418 IV-Therapy

INTRAVENOUS INFUSION
4= Competent 3= Very Good 2=Good 1= Needs Improvement

Purpose: To supply fluid when clients are unable to take in an adequate volume of 4 3 2 1
fluids by mouth. To replace fluid and electrolyte imbalance. To establish a lifeline
for rapidly needed medications.
ASSESSMENT
1 Vital signs (pulse, respiratory rate, and BP) for baseline data.
Allergy to latex (e.g., tourniquet), tape, or iodine.
Bleeding tendencies. Disease or injury to extremities
PLANNING
2 Due to the need for knowledge of anatomy and use of sterile technique, IV
infusion therapy is not assigned to AP.
Equipment includes: Infusion set, Sterile parenteral solution, IV pole torniquet, IV
cannula, clean/sterile gloves, transparent dressing, micropore tape, cotton with
alcohol, IV splints, Infusion pumps, sharp container.
IMPLEMENTATION:
3 Make sure that the client’s clothing or gown can be removed over the IV apparatus
if necessary.
PERFORMANCE:
4 Introduce self and verify the client’s identity using agency protocol.
5 Explain to the client what you are going to do, Venipuncture can cause discomfort
for a few seconds, but there should be no ongoing pain after insertion
6 Perform hand hygiene and observe other appropriate infection prevention
procedures
7 Assist the client to a comfortable position, either sitting or lying. Provide privacy
and expose only the limb to be used for insertion
8 Open and prepare the infusion set. Remove tubing from the package and straighten
it out. Close the clamp. Leave the ends of the tubing covered with the plastic caps
until the infusion is started. Rationale: This will maintain the sterility of the ends
of the tubing
19 Remove the protective cover and exposé the insertion site of the bag or bottle
10 Remove the cap from the spike and insert the spike into the insertion site of the
bag or bottle
11 Hang the solution container on the pole at 1 m (3 ft) above the client’s head.
Rationale: This height enable gravity to overcome venous pressure and facilitate
flow of the solution into the vein
12 Squeeze the chamber gently until it is half full of solution. Rationale: The drip
chamber is partially filled with solution to prevent air from moving down the
tubing.
13 Prime the tubing by releasing the clamp and let the fluid run through the
tubing until all bubbles are removed. Rationale: to prevent the introduction of air
into the client. Air bubbles smaller than 0.5 mL usually do not cause problems in
peripheral lines.
14 Perform hand hygiene again just prior to client contact.
15 Select the venipuncture site. Select a well-dilated vein. Use the client’s
nondominant arm, unless contraindicated
16 Place a towel or bed protector under the extremity to protect lines
17 Apply a tourniquet 15 to 20 cm (6 to 8 in.) above the venipuncture site. Rationale:
The tourniquet must be tight enough to obstruct venous flow but not so tight that it
occludes arterial flow
18 Using your index (& middle) palpate vein by pressing downward. Note for
resilient, soft and bouncy feeling while releasing pressure.
19 If area of insertion needs cleaning, use soap and water first then dry.
20 Use antiseptic swab or cotton applicator to clean insertion site using friction in a
horizontal plane (1st swab) and vertical plane (2nd swab) and in a circular motion
moving outward (3rd swab).
21 Perform venipuncture. Anchor vein by placing thumb over it and stretching against
direction of insertion 4 – 5 cm distal to site.
22 Insert catheter with bevel up at 10 – 30-degree angle slightly distal to actual site of
venipuncture in direction of vein
23 Observe for blood return in flashback chamber of catheter.
24 Lower the angle of the catheter until it is almost parallel with the skin, and
advance the needle (stylet) and catheter approximately 0.5 to 1 cm (about 1/4 in.)
farther into the vein
25 Holding the needle assembly steady, advance the catheter forward off the stylet
until the hub is at the venipuncture site.
26 Release the tourniquet. Put pressure on the vein proximal to the catheter to reduce
blood oozing out of the catheter.
27 Stabilize the catheter hub and apply pressure distal to the catheter with your finger.
Rationale: This prevents excessive blood flow through the catheter.
28 Carefully remove the stylet, engage the needle safety device if it does not engage
automatically. Place the stylet directly into a sharp’s container.
29 Attach distal end of IV tubing to IV catheter and begin infusion by slowly opening
roller clamp to regular rate (gravity flow).
30 Stabilize the catheter and apply a dressing. Sterile gauze dressing or transparent
dressing is used. Label the dressing with the date and time of insertion, gauge, and
your initials
31 Loop the tubing and secure it with tape. Rationale tubing prevent the weight of
the tubing or any movement from pulling on the needle or catheter
32 Discard the tourniquet. Remove and discard gloves. Perform hand hygiene
33 Ensure appropriate infusion flow. Apply a padded arm board to splint the joint if
needed. Adjust the infusion rate of flow according to the order
EVALUATION
34 Regularly check the client for intended and adverse effects of the infusion.
35 At least every 4 hours, check the skin status at IV site (warm temperature and
absence of pain, redness, or swelling),
36 After IV insertion, teach patient Any limitations as to movement or mobility and
protection of the site, Signs and symptoms to report to the nurse. Infection Control
prevention
DOCUMENTATION
TOTAL = 140
Name _________________________________________Score__________________________________________
Year and Section________________________________Clinical Instructor________________________________

Reference: Module 15: IV Therapy: Fundamentals of Nursing
Kozier and Erb’s Fundamentals of Nursing 11th Edition

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INTRAVENOUS INFUSION

4= Competent 3= Very Good 2=Good 1= Needs Improvement

Year and SectionClinical Instructor

Kozier and Erb’s Fundamentals of Nursing 11th Edition

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