RETURN DEMONSTRATION (NCMA 113)
IVT INFUSION
Note: Before preparing infusion, verify
primary care provider’s order:
- Type of solution to be administered
- Rate of flow/time the infusion to be
completed
- Any client’s allergies
PURPOSE
- Supply fluid for clients unable to
take adequate fluid volume orally
- Provide salts & other electrolytes to
maintain electrolyte balance
- Provide water-soluble vitamins &
medication
- Provide dextrose for metabolism
- Establish lifeline for rapidly needed
medications
ASSESSMENT
- Vital signs for baseline of data
(RR,PR, & BP)
- Allergies to latex, tape or iodine
- Bleeding tendencies
- Disease/injury of extremities
- Status of veins
Note: Avoid recently used sites because it is
prone to complications & discomfort.
- Determine client’s dominant hand
Note: If venous sites are not found do not do
blind venipuncture or use vascular
visualization method
- Agency policy about hair clipping
the area before a venipuncture
Note: It is not recommended for possible
scratch or following infection.
PLANNING
Factors that may affect choice of vein & size
of catheter
1. How long client is likely to have IV
2. Kinds of fluid to be infused
3. Medication client is receiving
- Review clients record regarding
previous infusion. Note for any
complications and how it is
managed.
- Consider using local anesthetics to
reduce pain & discomfort during
catheter insertion.
EQUIPMENT
- Substitute appropriate equipment for
clients with tape, iodine or latex
allergies
● Infusion set
● Extension tubing (optional)
● Sterile parenteral solution
● IV pole
● Non Allergenic tape
● Clean gloves (Sterile is needed for
site palpation after skin antisepsis)
● Single-used and latex free tourniquet
● Antiseptic swab (10%
povidone-iodine, 2% chlorhexidine
gluconate with alcohol [preferred for
its residual effect lasting for 48hr], or
70% isopropyl alcohol
● IV catheter with passive system
mechanism
Rationale: automatically retracts
needle to avoid needlestick injury.
#20&#24 gauge for adult clients.
Choose appropriate type and size
based on size of the vein and purpose
of IV. Always have extra catheter
with ones in different sizes available
● Stabilization device
● IV protection device
 RETURN DEMONSTRATION (NCMA 113)
● Sterile gauze dressing/Transparent
semipermeable membrane dressing
(preferred)
● Towel/bed protector
● Local anesthetics (optional & per
agency policy)
● Splint (if required)
● Vein visualization device (if needed)
● Electronic infusion device or pump
(if applicable)
IMPLEMENTATION
PREPARATION
1. Select time to perform venipuncture
convenient to the client. If urgent,
provide scheduled care before
infusion establishment to minimize
excessive movement of affected
limb.
Rationale: Moving affected limb after
infusion establishment can remove
catheter.
2. Make sure client’s gown or clothing
can be removed over the IV
apparatus.
3. Visitors/family members may be
asked to leave if desired by nurse or
client.
PERFORMANCE
1. Introduce self, verify client’s
identity, explain procedure, why it is
necessary and how client will
participate. If possible, explain how
long the IV will remain & how it will
be used
2. Hand hygiene & other infection
prevention procedures
3. Place client in a comfortable position
whether sitting or lying. Expose the
limb site to be used still providing
privacy.
4. Apply a medication label to the
solution bottle if medication is
needed. If not applied, put it upside
down on the container.
Rationale: can be easily read when
the container is hanging up.
5. Open & prepare the packaging of the
infusion set & straighten it out. Slide
tubing clamp below drip chamber &
close the clamp. Leave ends of
tubing covered with plastic caps until
the infusion starts.
Rationale: Keep the sterility of
both ends of tubing
6. Spike solution container by
removing the protective cover of the
bag, removing the cap of the spike
and insert the spike at the insertion
site
7. Hang the solution in the pole and
adjust the pole for about 1 cm (3ft)
above client’s head.
Rationale: enable gravity to
overcome venous pressure and
facilitate flow of the solution into
the vein.
8. Partially fill drip chamber by
squeezing the chamber until half full
solution.
Rationale: prevent air from
moving down the tubing.
9. Prime tubing by removing the
protective cap holding tubing over a
container and releasing the clamp.
Let the fluid run through the tubing
until all bubbles are removed. Tap
the tubing if necessary with fingers
 RETURN DEMONSTRATION (NCMA 113)
to help the bubbles move. Reclamp
the tubing and replace tubing cap
Rationale: prevent the introduction of air
into the client
10. Hand hygiene
11. Select venipuncture site
- Use non dominant arm, look for
relatively straight and palpable veins,
site sufficiently distal to the wrist or
elbow such that the tip of the
catheter will not be at a point of
flexion
Rationale: Joint flexion can increase risk
of irritation of vein walls by the catheter.
- Choose the site most likely to last the
full length of the IV therapy, which
most likely will be using a vein in
the forearm
- Check agency protocol about
shaving if the site is very hairy
12. Dilate the vein by placing extremity
in a dependent position (lower than
the client’s heart).
Rationale: Gravity slows venous return
and distends the veins. Distending the
veins makes it easier to insert the needle
properly
- Apply a tourniquet 15 to 20 cm (6 to
8 in.) above the venipuncture site.
Rationale: The tourniquet must be tight
enough to obstruct venous flow but not
too much that it obstructs arterial flow.
Obstructing arterial flow inhibits venous
filling. If a radial pulse can be palpated,
the arterial flow is not obstructed.
13. Remove the tourniquet while
preparing the insertion site
14. Minimize insertion pain as much as
possible by Transdermal analgesic
creams
15. Apply clean gloves and clean the
venipuncture site.
Rationale: Gloves protect the nurse from
contamination by the client’s blood.
- Clean the skin with soap and water if
visibly soiled. Remove excess hair if
necessary using scissor or surgical
clippers.
- chlorhexidine solution (preferred),
use a backand-forth motion for 30
seconds to scrub the insertion site
and surrounding area. Allow the site
to completely air dry before inserting
the catheter. Do not fan, blow on, or
wipe the skin
- povidone-iodine, apply using
applicator and allow to remain on the
skin for 1.5 to 2 minutes or longer to
completely dry for adequate
antisepsis
16. Reapply a tourniquet or use vein
visualization technology, if needed.
- If vein palpation is necessary after
application of skin antiseptic, apply
sterile gloves.
17. Insert the catheter and initiate the
infusion.
- Remove the catheter assembly from
its sterile packaging. Review
instructions. Remove the cover of the
needle (stylet).
- Use the nondominant hand to pull
the skin taut below the entry site
Rationale: stabilizes the vein and makes
the skin taut for needle entry, make initial
tissue penetration less painful.
- Holding the over-the-needle catheter
at a 15- to 30-degree angle with
needle (stylet) bevel up, insert the
 RETURN DEMONSTRATION (NCMA 113)
catheter through the skin and into the
vein
- Once blood appears (backflow)
lower the angle of the catheter until
it is almost parallel with the skin, and
advance the needle (stylet) and
catheter approximately 0.5 to 1 cm
(about 1/4 in.) farther into the vein
Rationale: catheter is advanced to ensure
that it, and not just the stylet, is in the
vein
- No backflow, try redirecting the
catheter assembly again toward the
vein. If the stylet has been
withdrawn from the catheter even a
small distance, or the catheter tip has
been pulled out of the skin, must be
discarded and a new one used.
Rationale: Rationale: Reinserting can
result in damage or slicing of the catheter.
A catheter removed from the skin is
considered contaminated and cannot be
reused
- hematoma, the insertion has not been
successful. Immediately release the
tourniquet, remove the catheter,
applying pressure over the insertion
site with dry gauze. Attempt the
venipuncture in another site, in the
opposite arm if possible
Rationale: Placing the tourniquet back
above the unsuccessful site may cause it to
bleed. Placing the IV below the
unsuccessful site could result in infusing
fluid into the already punctured vein,
causing it to leak.
- Release the tourniquet and put
pressure on the vein proximal to the
catheter to eliminate or reduce blood
oozing out of the catheter. Stabilize
the hub with the thumb and index
finger of the nondominant hand.
- Remove the protective cap from the
distal end of the tubing and hold it
ready to attach to the catheter
- Stabilize the catheter hub and apply
pressure distal to the catheter with
your finger
Rationale: This prevents excessive blood
flow through the catheter
- remove the stylet, engage the needle
safety device if it does not engage
automatically, and attach the end of
the infusion tubing to the catheter
hub
- Initiate the infusion or flush the
catheter with sterile normal saline.
Rationale: Blood must be removed from
Otherwise, the blood will clot inside the
lumen.
- Stabilize the catheter and apply a
dressing by securing the catheter
according to the manufacturer’s
instructions and agency policy. If
tape is used, it must be sterile tape or
surgical strips and they should be
applied only to the catheter adapter
and not placed directly on the
catheter–skin junction site. Use of a
manufactured stabilization device is
preferred
- Apply a TSM dressing over the
insertion site. Additional tape may be
used to secure the IV catheter below
the TSM, if necessary. Do not place
tape on the TSM dressing
- Label the dressing with the date and
time of insertion, gauge, and your
initials
 RETURN DEMONSTRATION (NCMA 113)
- Apply an IV site protection device, if
available. help prevent dislodgement
of the catheter and still provide easy
assessment of the IV site
- Loop the tubing and secure it with
tape
Rationale: prevent the weight of the
tubing or any movement from pulling on
the needle or catheter.
18. Discard the tourniquet, remove and
discard gloves, perform hand
hygiene
19. Ensure appropriate infusion flow,
apply a padded arm board to splint
the joint if needed, adjust the
infusion rate of flow according to the
order
20. Label the IV tubing with the date and
time of attachment and your initials
Rationale: The tubing is labeled to ensure
that it is changed at regular intervals
21. complete the following client
teaching:
- Any limitations as to movement or
mobility and protection of the site
- Signs and symptoms to report to the
nurse
- Alarms if an electronic infusion
device is being used
- Infection prevention precautions,
including hand hygiene by all
healthcare providers who provide
care
22. Document all assessments and
interventions
- Record the venipuncture on the
client’s chart.Include the date and
time of the venipuncture; use of
visualization technology as
appropriate; type, length, and gauge
of the needle or catheter;
venipuncture site, how many
attempts were made, amount and
type of solution used, including any
additives (e.g., kind and amount of
medications); flow rate; the type of
dressing applied; the client’s general
response; and client education.
IVT DISCONTINUING
PURPOSE
- discontinue an IV infusion when the
therapy is complete or when the IV
site needs to be changed
ASSESSMENT
- Appearance of the venipuncture site
- Any bleeding from the infusion site
- Amount of fluid infused
- Appearance of short peripheral
catheter
PLANNING
- Review the client record regarding
the primary care provider’s orders.
Note if there were any previous
infusions and if there were any
complications and how they were
managed.
EQUIPMENT
- Clean gloves
- Linen-saver pad
- Small sterile dressing and tape
IMPLEMENTATION
1. Introduce self, verify client’s
identity, explain procedure, why it is
necessary and how client will
participate. If possible, explain how
long the IV will remain & how it will
be used
 RETURN DEMONSTRATION (NCMA 113)
2. Hand hygiene & other infection
prevention procedures
3. Place client in a comfortable position
sitting or lying. Expose IV site,
provide for client privacy. Place a
linen saver pad under the extremity
that has the IV.
4. Prepare the equipment by clamping
the infusion tubing…
Rationale: prevents the fluid from flowing
out of the needle onto the client or bed
…Apply clean gloves, remove the dressing,
stabilization device, and tape at the site
while holding the needle firmly and
applying countertraction to the skin…
Rationale: Countertraction prevents
pulling the skin and causing discomfort.
… Assess the vascular access site…
Rationale: signs of infection or phlebitis
…Apply the sterile gauze above access site
with the nondominant hand. Only touch the
upper portion of the gauze pad
5. Withdraw the catheter from the vein
with the dominant hand by pulling it
out along the line of the vein using
gentle, even pressure
Rationale: avoids injury to the vein. Do
not press down on the sterile gauze pad
while removing the catheter
… immediately apply firm pressure to the
site, using sterile gauze, for a minimum of
30 seconds or until hemostasis is achieved…
Rationale: Pressure helps stop the
bleeding and prevents hematoma
formation
…Hold client’s arm above heart level if any
bleeding persists…
Rationale: decreases blood flow to the
area
…Teach client to inform the nurse if the site
begins to bleed at any time or any other
abnormalities in the area
6. Examine the catheter removed from
the client make sure it is intact…
Rationale: If a piece of tubing remains in
the client’s vein it could move centrally
(toward the heart or lungs)
…Report a broken catheter to the nurse in
charge or the primary care provider
immediately. If a broken piece can be
palpated, apply a tourniquet above the
insertion site.
Rationale: Application of a tourniquet
decreases the possibility of the piece
moving until a primary care provider is
notified
7. Cover the venipuncture site by
applying new sterile dressing to the
site with tape…
Rationale: The dressing continues the
pressure and covers the open area in the
skin, preventing infection.
… Discard used supplies appropriately,
remove and discard gloves, perform hand
hygiene
8. Read the amount remaining in the IV
solution container.
9. Apply a black-out label over the
existing IV solution label prior to
discarding the IV solution into a
biohazard container
Rationale: The existing IV label contains
client information. The black-out label
conceals client information and ensures
client confidentiality. These labels are
called IV HIPAA-compliant labels.
10. Document all relevant information.
Record:
 RETURN DEMONSTRATION (NCMA 113)
- amount of fluid infused on
the intake and output record
and in the record
- container number, type of
solution used, time of
discontinuing the infusion,
and the client’s response.
BLOOD TRANSFUSION USING Y-SET
PURPOSE
- restore blood volume after severe
hemorrhage
- restore the oxygen-carrying capacity
of the blood
- provide plasma factors, such as
antihemophilic factor (AHF) or
factor VIII, or platelet concentrates,
which prevent or treat bleeding
ASSESSMENT
- Vital signs; oxygen saturation is
often included
- Physical examination: fluid balance
and heart and lung sounds as
manifestations of hypo- or
hypervolemia
- Status of infusion site and patency of
vascular access device
- Blood test results such as
hemoglobin value or platelet count
- Any unusual symptoms
PLANNING
- Review the client record previous
transfusions. Note any complications
and how they were managed
- Confirm the primary care provider’s
order (number and type of units and
the desired speed of infusion)
- In some agencies, written consent for
transfusion is required. Check policy
and obtain as indicated.
- Know the purpose of the transfusion.
- Plan to begin the transfusion as soon
as the component is ready. Typing
and crossmatching can take several
hours.
- Note any premedication ordered by
the primary care provider
EQUIPMENT
- Unit of whole blood, PRBCs, or
other component
- Blood administration set
- IV pump, if needed (use EIDs that
have a labeled indication for blood
transfusion)
- 250 mL normal saline for infusion •
IV pole
- Venipuncture set containing a #20- to
#24-gauge catheter (if one is not
already in place)
- Alcohol swabs
- Tape
- Clean gloves
IMPLEMENTATION
● If the client has an IV solution
infusing, check whether the IV
catheter and solution are appropriate
to administer blood
● If the client does not have an IV
solution infusing,infusion must be
running before the blood is obtained
from the blood bank. you will need
to perform a venipuncture on a
suitable vein and start an IV infusion
of normal saline
 RETURN DEMONSTRATION (NCMA 113)
● Obtain assistance of another RN to
perform client and blood
identification process
1. Introduce self, verify the client’s
identity, explain what you are going
to do, why it is necessary, and how to
participate. Instruct the client to
report any sudden chills, nausea,
itching, rash, dyspnea, back pain, or
other unusual symptoms
2. Prepare the client by assisting to a
comfortable position, either sitting or
lying. Expose the IV site but provide
for client privacy.
3. hand hygiene and other appropriate
infection prevention procedures
4. Prepare the infusion equipment by
ensuring that the blood filter inside
the drip chamber is suitable for the
blood components to be transfused.
Attach the blood tubing to the blood
filter, if necessary…
Rationale: allow the blood components
through easily but are designed to trap
clots.
… Apply gloves, close all the clamps on the
Y-set: the main flow rate clamp and both
Y-line clamps, insert the piercing pin (spike)
into the saline solution, hang the container
on the IV pole about 1 m (39 in.) above the
venipuncture site.
5. Prime the tubing by opening the
upper clamp on the normal saline
tubing ,squeeze the drip chamber
until it covers the filter and one-third
of the drip chamber above the filter,
Tap the filter chamber to expel any
residual air in the filter, Open the
main flow rate clamp, and prime the
tubing with saline, Close both
clamps
6. Start the saline solution
- If an IV solution
incompatible with blood is
infusing, stop the infusion
and discard the solution and
tubing
- Attach the blood tubing
primed with normal saline to
the IV catheter
- Open the saline and main
flow rate clamps and adjust
the flow rate. Use only the
main flow rate clamp to
adjust the rate
- Allow a small amount of
solution to infuse to make
sure there are no problems
with the flow or with the
venipuncture site.
Rationale: Infusing normal saline before
initiating the transfusion also clears the
IV catheter of incompatible solutions or
medications
7. Obtain the correct blood component
for the client
- Check the primary care provider’s
order with the requisition.
- Check the requisition form and the
blood bag label with a laboratory
technician or according to agency
policy. Specifically, check the
client’s name, identification number,
blood type and Rh group, the blood
donor number, and the expiration
date of the blood. Observe the blood
for abnormal color, RBC clumping,
gas bubbles, and extraneous material.
 RETURN DEMONSTRATION (NCMA 113)
Return outdated or abnormal blood
to the blood bank.
- With another nurse and in the
presence of the client, verify the
following before initiating the
transfusion:
● Order: blood or component
against the primary care
provider’s written order
● Transfusion consent form:
Ensure the form is completed
per facility policy.
● Client identification: The
name and identification
number on the client’s
identification band must be
identical to the name and
number attached to the unit
of blood.
● Unit identification:unit
identification number on the
blood container, the
transfusion form, and the tag
attached to the unit must
agree.
● Blood type: The ABO group
and Rh type on the primary
label of the donor unit must
agree with those recorded on
the transfusion form.
● Expiration: expiration date
and time of the donor unit
should be verified as
acceptable.
● Compatibility: compatibility
testing must be recorded on
the transfusion form and on
the tag attached to the unit.
● Appearance: no
discoloration, foaming,
bubbles, cloudiness, clots or
clumps, or loss of integrity of
the container.
- If any of the information does not
match exactly, notify the charge
nurse and the blood bank. Do not
administer blood until discrepancies
are corrected or clarified.
- Sign the appropriate form with the
other nurse according to agency
policy.
- Make sure that the blood is left at
room temperature for no more than
30 minutes before starting the
transfusion.
Rationale: As blood components warm,
the risk of bacterial growth also increases.
If the start of the transfusion is
unexpectedly delayed, return the blood to
the blood bank after 30 minutes. Do not
store blood in the unit refrigerator.
Rationale: temperature of unit
refrigerators is not precisely regulated
and the blood may be damaged.
8. Prepare the blood bag by inverting
the blood bag gently several times to
mix the cells with the plasma…
Rationale: Rough handling can damage
the cells.
…Expose the port on the blood bag
by pulling back the tabs, insert the
remaining Y-set spike into the blood bag.
9. Establish the blood transfusion by
closing the upper clamp below the
IV saline solution container, open the
upper clamp below the blood bag.
The blood will run into the
saline-filled drip chamber. If
necessary, squeeze the drip chamber
to reestablish the liquid level with
 RETURN DEMONSTRATION (NCMA 113)
the drip chamber one-third full. (Tap
the filter to expel any residual air
within the filter.), Readjust the flow
rate with the main clamp,
- Remove and discard gloves
- Perform hand hygiene
10. Observe the client closely for the
first 15 minutes.
- start the transfusion slowly at
approximately 2 mL per minute for
the first 15 minutes, and remain
near the patient; increase the
transfusion rate if there are no signs
of a reaction
Rationale: small amount is enough to
produce a severe reaction, could be
treated successfully
- Note adverse reactions, such as
chills, nausea, vomiting, skin rash,
dyspnea, back pain, or tachycardia.
Rationale: The earlier a transfusion
reaction occurs, the more severe it tends
to be. Promptly identifying such reactions
helps to minimize the consequences.
- Remind the client to call a nurse
immediately if any unusual
symptoms are felt during the
transfusion
- If any reactions occur, report them to
the nurse in charge, and take
appropriate nursing action
11. Document relevant data.
- starting the blood, including vital
signs, type of blood, blood unit
number, sequence number, site of the
venipuncture, size of the catheter,
and drip rate.
12. Monitor the client
- 15 minutes after initiating the
transfusion check the vital signs. If
no signs of a reaction, establish the
required flow rate. Most adults can
tolerate receiving 1 unit of blood in
1.5 to 2 hours. Do not transfuse a
unit of blood for longer than 4
hours. If the client has a reaction and
the blood is discontinued, send the
blood bag and tubing to the
laboratory for investigation of the
blood
13. Terminate the transfusion
- Apply clean gloves.
- no infusion is to follow, clamp the
blood tubing. If another transfusion
is to follow, clamp the blood tubing
and open the saline infusion arm.
- If the primary IV is to be continued,
flush maintenance line with saline
solution. Disconnect the blood
tubing system and reestablish the IV
infusion using new tubing. Adjust
the drip to the desired rate.
- Measure vital signs.
14. Follow agency protocol for
appropriate disposition of the used
supplies.
- Discard the administration set
according to agency practice:
❖ Dispose of blood bags and
administration sets. fill in the
time the transfusion was
completed and the amount
transfused.
❖ Attach one copy of the requisition to
client’s record and another to the
empty blood bag
❖ Agency policy generally involves
returning the bag to the blood bank
for reference in case of subsequent or
delayed adverse reaction.
 RETURN DEMONSTRATION (NCMA 113)

- Remove and discard gloves

- Perform hand hygiene.
15. Record completion of the
transfusion, amount of blood
absorbed, the blood unit number, and
the vital signs. If the primary IV
infusion was continued, record
connecting it. Also record the
transfusion on the IV flow sheet and
intake and output record.