STARTING AN INTRAVENOUS INFUSION

Definition:

Intravenous infusion is a method of replacing fluid loss, or correcting an electrolyte

imbalance. Intravenous infusions are used when patients need fluids, electrolytes,
medications, or nutritional supplements that cannot be taken orally or need to be given
continuously.

Purposes:

1. To supply fluid when patients are unable to take in an adequate volume of fluid by
mouth.
2. To provide salts needed to maintain electrolyte balance.
3. To provide glucose (dextrose), the main fuel for metabolism
4. To provide water-soluble vitamins and medications
5. To establish a lifeline for rapidly needed medications

Special Considerations:

Before starting an infusion, the nurse must determine the following:

1. The exact orders (type of solution, the amount to be administered, rate of

flow) 2. Whether the patient has any allergies (e.g. to tape or povidone -iodine)
3. The agency protocol about shaving the area before a venipuncture.

Equipment/Materials:

Infusion set
Container sterile parenteral solution
IV pole
Adhesive or non allergenic tape
Clean gloves
Tourniquet
Antiseptic swab
Antiseptic ointment, such as Povidone – Iodine (Betadine)
Intravenous catheter
Gauze squares or other appropriate dressings
Arm splint, if required
Towel or pad
 ACTION RATIONALE
1. Prepare the patient. Explain the procedure. Patients often want to know how long the
process will last; eliminates anxiety.
2. Wash or disinfect your hands To minimize the transfer of microorganisms.
3. Open and prepare the infusion set.

ACTION RATIONALE
a. Remove tubing from the container and
straighten it out.
b. Slide the tubing clamp along the tubing
until it is just below the drip chamber
to facilitate its access.
c. Close the clamp.
d. Leave the ends of the tubing covered This will maintain the sterility of the ends of
with the plastic caps until the infusion is the tubing.
started.
4. Spike the solution container.
a. Remove the protective cover from
the entry site of the bag.
b. Remove the cap from the spike, and
insert the spike into the insertion
site of the bag or bottle (follow
manufacturer's instructions).
5. Hang the solution container on the pole. This height is needed to enable gravity to
a. Adjust the pole so that the container overcome venous pressure and facilitate flow
is suspended about 1 m of the solution into the vein.
(3ft). Above the client's head
6. Partially, fill the drip chamber with The drip chamber is partially filled with
solution. solution to prevent air from moving down the
a. For a flexible drip chamber tubing.
squeeze the chamber gently
until it is half full of solution.
b. For a firm drip chamber. The
chamber will usually fill
automatically.
7. Prime the tubing.
a. Remove the protective cap and hold The tubing is primed to prevent the
the tubing over a container. introduction of air into the patient’s vein. Air
Maintain the sterility of the end of bubbles in large amounts (eg. 10 ml) can
the tubing and the cap. create emboli in the bloodstreams. However,
b. Release the clamp and let the fluid air bubbles smaller than 0.5 ml usually do not
run through the tubing until all cause problems in peripheral line.
bubbles are removed. Tap the
tubing if necessary with your fingers
to help the bubbles move.
c. Reclamp the tubing and replace the
tubing cap, maintaining sterile
technique.

ACTION RATIONALE
d. For caps with air vents, do not
remove the cap when priming the
tubing. The flow of solution through
the tubing will cease when the cap
is moist with one drop of solution.

8. Apply appropriate labels to the solution For proper identification of the patient.
container. Include the patient's name, date
and note time the infusion started.
9. Wash hands. To eliminate the transfer of microorganisms
that could cause infection.
10. Select and prepare the venipuncture site. Veins can become sclerotic from irritation by
Starting at the distal end of the vein, select the infusion or needle. Sclerosis may then
a site by palpating accessible veins. interfere with venous flow. If so, use more
proximal parts of the veins.
11. Dilate the vein.
a. Place the extremity in a dependent Gravity slows venous return and distends the
position (lower than the patient's heart) veins.
b. Apply a tourniquet firmly 15-20 cm. (68
in) above the venipuncture site. The Distending the veins makes it easier to insert
tourniquet must be tight enough to the needle properly.
obstruct venous flow but not so tight
that it will occlude arterial flow. Obstructing arterial flow inhibits venous filling.
If a radial pulse can be palpated, the arterial
 c. If the vein is not sufficiently dilated: flow is not obstructed.

i. Massage or stroke the vein distal to

the site and in the direction of the This action helps fill the vein.
venous flow toward the heart.

ii. Encourage the patient to clench and

uncleanch the fist rapidly. Contracting the muscles compresses the distal
veins, forcing blood along the veins and
distending them
iii. Lightly tap the vein with your fingertips.
d. If the above steps fail to distend the Tapping may distend the vein.
vein so that it is palpable, remove the Heat dilates superficial blood vessels, causing
tourniquet, and apply heat to the entire them to fill.
extremity for 10-15 min. Then repeat
the steps above.

ACTION RATIONALE
12. Don clean gloves and clean the Gloves protect the nurse form contamination
venipuncture site. by the patient's blood.

a. Clean the skin at the site of entry with a To lessen the microorganisms present on the
topical antiseptic swab (eg. Alcohol) site of entry.
and then an anti-infective solution such
as povidone-iodine. (Betadine)

b. Use a circular motion, moving from the This motion carries microorganisms away from
center outwards for several inches. the site of entry.

c. Permit the solution to dry on the skin. Povidone-Iodine should be in contact with the
skin for 1 minute to be effective.
13. Insert the catheter and initiate the
infusion.
a. Use one thumb to pull the skin taut This stabilizes the vein and makes the skin taut
below the entry site. for needle entry. It can also make initial tissue
b. Insert the catheter by the direct or penetration less painful.
indirect method. The direct method is
preferred for larger veins and the
Indirect method for smaller veins
c. For the direct method, hold the needle
catheter over the desired venipuncture
site with the level up, at a 15-30
degree angle and insert the catheter
through the skin, into the vein in one
thrust.
d. For the indirect method, hold the
needle at a 30 – 40 angle, pierce the
skin, then reduce the angle until it is
almost parallel to the skin and advance
the needle into the vein. Sudden lack
of resistance is felt on the vein.
e. Once blood appears in the lumen of the
needle or you feel the lack of
resistance, then advance the needle so
that it is inserted 2.5 cm (1 in).
f. Release the tourniquet.
g. Remove the protective cap from the
distal end of the tubing, and hold it
ready to attach to the catheter,
maintaining the sterility at the end.

ACTION RATIONALE
h. Attach the end of the infusion tubing to
the catheter hub.
14. Tape the catheter.
a. Place a small gauze dressing under the This will support the catheter in position.
hub.
b. Tape the catheter by the U method or
according to manufacturer's
instructions. Using three strips of
adhesive tape, each about 7.5 cm (1 in)
long.
i. Place one strip, sticky side up, under
the catheter's hub.
ii. Hold each end over so that the
sticky sides are against the skin.
iii. Place second strip, sticky side down,
over catheter hub.
iv. Place third strip, sticky side down,
over tubing hub.
15. Dress and label the venipuncture site and
tubing according to agency policy.
a. In some agencies, the nurse puts a
small amount of antiseptic ointment,
such as Povidone-Iodine, over the
venipuncture site, and then a gauze
square. In other agencies, a sterile
transparent occlusive dressing is
applied after the ointment.

b. Remove soiled gloves and discard

This permits assessment of the site without
appropriately.
disturbing the dressing. This type of dressing
can be left on for 72 hours, and then changed.

c. Loop the tubing, and secure it to the Looping and securing the tubing prevent the
dressing with tape. weight of the tubing or any movement from
pulling on the needle or catheter.

d. Label on a piece of tape, the date and

time of insertion, type and gauge of
needle or catheter used, and your
initials. Apply the tape over the
venipuncture dressing.
ACTION RATIONALE
16. Ensure appropriate infusion flow
a. Apply a padded arm board (folded towel
on a board) to splint the elbow or wrist
joint, as needed.

b. Adjust the infusion rate of flow To keep the venipuncture site intact.
according to the order.
17. Label the IV tubing
a. label tubing with date, time of The tubing is labeled to ensure that it is
attachment and initials. This labeling changed at regular intervals (ex. Every 24.72
may also be done when the infusion is hours according to agency policy).
started.
18. Document relevant data, including
assessment.
a. Record the start of the infusion on the Documentation as basis for evaluation and
patient's chart. Some agencies provide continuity of care.
a special form for the purpose. Include
the date and time of the venipuncture,
amount and type of solution used,
including any additives (e.g. kind and
amount of medications); absorption
time, container number; drip rate, type
and gauge of the needle or catheter;
venipuncture site; and the patient's
general response.

Illustration 1: TOP: Dorsum of

the
hand BOTTOM: Dorsal Plexus of
the foot
SITES FOR IV INSERTION
 CHANGING INTRAVENOUS BAG OR BOTTLE

Definition:
Replacement of the intravenous solution containers when only a small amount of fluid
remains in the drip chamber.

Purposes:
To maintain the flow of required fluids.
Equipment/Materials:
Container with the correct kind and amount of intravenous solution

Special Considerations:

Obtain the correct bag or bottle of fluid, using the three checks. The three checks to
ensure that it is the correct fluid ordered.

1. The right patient receives the right IV fluid at the right

time 2. The correct IV fluid is infusing at the right time
3. The IV dressing is intact. The site is clear.

ACTION RATIONALE
1. Wash or disinfect your hands. To prevent or minimize the transfer of
microorganisms that could cause infection.
2. Identify the patient, using 2 identifiers. To make sure that the right patient receives
the IV fluids.
3. Explain what you are going to do, if Explaining what will be done helps to alleviate
appropriate. There may be no need to the patient's anxiety or fear. It is also an
awaken the patient if he or she is asleep excellent time for patient teaching.
because you can change the container
without disturbing the patient. The companion
may be asked to ensure the identity of the
patient.
4. Remove the cover from the entry port and So that it will be within easy reach for
place the IV bag or bottle on the bedside connection.
ACTION RATIONALE
stand or table.

5. Turn off the IV flow using the slide or To prevent the drip chamber to be empty
screw clamp, or if the IV is on a pump, while in the process of changing the bag.
turn the pump to the correct mode.
6. Invert the old IV bag or bottle To prevent any remaining fluid from spilling on
the floor.
7. Remove the tubing spike from the old IV Touching the tubing will contaminate it and
bag. Be careful not to contaminate the consequently contaminate the fluid.
tubing spike by touching it with your hand.
8. Insert the tubing spike into the new IV bag To gain access to the fluid in the new IV bag or
or bottle. bottle, and resume intravenous infusion.
9. Invert the new bag and hang it on the IV For convenience and safety.
pole.
10. Turn on the flow and regulate the rate. For each IV bag or bottle, the IV rate should be
verified and checked so that the IV is infusing
at the ordered rate.
12. Wash or disinfect your hands. To minimize the transfer of microorganisms
that could cause infection.
13. Document:
a. Time of IVF change and exact contents Documentation as basis for evaluation and
of new IV bag/bottle. continuity of care.
b. Volume of fluid infused from the
previous IV bag/bottle.
c. Assessment of IV site and dressing
according to the policies of the hospital
or facility.
d. The right patient received the right IVF
at the right time.
e. The right IVF is infusing at the right
rate.
f. The IV dressing it intact, and the site is
 clear.

DISCONTINUING AN INTRAVENOUS INFUSION

Important: Infusions are usually discontinued for any of the following reasons:

1. The patient's oral fluid intake and hydration status are satisfactory, therefore no
further IV solutions are ordered.
2. There is a problem with the infusion that cannot be fixed.
3. The medications administered by the intravenous route (e.g antibiotics) are no
longer required.

Special Considerations:

1. Before removing a catheter or needle from the vein, determine whether a sterile
injection cap (heparin or saline lock) should be attached to the catheter so that
intravenous medications can be administered intermittently.
2. Assess appearance of the venipuncture site and take note of any bleeding, as well as
the amount of fluid infused.

Equipment/Marerials:

Clean gloves
Dry or antiseptic – soaked swabs according to agency practice.
Small sterile dressing and tape

ACTION RATIONALE
1. Prepare the equipment
a. Clamp the infusion tubing. Clamping the tubing prevents the fluid from
flowing out of the needle, on the patient, or
on the bed.

b. Loosen the tape at the venipuncture Movement of the needle can injure the vein
site while holding the needle firmly and and cause discomfort to the patient. Applying
applying counter pressure on the skin counter pressure prevents pulling the skin
at the venipuncture site. and causing discomfort.

c. Don clean gloves, and hold a sterile Gloves prevent direct contact with the
 gauze on the venipuncture site. patient's blood.
The Sterile gauze prevents contamination of
the venipuncture site.
2. Withdraw the needle or catheter from the
vein.
a. Withdraw the needle or catheter by Pulling out in line with the vein prevents injury
pulling it out along the line of the vein. to the vein.
ACTION RATIONALE
b. Immediately apply firm pressure to the Pressure helps stop the bleeding and prevent
site, using sterile gauze, for 2-3 hematoma formation.
minutes.
c. Raise the patient's arm or leg above the Raising the limb decreases blood flow to the
level of the body if any bleeding area.
persists.
3. Examine the catheter removed from the If a piece of tubing remains in the patient's
patient. vein it could move centrally (toward the heart
a. Check the catheter to make sure it is or lungs) and cause serious problem.
intact.

b. Report a broken catheter to the nurse

in charge or physician immediately.

c. If the broken piece can be palpated, Application of a tourniquet decreases the

apply a tourniquet above the insertion possibility of the piece moving, until a
site. physician is notified.
4. Cover the venipuncture site. To protect the venipuncture site from
a. Apply the sterile dressing. contamination.
b. Discard the IV solution container, if
infusion is to be discontinued and
discard the used supplies appropriately.

5. Document all relevant information. Documentation as basis for evaluation and

a. Record the amount of fluid infused on continuity of care.
the I & O record of the chart, according
to agency or hospital practice. Include
the type of solution used, the time
when the infusion was discontinued
and the patient's response.