PHINMA EDUCATION NETWORK

College of Nursing

NUR 146: Care of Mother and Child at Risk- RLE

INTRAVENOUS THERAPY

EQUIPMENT

● IV Administration Set
● Non-Allergenic Tape
● IV Solution
● Syringe
● Tourniquet
● IV Cannula
● IV Dressing
● Alcohol Swab
● IV Pole

ASSESSMENT: SCRIPT

1. Gather all equipment and bring it to the
bedside. Check intravenous (IV) solution and
medication additives with physicians’ order.
Rationale:
Having equipment available saves time and
facilitates accomplishment of tasks. Checking
the order ensures that the patient receives
the ordered IV solution and medication.
Nurse: Good morning! I am your nurse Liza
for this shift from 8am-4pm. Your doctor has
ordered IV fluids and IV medication. I will be
your nurse to insert your Intravenous fluid so
we can start infusing and administering your
medication. But before we start, May I know
your full name?
Patient: Hello Liza, I am Maria Dela Cruz.

2. Explain the need for IV solution and
procedure to patients.
Rationale:
Explanation allies anxiety.
Nurse: The insertion of the IV Fluid is a bit
painful, so expect a little discomfort. I suggest
having a deep breathing while inserting the
catheter to decrease your anxiety.
Patient: Oh, thanks for the info, I heard of
that. I will take your advice, nurse Liza.

3. Perform hand hygiene. If using an Nurse: (After hand hygiene) “I have here a
anesthetic (numbing) cream, apply cream to numbing cream to ease pain.
a couple of potential insertion sites.
Patient: Oh, that’s better! Thank you nurse
Rationale: Liza.
Hand hygiene deters the spread of
microorganisms. Anesthetic (numbing)
cream decreases the amount of pain felt at
the insertion site. Some of the numbing
cream takes up to an hour to become
effective.
 IMPLEMENTATION
4. Prepare IV solution and tubing.
a. Maintain aseptic technique when opening
sterile packages and IV solution.
b. Clamp tubing, uncap spike, and insert into entry
site on bag as manufacturer directs.
c. Squeeze the drip chamber and allow it to fill at
least half way.
d. Remove cap at end of tubing, release clamp
and allow fluid to move through tubing. Allow fluid
to flow and recap the end of tubing, maintaining
sterility of setup.
e. If an electronic device is used, follow
manufacturer’s instructions for inserting tubing
and setting infusion rate.
f. Apply a label if medication was added to the
container. (Pharmacy may have added medication
and applied labels.) Label tubing with date and
time tubing is hung.
g. Place time-tape on container and hand IV on
pole.
5. Place the patient in low Fowler's position in bed.
Place a protective towel or pad under the patient's
arm.
6. Select appropriate site and palpate accessible
veins. ∙
7. If the site is hairy and agency policy permits, clip
a 2∙-inch area around the intended entry site.
8. Apply tourniquet 5-6 inches above
venipuncture site to obstruct venous blood flow
and distend vein. Direct tourniquet ends away
from the entry site. Check to be sure the radial
pulse is still present. ∙
SCRIPT
a. Asepsis is essential for preventing the
spread of microorganisms.
b. This punctures the seal in the IV bag.
∙ Suction causes fluid to move into drip chamber
and prevents air from moving down the tubing
c. This removes air from tubing; in larger
amounts, air can act as an embolus.
d. This ensures correct flow rate and
proper use of equipment.
e. This provides for administration of the
correct solution with prescribed
medication or additive.
f. This permits immediate evaluation of
IV according to schedule.
g. This will inform the upcoming shift on
duty about the due time of the IV fluid.
The supine position permits either arm to
be used and allows for good body
alignment.
The use of an appropriate sit decrease
discomfort for the patient and reduces the
risk for damage to body tissues.
Hair can harbor microorganisms.
Interrupting the blood flow to the heart
causes the vein to distend. Interrupting
the arterial flow impedes venous filling.
Distended veins are easy to see, palpate,
and enter. The end of the tourniquet
could contaminate the area of injection if
directed toward the site of entry.
9. Ask the patient to open and close his or her fist.
Observe and palpate for a suitable vein. Try the
following techniques if the vein cannot be felt.
a. Release a tourniquet and have the patient
lower his or her arm below the level of the heart to
fill the veins. Reapply tourniquet and gently tap
over the intended vein to help distend it
b. Remove the tourniquet and place warm moist
compresses over the indented vein for 10-15
minutes.
10. Don clean gloves. ∙ ∙
11.If using intradermal lidocaine:
Cleanse small area of possible insertion site
with alcohol using a circular motion.
Inject a small amount (0.2 to 0.3 ml) of cream:
Wipe cream off insertion site.
Cleanse the entry site with an antiseptic solution
(alcohol swab) followed by antimicrobial
solution (povidone iodine) according to
agency policy.
- Use a circular motion to move from the
center outward for several inches.
12. Use the nondominant hand, placed about 1 to
2 inches below the entry site, to hold skin taut
against the vein. Avoid touching prepared
sites.
13. Enter skin gently with catheter help by the hub
in the dominant hand, bevel side up, at a 10-
to-30- degree angle.
∙
Catheter may be inserted from either directly
over vein or from side of vein. While following the
course of the vein, advance needle or catheter
into vein. A sensation of "give" can be felt when
a needle enters a vein.
14. When blood returns through the lumen of
needle of flashback chamber of catheter, advance
either device 1/8 to 1/4 inches farther into vein.
∙ helps to prevent dislodgement.
A catheter needs to be advance until the hub
is at the venipuncture site, but the exact
technique depends on the type of device used.
15. Release tourniquet.
∙ the vein is maintained if the connection is
Contracting the muscles of the forearm
forces blood into the veins, thereby
distending them further.
a. Lowering the arm below heart level,
tapping the vein, and applying
warmth help distend veins by filling
them with blood.
b. Warm moist compresses help dilate
veins.
Gloves protect against transmission of
HIV and other blood-borne infections.
The lidocaine numbs the skin and makes
the insertion less painful.
Cleansing that begins at the site of entry
and moves outward in a circular motion
carries organisms away from the site of
entry. Organisms on the skin can be
introduced into the tissues or the
bloodstrem with the needle.
Pressure on the vein and surrounding
tissues helps prevent movement of the
vein a needle or catheter is being
inserted. The needle entry site and
catheter must remain free of
contamination from unsterile hands.
This allows needle or catheter to enter
the vein with minimal trauma and deters
passage of the needle through the vein.
The tourniquet causes increased venous
pressure, resulting in automatic backflow.
Placing the catheter well into the vein
Bleeding is minimized and the patency of
Quickly remove protective cap from IV tubing and
attach tubing to catheter or needle. Stabilize
catheter or needle with nondominant hands.
16. Start solution flow promptly by releasing the
clamp on the tubing. Examine the tissue around
the entry site for signs of infiltration.
17. Secure the catheter with narrow non allergenic
tape (1/2 inch) placed sticky side up under hub
and crossed over the top of the hub. ∙
18. Place sterile dressing over the venipuncture
site.
∙ patients at increased risk for infection.
Agency policy may direct nurses to use gauze
dressing or transparent dressing. Apply tape to
dressing if necessary. Loop tubing near the entry
site and anchor to dressing. ∙
19. Mark date, time, site and type and size of
catheter used for infusion on the tape.
Anchor tubing.
20. Remove all equipment and dispose of it in
the proper manner. Remove gloves and
perform hand hygiene
21. Anchor arm to and arm board for support, if
necessary, or apply site protector or tube-
shaped mesh netting over insertion site.
22. Adjust rate of solution flow according to
amount prescribed or follow manufacturer's
directions for adjusting the flow rate on the
infusion pump.
23. Document the procedure and the patient's
response. Chart time, site device, used, and
solution.
24. Return to check flow rate and observe for
infiltration 30 minutes after starting infusion.
made smoothly between the catheter and
tubing.
Blood clots form readily if IV flow is not
maintained. If the catheter accidentally
slips out of the vein, the solution will
accumulate and infiltrate into surrounding
tissue.
The smooth structure of the vein does not
offer resistance to the movement of the
catheter. The weight of the tubing is
sufficient to pull it out of the vein if it is not
well anchored. Non-Allergenic tape is less
likely to tear fragile skin
Transparent dressing allows easy
visualization of site but may place
Gauze dressing absorbs drainage and
may have a decreased infection rate.
Discussion continues about the
effectiveness of various types of
dressings.
Other personnel working with the
infusion will know what type of device is
being used, the site, and when it was
inserted.
Hand hygiene deters the spread of
microorganisms
An arm board or site protector helps to
prevent the position of the catheter in the
rate of flow.
The physician prescribes the rate of flow.
This provides accurate documentation
and ensures continuity of care.
This documents the patient's response to
infusion.
NAME OF STUDENTS: OVERALL RATING:

LEVEL & BLOCK: SCHOOL YEAR AND

TERM
INTRAVENOUS THERAPY EVALUATION CHECKLIST

PERFORMED PERFORME UNABLE Remarks

Procedure/Skill INDEPENDENTLY D WITH TO
ASSISTANCE PERFORM
 0-1 2-3 4-5

1. Gather all equipment and bring it to the

bedside. Check intravenous (IV) solution
and medication additives with physician’s
order.
2. Explain the need for IV solution and
procedure to patients.
3. Perform hand hygiene. If using an
anesthetic (numbing) cream, apply cream
to a couple of potential insertion sites.
4. Prepare IV solution and tubing.
a. Maintain aseptic technique when
opening sterile packages and IV solution.

b. Clamp tubing, uncap spike, and insert

into entry site on bag as manufacturer
directs.

c. Squeeze the drip chamber and allow it

to fill at least half way.

d. Remove cap at end of tubing, release

clamp and allow fluid to move through
tubing. Allow fluid to flow and recap the
end of tubing, maintaining sterility of
setup.

e. If an electronic device is used, follow

manufacturer’s instructions for inserting
tubing and setting infusion rate.

f. Apply a label if medication was added

to the container. (Pharmacy may have
added medication and applied labels.)
Label tubing with date and time tubing is
hung.

g. Place time-tape on container and hand

IV on pole.
5. Place the patient in Fowler’s position in
bed. Place a protective towel or pad
under the patient’s arm.
6. Select appropriate site and palpate
accessible veins.
7. If the site is hairy and agency policy
permits, clip a 2-inch area around the
intended entry site.
8. Apply tourniquet 5-6 inches above
venipuncture site to obstruct venous
blood flow and distend vein. Direct
tourniquet ends away from the entry
site. Check to be sure the radial pulse
is still present.

8. Ask the patient to open and close his or

her fist. Observe and palpate for a
suitable vein. Try the following
techniques if the vein cannot be felt.

a. Release tourniquet and have

a patient lowers his or her arm below
the level of the heart to fill the veins.
Reapply tourniquet and gently tap over
the intended vein to help distend it

b. Remove tourniquet and place warm

moist compresses over indented vein for
10-15 minutes.

10. Don clean gloves.

11. If using intradermal lidocaine:

Cleanse small area of possible insertion
site with alcohol using a circular motion.
Inject a small amount (0.2 to 0.3 ml) of
cream: Wipe cream off insertion site.
Cleanse the entry site with an antiseptic
solution (alcohol swab) followed by
antimicrobial solution (povidone iodine)
according to agency policy. Use a
circular motion to move from the center
outward for several inches.

12. Use the nondominant hand, placed

about 1 to 2 inches below the entry site,
to hold skin taut against the vein. Avoid
touching prepared sites.

13. Enter skin gently with catheter help by

the hub in the dominant hand, bevel side
up, at a 10-to-30-degree angle. Catheter
may be inserted either directly over the
vein or from the side of the vein. While
following the course of the vein, advance
needle or catheter into vein. A sensation
of "give" can be felt when a needle
enters vein.
14. When blood returns through the lumen
of the needle of the flashback chamber of
the catheter, advance either device 1/8 to
1/4 inches farther into the vein. A
catheter needs to be advanced until the
hub is at the venipuncture site, but the
exact technique depends on the type of
device used.

15. Release tourniquet. Quickly remove

protective cap from IV tubing and
attach tubing to catheter or needle.
Stabilize catheter or needle with
nondominant hands.

16. Start solution flow promptly by

releasing the clamp on the tubing.
Examine the tissue around the entry
site for signs of infiltration.

17. Secure the catheter with narrow non

allergenic tape (1/2 inch) placed
sticky side up under hub and crossed
over the top of the hub.

18. Place sterile dressing over the

venipuncture site. Agency policy may
direct nurses to use gauze dressing or
transparent dressing. Apply tape to
dressing if necessary. Loop tubing
near the entry site and anchor to
dressing.

19. Mark date, time, site and type and size

of catheter used for infusion on the
tape. Anchor tubing

20. Remove all equipment and dispose of

it in the proper manner. Remove
gloves and perform hand hygiene.

21. Anchor arm to and arm board for

support, if necessary, or apply site
protector or tube- shaped mesh
netting over insertion site.

22. Adjust rate of solution flow according

to amount prescribed or follow
manufacturer's directions for adjusting
the flow rate on the infusion pump.
23. Document the procedure and the
patient's response. Chart time,
site device, used, and solution.

24.Return to check flow rate and observe

for infiltration 30 minutes after starting
infusion.
Remarks:

STUDENTS SIGNATURE OVER PRINTED NAME

CLINICAL INSTRUCTOR