IV INFUSIONS

I. ADMINISTERING IV THERAPY
- physician is responsible for prescribing kind and amount of solution to
be used
- nurse is responsible for initiating, monitoring, and discontinuing therapy
- nurse must understand patient’s need for IV therapy, type of solution
being used, desired effects,
and untoward reactions that may occur

Steps to Remember: maintain strict aseptic technique

examine solution for type, amt, expiration date, character of
solution, lack of damage
to container
select and prepare IV infusion pump, as indicated
administer IV fluids at room temp
monitor for IV patency before administration of IV meds
maintain occlusive dressing
flush IV lines between administration of incompatible
solutions

A. EQUIPMENT
- sterile technique must be observed
- disposable infusion tubing and needles are used to help eliminate sources of
contamination and reduce cost
- equipment varies according to manufacturer
- most solutions are dispensed in 1-L or 500-mL flexible or rigid plastic
containers
- because plastic bags collapse under atmospheric pressure as solution
enters patient’s vein, they do
not require a vent for air to enter to replace fluid flowing from
container
- some meds bond with plastic in IV bags, glass bottles are then required

1. Basic Administration Set

spike or piercing pin is inserted into container, usually with twisting
motion
rate of flow is manually controlled by clamp or constricting device
on tubing
drip meter or drip chamber connects solution bottle and tubing and
permits number of drops
per minute of solution to be determined
some administration sets have in-line filter

- IV catheters are plastic tubes that have been mounted on a needle or

are threaded through a needle
for insertion
- flexible catheter remains in vein
- over-the-needle catheter is easy to insert and stable, placement is
easily detected w/ x-rays
 - single- or double-winged infusion needles (butterflies) are short-
beveled, thin-walled needles with
plastic flaps - - used in pediatric settings
- not flexible, more likely to infiltrate
- devices available that minimize potential for injury and promote safety
when connecting, accessing,
or disposing of IV equipment
- needleless systems & needle-housing systems (recessed &
protected needle) are common

2. Vascular – length of time infusion therapy is needed, type of med or

product that will be delivered IV,
patient’s health, and individualized needs determine which option
is used

a. Peripheral Venous Catheters – over-the-needle catheters are most

common
- when infusion therapy will be brief, short (< 3 in. )
catheter may be ordered
- insertion site should be rotated at least every 72 – 96 hrs.
- smallest gauge device is usually selected
- dextrose solution 10% or less may be administered this
route

b. Midline Peripheral Catheter – inserted peripherally, normally

through antecubital fossa, but are
longer (> 3 ins)
- not considered to be central lines and should not be infuse
vesicants, hyperosmolar
or irritating solutions
- no set guidelines for length of time it can remain in place
(median of 7 days, possibly
as long as 49 days)

c. Central Venous Access Devices (CVADs) – integral component of pt.

care in acute,
ambulatory, and subacute care settings, as well as home and
long-term care facilities
- provide access for variety of IV fluids, meds, blood products,
and nutritional
solutions
- allow a means for hemodynamic monitoring and blood
sampling
- introduced into subclavian or internal jugular vein and
passed to superior vena cava
just above right atrium
- require x-ray confirmation of position
- pt’s diagnosis, type of care that is required and other factors
(irritating drugs, limited
 venous access, pt. request) determine type of CVAD
used

i. Types:
Peripherally Inserted Central Catheter (PICC) – can be
introduced into peripheral
vein and advanced as far as superior vena cava
- x-ray verification is always required before use
- may have single or dual lumens
- normally replaced as needed (no longer patent or site
looks infected)
- indications include administration of IV antibiotics for
extended period (2 – 6
wks), infusion of parenteral nutrition,
chemotherapy, continuous narcotic infusions,
vesicants, hyperosmolar solutions, blood
components, other specific meds (vasopressors,
anticoagulants), and long-term rehydration
- advantageous because it’s inserted at bedside, risk
for pneumothorax is
decreased, cost-effective and provides adequate
hemodilution for
meds
- nursing responsibilities include sterile dressing
changes, routine heparin or
saline flushes, careful observation for any
complications

DOCUMENT: appearance of site, length of external part of

catheter, dates of
dressing and cap change, flushing frequency and
routine, and any
problems

Nontunneled Percutaneous Central Venous Catheters –

have shorter dwell time
(3 – 10 days) and are introduced through skin into
jugular, subclavian, or
femoral veins, and sutured into place
- can have double-, triple- or quadruple-lumens
- tip rests in superior vena cava
- may be inserted at bedside or in outpatient settings
- high risk for complications (infection and
pneumothorax)

Tunneled Central Venous Catheter – intended for long-

term use, placed through
small incision into jugular or subclavian vein (where tip
lies) and tunneled in
 subcutaneous tissue under skin for 3 – 6 ins. to its exit
site
- initially sutured into place, but after 7 – 14 days,
sutures are removed

Implanted Port – tip is placed in subclavian or jugular vein,

proximal end or port is
usually implanted in subcutaneous pocket of upper
chest wall, no external
parts

peripheral access system ports - placed in

antercubital area of arm
- initially used for chemotherapy
- now used for any pt requiring long-term
intermittent infusions
- special angled noncoring needle is inserted
through skin and rubber
septum and into port reservoir
- require minimal care, but discomfort may be a
disadvantage
- ensure all numbing cream is removed and skin
adequately cleaned
before accessing port

- nursing responsibilities with central venous catheters

include using sterile
techniques, changing dressing, carefully assessing for
any sign of infection,
changing injection caps on lumens, and flushing with
prescribed solution
(saline, heparin) to prevent clotting and blockage

3. Starting an IV Infusion
prepare IV solution and tubing
maintain aseptic technique when opening pkgs./solution
clamp tubing, uncap spike, insert into entry site on bag
squeeze drip chamber, allow it to fill at least half way
remove cap at end of tubing, release clamp, allow fluid to
move through tubing until all
air bubbles have disappeared
close clamp and recap tubing, maintaining sterility
if electronic device is to be used, follow mfg.’s instructions for
inserting tubing and setting
infusion rate
label if med was added to container (pharmacy may have added
and applied label)
place time-tape on container as necessary, hang bag on IV pole
apply tourniquet
cleanse area with antiseptic solution
 with nondominant hand place about 1 or 2 ins below entry site,
hold skin taut against vein
enter skin gently with catheter held by hub, bevel side up, at 10- to
30-degree angle, directly
over or into the side of vein following the course of the vein
- sensation of “give” can be felt when needle enters the vein

***Special Considerations:
Older Adults - avoid vigorous friction at insertion site and using too
much alcohol
Infants / Children – hand insertion sites should not be the 1st choice
- scalp and feet can be used as alternate sites for infants
- do not use feet if child is able to walk
- do not replace peripheral catheters in pediatric pts unless
clinically indicated
- may elect to omit use of tourniquet on pts with prominent
but especially fragile veins

B. SITE SELECTION
1. Accessibility of a Vein
- determine most desirable accessible vein (lower cephalic,
accessory cephalic, basilic are
good sites)
- if pt is right-handed and both arms appear equally usable,
the left is selected
- determine accessibility based on patient’s condition
- do not use antecubital veins if another vein is available
- because flexion of pt’s arm can displace IV catheter over
time
- do not use veins in leg, unless other sites are inaccessible - -
danger of stagnation of
peripheral circulation and possible serious complications
- do not use veins in surgical areas
- select scalp veins for infants because of accessibility and relative
ease of preventing
dislocation of needle

2. Condition of Vein – thin-walled and scarred veins, especially in some

older pts., make continued
infusion a problem

3. Type of Fluid to be Infused – select vein appropriate for solution

- hypertonic solutions, irritating meds, rapid rate administration and
high viscosity solutions
should be given in a large vein to minimize trauma and
facilitate rate of flow
 - advise pt that some meds administered IV may cause irritation
and pain

4. Anticipated Duration of Infusion – select site where restriction in

movement is kept to minimum
- change peripheral venous catheter sites every 72 to 96 hrs,
starting with sites as distal as
possible and moving in proximal direction on alternate arms

5. Other Considerations – select catheter with smallest gauge and

shortest possible length
- insert into largest vein available
- select site that is naturally splinted by bone (back of hand,
forearm)
- if site is not splinted (wrist), use an immobilizer
- select site distal to heart and move proximally
- select site while moving toward heart and away from damaged
vein

C. INITIATION OF IV INFUSION
- perform final check of solution to ensure it’s clear and contains no
particles
- especially important when substances have been added
- commercially available in-line filters help reduce risk of
contamination
- advisable to use product that eases discomfort of venipuncture for
those with a fear of needles

D. REGULATION AND MONITORING

- nurse is responsible for maintaining proper flow rate while ensuring
comfort and safety of patient
- physician prescribes amt of solution to be infused within specified
period
- rate if determined on basis of amt of solution to be infused over 1 hr
(drip rate)
- drop factor (drops per mL of solution) is determined by size of opening
in infusion apparatus
- buretrol (volume-control device) is used to reduce risk of fluid-overload
or med overdose
- common in pediatrics
- used to deliver intermittent meds that need to be further diluted
and over a specific time
- time tape can be placed on container to provide quick reference for
nurse to monitor rate
- gives hourly indication of where fluid level should be

Factors that Affect Flow Rate: height of container in relation to patient

infiltration
 patient’s blood pressure knot or
kink in tubing
patient’s position patency of IV
catheter

- too slow a flow may result in fluid volume deficit, because input is
not balancing fluid lost or it
may delay restoration of balance
- too rapid a flow can overtax the body’s capacities to adjust to
increase in water volume or
electrolytes it contains, and lead to fluid volume excess