANNULA
◦ LENGTH: 0.75 to 1.25 inches long
◦ DIAMETER: narrow diameter of the cannula to
occupy minimal space within the vein
◦ Should not rest in a flexion area
◦ GAUGE:
◦ 20-22 gauge for most IV fluids; a larger caustic or
viscous solution
◦ 14 to 18 gauge for blood administration and for
trauma patients and those undergoing surgery
◦ 22 to 24 gauge for elderly patients
TEACHING THE
PATIENT
◦ EXCEPT IN EMERGENCY
SITUATIONS, patient should be
prepared for IV infusion
◦ Things to educate:
◦ Venipuncture
◦ Expected length of infusion
◦ Activity restrictions
PREPARING THE
INTRAVENOUS
SITE
◦ Nurse should ask the patient for allergies to
latex or iodine.
◦ Excessive hair at selected site may be
removed by clipping if necessary
(facilitates insertion and adherence
of dressings)
◦ IV set should be remained sterile
◦ Perform hand hygiene
◦ Put on gloves during venipuncture
IV SET
STARTING INTRAVENOUS INFUSION
1. CHECK IV SOLUTION AND MEDICATION ADDITIVES WITH THE
PHYSICIAN'S ORDER.
(Ensures the client receives the correct IV solution and medication)
2. WASH HANDS
(Prevents spread of microorganism)
3. GATHER EQUIPMENT AND PREPARE IV
SOLUTION AND TUBING
a. Maintain aseptic technique when opening sterile packages and IV solution .
(prevents contamination of IV solution and set which can infect the patient rapidly)
b. Clamp tubing, uncap the spike and insert into the entry site.
(Puncture the seal in the IV bag or bottle)
c. Squeeze the drip chamber and allow it to fill at least halfway.
(suction effect causes fluids to move into the drip chamber and also prevents air from
moving down the tubing)
d. Remove the cap at the end of the tubing, release the clamp and allow the fluid to
move through the tubing (this is termed as priming the tubing). Allow fluid to flow
until all air bubbles have disappeared. Close the clamp recap the end of the
tubing, maintaining the sterility of the setup.
(removes air from the tubing which in large amounts, act as an air embolus)
4. Identify and explain the procedure to the patient.
(allays anxiety)
5. Have the patient in a supine or low Fowler's position in bed
(supine position permits either arm to be used and allows good body alignment. Low
fowler's position is usually the most comfortable for the patient)
6. Suspend the bag or bottle of solution in the IV stand.
(fluid height should be 18-24 inches above the level of the vein. This height is sufficient
to overcome venous pressure)
7. Assist physician or nurse with the procedure.
8. Adjust the rate of flow according to the doctor's order.
(Provides appropriate IV therapy as ordered)
9. Complete the label and tape to the IVF bag,
(facilitates assessment and safe discontinuation)
10. Do after care.
(deters spread of microorganism)
11. Document date and time of therapy; type and amount of solution; additives and
dosages; flow rate; gauge; length and type of vascular access device;
Catheter insertion site; type of dressing applied; patient response to procedure;
patient teaching
(promotes continuity of care)
REGULATING INTRAVENOUS
FLOW RATE
BEFORE THE INFUSION OF
IV SOLUTION IS BEGUN,
THE NURSE SHOULD
MATHEMATICALLY
CONVERT THE RATE OF
INFUSION BY THE
PHYSICIAN INTO
COMPARABLE DROPS PER
MINUTE.
Note:
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PURPOSES OF REGULATION of IV
FLOW RATE:
✓
✓
✓
✓
To comply with prescribed rate
ordered by the physician.
To maintain an equal and constant
rate of fluid administration
throughout the duration of the
infusion.
To assist in reassessing the progress
of fluid infusion
To prevent circulatory overload or
insufficient correction of
hypovolemia.
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Nursing
Considerations:
1. Read the current written medical
order for the volume and number of
hours of infusion.
2. Determine the manufacturer’s drop
factor and the ratio of drops per milliliter.
EQUIPMENTS NEEDED!
✓
Jot down notebook and ballpen
✓ Wrist Watch with a second hand
✓ Strip of tape as marker or to be
used as time strip if necessary.
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PROCEDURE:
◂
◂
◂
1. Check the physician’s order
2. Check the patency of the IV line and needle
3. Verify the drop factor ( number of drops in 1ml.) of the
equipment in use.
NOTE: Equipment labeled as MICRO DROP or MINI DROP is standard and delivers 60
mgtts/ml but MACRO Drop delivery system vary.
SOME MANUFACTURER are the following:
✓
Travenol Macro drop = 10gtts/min
✓
Abbott Macro drop = 15 gtts/min
✓
McGraw Macro drop= 15 gtts/min
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1
CONT.
4. Calculate the flow rate using the standard formula:
RATE =
VOLUME ( CC) X GTT FACTOR (CC)
DURATION (HRS.) X 60 MIN/HR –
◂
Example:
How many hours would 500 cc
D5IMB last if the rate is 30
mgtts/min?
DURATION= 500CC X 60mgtts/cc
30 mgtts/min x 60
min./hr
= 16.7 hours
constant
DURATION =
VOLUME (CC) X GTT FACTOR (CC)
Rate (gtt/min) x 60 min/hr. - constant
2
2
Cont.
◂
◂
◂
5. Count the drops per minute in the
drip chamber. Hold the watch beside
the chamber.
6. Adjust the IV clamp as needed and
recount the drops per minute if
necessary
7. Monitor the IV flow rate at frequent
intervals. Document the client’s
response to the infusion at the
prescribe rate.
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COMPLICATIONS
OF INTRAVENOUS
ADMINISTRATION
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MANAGING
SYSTEMIC
COMPLICATIONS
Overloading the circulatory
system with excessive IV
fluids causes increased blood
pressure and central venous
pressure
Pyogenic substances in either
the infusion solution or the
IV administration set can
cause bloodstream infections
In severe sepsis, vascular
collapse and septic shock
may occur.
- s/sx
- Moist
Crackles
- -cough
-restlessness
-edemaweight gain
-dyspnea
FLUID
OVERLOAD
AIR
EMBOLISM
SIGNS AND
SYMPTOMS:
- ABRUPT
TEMPERATURE
ELEVATION
- TACHYCARDIA
- BACKACHE
- DIARRHEA
- CHILLS
- GENERALIZE
MALAISE
INFECTION
PREVENTION
:
Air entering into central veins
gets to the right ventricle, where
it lodges against the pulmonary
valve and blocks the flow of
blood from the ventricle into the
pulmonary arteries.
SIGNS AND
SYMPTOMS:
- PALPITATIONS
- - DYSPNEA
- JUGULAR VEIN
DISTENTION
- -CYANOSIS
- CHEST,
SHOULDER AND
LOWER BACK PAIN
-Performing careful hand hygiene before every contact with any part of
the infusion system or the patient
- Examining the IV containers for cracks, leaks, or cloudiness, which
may indicate a contaminated solution
- Using strict aseptic technique Firmly anchoring the IV cannula to
prevent to-and-fro motion (e.g., a catheter stabilization device will
help).
Sutureless securement devices avoid disruption around the
catheter entry site and may decrease the degree of bacterial
contamination
- Inspecting the IV site daily and replacing a soiled or wet dressing
with a dry sterile dressing (antimicrobial agents that should be used
for site care include 2% tincture of iodine, 10% povidone–iodine,
alcohol, or chlorhexidine gluconate, used alone or in combination)
- Disinfecting injection/access ports with antimicrobial solution before
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and after each use
- Removing the IV cannula at the first sign of local inflammation,
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contamination, or complication Replacing the peripheral IV cannula
according to agency policy and procedure
LOCAL
COMPLICATIONS
Infiltration and
Extravasation
Infiltration is the unintentional
administration of a
nonvesicant solution or
medication into surrounding
tissue. This can occur when the
IV cannula dislodges or
perforates the wall of the vein.
- s/sx
Edema around
the insertion site
- Leakage of IV
fluid from site
- Discomfort
- Decrease flow
rate
-
Thrombophlebitis refers to
the presence of a clot plus
inflammation in the vein.
Phlebitis
-
SIGNS AND
SYMPTOMS:
-Localized pain
-Redness
-Warmth
Sluggish flow rate
- Fever
- Malaise
- Leukocytosis
Thrombophlebitis
Phlebitis, or inflammation of a
vein, can be categorized as
chemical, mechanical, or
bacterial
SIGNS AND
SYMPTOMS:
-Redness
Warm at the area
Pain and tenderness at
site
Swelling
Clotting and
Hematoma:
SIGNS AND
SYMPTOMS:
-Ecchymosis
-Leakage of
Blood at
insertion site
-decrease flow
rate
-blood back
flow in IV
tubing
Blood clots may form in the IV line as a
result of kinked IV tubing, a very slow
infusion rate, an empty IV bag, or failure
to flush the IV line after intermittent
medication or solution administrations.
Hematoma results when blood leaks into
tissues surrounding the IV insertion site.
Leakage can result if the opposite vein
wall is perforated during venipuncture,
the needle slips out of the vein, a cannula
is too large for the vessel, or insufficient
2after
pressure is applied to the site
removal of the needle or cannula
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INFILTRATION AND EXTRAVASATION MANAGEMENT
✓
✓
✓
✓
✓
✓
-Infusion should be stopped
IV catheter should be discontinued
A sterile dressing applied to the site after
careful inspection to determine the extent
of infiltration.
IV infusion should be started in a new site
or proximal to the infiltration site if the
same extremity must be used again
A warm compress can be applied if the
solution was isotonic with a normal pH
A cold compress may be applied If the
infiltration is recent and the solution was
912 hypertonic or had an increased pH
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PHLEBITIS
MANAGEMENT:
Discontinuing the IV line and restarting it in
another site
❖
Applying a warm, moist compress to the
affected site
PREVENTION:
❖
Using aseptic technique during insertion
❖
Using the appropriate-size cannula
❖
Considering the composition of fluids and
medications when selecting a site
❖
Observing the site hourly for any
complications
❖
Anchoring the cannula or needle well
❖
Changing the IV site according to agency
policy and procedures
❖
ASSESSING FOR
PHLEBITIS
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PHLEBITIS
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THROMBOPHLEBITIS MANAGEMENT:
Discontinuing the IV infusion
➢
Applying a cold compress first to
decrease the flow of blood and
increase platelet aggregation
➢
Followed by a warm compress
➢
Elevating the extremity
➢
Restarting the line in the opposite
extremity
➢
IV line should not be flushed
NOTE: If purulent drainage exists, the
site is cultured before the skin is
cleaned.
➢
PREVENTION!!
• avoiding trauma to the vein at the
time the IV line is inserted
• observing the site every hour
• checking medication additives for
compatibility
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HEMATOMA AND CLOTTING MANAGEMENT:
◂
❑
❑
❑
❑
❑
❑
HEMATOMA:
Removing the needle or cannula
Applying light pressure with a
sterile, dry dressing
Applying ice for 24 hours to the site
to avoid extension of the hematoma
Elevating the extremity to maximize
venous return
Assessing the extremity for any
circulatory, neurologic, or motor
dysfunction
Restarting the line in the other
extremity if indicated
CLOTTING AND OBSTRUCTION:
✓ Infusion must be discontinued
✓ Restart in another site with a new
cannula and administration set
✓ The tubing should not be irrigated
or milked
✓ Clot should not be aspirated from
the tubing
✓ Not allowing the IV solution bag
to run dry
✓ Maintain patency
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POST- THERAPY PREPARATION:
Peripheral IV
cannulas and the
site are routinely
changed aseptically
and re-sited every
48-72 hours or
when necessary
In the days
that follow
the therapy,
check the
injection site
for bruising
or swelling.
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INDICATION FOR DISCONTINUING AN INTRAVENOUS
INFUSION
◂
◂
◂
1. The client’s oral fluid intake and
hydration status are satisfactory that
no further IV solutions are ordered.
2. There is a problem with infusion
that cannot be fixed/ complications
arise with the patency.
3. The medications administered by
IV route are no longer required.
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DISCONTINUING
IV INFUSION
1. Verify written doctor’s order to discontinue IV
including IV medicines
2.Observe 10 rights.
3. Assess and inform the patient for the
discontinuation of IV infusion and of any
medicine.
4. Prepare the necessary material ( IV TRAY,
STERILE COTTON BALL, ALCOHOL SWAB OR
PICK-UP FORCEPS IN ANTISEPTIC SOLUTION
PLASTER, KIDNEY BASIN/ WASTE
RECEPTACLE)
5. Wash hands before and after the procedure.
6. Close the roller clamp of the IV administration
set.
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5
Cont.
7. Moisten adhesive tapes around the IV catheter with
cotton ball with alcohol; remove the plaster gently.
8. Use pick-up forceps to get cotton ball with alcohol
and without applying pressure, remove needle or IV
catheter then immediately apply pressure over the
venipuncture site using the swab for 2-3 minutes.
* Hold the client’s arm/ leg above the body if bleeding
persists.
9. Inspect IV catheter for completeness
10. Apply the sterile dry cotton ball over the
venipuncture site
11. Discard all waste materials including IV cannula
according to Health Care Waste Management
12. Document the date and time of termination, status of
insertion site and integrity of IV catheter and endorse
accordingly.
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DOCUMENTATION:
NURSE’S NOTE
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IV FLOW SHEET
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INTAKE AND
OUTPUT SHEET
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VITAL SIGNS
SHEET:
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THANKS
Does anyone have any questions?
REFERENCES: Brunner & Suddarth's Textbook of
Medical-Surgical Nursing (14th ed.). Philadelphia:
Wolters Kluwer. Ignatavicius, D.D., Workman, M.L., &
Rebar, C.R. (2018).
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