STARTING AN INTRAVENOUS

INFUSION
Definition:
•Provides route for administration of
fluids, medication, blood or nutrients •Tourniquet
Materials Needed: •Aseptic swab
•Solution •Tape
•IV cannula or steel-winged needle •Bandage scissors
•Administration set •Dressing material
•IV pole •Arm boar
ASSESSMENT
1. Review physician’s order
PLANNING
1. Wash your hands
2. Choose appropriate equipment
3. Set up IV fluid tubing
4. Take equipment to bedside
IMPLEMENTATION
1. Identify patient and explain the procedure
2. Wash your hands
3. Select a position of comfort for yourself
4. Put on gloves.
5. Locate vein. Apply tourniquet 5 to 12 cm. (2-6 inches)
above the injection site
6. Prepare site with effective topical antiseptic according to
hospital policy or cotton balls with alcohol on circular
motion and allow 30 seconds to dry.
7. Using the IV Cannula:
•Pierce the skin with the needle, positioned on 15-30 degree angle, upon
flashback visualization, decrease the angle, and advance the catheter and
stylet into the vein.
•Position the IV catheter parallel to the skin. Hold stationary and slowly
advance the catheter off of the stylet until the hub meets the puncture site.
•Release the tourniquet, remove the stylet while applying digital pressure
over the catheter with one finger about ½ inch from the tip of the inserted
catheter
8. Attach the infusion tubing and open the roller clamp
enough to allow the fluid to drip.
10. Anchor needle firmly in place with tape.
11. Place a transparent tape/dressing directly over the
puncture site.
12. Regulate the flow of infusion according to the
physician’s order.
13. Label the IV fluid bottle
MONITORING AND MAINTAINING AN
INFUSION
Definition:
• An important responsibility is to monitor an IV infusion so
that the flow of the correct solution is maintained at the
correct rate

Materials Needed:
• Watch with a second hand
ASSESSMENT
1. Identify whether the patient has IV fluid running.
2. Examine IV record for accuracy and completeness as to:
• Number of IV infusing
• Ordered contents of the fluid container
• Time the IV was hung
• Time the IV is to be completed
3. Review information about IV infusing if not familiar with.
4. Identify patient
5. Explain that you are monitoring the IV infusion
6. Check IV container
• Date and time
• Correct solution infusing
• The number of IV container is correct
• The fluid level in the container and designated time of completion
7. Inspect drip chamber
• Filled to an appropriate level
• Dripping
• Rate is correct
8. Check tubing for kinks or obstruction
9. Examine IV site for phlebitis or infiltration
• Skin color and temperature
• Pain
• Swelling
10. If arm board is in use, remove, examine for skin irritation
and circulation impairment and replace
11. Identify specific problem present
PLANNING
1. Plan an appropriate course of action on the IV problem
Noted.
IMPLEMENTATION
1. Carry out action planned
 ADMINISTERING MEDICATIONS VIA:
(1) IV PUSH, (2) DRUG INCORPORATION & (3) VOLUMETRIC CHAMBER

ASSESSMENT
1. Validate the orders
2. Examine the medication administration record for accuracy and completeness
3. Review information on the drug, including:
•Effects
•Dilution
•Rate of administration
•Potential for incompatibility with other fluids or medications to be given
4. Assess for what type of IV access is present
PLANNING
5. Determine equipment you will need
6. Wash your hands
7. Select materials needed:
IMPLEMENTATION
8. IV Push
a. Explain procedure (Name of medicine and action) before
administration
b. Check the IV site placement. Check for ANST of the drug for IV
push (if applicable )
c. Disinfect the Y-port using an alcohol swab.
d. Kink tubing, pierce through the Y-injection site and push prepared
drug slowly as ordered
e. Flush IV tubing after drug administration
f. Regulate rate of IVF infusion as ordered
9. Incorporation of drug into IVF
a. Follow procedure a and b on IV push
b. Locate and disinfect the injection port with an alcohol
swab.
c. Close the roller clamp. Remove the IV bottle from the
stand.
d. Incorporate prepared drug aseptically.
e. Shake the bottle to mix incorporated medicine with the IV
solution, hang the bottle, regulate flow rate, and place an IV
label
10. Incorporation into the volumetric chamber
a. Follow procedure 1 and 2 on IV push
b. Set up the Volumetric Chamber
c. Open the package and close all the clamps.
d. Spike into the ordered IV fluid.
e. Open the roller clamp above the volumetric chamber and run down the ordered
amount of IV solution. Close clamp once the amount is reached.
f. Open the roller clamp below the volumetric chamber to prime the tubing. Close the
clamp and attach a needle at the end of the tubing.
g. Disinfect injection port at the volumetric chamber.
h. Incorporate prepared drug.
i. Clamp tubing from the main IV bottle and attach the needle of the volumetric chamber
to the y-port.
j. Regulate the flow rate of IVF infusion as ordered.
k. Place IV label on the volumetric chamber
 MANAGING BLOOD TRANSFUSION
Definition: •Packed cells or whole blood (as
•Provides replacement of blood ordered)
products to increase client’s fluid •Blood crossmatching result
volume, hemoglobin, and hematocrit •Vital signs flow sheet (for
for improved circulation and oxygen monitoring)
distribution.
•Non-sterile gloves
•Prevents over administration of
blood products or the development •Alcohol swabs
of complications associated with a
transfusion.
Materials Needed:
•Blood transfusion tubing (blood Y
set with in-line filter)
•1L Normal saline solution (0.9 NaCl)
ASSESSMENT
1. Review physician’s order for type, amount, and rate of infusion
2. Obtain baseline vital signs, circulatory, respiratory, and skin status.
3. Review baseline complete blood count, blood type and cross-
match
PLANNING
1. Determine equipment you will need
2. Wash your hands
3. Gather materials needed
IMPLEMENTATION
1. Explain the procedure to the client particularly the need for frequent vital sign
checks.
2. Request blood/blood component from hospital blood bank to include blood
typing and cross matching
3. Warm blood at a room temperature by wrapping the blood bag with a towel.
Blood should be transfused not more than 20 minutes from the time it arrives
from the blood bank.
4. Have a co-nurse countercheck the compatible blood to be transfused:
•Name and identification number
•Clients’ blood group and Rh type
•Donor’ blood group and Rh type
•Crossmatch compatibility
•Blood unit and serial component
•The expiration date of blood product
5. Give pre-medication 30 minutes before transfusion if any is
ordered
6. Wash hands and don gloves
7. Initiate an IV line with appropriate IV catheter with Plain
NSS, anchor catheter properly, and regulate the rate
8. Open compatible blood aseptically and spike blood bag
carefully with the BT set, hang the bag, prime the tubing, and
remove bubbles.
9. Disinfect the Y injection port of the IV tubing and insert the
needle from the BT administration set, and secure with
adhesive tapes.
10. Close IV fluid of Plain NSS or regulate to KVO while
transfusion is ongoing.
11. Transfuse the blood (4-6 hrs) via injection port at 10-12
gtts initially for 15 minutes, then regulate at the ordered
rate.
12. Observe for any untoward signs and symptoms
(flushed
skin, chills, elevated temperature, itchiness, urticaria, and
dyspnea); if any occurs, STOP the infusion, open IV line
with NSS, and report to the physician
13. Remove gloves.
14. Swirl the bag once in a while
15. If blood is consumed, close roller clamp of BT set then
disconnect from IV line then regulate the IVF as ordered
EVALUATION
1. Carry out post BT order such as rechecking hemoglobin and hematocrit
levels, bleeding time, etc.

DOCUMENTATION
1. Document observations and interventions done