MCN Reviewer

IV therapy setting-up, maintaining, and discontinuing

Intravenous Therapy
• The goal of IV is to correct or prevent fluid and electrolyte imbalance disturbance.
• It allows to direct access to vascular system permitting the continuous infusion of
fluids over a period of time.
• To provide safe and appropriate therapy, nurses need to be knowledgeable about
the solution was ordered, equipment needed, procedures required, how to
regulate infusion, maintaining the system and discontinuing the IV.
• Regulate IV fluid continuously because of ongoing changes in patients fluid and
electrolyte balance.
Types of Solution
• Isotonic Solution
o Have the same effective osmolality as body fluids.
o Often used to restore vascular volume.
o Comes in 50, 250, 500, 1000 ml.
o Cloudiness and leak possible contamination
o Solution are used to expand vascular compartment.
▪ D5W avoided in ICP cerebral edema (Lactated ringers)
• Hypotonic Solution
o Have a lesser concentration of solutes
▪ Moving water into the cells
• Causes the cell to bloat
o 45% NACL / 0.33% NACL.
▪ Use to treat cellular dehydration
 • Hypertonic Solution
o Have an effective osmolality greater than body fluids.
o D5n5, d5/2ns, D5LR
o Dextrose 10% in water, draw fluid out of the cell causing it to shrivel

Equipment’s

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 • 16 Gauge
o This size is mostly use in the ICU or surgery areas.
o This large size enables many different procedures to be performed such as
blood administration, rapid fluid administration, and so forth.
• 18 Gauge
o This size allows you to do most of the tasks that the 16 gauge can, but it
large and more painful to the patient.
o Some common uses include administering blood, pushing fluids rapidly.

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 • 20 Gauge
o This size is better for patients with smaller veins.
• 22 Gauge
o This small size is good for when patient’s won’t need an IV long and aren’t
critically ill.
• 24 Gauge
o This size is used for pediatrics and it is usually only used as a last resort as an
IV in the adult population.

Tubing lines
• Main IV line, used in continuous infusion flow through the tubing and connects
directly into the IV tubing.
• Secondary Intravenous (IV) infusions are a way to administer smaller volume
controlled amounts of IV solution (25- 250 mL).
• The secondary solution bag is typically hung higher than the primary infusion bag
and is subsequently “piggybacked” on top of the primary IV infusion.

Trifuse
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IV Sites
• Site choses for venipuncture includes:
o Client’s age
o Length of time
o Type pf solution used and the condition of veins
• For adults veins in the hands and arms are used.
• Infants scalp and dorsal foot.
• Basilic, Cephalic, and Metacarpal veins are used for continuous infusion.

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Regulation of flow rate
• Organize all equipment at the bedside for efficient insertion because fluids is
infused in bloodstream, aseptic technique should be used.
• Number of drops delivered per milliliter of solution varies with different brands and
type of infusion set.
o The rate is called Drip factor or sometimes called drop factor.
• 2 methods
o Number of ml to be administered in 1 hour (ml/hr)
o Number of drops to be given for a minute (gtt/min)

Factors influencing the flow rate:

o Position of the forearm
o Position and patency of the tubing
o Height of the infusion bottle (1.4 cm)
o Infiltration of fluid leakage.

Maintaining the system

• Line maintenance involves:
o Keeping the system intact and sterile
o Changing IV Fluid containers, tubing and contaminated site
o Helping client with self-care activities
o Monitor complications of IV
• Principles:
o Always maintain the integrity of the IV line.
o Never disconnect tubing because it becomes tangled
o Never let the tubing touch the floor
o Never use stopcocks in connecting more than one solution to a single IV site
o Clean IV parts with 70% alcohol

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Changing IV fluid containers tubing and dressing
• Patients receiving IV therapy over several days required periodic change.
• A sterile dressing over an IV site reduce the entrance of bacteria.

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Complications of IV therapy
• Circulatory Overload
o IV solution infused too rapidly or too great an amount
o Signs and symptoms
▪ Crackles in the lungs
▪ Shortness of breath
▪ Cardiac dysrhythmia
o Nursing Intervention:
▪ Reduce of Flow rate and notify patient’s physician
▪ Raise head of bed (HOB)
▪ Administer oxygen and diuretics if ordered by AP
▪ Monitor VS
• Infiltration
o IV fluid entering subcutaneous tissue around venipuncture site.
• Extravasation
o Technical term used when a vesicant solution enters a tissue
o Tissue damaging
o Assessment findings:
▪ Skin around catheter site is taut, blanched, cool to touch.
▪ Edematous and maybe painful
o Nursing intervention
▪ Stop infusion
▪ Elevate extremity
▪ Apply warm, moist or cold compress
▪ Start new IV line in the other extremity

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 • Phlebitis
o Inflammation of inner layer of a vein.
o Assessment findings
▪ Redness, tenderness, pain, and warmth
▪ Possible long cord
▪ Palpable long cord
o Nursing Intervention
▪ Stop infusion and discontinues IV
▪ Start IV line in other extremity or proximal distance to that of the
previous one
▪ Apply, warm to moist compress

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 • Local Infection
o Infection of catheter skin entry point during infusion or after removal of IV
catheter.
o Assessment finding
▪ Redness, heat and swelling of catheter site
▪ Possible pus drainage
o Nursing intervention
▪ Culture any drainage
▪ Clean skin with alcohol; remove catheter and save for culture
▪ Apply sterile dressing
▪ Notify physician
▪ Start new line
• Bleeding at venipuncture site
o Oozing or slow, continues seepage of blood from venipuncture site
o Nursing intervention
▪ Assess if IV system is intact
▪ If catheter is within the vein, apply pressure dressing over site.
▪ Start new IV line in the other arm.

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Discontinuing IV
Procedure
• Purpose
o Maintains or replace fluids, electrolytes, vitamins, proteins, fats, and calories
in the patient who cannot maintain an adequate intake by mouth.
o Restore the volume of blood components
o Administer safe and effective infusions of medications by using the
appropriate vascular access.
o Provide avenue for hemodynamic monitoring and diagnostic testing.
• Assessment
o Verify reason for initiation of IV therapy
o Check orders for type and rate of fluid and/or specified IV site
o Assess status of skin on hands and arms; presence of hair or abrasions;
previous IV sites
o Determine client’s ability to avoid movement of arms or hands during
procedure
o Check for allergy to tape
o Determine client’s knowledge of IV therapy
• Nursing Consideration:
o Maintain asepsis throughout the procedure.
o Clip hair if the site is too obscured
o Provide privacy to the patient at all times.
o Check for drug to drug incompatibility
o Verify for skin test of the drug for IV administration.
• Equipment
o Antiseptic swab
o Dry cotton balls
o Cotton balls with alcohol
o Gauze dressing
o Tape
o Pair of scissors
• Implementation
o Check physician’s orders
o Perform hand hygiene

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 o Prepare materials needed
o Identify the client by asking for the name or checking the identification band.
o Introduce yourself to the client
o Explain the procedure to the client
o Assess client’s status
o Close the roller clamp
o Moisten adhesive tapes with cotton balls with alcohol
o Remove the tapes gently
o Use pick up forceps to get cotton balls with alcohol and without applying
pressure, remove the needle or IV catheter then immediately apply pressure
over the venipuncture site.
o Inspect the IV catheter for completeness.
o Place the dressing or tape over the venipuncture site
o Place patient in a comfortable position
o Remove and dispose supplies and equipment used. Note: Discard all waste
materials following agency’s protocol.
o Perform hand hygiene.
o Document and report the client’s response (Record the time of
discontinuance, status of insertion site and integrity of IV catheter.)

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