Silliman University

College of Nursing
Dumaguete City
Level III – NCM 102

Submitted by:

Elissa Maryle P. Hucal

Kevin T. Katada

Submitted to:
Ms. Mary Nathalie Cata-al
 VISION
A leading Christian Institution committed to total human development for the wellbeing of society and
environment.

MISSION
Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ; provide an
environment where Christian fellowship and relationship can be nurtured and promoted.

Provide opportunities for growth and excellence in every dimension of the University life in order to
strengthened character, competence and faith.

Instill in all members in the University, community an enlightened social consciousness and a deep
sense of justice and compassion.

Promote unity among people and contribute to national development.

Topic Description: This topic deals on the review of IV therapy and its purposes in the care of hospitalized patients. It emphasizes on the nurse’s responsibility in
preventing complications and providing patient safety before, during and after the procedure.

Time Allotment: 1.5 to 2 Hours

Placement: Level III NCM 102 2nd Semester

Central Objective: At the end of two hours socialized discussion, the students shall acquire comprehensive knowledge, strengthen skills and manifest positive
attitude in maintaining safety and preventing complications during IV therapy.

Specific Objectives Content T.A. T-L Evaluation

Activities Methods
Within the 1.5-2 Hours
discussion, the student I. Introduction of IV therapy 5mins Interactive Oral
nurse shall: a. Definition discussion Evaluation
 Appreciate the Intravenous (IV) therapy is the administration of fluids or medication via a needle or a catheter and giving
importance of the IV (sometimes called a cannula) directly into the bloodstream. The practice of IV therapy is governed by state nurse of
therapy in the care of practice acts as statutory laws. Some states now include IV therapy within the licensed practical nurse (LPN) and
handouts.
patients. licensed vocational nurse (LVN) roles. The practice acts define the parameters within which individuals are
qualified and licensed to practice nursing in a particular state and serve to codify the nursing obligation to act in
the best interest in the society.

b. Goals
i. Maintain or replace body stores of water, electrolytes, vitamins, proteins, fats and
calories when a patient or client cannot maintain an adequate intake by mouth.
ii. Restore acid-base balance
iii. Restore volume of blood components
iv. Provide avenues for the administration of medication
v. Provide nutrition while resting the gastrointestinal tract
20min
 Enumerate at least II. Physiologic Assimilation of Solutions
1. Isotonic Solution s
three principles in IV
therapy. - has the same osmolarity as serum and other body fluids, hence, it stays where it is infused
(intravascular space). It expands this compartment without pulling fluids from other compartments
 Correctly classify (intracellular & interstitial) Ex.: LR, NSS (0.9 NS)
 IVF. Indications: Blood loss or hypovolemia
2. Isotonic solution has a total electrolyte content approximately 310 mEq/L.
4. Used most commonly for extracellular fluid replacement.

2. Hypertonic Solution
- osmolarity is higher than serum. When infused, it initially increases the osmolarity causing the
fluid to be pulled from the interstitial and intracellular compartments into the blood vessels
(intravascular space). Ex.: D5, 45 NS, D5N5, D5LR
Indications: Regulate urine output, stabilize blood pressure, reduce risk of edema, post-op patients
5. Hypertonic solution has a total electrolyte content of 375 mEq/L or greater.

3. Hypotonic Solution
- osmolarity is lower than serum. When infused, fluids shift out of the blood vessels (intravascular
space) and into the cells and interstitial spaces where osmolarity is higher. It hydrates the cells while
reducing the fluid in the circulatory system.
Ex.: 0.45 NS, 0.33 NS, Dextrose 2.5% in water
Indications: Dehydration, DKA, HHNK
6. Hypotonic solution has the total electrolyte content below 250 mEq/L

III. Phillip’s 15 step method for starting a peripheral line

 Verbalize 10min
understanding on the PHASE STEP s
significance of the Precatheterization 1. Check physician’s order
proper sequence in (preparation)
starting a peripheral 2. Wash your hands for 15 to 20 seconds.
line. 3. Prepare the equipment.
4. Assess the patient.
5. Select the site and dilate the vein.
Catheterization 6. Select the needle (catheter).
(venipuncture)
7. Put on gloves.
8. Prepare the site.
9. Enter the vein using the direct or indirect
method.
10. Stabilize the catheter with tape and apply
a dressing.
 Post Catheterization 11. Label the site, tubing and bag.
(clean-up)
12. Properly dispose of used equipment.
13. Educate the patient.
14. Calculate the drip rate if applicable.
15. Document the procedure.

STARTING A PERIPHERAL LINE- the Phillip’s 15-step approach to starting a peripheral line offers an
organized and thorough method. Remember to always check your institution’s policy before performing any
procedure.

CHECK PHYSICIAN’S ORDER- a physician’s order is necessary to initiate IV therapy. According to the
IWS, a prescriber’s verbal order written by a nurse in the medical record in a hospital setting should be
signed by the prescriber within an appropriate time (according to institution’s policy). The order should
include solution, volume, rate and route. If medication is ordered, the order should also include the
medication, dosage and frequency.

WASH HANDS- before beginning the procedure, wash your hand for 15 to 20 seconds. Wear gloves when
inserting the catheter and any time you have a risk of exposure to body fluid.

GATHER EQUIPMENT- obtain the following equipment:

 Clean gloves
 Prepping solution (70% isopropyl alcohol, povidone-iodine [Betadine] or chlorhexidine).
 Sterile 2-inch by 2-inch gauze pads.
 ½ inch or 1 inch tape.
 Disposable latex (or non-latex, in the case of allergy) tourniquet.
 Catheters (over the needle sizes, 18, 20,22 and 24 are the most common).
 Appropriate administration set.
 IV solution (inspected for puncture holes, visible contamination, and expiration date).
 Prn device (locking device) if the catheter is maintained as a saline lock.
 IV pole if needed.

ASSESS AND PREPARE PATIENT- several factors should be considered before venipuncture. The type
of solution, condition of vein, duration of therapy, catheter size needed, patient age, patient activity, presence
of disease or previous surgery, presence of a dialysis, shunt or graft, medications being taken by the patient
(such as anticoagulant) and allergies must be assessed before a venipuncture. Provide privacy for the
procedure, explain procedure by talking with the patient before assessing the upper arms for suitable
venipuncture sites.

SELECT SITE AND DILATE VEINS- proper vein selection is important to accommodate the prescribed
therapy and to minimize potential complications. Avoid use of an arm on the side where the patient has had a
mastectomy, has a dialysis access site, or is scheduled for a surgical procedure. The patient’s condition and
diagnosis, age, vein condition, size, location and type and duration of therapy should be considered before
initiation of intravenous therapy. The vein should be able to accommodate the gauge and length of catheter
used.

CHOOSE THE CATHETER- needles have been largely replaced with flexible plastic catheters that are
inserted over a needle. The needle is removed after the catheter is in place. these are available in a variety of
sizes (gauge) and lengths. For patient comfort, choose the smallest gauge catheter (20 -40 gauge) for fluids
and slow infusion rates. Use larger catheters (18 gauge) for rapid fluid administration and viscous solutions
such as blood. Refer to institution policy and equipment stock for specific recommendations. Keep in mind
that the INS recommends that short peripheral catheters be removed every 72 hours and immediately upon
suspected contamination.

GLOVES- the CDC recommends following standard precautions whenever exposure to blood or body fluids
is likely. Wearing latex or vinyl gloves provides basic protection from blood and body fluids.

PREPARE THE SITE- clean the peripheral insertion site with an antimicrobial solution before catheter
placement. If the patient’s skin is dirty, wash it with soap and water before applying the antimicrobial
solution. If the patient has excess hair, it can be clipped with scissors. Avoid using alcohol after an
antimicrobial preparation because alcohol negates the anti-infective action of the prep agent.

Apply the solution in a circular motion, starting at the intended site and working outward to clean an area 2
to 3 inches in diameter. If alcohol is used, it should be applied with friction for at least 30 seconds or until the
final applicator is visually clean. Blotting of excess solution at the insertion site is not recommended. Allow
the solution to air dry completely.

INSERT THE CATHETER- venipuncture can be performed using a direct (one-step) or indirect (two-step)
method. The direct method is appropriate for small gauge catheters, fragile hand veins, or rolling veins. The
indirect method can be used for all venipunctures.
Hold the catheter with the bevel (slanted opening) of the needle facing up. With the tourniquet in place, enter
the vein using either the direct or indirect approach. When using the direct entry approach, hold the needle at
a 30 to 45 degree angle directly above the vein and then penetrate the skin and vein in one motion. When
using some newer catheters, the angle of insertion is minimal.
The tourniquet is then released and the IV solution or injection cap is connected to the hub of the catheter.
Blood may ooze from the hub at this time. If an injection cap is being used, the catheter is flushed with 0.9%
sodium chloride solution to check for patency. A smooth, easy flush and no signs of infiltration indicate that
the catheter is patent and that the prescribed solution can be administered.

STABILIZE THE CATHETER AND DRESS THE SITE- a common problem in IV therapy is
dislodgement of the catheter. Secure taping keeps the catheter in place and stable thus preventing
complications caused by damage to the intima of the vein. There are several different techniques for taping a
catheter securely, including the U, H and chevron methods. Take care to apply tape in a manner that does not
constrict blood flow to the extremities.

A transparent semi permeable membrane dressing allows the nurse to stabilize the catheter and monitor the
venipuncture site for redness or swelling and provides an occlusive dressing for the site. Another acceptable
method of dressing management is the use of sterile 2-inch by 2-inch gauze over the venipuncture site and a
piece of 1-inch tape over the gauze. Band-aids are not acceptable dressings over catheter.

Arm boards are not used routinely. However if a confused patient places the IV site in danger, the extremity
can be immobilized as a last resort; this requires a physician’s order.

LABEL THE SITE- the IV set-up should be labeled in three areas: the insertion site, the tubing, and the
solution container. Once the venipuncture procedure is completed, label the set-up with the date, time,
catheter type and size and your initials.

DISPOSE OF EQUIPMENT- all needles, catheters, and blood contaminated equipment should be disposed
of according to institution’s policy in a tamper-proof, nonpermeable container.

EDUCATE THE PATIENT- patients have the right to receive information on all aspects of their care in a
manner they can understand. They also have the right to accept or refuse treatment. Explain the rationale for
the IV therapy that has been ordered. Explain your actions as you start the IV, and be sure the patient
understands how to protect the site and problems to report.

CALCULATE DRIP RATE- all IV infusions should be monitored frequently for accurate flow rates and
complications associated with infusion therapy.
 DOCUMENT- document your actions and the patient’s response in the medical record according to
institution policy. All IV solutions are also documented on the medication administration record. Include the
following:
 Date and time of insertion
 Manufacturer’s brand name and style of device
 Gauge and length of the device
 Location of the assessed vein.
 Solution infusing and rate of flow.
 Method of infusion (gravity or pump).
 Number of attempts needed for a successful IV start.
 Patient’s response and specific comments related to the procedure.
 Signature.

IV. Types of I.V. administration

 Correctly identify all
equipments needed for 15min
IV therapy. a. BOLUS MEDICATION
s
 State correctly at least
two to three Giving bolus through a peripheral line
appropriate health You may need to give a drug by I.V. bolus, such as Atropine, especially in emergency situations.
teachings for each
kind of IV infusion. What You Need:

-prescribed drug
-syringe of appropriate size (either needleless system or one with a 20G or 22G 1” needle
-alcohol or povidone-iodine pads
-gloves

Getting Ready
o If the drug isn’t compatible with the patient’s I.V. solution, also get two 3-mL syringes with 20G or 22G
1” needles & fill them with normal saline solution.
o Check your facility’s policy to see if you need another 3-mL syringe with heparin flush solution.
o Verify the order on the patient’s chart.
o Make sure drug is compatible with I.V. solution.
o Check expiration date, & reconstitute or dilute the drug as needed.
 o Identify the patient by checking the armband or by letting him/her identify himself.
o Wash your hands & put on gloves.

How You Do It
1. Close the flow-control clamp on the existing I.V. line.
2. Clean the Y-port closest to the venipuncture site with an alcohol pad or a povidone-iodine pad.
3. Insert the needle of the syringe on the needleless system into the Y-port, & inject the drug at the
prescribed rate.
4. Remove the syringe from the Y-port, open the flow-control clamp, and set the primary flow rate as
prescribed.

Practice Pointers
 Because a bolus drug takes effect rapidly, you’ll need to monitor the patient carefully for adverse
reactions, such as hypersensitivity, hypotension, or cardiac arrhythmias.
 Make sure I.V. line is still patent after you’ve given a bolus dose.

What to Teach
 Tell the patient the name of the bolus drug, why you’re giving it, and any adverse effects he/she may
experience or should report.
 Advise him/her to report pain, redness, swelling, or other problems with the insertion site.

Giving bolus through a saline lock

A saline lock converts an I.V. line into an intermittent infusion device. It connects to the venous access device by
luer-lock, and it has a latex cap through which you can give repeated bolus doses using either a needle or a
needleless system.

What You Need

-prescribed drug
-syringe of appropriate size 20G or 22G 1” needle
-alcohol or povidone-iodine pads
-gloves
-two 3-mL syringes with 20G or 22G 1” needles filled with normal saline solution

Getting Ready
 o Check your facility’s policy to see if you need another 3-mL syringe with heparin flush solution.
o Verify the order on the patient’s chart.
o Make sure drug is compatible with I.V. solution.
o Check expiration date, & reconstitute or dilute the drug as needed.
o Identify the patient by checking the armband or by letting him/her identify himself.
o Wash your hands & put on gloves.

How You Do It
1. Clean the Y-port closest to the venipuncture site with an alcohol pad or a povidone-iodine pad.
2. If saline lock is patent, you should be able to aspirate blood through it. To do so, insert the needle of a
saline-filled syringe and aspirate.
3. If no blood appears, apply a tourniquet above the site for about 1 minute. Aspirate again.
4. If no blood still doesn’t appear, remove tourniquet & slowly inject normal saline solution & watch for
signs of infiltration, such as puffiness or pain at the site.

If you see swelling – stop!

5. If infiltration occurs, remove the saline lock & insert a new one.
6. After you’ve flushed the saline lock, maintain positive pressure and withdraw syringe & the needle.
7. Insert the drug-filled syringe into the infusion port, & inject the drug at the prescribed rate & volume.
8. Flush the lock with the second saline syringe & then heparin if needed.
9. Discard used items according to standard precautions.

Practice Points
 Because a bolus drug takes effect rapidly, you’ll need to monitor the patient carefully for adverse
reactions, such as hypersensitivity, hypotension, or cardiac arrhythmias.
 To keep the device patent, flush it twice – according to your facility’s policy – with enough solution to
fill the saline lock & to clear residual blood.
 Saline can be used for up to 72 hours if it functions properly and if your facility’s policy allows.

What to Teach
 Tell the patient the name of the bolus drug, why you’re giving it, and any adverse effects he/she may
experience or should report.
 Advise him/her to report pain, redness, swelling, or other problems with the insertion site.

Giving bolus directly into a vein

If your patient needs rapid drug action – for example, in emergencies – you may need to inject the drug directly
into a vein.

What You Need

-winged venipuncture device

-tourniquet
-alcohol pads or povidone-iodine pads
-two syringes filled with the prescribed drug
-appropriate bandage
-sterile 2”x2” gauze pads
-gloves

Getting Ready
o Verify the order on the patient’s chart.
o Identify the patient by checking the armband or by letting him/her identify himself.
o Explain procedure to the patient.
o Wash your hands and put on gloves.

How You Do It
1. Select the largest suitable vein, keeping in mind the number of injections the patient may be receiving &
the need to preserve proximal veins for future use. The smaller the vein you use for injection, the more
the drug must be diluted to minimize irritation.
2. Apply tourniquet above the injection site to distend it.
3. Clean the injection site according your facility’s policy period. If you use both alcohol and povidone-
iodine, apply the alcohol first. Start at the site, then spiral outward about 2” (5 cm).
4. Insert the venipuncture needle, bevel up into the vein. You should see blood flashback.
5. Tape the wings of the device to the patient’s skin.
6. Insert a syringe of normal saline solution into the device. Withdraw the plunger to check again for blood
flashback.
7. After you see blood backflow, remove the tourniquet and slowly inject normal saline solution into the
vein. Watch for signs of infiltration such as puffiness or pain.
8. Remove the saline-filled syringe, and insert the drug-filled syringe into the venipuncture device.
9. Inject the drug as prescribed.
10. If the drug is vesicant, double-check the patency of the device after injecting every 2-3 mL of the drug.
11. Withdraw the empty syringe, and insert the second syringe filled with normal saline solution. Flush the
 venipuncture device to ensure delivery of the full drug dose.
12. Another method is to attach a 3-mL syringe filled with normal saline solution to one side of a three dash
way stopcock and the drug-fille syringe to the other side. Then attach the stopcock to the venipuncture
device. You can check for blood backflow, inject the drug, and flush the device by turning the stopcock
to appropriate positions.
13. Remove the venipuncture device from the vein and cover the site with a sterile 2”x2” gauze pad.
14. Apply pressure to the site for at least 3 minutes to prevent formation of a hematoma.
15. After the bleeding stops, apply a dressing.
16. Discard used items according to standard precautions.

Practice Points
 Certain drugs are packaged by the manufacturer with specific administration guidelines, such as the
appropriate injection rate. Make sure you follow these directions.
 Because a bolus drug takes effect rapidly, you’ll need to monitor the patient carefully for adverse
reactions, such as hypersensitivity, hypotension, or cardiac arrhythmias.
 Make sure your facility has a written policy concerning direct I.V. bolus injection, & follow it carefully.

What To Teach
 Tell the patient the name of the bolus drug, why you’re giving it, and any adverse effects he/she may
experience or should report.
 Advise him/her to report pain, redness, swelling, or other problems with the insertion site.

B. INTERMITTENT INFUSION

Usually intermittent drug infusion is given through a secondary administration set or a volume-control set.

Giving intermittent infusion through a secondary line

Most primary administration sets have one or two Y-sites that allow secondary administration – commonly
known as a piggyback infusion. When a piggyback infusion runs for several hours, it’s known as a continuous
secondary infusion.

What You Need

-prescribed drug
-continuous secondary tubing or piggyback extension tubing
-extension hook
-20G or smaller 1” needle or needleless system
-medication label
-alcohol pads
-1” adhesive tape
-gloves

Getting Ready
o If the drug is incompatible with the primary I.V. solution, also get two 3-mL syringes with 22G 1”
needles; fill them with normal saline solution.
o Check your facility’s policy to see if you need another 3-mL syringe with heparin flush solution.
o You may also need an infusion pump or a time tape.
o Verify the order on the patient’s chart.
o Identify the patient by checking the armband or by letting him/her identify himself.
o Wash your hands and put on gloves.

How You Do It
1. If you need to add a drug to a secondary I.V. solution, remove any seals from the secondary container.
Most solution bags have sealed outlet and unsealed injection ports, whereas most bottled solutions have a
seal covering their dual-outlet port.
2. Clean the injection port with an alcohol pad.
3. Inject the prescribed drug into the solution, and gently agitate the container to thoroughly mix the
solution.
4. Label the container with the patient’s name, the date and time, the drug and amount mixed, and your
initials.
5. Remove the secondary administration set from its packaging.
6. Straighten the tubing, and close the roller clamp.
7. Remove the protective cap from the distal end of the tubing, and attach the 20G (or smaller) needle or
needleless adapter.
8. Remove the protective cap from the infusion (outlet) port of the drug container; then remove the cap
from the I.V. piercing spike.
9. Insert the spike into the port of the container.
10. If the drip chamber has a vent on the side, close it if you’re using a bag and open it if you’re using a
bottle.
11. If you haven’t already done so, take the equipment and the prepared I.V. solution to the bedside.
12. Examine the primary I.V. container for cracks or leaks.
 13. Locate the Y-port on the primary line.
14. For an intermittent piggyback infusion, the port should be positioned above the roller clamp. For a
continuous secondary infusion, it should be near the lower end of the primary line.
15. Hang the secondary setup on the I.V. pole.
16. Using an alcohol pad, clean the selected Y-port on the primary I.V. tubing.
17. Insert the needle or needleless adapter from the secondary line into the Y-port of the primary line.
18. Securely tape the connection, unless you’re using a click-clock device with a recessive needle. This
device doesn’t require taping because a plastic covering locks the needle in place.

Giving a piggyback infusion

1. To infuse a piggyback drug without also infusing the primary solution, hang the piggyback container
above the level of the primary I.V. solution, using the extension hook that’s supplied with the piggyback
infusion set.
2. Open the roller clamp on the piggyback tubing; then adjust the roller clamp of the primary set to regulate
the infusion rate of the piggyback infusion. The primary I.V. solution won’t run while the piggyback
drug infuses. (To infuse the primary and secondary solutions simultaneously, hang them at the same
height.)
3. If the secondary solution isn’t compatible with the primary solution, flush the primary line before and
after the piggyback solution is infused.

Giving a continuous secondary infusion

1. For a continuous secondary infusion, adjust the roller clamp on the secondary line to the desired drip
rate. Then adjust the roller clamp on the primary line to achieve the desired total infusion rate.
2. If your facility policy allows, use a pump on the secondary line to maintain steady flow rate (or a time
tape to verify a steady rate).
3. If you’re using a continuous secondary setup and the primary and secondary solutions are incompatible,
stop the primary infusion. Flush the line with two or 3 mL of normal saline solution. Then start the
secondary infusion. At the end of the secondary infusion, flush the line again before restarting the
primary infusion.
If you can’t interrupt the primary infusion to run an incompatible secondary infusion, consider a double-lumen
catheter or starting another I.V. line.

C. CONTINUOUS INFUSION
The continuous infusion method allows a drug to be administered over an extended period. You may give a bolus
dose first, then switch to a continuous infusion to maintain drug levels in the patient’s blood.

Giving continuous infusion using an infusion pump

You may need to give your patient a continuous infusion of a drug after a bolus dose such as heparin.

What You Need

-Infusion pump
-drug administration set compatible with the device
-3-mL syringe with a needleless system or a 25G 5/8” needle
-flushing solution
-alcohol pads
-patency solution (if indicated)
-gloves

Getting Ready
o Verify the order on the patient’s chart.
o Identify the patient by checking the armband or by letting him/her identify himself.
o Set up the infusion pump according to the manufacturer’s instructions and facility’s policy. Program the
infusion as prescribed.
o Wash your hands and put on gloves.

How You Do It
1. Make sure the clamp on the administration set is closed and the line has no air bubbles in it.
2. Inject normal saline solution into the patient’s vascular access device to make sure it’s patent.
3. Wipe the port again with a clean alcohol pad.
4. Connect tubing of the administration set to the device.
5. Open the clamp and begin the infusion.
6. Discard used items according to standard precautions.
Practice Points
 Make sure you know how to troubleshoot the device you’re using and that you know your facility’s
policy about it.
 The amount or type of infusion to be administered, the patient’s age and condition and the care setting
may influence the infusion device you use. If the patient needs to receive the infusions at home, consider
 his lifestyle, his use of ambulatory devices, and the level of family support available to him.

What To Teach
 Tell the patient the name of the bolus drug, why you’re giving it, and any adverse effects he/she may
experience or should report.
 Advise him/her to report pain, redness, swelling, or other problems with the insertion site.
 If the patient will receive infusions at home, make sure he or a caregiver can administer them safely and
correctly. Also make sure you teach how to take care of the I.V. site and identify complications.
 Recognize correctly
the causes of different V. Complications
complications of IV A. Infiltration 25mins
therapy - Infiltration is the unintentional administration of a nonvesicant solution or medication into
 Recognize the specific surrounding tissue.
signs and symptoms 1. Causes
of each IV  Can occur when the IV cannula dislodges or perforates the wall of the vein.
complication. 2. Clinical manifestations
 Identify 2-3  Edema around the insertion site
immediate nursing  Leakage of IV fluid from the insertion site
interventions for each  Discomfort and coolness in the area of infiltration
complication.  A significant decrease in the flow rate
3. Prevention
 Closely monitor the insertion site
 Use appropriate size and type of cannula for the vein
 Make certain IV site is secure
 Use of armboard on flexor areas is useful
 Lift the arm and evaluate for dependent swelling
 Be sure that tape is not too tight it can obstruct circulation
 Use catheters that are flat – will decrease skin and vein tearing
 Minimize movement of the catheter in the skin
 Proper venipuncture technique
4. Nursing interventions
 Infusion should be stopped, the IV discontinued, and 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 if the extremity is used.
 Apply warm compress to the site to increase circulation and to ease the pain
  Affected extremity should be elevated to promote the absorption of fluid
 A cold compress may be applied to the area if the infiltration is recent

B. Thrombophlebitis
- Refers to the presence of clot and plus inflammation in the vein.
1. Causes
 Length of time IV line is in place
 The composition of the fluid or medication infused (especially its pH and tonicity)
 The size and site of the cannula inserted
 Ineffective filtration
 Improper anchoring of the line
 Introduction of microorganisms at the time of insertion
2. Clinical manifestations
 Localized pain, redness, warmth, and swelling around the insertion site or along the path of the
vein
 Immobility of the extremity because of discomfort and swelling
 Sluggish flow rate, fever, malaise, and leukocytosis
3. Prevention
 Using aseptic technique during insertion
 Using the appropriate size cannula or needle for the vein, 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
4. Nursing interventions
 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.

C. Bacteremia
- Contamination of IV site and solution which results to fever, chills and general malaise
1. Causes
 Incorrect insertion of catheter
  Inadequate preparation of IV site
 Inadequate care of IV site
2. Clinical manifestations
 Vein is sore and red
 “cord-like” vein
 Fever
3. Prevention
 Practice good handwashing
 Maintain aseptic technique in the care of IV site
 Observe IV site routinely
 Provide routine care along with proper dressing
4. Nursing interventions
 Discontinue IV line and restart it in another vein as ordered
 Monitor V/S
 Notify physician

D. Circulatory overload
- Overloading the circulatory system with excessive IV fluids causes increased blood pressure and
central nervous pressure.
1. Causes
 Rapid infusion of an IV solution or hepatic, cardiac, or renal disease
2. Clinical manifestations
 Moist crackles on auscultation of the lungs
 Edema
 Weight gain
 Dyspnea
 Rapid shallow breathing
3. Prevention
 Using an infusion pump for infusions and by carefully monitoring all infusions
 Know patient’s cardiovascular history
4. Nursing interventions
 Decrease the IV rate
 Frequently monitor vital signs
 Asses breath sounds
  Place the patient in high Fowler’s position
 Notify the physician

E. Air embolism
- An abnormal circulatory condition in which air/gas travels through the bloodstream and becomes
lodged in a blood vessel.
1. Causes
 Air enters catheter during tubing changes
 Air enters tubing during IV push
2. Clinical manifestations
 Dyspnea and cyanosis
 Hypotension
 Weak, rapid pulse
 Loss of consciousness
 Chest, shoulder, and lower back pain
3. Prevention
 Using a Luer-Lok adapter on all lines
 Filling all tubing completely with solution
 Using an air detection alarm on an IV pump
4. Nursing interventions
 Immediately clamp the cannula
 Place the patient on the left side in the Trendelenburg position
 Assessing vital signs and breath sounds administer oxygen
 Stay with the patent
 Notify the physician

F. Hemorrhage
1. Causes
 Loose connection of tubing or injection port
 Inadvertent or accidental removal of peripheral or central catheter
 Anticoagulant therapy
2. Clinical manifestations
 Oozing or trickling of blood from IV site or catheter
 Notify physician
3. Prevention
  Tape all catheters securely – use transparent dressing for peripheral or central catheters
 Tape the remaining catheter lumens in a loop so tension is not directly on the catheter
 Keep pressure on site at least 10 mins. after removal of catheter for anti-coagulated clients
4. Nursing interventions
 Pressure dressing may be applied over the site to control the bleeding
 Notify the physician

G. Venous thrombosis
1. Causes
 Stasis of blood (venous stasis)
 Vessel wall injury
 Altered blood coagulation
2. Clinical manifestations
 Deep veins
- Edema and swelling of the extremities
- Tenderness
- Signs of pulmonary embolus are the first indication of deep vein thrombosis
 Superficial veins
- Pain or tenderness, redness, and warmth in the involved area.
3. Prevention
 Apply elastic compression stockings
 Use of intermittent pneumatic compression devices
 Special body positioning and exercise
4. Nursing interventions
 If patient is receiving anticoagulant therapy, frequently monitor the partial thromboplastin time,
prothrombin time, hemoglobin and hematocrit values, platelet count, and fibrinogen level
 Observe closely to detect bleeding
 If bleeding occurs, report immediately and discontinue anti coagulant therapy.
 Drills on IV
computation
 Accurately solve for VI. IV Computation
the hourly volume and 40mins
the rate of infusion in MACROSET – 15 gtts/minute
a given hypothetical or 20 gtts/minute
problem.
HV= Rate of infusion x 60 min/hr.
MICROSET – 60 gtts/minute 15 gtts/min

HV= Rate of infusion x 60

R= HV x 15 gtts/min
min/hr.
60 gtts/min 60min/hr

R = HV HV= R x 4
R= HV x 60 gtts/min 4
60min/hr

Hourly volume=Rate of infusion BLOODSET – 10 gtts/minute

HV= Rate of infusion x 60 min/hr.

10 gtts/min

R= HV x 10 gtts/min
60min/hr

R = HV HV= R x 6
6 20-25 item
 Verbalize appreciation quiz
VII. Evaluation
on the importance of
maintaining and 5mins
 preventing safety
during IV therapy.

References:
 Potter, P. & Perry, A. (2001) Fundamentals of Nursing. (5th Ed.) Missouri: Mosby Inc.
 Kozier, B. (2004) Fundamentals of Nursing. New Jersey: Pearson Education Inc.
 Lippincott Williams & Wilkins. Medical Administration Made Incredibly Easy: Springhouse 2003.
 Lippincott The Manual of Nursing Practice 7th Ed. Lippincott 2001.
 Williams and Hopper Understanding Medical Surgical Nursing 3rd Ed. FA Davis 2003.