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

Course or Learning Outcomes

At the end of this module, the student will be able to:
1. Explain the purposes of starting and IV infusion
2. Assess the patient prior to IV insertion
3. Plan to initiate IV infusion
4. Prepare the necessary equipment needed for IV insertion
5. Implement the IV insertion
6. Do a sample documentation
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
 Sterile parenteral solution
  IV pole
 Adhesive or non-allergenic tape
 Clean gloves
 Tourniquet
 Antiseptic swabs
 Antiseptic ointment
 Intravenous catheter
 Sterile gauze dressing
 Arm splint
 Towel or pad
 Electronic infusion device 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

References:

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/Extravasation_injury_managem
ent/.