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 • Infusion Pump
• 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
Selected IV Solutions
nurse to monitor the rate at which the solution
is entering the patient Isotonic Solution
• factors: height of the container, BP, patient’s 5% dextrose in water (D5W)
position, patency of the IV catheter, Supplies about 170 cal/L and contains 50 g of glucose
infiltration, knot or kink Should not be used in excessive volumes because it does
• check the infusion every hour or more not contain any sodium; thus the fluid dilutes the
frequently, if indicated amount of sodium in the serum. Brain swelling, or
hyponatremic encephalopathy, can develop rapidly and
• Calculate the flow rate:
cause death unless it is promptly recognized and treated.
EXAMPLE—Administer 1000 mL D5W over
0.9% NaCl (normal saline)
8 hours (set delivers 60 gtt/1 mL).
Not desirable as routine maintenance solution because it
provides only Na+ and Cl-, which are provided in
a. Standard formula excessive amounts.
gtt/min = volume (mL) x drop factor (gtt/mL) May be used to expand temporarily the extracellular
time (minutes) compartment if circulatory insufficiency is a problem;
also used to treat diabetic ketoacidosis.
gtt/min = ?
Lactated Ringer’s Solution
b. Short formula using milliliters per hour
A roughly isotonic solution that contains multiple
gtt/min = mL per hour x drop factor (gtt/mL)
electrolytes in about the same concentrations as found in
time (60 min) plasma (note that this solution is lacking in Mg2+ and
Find milliliters per hour by dividing 1000mL by 8 PO43-)
hours: 1000mL / 8 = 125 mL/hr Used in the treatment of hypovolemia, burns, and fluid
gtt/min = 125 mL/hr x 60 gtt/mL lost as bile or diarrhea
Useful in treating mild metabolic acidosis
60 min/hr
Hypotonic Solution
c. Dimensional Analysis
0.33% NaCl 1/3-strength saline)
gtt/min = gtt x mL x hr
A hypotonic solution that provides Na+, Cl-, and free
mL hr min
water Na+ and Cl- allows kidneys to select and retain
gtt/min = 60gtt x 1000mL x 1 hr needed amounts
1mL 8 hr 60 min Free water desirable as aid to kidneys in elimination of
gtt/min = 125gtt/min solutes
• Count drops per minute in drip chamber 0.45% NaCl ½-strength saline)
(number of gtt/15 sec interval x 4). Hold watch A hypotonic solution that provides Na+, Cl- and free
beside drip chamber. water
• Adjust IV clamp as needed and recount drops Often used to treat hypernatremia (because this solution
per minute contains a small amount of Na+, it dilutes the plasma
• Mark IV container according to agency policy sodium while not allowing it to drop too rapidly)
and manufacturer’s recommendations. Use a Hypertonic Solution
time tape or label if indicated to measure 5% dextrose in 0.45% NaCl
amount to be infused at timed intervals. A common hypertonic solution used to treat
• Monitor IV flow rate at frequent intervals. hypovolemia; used to maintain fluid intake
Document patient’s response to infusion at 10% dextrose in water (D10W)
prescribed rate.
Supplies 340 cal/L • usually introduced into the subclavian or
Used for peripheral parenteral nutrition (PPN) internal jugular vein and passed to the superior
5% dextrose in 0.9% NaCl (normal saline) vena cava just above the right atrium
Replaces nutrients and electrolytes • require radiographic confirmation of position
Can temporarily be used to treat hypovolemia if plasma Types of CVADS
expander is not available • Peripherally Inserted Central Catheters
Vascular Access Devices (PICCs)
• Factors • Nontunneled percutaneous central venous
• length of time the infusion therapy is needed catheters
• type of medication or product that will be • Tunneled central venous catheters
delivered intravenously • Implanted ports
• patient's health status and needs determine • PICCs
which option is used • >20 cm depending on patient size, that can be
• what will pose the least risk for IV introduced into a peripheral vein
complications – basilic, brachial, or cephalic veins
• Peripheral Venous Catheters • advanced as far as the superior vena cava
• Over-the-needle catheters - the most common • specially trained registered nurse or physician
type of peripheral vascular catheter used. can insert this type of catheter
• infusion therapy will be brief, a short (<3 • radiographic verification
inches) peripheral catheter
• single or multiple lumens
• insertion site should be rotated at least every
• PICCs
72 to 96 hours for an adult
• for long-term IV therapy, from 6 weeks to 6
• child - the site can remain in place until the IV
months
intervention is completed unless a
complication develops • normally replaced as needed
• (CVADs) are now an integral component of • less risk of complications because the catheter
patient care in acute, ambulatory, and subacute is inserted peripherally
care settings, as well as in the home and long- – infection
term care facilities. – pneumothorax
• provide access for a variety of IV fluids, • cost effective
medications, blood products, and TPN
• provide adequate hemodilution for medications
solutions
• Nontunneled Percutaneous Central Venous
• allow a means for hemodynamic monitoring
Catheters
and blood sampling
• have a shorter dwell time (3–10 days)
• CVAD
• introduced through the skin into the internal the upper chest wall, and no external parts of
jugular, subclavian, or femoral veins and the system are visible
sutured into place • placed in the antecubital area of the arm
• can have double, triple, or quadruple lumens (peripheral access system ports)
• >8 cm, depending on patient size • initially used for chemotherapy
• Nontunneled Percutaneous Central Venous • Implanted Port
Catheters • now used for any patient requiring long-term
• tip rests in the superior vena cava intermittent infusions
• may be inserted at the bedside or in outpatient • a special angled noncoring needle is inserted
settings through the skin and rubber septum and into
• associated with a high risk for complications , the port reservoir
accounting for most catheter-related • require minimal care, but the discomfort of
bloodstream infections accessing the port may be a disadvantage for
– infection some patients
– pneumothorax the catheter is placed • Implanted Port
Actions
1. Verify the IV order against the physician order.
Clarify any inconsistencies. Check the patient's chart
Suction causes fluid to move into the drip chamber and The use of an appropriate vein decreases discomfort for
prevents air from moving down the tubing. 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.
d. Remove the cap at end of the IV tubing and while Interrupting the blood flow to the heart causes the vein
maintaining its sterility, open the IV tubing clamp, and to distend. Distended veins are easy to see, palpate, and
allow fluid to move through tubing. Allow fluid to flow enter. The end of the tourniquet could contaminate the
until all air bubbles have disappeared and the entire area of injection if directed toward the site of entry.
length of the tubing is primed (filled) with IV The tourniquet may be applied too tightly, so
solution. Close the clamp and recap the end of tubing, assessment for the radial pulse is important.
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.
13. Instruct the patient to hold the arm lower than the
f. Apply the label if medication was added to container heart.
(pharmacy may have added medication and applied the
Lowering the arm below the heart level helps distend
label). Label the tubing with the date and time that
the veins by filling them.
tubing was hung.
14. Ask the patient to open and close the fist. Observe
This provides for administration of correct solution with
and palpate for a suitable vein. Try the following
prescribed medication or additive. Labeling the tubing
techniques if a vein cannot be felt:
alerts nursing staff of the need for IV tube changes.
Consult hospital policy. In general, IV tubing is changed Contracting the muscles of the forearm forces blood into
every 72 hours. the veins, thereby distending them further.
g. Place time-tape on the container and hang the IV on a. Massage the patient's arm from proximal to distal
the pole. end and gently tap over the intended vein.
This permits immediate evaluation of the IV according Massaging and tapping the vein help distend veins by
to the time-tape schedule. filling them with blood.
8. Place the patient in low Fowler's position in bed. b. Remove the tourniquet and place warm moist
Place protective towel or pad under the patient's arm. compresses over the intended vein for 10 to 15 minutes.
Close the door to the room or pull the bedside curtain. Warm moist compresses help dilate veins.
The supine position permits either arm to be used and 15. Put on clean gloves.
allows for good body alignment. Gloves protect against transmission of HIV, hepatitis,
Closing the door provides for patient privacy. and other blood-borne infections.
9. Provide emotional support as needed. 16. If using intradermal lidocaine, cleanse the insertion
The patient may experience anxiety because he/she may site with alcohol using a circular motion. Inject a small
fear needle stick or IV infusion in general. amount (0.2 to 0.3 mL) of lidocaine into the area. If
10. Select and palpate for an appropriate vein. Avoid numbing cream was used, wipe cream off the insertion
an arm that has been compromised, such as with the site. Cleanse the site with an antiseptic solution such
presence of arteriovenous fistula. 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 22. Secure the catheter with narrow nonallergenic tape
less painful. Cleansing that begins at the site of entry (½ inch) placed with the sticky side up under the hub
and moves outward in a circular motion carries and crossed over the top of the hub.
organisms away from the site of entry. Organisms on the The weight of the tubing is sufficient to pull it out of the
skin can be introduced into the tissues or the vein if it is not well anchored. Nonallergenic tape is less
bloodstream with the needle. Chlorhexidine is the likely to tear fragile skin.
preferred antiseptic solution but iodine, iodophor, and
23. Place sterile dressing over the venipuncture site.
70% alcohol are considered acceptable alternatives. If
Agency policy may direct nurse to use gauze dressing or
there is difficulty visualizing or palpating the intended
transparent dressing. Apply tape to dressing if
vein for IV insertion, a tourniquet may be left in place.
necessary. Loop the tubing near the site of entry, and
17. Use the nondominant hand, placed about 1 or 2 anchor to dressing.
inches below the entry site, to hold the skin taut against
Transparent dressing allows easy visualization. Gauze
the vein. Avoid touching the prepared site. Ask the
dressings are capable of absorbing drainage.
patient to remain still while the venipuncture is
performed. Securing the Catheter