GUIDELINES AND PROCEDURES IN

INTRAVENOUS PRACTICE

I. OBJECTIVES

At the end of the discussion:1. The students shall be guided on how to

provide safe and quality nursing care to patients receiving INTRAVENOUS (IV) therapy.

2. The students shall be able to define terms associated with IV therapy.

3. Their knowledge, attitude and skills regarding IV therapy are enhanced.

INTRAVENOUS THERAPY

- Is the insertion of needle, cannula or catheter into a vein based on a physician’s written prescription. The needle or catheter is connected to a sterile tubing and a fluid container to provide medication and fluids.

INDICATIONS OF INTRAVENOUS THERAPYTo maintain hydration and/or correct dehydration in patients unable to tolerate

sufficient volumes of oral fluids/medications. Parenteral nutrition. Administration of drugs. Transfusion of blood or blood products. CONTRAINIDCATION OF INTRAVENOUS THERAPY:

- Administration of irritant fluids or drugs through

peripheral IV access.

COMPLICATIONS OF INTRAVENOUS THERAPY:

1. INFILTRATION - dislodgement of the IV cannula from the vein and the leaking of

fluid from the venipuncture site to surrounding tissuesS/Sx : swelling, blanching, and coolness of surrounding tissues Fluid flows slowly or stops Absence of backflow from the IV tubing

2. THROMBOPHLEBITIS- inflammation of the veins caused by injury to vein during

venipuncture, prolonged use of catheter, irritation to vein due to rapid infusion of irritating solutions ( NaHCO3 )S/Sx : tenderness Swelling , warmth, and redness at infusion sit

3. BACTEREMIA- presence of bacteria in the blood- it is caused by underlying phlebitis, used of contaminated

equipments/solutions, prolonged use of IV device

S/Sx: Hyperthermia, chills Nausea and vomiting Malaise, backache, headache

4. CIRCULATORY OVERLOAD- delivery of excessive amounts of fluid

S/Sx: Elevated blood pressure Engorged neck veins DOB, pulmonary crackles

5. AIR EMBOLISM

> occurs when air enters the catheter due to the presence of air in tubing when giving medications

S/Sx : Decreased BP, increased HR Cyanosis, tachypnea, decreased LOC and mentation

6. CATHETER EMBOLISM7. INFECTION OF VENIPUNCTURE SITE8. PULMONARY CONGESTION

INITIATION OF IV THERAPY The initiation of IV therapy shall be to provide peripheral intravascular access for therapeutic indications. This requires a physician’s written prescriptions.

CHOICE OF CANNULA FOR PERIPHERAL IV INFUSIONFactors to consider for the choice of cannula are:

Purpose of the infusion Type of infusion Size and condition of the patient’s vein Duration of treatment Condition of patient

SELECTION OF VENIPUNCTURE SITEFactors to consider: Patient’s condition and age Size and condition of the vein Type and duration of therapyADULT: hands and arms ( metacarpal, basilic, cephalic

veins )INFANTS: scalp vein, dorsal vein of the footANCHORING OF CANNULA AND TUBING

- Good anchoring allows normal blood flow, prevents movement of cannula and irritation of vein thus protecting the venipuncture site.IV CANNULA REMOVAL

- peripheral IV cannulas and the site are routinely changed

aseptically or re-sited every 48-72 hours or when necessary.

NURSING CONSIDERATIONS IN CHOOSING A VENIPUNCTURE SITE

Use distal vein of the arms first. Use client’s nondominant arm when possible Select a vein that is:

a. easily palpated and feels soft and dullb. naturally splinted by bonec. large enough to allow adequate circulation around

the catheter Avoid using veins that are:

a. in areas of flexion b. damaged by previous use, phlebitis, infiltration, or

sclerosisc. continually distended with blood, or knotted, or

tortuousd. in a surgically compromised or injured extremity

PROCEDURAL PROBLEMS ASSOCIATED WITH IV THERAPY

Fluctuating flow rateSluggish IVTubing/ loose connection/ disconnectionBlood back up in tubing IV line obstruction/ kinking of IV tubing Clogged filterBreak in aseptic techniqueLeaks due to inappropriate device 

RISKS ASSOCIATED WITH INTRAVENOUS THERAPY:

Infectious organism exposureNeedle stick injuryChemical exposure 

TYPES OF IV SOLUTIONS:

A) ISOTONIC SOLUTIONS - Solutions that have the same solute concentration as body

fluids and provide fluid volume but do not alter fluid or

electrolyte concentrations ( e.g. PNSS, D5W, PLRS )

NURSING INTERVENTIONS:1. Monitor client for fluid overload because they

expand the intravascular compartment.2. Avoid D5W for patients at risk for increased ICP. ( IVC to intracellular compartment )

B) HYPOTONIC SOLUTIONS - solutions that have solute concentration

lower than that normally found in the body

fluids ( e.g. Distilled water, 0.45% saline,

0.33% saline )- this will cause the cell to swell

NURSING CONSIDERATIONS:1. Contraindicated for patients with

increased ICP because fluid shift into the brain cells

C) HYPERTONIC SOLUTIONS- solutions that have solute concentration higher than that

normally found in the body fluids - this will cause the cell to shrink ( e.g. D5LRS, D5NSS )

NURSING CONSIDERATIONS:1. Monitor patient for circulatory overload because this

solution expand the intravascular compartment.2. Contraindicated for patients with kidney and heart

problems.3. Contraindicated for patients who are dehydrated

because they draw fluid from the cells to the IVC.

EQUIPMENT NEEDED:

A) SETTING UP AN IV INFUSION1. Verify written prescription and make IV label.2. Observe ten (10) R’s when preparing and

administering IVF.3. Explain procedure to reassure patient and/or

significant others, secure consent if necessary4. Assess patient’s vein; choose appropriate site

location, site/condition5. Do hand hygiene before and after the procedure6. Prepare necessary materials for procedure (IV tray

with IV solution, administration set, IV cannula, forceps soaked in antiseptic solution, alcohol swabs or cotton balls soaked in alcohol with cover (this should be exclusively used for I.V.). plaster, tourniquet, gloves, splint, and IV hook), sterile 2x2 gauze or transparent dressing.

B) INTRAVENOUS INSERTION1. Verify the written prescription for IV therapy;

check prepared IVF and other things needed2. Explain procedure to reassure the patient and

significant others and observed the 10 R’s.3. Do hand hygiene before and after the procedure.4. Choose the site for IV5. Apply tourniquet 5 to 12 cm (2-6 in) above

injection site depending on condition of patient.6. Check for radial pulse below tourniquet7. Prepare site with effective topical antiseptic

according to hospital policy or cotton balls with alcohol in circular motion and allow 30 seconds to dry. (No touch technique)

Note: CDC Universal Precaution: Always wear gloves when doing any venipuncture.

8. Using the appropriate IV cannula, pierce skin with needle positioned on a 15-30 degree angle.

9. Upon flashback visualization decrease the angle, advance the catheter an stylet (1/4 inch) into the vein, check if tip of catheter can be rotated freely inside the vein..

10. Position the IV catheter parallel to the skin. Hold stylet stationary and slowly advance the catheter until the hub is 1 mm to the puncture site.

11. Slip a sterile gauze under the hub. Release the tourniquet, remove the stylet while applying digital pressure over the catheter with one finger about 1-2 inch from the tip of the inserter catheter.

12. Connect the infusion tubing of the prepared IVF aseptically to the IV catheter

 

7. Check the sterility and integrity of the IV solution, IV set and other devices

8. Place IV label on IVF bottle duly signed by RN who prepared it (patient’s name, room no., solution, drug incorporation, bottle sequence and duration, time and date.

9. Open the seal of the IV infusion aseptically and disinfect rubber port with cotton bal with alcohol

10.Open IV administration set aseptically and close the roller clamp and spike the infusate container aseptically.

11.Fill drip chamber to at least half and prime it with IV fluid aseptically.

12.Expel air bubbles if any and put back the cover to the distal end of the IV set (get ready for IV insertion)

13. Open the clamp, regulate the flow rate. Reassure patient.

14. Anchor needle firmly in place with the use of: transparent tape/dressing directly on the puncture site tape (using any appropriate achoring style) Band-aid

Note: Never place unsterile tape directly on IV insertion

site, instead place a small piece of sterile OS and then secure it with adhesive tape. 

15. Tape a small loop of IV tubing for additional anchoring; apply splint (if needed)

16. Calibrate the IVF bottle and regulate flow of infusing according to prescribed duration

17. Label on IV tape near the IV site to indicate the date

of insertion, tape and gauge of IV catheter and countersign.18. Label with plaster on the IV tubing to indicate

the date when to change the Iv tubing.19. Observe the patient and report any untoward

effect20. Document in the patient’s chart and endorse to incoming shift21. Discard sharps and waste according to Health

Care Waste Management (DOH/DENR)

C) CHANGING AN IV SOLUTION 1. Verify doctor’s prescription in doctor’s order sheet;

countercheck IV label, IV card, infusate sequence, type, amount, additives (if any), duration of infusion.

2. Observe ten (10) R’s3. Explain procedure to reassure the patient and

significant others and assess IV site for redness, swelling, pain and etc.

4. Change IV tubings and cannula if 48-72 hrs, has lapsed after IV insertion.

5. Wash hands before and after the procedure6. Prepare necessary materials; place on an I.V. tray.7. Check sterility and integrity of IV solution8. Place IV label on the IV bottle.

9. Calibrate new IV bottle according to the duration of infusion as per prescription

10. Open and disinfect rubber port of IV solution to follow.

11. Close the roller clamp and spike the container12. Regulate the flow rate based on the prescribed

infusion rate of infusion. Expel air bubbles (if any).13. Reiterate assurance to patient and significant

others14. Discard all waster materials according to Health

care Waste Management (DOH/DENR)14. Document and endorse accordingly.

D) DISCONTINUING IV INFUSION1. Verify written doctor’s order to discontinue IV

including IV medicines2. Observe ten (10) Rs.3. Asses and inform the patient for the

discontinuation of IV infusion and of any medicine4. Prepare the necessary material; IV tray or injection

tray with sterile cotton balls with alcohol, plaster, pick-up forceps in antiseptic solution, kidney basin band aid.

5. Wash hands before and after procedure6. Close the roller clamp of the IV administration set.7. Moisten adhesive tapes around the IV catheter

with cotton ball with alcohol; remove plaster gently.

8. Use pick-up forceps to get cotton ball with alcohol and without applying pressure, remove needle or IV

catheter then immediately apply pressure over the

venipuncture site.9. Inspect IV catheter for completeness10. Place dressing over the venipuncture site11. Discard all waste materials including the IV cannula according to Health Care Waste Management (DOH/DENR)12. Reassure patient13. Document time of discontinuance, status of insertion

site and integrity of IV catheter and endorse accordingly

BLOOD TRANSFUSION

BLOOD TRANSFUSION> introduction of whole blood or blood components into the venous circulation

BLOOD GROUPS Type A Type B Type AB Type OANTIGENS – proteins that are present on the

surface of an individuals RBCANTIBODIES -

BLOOD PRODUCTS FOR TRANSFUSIONPRODUCT USE

WHOLE BLOOD Not commonly used except for extreme cases of acute hemorrhage.

PACKED RED BLOOD CELLS Used to increase the o2- carrying capacity of blood

AUTOLOGOUS RED BLOOD CELLS Used for blood replacement following planned elective surgery. Client donates blood 4-5 weeks prior to surgery

PLATELETS Replaces platelets in clients with bleeding disorders or platelet deficiency

FRESH FROZEN PLASMA Expands blood volume and provides clotting factors

ALBUMIN AND PLASMA PROTEIN FRACTION

CLOTTING FACTORS AND CRYOPRECIPITATE

Blood volume expander, provides plasma proteins

Used for clients with clotting factor deficiencies

RHESUS ( RH ) FACTOR

BLOOD TYPING AND CROSSMATCHING> this procedure is done to determine the ABO blood

group and RH factor status> it is also performed to pregnant women and neonates to

assess for possible intrauterine exposure of either to an

incompatible blood type ( particularly Rh factor ) incompatibilities. TRANSFUSION REACTIONS

a. hemolytic transfusion reaction - result from a transfusion of ABO or Rh

incompatible blood

TRANSFUSION REACTIONS CLINICAL SIGNS

HEMOLYTIC REACTION:Incompatibility between client’s blood and donor’s blood

Chills, fever, headache, backche, dyspnea, cyanosis, chest pain, tachycardia, hypotension

FEBRILE REACTION:Sensitivity of the client’s blood to WBC, platelets, or plasma protein

Fever, chills, warm flushed skin, headache, anxiety, muscle pain

ALLERGIC REACTION (mild):Sensitivity to infused plasma proteins

ALLERGIC REACTION (severe):Antigen-antibody reaction

Flushing, itching, urticaria, bronchial wheezing

Dyspnea, chest pain, circulatory collapse, cardiac arrest

CIRCULATORY OVERLOAD:Blood administered faster than the circulation can accommodate

Cough, dyspnea, crackles (rales), distended neck veins, tachycardia, hypertension

SEPSIS:Contaminated blood administered

High fever, chills, vomiting, diarrhea, hypotension

PROCEDURE: BLOOD TRANSFUSION1. Verify doctor’s written prescription and make a

treatment card according to hospital policy.2. Observe ten (10) Rs when preparing and

administering any Blood or blood component.3.Explain the procedure/rationale for giving blood

transfusion to reassure patient and significant others and secure consent. Get patient’s history regarding previous transfusion.

4 .Explain the importance of the benefits on Voluntary Blood Donation (RA 7719-National Blood Service Act of 1994)

5. Request prescribed blood/blood component from blood

bank to include blood typing and cross-matching and

blood result of transmissible disease

6. Using a clean lined tray, get compatible blood from hospital blood bank.

7. Wrap blood bad with clean towel and keep it at room temperature.

8. Have a doctor and a nurse assess patient’s condition. Countercheck the compatible blood to be transfused against the cross-matching sheet noting ABO grouping and RH, serial number of each blood unit, and expiry date with the blood bag label and other lab blood exam as required before transfusion (Hgb & Hct)

9. Get the baseline vital signs- BP, R, T before transfusion. Refer to the Physician accordingly

10. Give pre-med 30 minutes before transfusion as prescribed

11. Do hand hygiene before and after the procedure12.Prepare equipment needed for BT.(IV injection

tray, compatible BT set, IV catheter/ needle G18/19, plaster, tourniquet, blood component to be transfused. Plain Nss 500 cc, IV set, g 18 needle (only if neeced), IV hook, gloves, sterile 2x2 gauze or transparent dressing, etc.

13. If main IVF is with Dextrose 5%, initiate an IV line with appropriate IV cath with Plain NSS on another site, anchor catheter properly and regulate IV drops

14. Open compatible blood set aseptically and close roller clamp. Spike blood bag carefully; fill the drip chamber at least half full; prime tubing and remove air bubbles. (if any). Use needle g 18 or 19 for side drip (for adults) or of 22 for pedia (if blood is given through the Y injection port, the gauge of needle is disregarded)

15. Disinfect the Y-injection port of IV tubing (Plain NSS insert the

needle from BT administration set and secure with adhesive tape.

16. Close roller clamp of IV fluid of plain NSS or regulate to KVO while transfusion is going on.17. Transfuse the blood via the injection port at 10-15 drops

initially for 15 mins. and then at the prescribed rate.18. Observe patient for 10-15 minutes for any untoward

immediate reaction.19. Observe patient on an on-going basis for any untoward

signs and symptoms such as flushed skin, chills, elevated temp., itchiness, urticaria and dyspnea. If any of these symptoms occur, stop the transfusion, open the roller clamp of the IV line with Plain NSS and report immediately to the doctor.

20. Swirl the bag hourly to mix the solid with the plasma. N.B. one BT set should be used for one or two units of blood

21. If blood is consumed, close the roller clamp of BT then disconnect from IV lines then regulate the IVF of plain NSS as prescribed22. Continue to observe and monitor patient post

transfusion, for delayed reaction could still occur. 23. Recheck Hgh and Hct, bleeding time, serial platelet

count within specified hours as prescribed 7/or per institution policy.24. Discard blood bag and BT set and sharps according to Health Care Waste Management (DOH/DENR)25.Document the procedure, pertinent observations and

nursing intervention and endorse accordingly.26.Remind the doctor about the administration of Calcium

Gluconate if patient had several units of BT (3-6 or more units of blood).

 

THE END…THANK YOU FOR

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