JH CERILLES STATE COLLEGE

in consortium with
Western Mindanao State University
West Capitol Road, Balangasan District, Pagadian City

Name of Student:

STARTING AN INTRAVENOUS INFUSION

STEPS SCORE
1. Review physician’s orders.
2. Wash hands.
3. Set up the IV fluid and tubing and take the equipment to the patient
bedside.
4. Identify the patient and explain procedure to the patient.
5. Adjust the lighting and provide privacy to the patient.
6. Put on gloves.
7. Locate a vein in which to start the IV. Place a tourniquet a few inches
from where you want to start, and ask the patient to open and close
his/her fist.
8. Release the tourniquet.
9. Cleanse the area thoroughly. Starting from the point to enter in a
circular motion away from the site to insert the needle, cleaning the skin
thoroughly at and around the vein selected.
10. Reapply the tourniquet.
11. Inspect the device for any defect.
12. Insert the needle at the chosen site.
13. Holding the cannula steady with dominant hand, release the tourniquet
with the other hand.
14. Correct the tubing and initiate flow. Remove the protective cap from the
IV tubing, correct it securely to the cannula, and open the regulator to
initiate the flow.
15. Remove gloves, tape the cannula securely and dress the site.

C.I’s Signature over Printed Name Date

 JH CERILLES STATE COLLEGE
in consortium with
Western Mindanao State University
West Capitol Road, Balangasan District, Pagadian City

Name of Student:
MONITORING AN INTRAVENOUS INFUSION

STEPS YES NO REMARKS

1. 1. Gather the pertinent data (primary care provider's order, the

type and sequence of solutions to be infused, and the rate of flow
and infusion schedule)

2. Ensure that the correct solution is being infused. If the solution

in incorrect, slow the rate of flow to a minimum to maintain the
patency of the catheter and then change the solution to the
correct one. Document and report the error according to agency
protocol.

3. Observe the rate of flow every hour.

• Compare the rate of flow regularly (every hour, against the
infusion schedule)
• If the rate is too fast, slow it so that the infusion will be
completed at the planned time.
• If the rate is too slow, check agency practice. Adjustments
above this rate require a primary care provider's order.
• If the rate of flow is 150 ml/h or more, check the rate of
flow more frequently (every 15 to 30 minutes).

4. Inspect the patency of the IV tubing and catheter.

 Observe the position of the IV solution. If it is less than 1
m (3 ft) above the IV site, readjust it to the correct height
of the pole.
 Observe the drip chamber. If it is less than half full,
squeeze the chamber to allow the correct amount of fluid
to flow in.
 Open the drip regulator and observe for a rapid flow of
fluid from the solution container into the drip chamber.
Then partially close the drip regulator to reestablish the
prescribed rate of flow.
 Inspect the tubing for pinches or kinks or obstructions to
flow, and the position of the tubing.

5. Inspect the insertion site for fluid infiltration. If infiltration is

present, stop the infusion and remove the catheter. Restart the
infusion at another site.

6. If the infiltration involves a vesicant drug, it is called extravasation

and other measures may be indicated.
 Stop the infusion immediately. Disconnect the tubing as close
to the catheter hub as possible and attempt to aspirate any drug
remaining in the hub. If an injectable antidote is available, the
catheter should remain in place.
 The primary care provider should be notified and if ordered,
the antidote administered.
 The affected arm should be elevated and depending on the
drug, heat or cold therapy should be implemented.

7. If infiltration is not evident but the infusion is not flowing,

determine whether the needle is dislodged from the vein.
 Gently pinch the IV tubing adjacent to the needle site.
 JH CERILLES STATE COLLEGE
in consortium with
Western Mindanao State University
West Capitol Road, Balangasan District, Pagadian City

 Use a sterile syringe of saline to withdraw fluid from the port

near the venipuncture site. If blood does not return, discontinue
the intravenous solution.

8. Inspect the insertion site for phlebitis (inflammation of a vein). •

Inspect and palpate the site at least every 8 hours.
 If phlebitis is detected, discontinue the infusion, and apply
warm compresses to the venipuncture site. Do not use this
injured vein for further infusions

9. Inspect the intravenous site for bleeding.

10. Teach the client ways to maintain the infusion system • Avoid
sudden twisting or turning movements of the arm with the needle or
catheter
 Avoid stretching or placing tension on the tubing.
 Try to keep the tubing from dangling below the level of the
needle.
 Notify a nurse if:
a. The flow rate suddenly changes or the solution stops
dripping.
b. The solution container is nearly empty.
c. There is blood in the IV tubing.
d. Discomfort or swelling is experienced at the IV site.

11. Document all relevant information.

C.I’s Signature over Printed Name Date

 JH CERILLES STATE COLLEGE
in consortium with
Western Mindanao State University
West Capitol Road, Balangasan District, Pagadian City

Name of Student:
CHANGING IV SOLUTIONS

STEPS YES NO REMARKS

1. Place the prepared IV bag and tubing near bedside.

2. Identify patient, perform handwashing and explain the procedure

to the patient.

3. Perform medication checks.

4. Remove the cover from entry port of a new container.

5. Take empty bag off the IV pole and invert it.

6. Close or turn off the roller clamp.

7. Remove spike from bag.

8. Invert new bag and insert spike.

9. Fill the drip chamber by compressing it with your thumb and

forefingers.

10. Hang new bag on IV pole.

11. Inspect tubing for air bubbles; gently tap to remove them.

12. Open roller clamp and regulate IV infusion rate as per

physician’s order.

13. Label the new IV solution bag.

14. Dispose old IV container bag and do hand washing.

15. Document IV solution bag change.

C.I’s Signature over Printed Name Date

 JH CERILLES STATE COLLEGE
in consortium with
Western Mindanao State University
West Capitol Road, Balangasan District, Pagadian City

Name of Student:

DISCONTINUING IV SOLUTIONS

STEPS YES NO REMARKS

1. Check orders carefully and wash hands.

2. Identify the patient & explain procedure to the patient

3. Clamp the infusion tubing.

4. Loosen the tape at the venipuncture site while holding

the needle firmly and applying countertraction to the
skin.

5. Don gloves and hold a swab above the venipuncture

site.

6. Withdraw the needle or catheter by pulling it along the

line of the vein.

7. Apply firm pressure to the site, using the swab, for 2-3
minutes.

8. Hold the patient’s arm or leg above the body if any

bleeding persists.

9. Check the needle or catheter to make sure it is intact.

10. Apply sterile dressing

11. Assess the patient’s response to the IV in terms of the

appearance of the venipuncture site.

12. Discard the IV solution container, if infusions are

being discontinued, and discard the used supplies
appropriately.

13. Document the time of discontinuing the infusion, the

container number, the type of solution, and the
patient’s response.

C.I’s Signature over Printed Name Date