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IV THERAPHY AND ITS COMPLICATIONS

Introduction

IV stands for “intravenous” or “inside the vein”.


It means that the patient receives substances directly to
their veins through a tube called a cannula. This could
be either medication or nutrition.

Although the primary care provider is


responsible for ordering IV therapy for clients, nurses
initiate, monitor and maintain the prescribed care
facilities but increasingly in community-based settings
such as clinics and client’s homes. This module talks
about IV therapy concerning:

1. Purposes
2. Assessment
3. Planning
4. Delegation
5. Equipment
6. Implementation
a. Preparation
b. Performance
7. Sample Documentation
8. Evaluation

Pretest
1. A man brings his elderly wife to the emergency department. He
states that she has been vomiting and has had diarrhea for the
past two days. She appears lethargic and is complaining of leg
cramps. What should the nurse do first?
A. Start an IV
B. Review results of electrolytes
C. Offer the woman foods that are high in sodium and potassium
content
D. Administer antiemetics.

2. The nurse administers an IV solution of D5 ½ normal saline to a


postoperative client. This is classified as?_____
3. True or False. The nurse recommends the flow rate of the infusion
4. True or False. Before starting an IV infusion, the nurse verifies the
client if he or she is allergic to seafood.
5. True or False. One of the purpose for starting intravenous infusion is
to provide water-soluble vitamins.
Starting an Intravenous Infusion
Before starting an infusion, the nurse determines the following:
� The type and amount of the solution
� The exact amount (dose) of any medication to be added to a
compatible solution
� The rate of flow or the time over which the infusion is to be
completed

Before preparing the infusion, the nurse first verifies the primary care
provider’s order indicating the type of solution, the amount to be
administered, the rate of flow the infusion and any client allergies.

Purpose:
� To supply fluid when clients are unable to take in an adequate
volume of fluids by mouth
� To provide salts and other electrolytes needed to maintain
electrolyte balance
� To provide glucose (dextrose), the main fuel for metabolism
� To provide water-soluble vitamins and medications
� To establish a lifeline for rapidly needed medications

Assessment

� Vital signs
� Skin turgor
� Allergy
� Bleeding tendencies
� Disease or injury to extremities
� Status of veins to determine appropriate venipuncture site

Planning

Prior to initiating the IV infusion, consider how long the client is


likely to have the IV, what kinds of fluid to be infused, and what
medications the client will be receiving or is likely to receive. These
factors may affect the choice of vein and catheter size.
� Delegation
Starting an IV infusion is a procedure done by registered nurse. Sterile
technique should be observed
Equipment
� Infusion set � Antiseptic swabs
� Sterile parenteral � Antiseptic ointment
solution � Intravenous catheter
� IV pole � Sterile gauze dressing
� Adhesive or non- � Arm splint
allergenic tape � Towel or pad
� Clean gloves � Electronic infusion device
� Tourniquet or pump
Implementation
Preparation
1. Prepare the client
● Prior to the performing of the procedure, introduce self. Explain
the procedure to the client. A venipuncture can cause discomfort
for a few seconds but there should be no discomfort while the
solution is flowing. Use a doll to demonstrate for children, and
explain the procedure for parents. Clients often want to know
how long the process will last. The primary care provider’s order
may specify the length of time of the infusion, for example:
3000mL for 24 hours
● Unless initiating IV therapy is urgent, provide any scheduled care
before establishing the infusion to minimize movement of the
affected limb during the procedure, moving the limb after the
infusion to minimize movement of the affected limb during the
procedure. Moving the limb after the infusion has been
established could dislodge the catheter
● Make sure that the client’s clothing or gown can be removed over
the IV apparatus if necessary. Some agencies provide special
gowns that open over the shoulder and down the sleeve for easy
removal

Performance:
Perform hand hygiene
1. Open the infusion set.
a. Remove the tubing from the container and straighten it
out
b. Slide the tubing clamp along the tubing until it is just below
the drip chamber to facilitate its access
c. Close the clamp
d. Leave the ends of the tubing covered with the plastic caps
until the infusion is started
2. Spike the solution container
a. Remove the protective cover from the entry site of the
bag.
b. Remove the cap from the spike and insert the spike into
the insertion site of the bag or bottle
3. Apply a medication label to the solution container if a medication
is added
a. In many agencies, medications and labels are applied in
the pharmacy; if they are not, apply the label upside down
on the container
4. Apply a timing label on the solution container (depending on
agency policy)
5. Hang the solution container on the pole
a. Adjust the pole so that the container is suspended about
1m (3ft).
6. Partially fill the drip chamber with solution
a. Squeeze the drip chamber gently until it is half full of the
solution
7. Prime the tubing
a. Remove the protective cap and hold the tubing over a
container. Maintain the sterility of the end of the tubing
and the cap
b. Release the clamp and let the fluid run through the tubing
until all bubbles are removed. Tap the tubing if necessary
with your fingers to help the bubbles move
c. Reclamp the tubing and replace the tubing cap,
maintaining sterile technique
d. For caps with air vents, do not remove the cap when
priming this tubing. The flow of solution through the
tubing will cease when the cap is moist with one drop of
solution
e. If an infusion pump, electronic device or controller is being
used, follow the manufacturer’s directions for inserting the
tubing and setting the infusion rate
8. Perform hand hygiene again just prior to client contact
9. Select the venipuncture site
a. Use the client’s non-dominant arm, unless contraindicated.
Identify possible venipuncture sites by looking at the veins
that are relatively straight, not sclerotic or tortous and
avoid venous valves. The vein should be palpable , but may
not be visible, especially with clients with dark skin.
Consider the catheter length; look for a site sufficiently
distal to the wrist or the elbow that the tip of the catheter
will not be at a point of flexion
b. Check agency protocol about shaving if the site is very
hairy.
c. Place a towel or bed protector under the extremity to
protect linens
10. Dilate the vein
a. Place the extremity in a dependent position
b. Apply the tourniquet firmly 15-20cm (6-8in) above the
venipuncture site
c. If the vein is sufficiently dilated:
● Massage or stroke the vein distal to the site and the
direction of venous flow towards the heart
● Encourage the client to clinch and unclench the fist
● Lightly tap the vein with your fingertips
d. If the preceding steps fail to distend the vein so that it is
palpable, remove the tourniquet and wrap the extremity in
a warm, moist towel for 10-15minutes
11. Put on clean gloves and clean the venipuncture site
a. Clean the skin at the site of entry with a topical antiseptic
swab
b. Use a circular motion, moving from the center outward for
several inches
12. Insert the catheter and initiate the infusion
a. If desired and permitted by the policy, inject 0.05 mL of 1%
lidocaine intradermally over the site where you plan to
insert the IV needle. Allow 5-10 seconds for the anesthetic
to take effect. Transdermal analgesic creams may also be
used, depending on the policy. Allow 30 minutes for the
transdermal analgesic to take effect
b. Use the non-dominant hand to pull the skin taut below the
entry site.
c. Holding the over the needle
catheter at a 15-30 degree angle
with bevel up, insert the catheter
through the skin and into the vein.
Sudden lack of resistance is felt as
the needle enters the vein. Jabbing,
stabbing or quick thrusting should
be avoided because it may cause
rupture to delicate veins
d. Once blood appears in the lumen of the needle or you feel
the lack of resistance, lower the angle of the catheter until
it is almost parallel with the skin, and advance the needle
and catheter approximately 0.5-1 cm (about ¼ inch)
farther. Holding the needle portion steady, advance the
catheter until the hub is at the venipuncture site. The exact
technique depends on the type of device used.
e. Release the tourniquet
f. Put pressure on the vein proximal to the catheter to
eliminate or reduce blood oozing out the catheter.
Stabilize the hub with thumb and index finger of the non-
dominant hand.
g. Remove the protective cap from the distal end of the
tubing and hold it ready to attach the catheter,
maintaining the sterility at the end.
h. Carefully remove the needle, engage the needle safety
device, and attach the end of the infusion tubing to the
catheter hub
i. Initiate the infusion
13. Tape the catheter.
a. Tape the catheter
14. Dress and label the venipuncture site and tubing according to
agency policy.
a. Unless there is an allergy, a sterile transparent occlusive
dressing is applied
b. Discard the tourniquet. Remove soiled gloves and discard
appropriately.
c. Loop the tubing and secure it with tape
d. Label the dressing with the date and type of insertion,
type, gauge if catheter used and your initials.
15. Ensure appropriate infusion flow
a. Apply a padded arm board to splint the joint as needed.
b. Adjust the infusion rate of flow according to the order
16. Label the IV tubing
a. Label with the tubing with the date and time of
attachment and your initials. This labeling may also be
done when the infusion is started
17. Document relevant data, including assessments
a. Record the start of the infusion on the client’s chart. Some
agencies provide a special form for this purpose. Include
the date and time of the venipuncture; amount and type
of solution, including any additives; container number;
flow rate; length and gauge of the needle or catheter;
venipuncture site, how many attempts were made and
location of each attempt; the type of dressing applied; and
the client’s general response.
Sample Documentation: 1/15/2008 0600 Inserted 20 gauge angiocath in
(L) forearm on first attempt. IV infusing at 125mL/hr as venoclysis.
Explained reason for IV. Stated understanding--
C.J. De Guzman, MAN

Complications of IV Therapy

Phlebitis-inflammation of the vein


a. Occurs when the cannula is too large for the vein or it is
improperly secured

Signs and symptoms:


a. Warmth
b. Swelling
c. Pain
d. Redness around the vein

Intervention:
a. Stop the infusion
b. No to massaging the site
c. Apply warm, moist pack to the site

Prevention:
a. Use the smallest needle possible suitable for the patient and
fluid being administered
b. Secure properly
c. Instruct patient to minimize movement
d. Avoid joints when placing catheter
Extravasation-when liquid in the IV leaks to the tissue of the surrounding
vein.
a. Caused by inserting the cannula too big for the patient
b. Caused by vesicant drugs

Signs and Symptoms:


a. Burning sensation
b. Swelling around the IV site
c. Necrotic ulcers

Intervention:
a. Stop the infusion immediately
b. Assess the severity if there are any ulcers
c. For mild extravasation: Grade 1 & 2
-stop the infusion
-remove the cannula
-elevate the limb

d. For grade 3 and 4 extravasation: injuries have a greater potential


for skin necrosis, compartment syndrome and the need for plastic
surgery involvement.
-stop the infusion
-remove constricting tapes
-leave cannula in the site until reviewed by doctor
-photograph the injury if this will not delay treatment
-doctor to commence irrigation procedure
-apply non-occlusive dressing
-elevate limb
-referral to plastic surgery

Prevention:
a. Ensure the drug is properly diluted before infusion or injection
b. Use the smallest needle possible suitable for the patient and fluid
being administered
c. Select the venipunctures carefully by choosing the distal vein.
d. Avoid wrist, fingers, antecubital fossa and dorsum of the hand
e. Don’t administer a vesicant in a 24 hour old IV site
f. Secure the IV site properly
g. Assess the site 1-2 hours after administration of the vesicant drug
to check for patency of the IV line.
h. Check for infiltration before administering the drug.
i. During the infusion, instruct the patient to report any pain or
burning sensation to the site for conscious patients

Air embolism-happens when air bubbles enter the vein

Signs and symptoms:


a. blue hue on the skin
b. low blood pressure
c. difficulty of breathing

Intervention:
a. Position the patient to the left side with head down
b. Administer oxygen
c. Monitor vital signs
d. Refer

Prevention: Prime the tubing prior to connecting to the IV catheter

Hypervolemia-abnormal increase in the blood volume. More likely


happen to pregnant women, young children, elderly or with people with
kidney problems.

Signs and symptoms:


a. Tachcardia
b. Distended neck veins

Intervention:
a. Slow down the infusion
b. Notify the physician
c. Verify correct fluid rate of administration

Prevention:
a. Ensure the correct fluid rate
b. Monitor intake and output

Infection-if the IV line, port, or skin on the site of injection are not
properly clean prior to inserting the IV.
Signs and symptoms:
a. Pain
b. Swelling
c. Fever
d. Discharge
Intervention:
a. Stop the infusion
b. Blood culture as ordered
c. Administer antibiotics as ordered
d. TSB for fever
e. Administer paracetamol as ordered

Prevention:
a. Observe sterile technique when doing the procedure
b. Hand hygiene
Post-test: Multiple choice: Board type
1. Patient D will undergo IV insertion. Your goal is to encourage the
patient to be inserted with IV. The most important objective to
keep in mind when measuring your nursing care is:
a. Achieve objectives for care
b. Brought about by healthy physiologic responses from the
patient
c. Provide care the is acceptable for care
d. Met needs of the patient

2. You successfully inserted the IV line of patient D. You will


document:
a. Patient feels comfortable
b. Patient accepted the insertion of IV line
c. Patient greeted the nurse
d. Patient takes medications

3. Apply the tourniquet firmly above the venipuncture site for


about?
A. 7 in
B. 10 cm
C. 50 cm
D. 5 in

4. Shaving is contraindicated in some institutions because


A. It increases the risk of infection
B. It is not contraindicated
C. Not included in protocols
D. All of the above is the answer

5. In order to prevent the reek of blood from the venipuncture,


make sure the that
A. Put pressure to the vein proximal to the catheter
B. Put pressure to the vein distal to the catheter
C. Put pressure to the catheter proximal to the vein
D. Put pressure to the catheter distal to the vein

6. Patient C was administered with an IV side drip of Potassium


chloride running at 10ugtts/min. You notice that there is redness
and the patient complained with pain at the site. You note:
A. Extravasation
B. Infiltration
C. Phlebitis
D. All of the above

7. Which of the following is not a sign and symptom of


extravasation?
A. Patient L, an adult patient has a HR of 121 bpm
B. Patient C, has a pain and redness at the site
C. Patient A, has a localized edema on her IV site
D. All of the above

8. Which of the following is a prevention of extravasation?


A. Tape the venipuncture site properly
B. Avoid inserting at the distal area of the hand
C. Assess the site every 2.5 hours
D. All of the above

9. IV complication that is caused by fail observation of sterile


technique during insertion
A. Infection
B. Extravasation
C. Cardiac overload
D. All of the above

10. Give atleast 1 IV complication

Reference:
Berman, A, et al. Fundamentals in Nursing. 8th ed., II, Pearson Education,
2008.
Haddaway, L C. Preventing and Managing Peripheral Extravasation, vol.
39, no. 10, 1 June 2020, pp. 26–27.,
doi:10.1097/01.NURSE.0000361260.92163.c1.
The Royal Children's Hospital Melbourne. Extravasation Injury
Management. The Royal Children's Hospital Melbourne,
www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Extravasa
tion_injury_management/.