INTRODUCTION TO INTRAVENOUS THERAPY

The use of intravenous (IV) therapy is common in the health care setting. IV therapy is a treatment that
infuses fluids, nutrients, blood, blood products, or medication directly into a vein. It is a fast, efficient way to infuse
fluids and medications into the body.

Intravenous therapy is treatment that infuses intravenous solutions, medications, blood, or blood products directly
into a vein. Intravenous therapy is an effective and fast-acting way to administer fluid or medication treatment in an
emergency situation, and for patients who are unable to take medications orally. Approximately 80% of all patients in
the hospital setting will receive intravenous therapy.

The most common reasons for IV therapy include:

1. To replace fluids and electrolytes and maintain fluid and electrolyte balance: The body’s fluid balance is regulated
through hormones and is affected by fluid volumes, distribution of fluids in the body, and the concentration of solutes
in the fluid. If a patient is ill and has fluid loss related to decreased intake, surgery, vomiting, diarrhea, or diaphoresis,
the patient may require IV therapy.
2. To administer medications, including chemotherapy, anesthetics, and diagnostic reagents: About 40% of all
antibiotics are given intravenously.
3. To administer blood or blood products: The donated blood from another individual can be used in surgery, to treat
medical conditions such as shock or trauma, or to treat a failure in the production of red blood cells. The infusion
restores circulating volumes, improving the ability to carry oxygen and replace blood components that are deficient in
the body.
4. To deliver nutrients and nutritional supplements: IV therapy can deliver some or all of the nutritional requirements for
patients unable to obtain adequate amounts orally or by other routes.

Guidelines Related to Intravenous Therapy

The following are general guidelines for peripheral IV therapy:

● IV fluid therapy is ordered by a physician or nurse practitioner. The order must include the type of solution or
medication, rate of infusion, duration, date, and time. IV therapy may be for short or long duration, depending on the
needs of the patient.
● IV therapy is an invasive procedure, and therefore significant complications can occur if the wrong amount of IV fluids
or the incorrect medication is given.
● Aseptic technique must be maintained throughout all IV therapy procedures, including initiation of IV therapy,
preparing and maintaining equipment, and discontinuing an IV system. Always perform hand hygiene before handling
all IV equipment. If an administration set or solution becomes contaminated with a non-sterile surface, it should be
replaced with a new one to prevent introducing bacteria or other contaminants into the system.
● Understand the indications and duration for IV therapy for each patient. Practice guidelines recommend that patients
receiving IV therapy for more than six days should be assessed for an intermediate or long-term device.
● If a patient has an order to keep a vein open, or “TKVO,” the usual rate of infusion is 20 to 50 ml per hour.
● Complications may occur with IV therapy, including but not limited to localized infection, catheter-related bloodstream
infection (CR-BSI), fluid overload, and complications related to the type and amount of solution or medication given.
● For an infusing peripheral IV, the site must be assessed every 2 hours and p.r.n.
● A saline lock site must be assessed every 12 hours and p.r.n.
Several potential complications may arise from peripheral intravenous therapy. It is the responsibility of the health
care provider to monitor for signs and symptoms of complications and intervene appropriately. Complications can be
categorized as local or systemic. Most complications are avoidable if simple hand hygiene and safe principles are
adhered to for each patient at every point of contact.

Potential Local Complications of Peripheral IV Therapy

Complication  Signs, Symptoms, and Treatment

Phlebitis is the inflammation of the vein’s inner lining, the tunica intima. Clinical indications are
localized redness, pain, heat, and swelling, which can track up the vein leading to a palpable venous
cord.

Mechanical causes: Inflammation of the vein’s inner lining can be caused by the cannula rubbing
and irritating the vein. It is recommended to use the smallest gauge possible to deliver the
medication or required fluids.
Phlebitis
Chemical causes: Inflammation of the vein’s inner lining can be caused by medications with a high
alkaline, acidic, or hypertonic solutions. To avoid chemical phlebitis, follow the Parenteral Drug
Therapy Manual (PDTM) guidelines for administering IV medications for the appropriate amount of
solution and rate of infusion.

Treatment: Immediately remove cannula. May elevate arm or apply a warm compress. Document
findings in chart. Initiate a new peripheral IV if necessary.

Infiltration occurs when a non-vesicant solution (IV solution) is inadvertently administered into

surrounding tissue. Signs and symptoms include pain, swelling, redness, skin surrounding insertion
site is cool to touch, change in quality or flow of IV, tight skin around IV site, IV fluid leaking from IV
site, and frequent alarms on the IV pump.
Infiltration
Treatment: Stop infusion and remove cannula. Follow agency policy related to infiltration. Always
secure peripheral catheter with tape or IV stabilization device to avoid accidental dislodgement.
Avoid areas of flexion and always assess IV site prior to giving IV fluids or IV medications.

Extravasation occurs when vesicant solution (medication) is administered and inadvertently leaks

into surrounding tissue, causing damage to surrounding tissue. Characterized by the same signs
and symptoms as infiltration but also includes burning, stinging, redness, blistering, or necrosis of
the tissue.
Extravasation
Treatment: Stop infusion and remove cannula. Follow agency policy for extravasation for specific
medications. For example, toxic medications have a specific treatment plan.

Hemorrhage is defined as bleeding from the puncture site.

Hemorrhage
Treatment: Apply gauze to the site until the bleeding stops, then apply a sterile transparent dressing.

Local infection at Local infection is indicated by purulent drainage from site, usually two to three days after an IV site is
IV site started.
 Treatment: Remove cannula and clean site using sterile technique. Monitor for signs and symptoms
of systemic infection.

Systemic complications can occur apart from chemical or mechanical complications

Systemic Complications of Peripheral IV Therapy

Safety considerations:

Cardiac and renal patients have increased risk of systemic complications.

Pediatric patients, neonates, and elderly people have increased risk of systemic complications.

Complication  Signs, Symptoms and Treatment

Pulmonary edema, also known as fluid overload or circulatory overload, is a condition caused
by excess fluid accumulation in the lungs, due to excessive fluid in the circulatory system. It is
characterized by decreased oxygen saturation, increased respiratory rate, fine or coarse
Pulmonary edema crackles at lung bases, restlessness, breathlessness, dyspnea, and coughing up pinky frothy
sputum. Pulmonary edema requires prompt medical attention and treatment. If pulmonary
edema is suspected, raise the head of the bed, apply oxygen, take vital signs, complete a
cardiovascular assessment, and notify the physician.

Air embolism refers to the presence of air in the vascular system and occurs when air is
introduced into the venous system and travels to the right ventricle and/or pulmonary
circulation. An air embolism is reported to occur more frequently during catheter removal than
during insertion, and the administration of up to 10 ml of air has been proven to have serious
and fatal effects. Small air bubbles are tolerated by most patients.

Signs and symptoms of an air embolism include sudden shortness of breath, continued
coughing, breathlessness, shoulder or neck pain, agitation, feeling of impending doom,
lightheadedness, hypotension, wheezing, increased heart rate, altered mental status, and
Air embolism jugular venous distension.

Treatment: Occlude source of air entry. Place patient in a Trendelenburg position on the left
side (if not contraindicated), apply oxygen at 100%, obtain vital signs, and notify physician
promptly.

To avoid air embolisms, ensure drip chamber is one-third to one-half filled, ensure all IV
connections are tight, ensure clamps are used when IV system is not in use, and remove all air
from IV tubing by priming prior to attaching to patient.

A catheter embolism occurs when a small part of the cannula breaks off and flows into the
Catheter embolism
vascular system. When removing a peripheral IV cannula, inspect tip to ensure end is intact.

Catheter-related Catheter-related bloodstream infection (CR-BSI) is caused by microorganisms that are

bloodstream infection introduced into the blood through the puncture site, the hub, or contaminated IV tubing or IV
 solution, leading to bacteremia or sepsis. A CR-BSI is a nosocomial preventable infection and
an adverse event.

CR-BSI is confirmed in a patient with a vascular device (or a patient who had such a device in
the last 48 hours before the infection) and no apparent source for the infection other than the
vascular access device with one positive blood culture.

Treatment: IV antibiotic therapy

To avoid CR-BSI, perform hand hygiene prior to care and maintenance of an IV system, and

use strict aseptic technique for care and maintenance of all IV therapy procedures.

IV Fluids, IV Tubing, and Assessment of an IV System

Patients are prescribed an IV solution (fluids) based on their electrolyte and fluid volume status. IV fluids are
commonly categorized as colloids and crystalloids.

A. Colloid solutions contain large molecules that cannot pass through semi-permeable membranes and are
used to expand intravascular volume by drawing fluid from extravascular space via high osmotic pressure.
Examples of colloid solutions are albumin, dextrans, and hydroxyethyl starches.
B. Crystalloid solutions contain solutes such as electrolytes or dextrose, which are easily mixed
and dissolvable in solution. Crystalloids contain small molecules that flow easily across semi-permeable
membranes, which allows for transfer from the bloodstream into the cells and tissues. They may increase
fluid volume in interstitial and intravascular space. Examples of crystalloid solutions are isotonic, hypotonic,
and hypertonic solutions.
1. Isotonic solutions have an osomolality of 250 to 375 mOsm/L. Isotonic solutions have the same osmotic
pressure as plasma, creating constant pressure inside and outside the cells, which causes the cells to
remain the same (they will not shrink or swell) and does not cause any fluid shifts within compartments.
Isotonic solutions are useful to increase intravascular volume, and are utilized to treat vomiting, diarrhea,
shock, and metabolic acidosis, and for resuscitation purposes and the administration of blood and blood
products. Examples of isotonic solutions include normal saline (0.9% sodium chloride), lactated Ringer’s
solution, 5% dextrose in water (D5W), and Ringer’s solution. It is important to monitor patients receiving
isotonic solutions for fluid volume overload (hypervolemia).
2. Hypotonic solutions have a lower concentration, or tonicity, of solutes and have an osomolality equal to or
less than 250 mOsm/L. The infusion of hypotonic solutions lowers the osmolality within the vascular space
and causes fluid to shift to the intracellular and interstitial space. Cells will swell but may also delete fluid
within the vascular space. Examples of hypotonic solutions include 0.45% sodium chloride, 0.33% sodium
chloride, 2.5% dextrose in water, and 0.2% sodium chloride. Monitor for hypovolemia and hypotension
related to fluid shifting out of the vascular space, and do not administer to patients with increased
intracranial pressure (ICP), as it may exacerbate cerebral edema. Use cautiously in patients with burns, liver
failure, and trauma.

3. Hypertonic solutions have a higher concentration, or tonicity, of solutes and have an osomolality equal to or
greater than 375 mOsm/L. The osmotic pressure gradient draws water out of the intracellular space into the
extracellular space. Examples of hypertonic solutions include D5W and 0.45% sodium chloride, D10W, and
3% sodium chloride. Hypertonic solutions may cause intravascular fluid volume overload and pulmonary
edema, and they should not be used for an extended period of time. Hypertonic solutions should not be
used in patients with heart or renal disease who are dehydrated.

● Although all IV fluids must be administered carefully, hypertonic solutions are additionally risky.
● An order for IV fluids may be continuous or as a bolus, depending on the needs of the patient. IV solutions
are available in 25 ml to 1000 ml bags. The frequency, duration, amount, and additives to solution must be
ordered by a physician or nurse practitioner; for example, an order may be “give NS at 125 ml/hr.”
 ● The most common types of solutions include normal saline (NS) and D5W. Patients may also have
medications, such as potassium chloride, thiamine, and multivitamins, added to IV solutions. To discontinue
an IV infusion, an order must be obtained from the physician or nurse practitioner.

Frequency of IV Tubing Changes

Safety considerations:
● All IV tubing must be changed using sterile technique.
● IV tubing is changed based on the type of tubing, time used, and the type of solution.
● If possible, coordinate IV tubing changes with IV solution changes.

Frequency of IV Tubing
Type of IV Tubing and Solution
Change

Primary tubing with hypotonic, isotonic, or hypertonic continuous solution, when

Every 72 -96 hours insertion site is changed, or when indicated by the type of solution or medication being
administered.

Secondary or intermittent IV solution or medication. Rationale: When an intermittent

infusion is repeatedly disconnected and reconnected for infusion, there is increased
Every 24 hours
risk of contamination at the catheter hub, needleless connector, and the male Luer end
of the administration set, potentially increasing risk for CR-BSI.

Infusions containing fat emulsions (IV solutions combined with glucose and amino
Every 24 hours acids infused separately or in a 3 in 1 admixture). Example: Total parenteral nutrition
(TPN).

4 hours or 4 units,
whichever comes first, Blood and blood products
or between products

Calculating the Drops per Minute (gtts/min) for an Infusion by Gravity

Steps Additional Information

An order may read:

1. Verify the physician
Example 1. Give NS IV 125 ml/hr
order.
Example 2. Give 1000 ml of NS IV over 8 hours.

2. Determine the drop The drop factor is the amount of drops (gtts) per minute. IV tubing is either macro
factor on the IV tubing (10, 15, or 20 gtts/min) or micro tubing (60 gtts/min). The drop factor (or
administration set. calibration of the tubing) is always on the packaging of the IV tubing.

Use the formula:

Infusion rate (ml/hr) X IV  drop factor (gtts/min)
= drops per minute
60 (Administration time is always in minutes)
3. Complete the
calculation using the To calculate ml/hr, divide 1000 ÷ 8 = 125 ml/hr.
formula. Example: Infuse IV NS at 125 ml/hr. IV tubing drop factor is 20 gtts/min
125 X 20 = 41.6 gtts/min, round up to 42 gtts/min
(Round down or up to the nearest whole
60 number)