ASSISTING IV INFUSION

 Definition:
Is an administration of fluid, electrolytes, or nutrients through
a needle or cannula inserted into a vein.
 Purpose:
To administer fluids intravenously when clients are unable to
take fluids orally and for medication purposes .
 Principles:
1. Assess vital signs for baseline data
2. Assess bleeding tendencies
3. Assess disease or injury to extremities
4. Assess status of veins to determine appropriate venipuncture sites
5. Observe appropriate infection control procedures
 Equipment:

IV solution
IV tubing
IV catheter or needle
IV pole for gravity infusion
Adhesive or non- allergenic tape
Clean gloves
Rubber Tourniquet
Antiseptic swabs
Antiseptic ointment such as Povidone Iodine
Sterile gauze, Dressing or transparent occlusive
dressing
Arm splint (if required)
 Types of Fluids

ISOTONIC SOLUTIONS

 has same osmolarity (or tonicity) as serum and other

body fluids.

a. Lactated Ringer’s
b. Normal Saline
c. D5 Water
 Indication
-hypotension due to hypovolemia.
HYPERTONIC SOLUTIONS

 Has an osmolarity higher than that of serum.

a. D5Nss
b. D5LR
c.D10W
d. D5 IMB
 Indications
Post-operative pt.
- reduces the risk of edema
- stabilizes the blood pressure
- regulates urine output
 treats hypoglycemia
HYPOTONIC SOLUTIONS

Has an osmolarity lower than serum osmolarity.

a. .33% NaCl
b. Dextrose 2.5% in water

 Indication
- Hyperglycemia
 Parts of Intravenous tubing
1. Spike
2. Drip chamber
 permits a predictable amount of fluids to be
delivered.
 10-20 drops set delivers macro drip per milliliter of
solution.
 60 drops set delivers micro drip per milliliter of

solution.
3. Roller valve or screw clamp- controls the rate of the
flow
4. Injection port- administering IV medication or
secondary infusion.
 Vein selection

1. Use distal veins of the arm first.

2. Use non dominant hand if possible.
3. Select the vein that is
a. Easily palpated & feel soft and full
b. Naturally splinted by bone
c. Large enough to allow adequate circulation
around the catheter
4. Consider the catheter length.
 Procedure  Rationale

 Check the doctor’s order

 To facilitate acceptance & willingness
to cooperate since venipuncture can
cause discomfort.
 Explain the procedure the patient

 3. Wash hands for appropriate infection

control procedures and to save time &
 Wash hands. Gather all equipment effort.

 4. To check if the order reflects the

 4. Inspect the solution of the patient’s actual condition. Cloudiness is
following: kind of solution ordered, an evidence that the container has
volume ordered & clearness & been opened previously. Leaks
expiration date indicate possible contamination.
5. Open the vacodrip set Follow the instructions
accompanying the set.
6. A. For bottle solution:
Remove the bottle’s metal
cap & inner disk on a
stable surface & wipe
rubber stopper with an
alcohol sponge, insert the
spike
B. For bag solution:
Place the bag flat on
stable surface, remove
protective cap, insert the
spike
7. Hang IV bottle/pack on IV pole & 7. Container should be
prepare strips of plaster. suspended about 1m(3ft)
above the client’s head. This
height is needed to enable
gravity to overcome venous
pressure & facilitate flow of
the solution into the vein.
Strips of plaster are used to
tape the catheter later.

8. Allowing the IV fluid to

8. Open the regulator & allow the completely displace the air in the
solution to run through the tubing
tubing , then close the
regulator. (Prime the chamber one third to
one half full by pressing it
between thumb and index finger)
9. Doctor applies tourniquet & offer 9. The tourniquet is used to dilate the
cotton ball w/alcohol to the doctor vein making it easier to insert the
& instruct patient to make a fist. needle properly. And should be
place firmly to15 to 20 cm above
the venous flow. If the radial pulse
can be palpated, the arterial flow is
not obstructed. Cotton ball w/
alcohol is used to disinfect the site.
The client should make a fist to
contract the muscles which
compresses the distal veins &
distending them. Tapping lightly the
vein w/ your fingertips may also
distend the vein.
10. Once backflow is present, 10. The doctor holds the
remove the needle & connect needle pointing in the
the end part of the tube. direction of blood flow at a
Release tourniquet & instruct 30o angle w/ bevel up &
patient to open the fist, then pierce the skin beside the
open the regulator. vein about 1cm (1 ½ in)
below the site planned for
piercing.

11. Plaster is used to secure

the needle properly.
( chevron method) a small
11. Offer plaster & gauze under the needle is
assist in anchoring. required keeping the
needle in position in the
vein.
12. Adjust the arm board or 12. Arm board or splint is
splint, bandage, and anchor used to stabilize the arm
securely. as well as the tubing.

13. Regulate the flow of the 13. To ensure appropriate

solution as ordered. infusion flow.

14. The watcher should

14. Instruct the patient or observe the patient all
watcher to call when there is the time and call the
a change in the rate of flow, nurse when there is a
or when the solution stops problem. Proper
flowing, when the site is communication should
painful or bulging, when the be established. This is
solution is almost consumed to prevent complications
and when there is air or associated with IV
blood in the tubing. therapy.
15. Leave the patient in a 15. Assess the
comfortable position. patient’s difficulties
after the infusion.

16. Carry the tray to the 16. Do after care.

utility room. Wash your Wash hands to
hands. observe appropriate
infection control
procedures.
 Termination
1. Close the regulator if 1. So that blood would not get
bottle/pack is almost in the tubing when fluid is
empty. consumed.
2. Remove the adhesive 2. For easy removal of the IV
tape. catheter.
3. Apply the pressure using 3. Pressure help stop the
Cotton ball with alcohol bleeding and prevents
over the point of insertion hematoma formation.
and withdraw the needle 4. To prevent the open skin
quickly. from infection and for
4. Dry the area with cotton continues application of
ball and apply adhesive force and pressure on
tape. area.
5. Leave the patient 5. Assess any difficulties the
comfortably and tidy the patient feels and apply
unit. appropriate nursing
interventions to settle the
problem.

6. Chart: Date, time, solution 6. For documentation purposes

used, bottle/pack number, and further use.
amount rate per minute,
site and doctor who
inserted the needle. In
numbering bottles/packs
used, ascertain whether the
number is for the whole
series or one day series.
Record the unusual
reaction of the patient or
the treatment, if there is
any.
 COMPLICATIONS OF IV THERAPY

 INFILTRATION
- when IV needle becomes dislodged from the vein. Fluid
flows into interstitial tissue.
- swelling, coolness, pallor & discomfort at the IV site.
 PHLEBITIS
-a result of injury to a vein
- heat, pain, redness, and edema develop around the site.
 AIR EMBOLISM
-Air in tubing delivered by IV push or infused by infusion
pump
- decrease BP, cyanosis, tachycardia, jugular vein distention,
loss of consciousness
 ALLERGIC REACTION

Minor reaction
- Rash, redness and itching
Major reactions
- Coughing, dyspnea, swollen tongue, cyanosis,
unconsciousness and death

 CIRCULATORY OVERLOAD

Delivery of excessive amounts of IV fluid

-Pulmonary edema, dyspnea, pink sputum, jugular vein
distention.
 IV FLUID COMPUTATION

1. For macro drip chamber, the drop factor is 15gtts/ml

This is used for adults unless specified
2. For Micro drip, the drop factor is 60mcgtts/ml
Indicated for pediatric patients.

A. GTTS/MIN= Vol. of fluid in cc x gtt factor

Hours to administer x 60 mins./hr

B. Cc/hour= Amount of fluid in ml

# of hours to administer

C. Time consumed = Amount of fluid in ml x drop factor

( Hour) gtts. /min x 60 min/hr

KVO or Keep Vein Open is 10ml/hr

 A physician ordered D5LR 1 liter to run for
8 hours for an adult patient, the nurse
started the infusion at 7:oo am Solve for:
a. gtts/min
b. cc/hr
c. time the IV will be consumed
 Example
 A physician ordered D5LR 1 liter to run for 8 hours for an adult patient, the
nurse started the infusion at 7:oo am Solve for:
a. gtts/min
b. cc/hr
c. time the IV will be consumed

a. 1000ml x 15gtts/min b. 1000ml c. 1000ml x 15gtts/min

8 x 60mins 8 31gtts/min x 60min/hr
= 15,000gtts = 125 cc/hr = 15,000gtts
480mins 1860gtts/hr
= 31gtts/min = 8 hours
at
3pm IVF will be consumed