IV Therapy Administration

• Intravenous (IV) therapy involves infusing fluids via an IV catheter for various purposes.
• These purposes include administering medications, blood products, supplementing fluid intake, providing fluid replacement, electrolytes, or nutrients.
• Nurses administer large-volume IV infusions and IV boluses, usually in a small amount of fluid.
• Nurses or pharmacists mix IV medication in a large fluid volume for continuous or intermittent IV infusion.

Procedure for IV Administration

• The provider prescribes the type of IV fluid and volume to infuse.
• The provider also prescribes the rate or total time for infusion.
• The nurse regulates the infusion using an IV pump or manually, ensuring correct fluid delivery.
• Nurses administer large-volume IV infusions continuously, like 0.9% sodium chloride at 100 mL/hr.
• Or intermittently, such as 0.9% sodium chloride 500 mL IV over 3 hours.
• A fluid bolus involves giving a large amount of IV fluid in a short time, typically under 1 hour.
• Fluid boluses rapidly replace fluid loss from dehydration, shock, hemorrhage, burns, or trauma.
• An 18-gauge or larger catheter is crucial for the rapid administration of a fluid bolus to adults.
• Medications can be administered as an IV bolus in a small amount, concentrated or diluted, over 1–2 minutes.

Advantages of IV Therapy

• Rapid absorption and onset of action are key benefits.
• IV therapy provides constant therapeutic blood levels.
• It causes less irritation to subcutaneous and muscle tissue.

Disadvantages of IV Therapy

• Circulatory fluid overload is possible with large solution volumes or rapid infusion rates.
• Immediate absorption allows little time to correct errors, and adverse effects can occur quickly.
• Solutions and IV catheters may irritate the vein lining.
• Failure to maintain surgical asepsis can lead to local or systemic infection.

Nursing Actions for IV Medication Infusions

• Administer medications mixed by a pharmacist in a large fluid volume (500–1,000 mL) as a continuous IV infusion like potassium chloride and vitamins.
• Deliver medications in premixed solution bags from the manufacturer.

Administering Volume-Controlled Infusions

• Some medications (antibiotics) are given intermittently in a small solution volume (25–250 mL).
• This is done through a continuous IV fluid system or with saline or heparin lock systems.
• Infuse medications for short periods on a schedule.
• Use a secondary IV bag or bottle, a volume-control administration set, or a mini-infusion pump.

Giving an IV Bolus Dose

• Inject medications in small solution amounts, concentrated or diluted, over 1–2 minutes.
• Administer medications directly into the peripheral IV or access port to achieve immediate bloodstream levels (with pain medication).
• Prepare medications in the correct concentration and administer at a safe rate (amount per minute).
• Use extreme caution and watch for adverse reactions or complications (redness, burning, or increasing pain).

Special Considerations for Older Adults, Anticoagulant Users, and Clients with Fragile Veins

• Avoid tourniquets, using a blood pressure cuff instead.
• Refrain from slapping the extremity to visualize veins.
• Avoid rigorous friction when cleaning the site.
• Use a small needle size, such as 22 or 24 gauge if possible.

Edema in Extremities

• Apply digital pressure over the selected vein to displace edema.
• Apply pressure with a cleaning solution swab.
• Cannulate the vein quickly.

Clients Who Are Obese

• Utilize anatomical landmarks to find veins.

Preprocedure Equipment

• Have an IV start kit available, including a tourniquet, antiseptic swabs, transparent dressing, sterile tape, gauze sponges, and a safety positioning device.
• Use the correct size catheter: 16-gauge for trauma patients needing rapid fluid volume, 16- to 20-gauge for surgery patients (rapid blood administration), or 20- to 24-gauge for other clients (children, older adults, short-term therapy).
• Use tubing, a prefilled syringe with 1–3 mL of 0.9% sodium chloride solution, an infusion pump, clean gloves, as well as scissors or clippers for hair removal.

Preprocedure Nursing Actions

• Check the prescription (solution, rate).
• Identify allergies to latex or tape.
• Follow the rights of medication administration.
• Check IV solution and medication compatibilities.
• Perform hand hygiene.
• Examine the IV solution for clarity, leaks, and expiration date.
• Don clean gloves.
• Evaluate extremities and veins.
• Clip hair around the insertion site with scissors (avoid shaving to prevent abrasion and infection risk).

Client Education for IV Therapy

• Ensure clients understand the procedure.
• They should lie in a comfortable position.

Intraprocedure Nursing Actions

• Apply a clean tourniquet or blood pressure cuff (especially for older adults) 10–15 cm (4–6 inches) above the insertion site to compress venous blood flow only.
• Select a vein using visualization, gravity, fist clenching, friction with the cleaning solution, or heat.
• Choose distal veins first on the nondominant hand.
• Choose a site that is not painful or bruised and won't interfere with activity.
• Choose a resilient vein with a soft, bouncy sensation on palpation.
• Avoid varicose veins, veins in the inner wrist with bifurcations, in flexion areas, near valves or in lower extremities.
• Also avoid the antecubital fossa (except for emergency access), veins in the back of the hand, sclerosed or hard veins, and veins in extremities with impaired sensitivity (scar tissue or paralysis).
• Lymph nodes removed, recent infiltration, a PICC line, or an arteriovenous fistula or graft and veins that had previous venipunctures should be avoided.
• Untie the tourniquet or deflate the blood pressure cuff.
• Cleanse the area at the site using friction in a circular motion from the middle and outwardly with chlorhexidine or the facility's specified cleaning agent. Allow it to air dry for 1–2 minutes.
• Remove the cover from the catheter, grasp the plastic hub, and examine the device for smooth edges.
• Retie the tourniquet or reinflate the blood pressure cuff.
• Place the extremity in a dependent position (below the level of the heart).
• Ask the client to slowly open and close their fist.
• Anchor the vein below the site of insertion.
• Pull the skin taut and hold it.
• Warn the client of a sharp, quick stick.
• Use a steady, smooth motion to insert the catheter into the skin at a 10–30° angle with the bevel up.
• Advance the catheter through the skin and into the vein, maintaining a 10–30° angle. A flashback of blood will confirm placement.
• Lower the hub of the catheter close to the skin to prepare for threading it into the vein about 0.6 cm (0.24 inches).
• Loosen the needle from the catheter and pull back slightly so it no longer extends past the catheter tip.
• Use the thumb and index finger to advance the catheter into the vein until the hub rests against the insertion site.
• Stabilize the IV catheter with one hand and release the tourniquet or blood pressure cuff with the other; apply pressure about 3 cm (1.2 inches) above the insertion site with the middle finger and stabilize the catheter with the index finger.
• Remove the needle and activate the safety device.
• Maintain pressure above the IV site to connect appropriate equipment to the IV catheter hub.
• Apply a dressing and leave it in place until catheter removal, unless it becomes damp, loose, or soiled.
• Avoid encircling the entire extremity with tape and taping under the sterile dressing.
• For a continuous IV infusion, regulate the infusion rate according to the prescription.
• Dispose of used equipment and supplies.
• Document the date and time of insertion, insertion site appearance, catheter size, dressing type, IV fluid and rate, number/locations/conditions of previous catheterizations, and client response.

Postprocedure Nursing Actions

• Maintain the patency of IV access.
• Continuous infusions should not be stopped, nor should blood be allowed to back up into the catheter. Clots can form, blocking fluid flow.
• Clients should not manipulate the flow rate device, change IV pump settings, or lie on the tubing.
• The IV insertion site dressing should not be too tight.
• Intermittent IV catheters need flushing with the appropriate solution after each medication administration or every 8–12 hours when not in use, according to facility policy.
• Monitor the site and infusion rate at least hourly.

Discontinuing IV Therapy

• Check the prescription.
• Prepare the equipment.
• Perform hand hygiene and don clean gloves.
• Clamp the IV tubing.
• Remove the tape and dressing while stabilizing the IV catheter.
• Apply a sterile gauze pad over the site, avoiding pressure on the vein, and do not use alcohol.
• Withdraw the catheter by pulling it straight back from the site, keeping the hub parallel to the skin.
• Elevate the extremity and apply pressure for 2–3 minutes until bleeding stops.
• Examine the site, apply tape over the gauze, and use a pressure dressing if necessary.
• Check that the catheter is intact, then dispose of it in the designated puncture-resistant receptacle, disposing of the IV solution and equipment in the appropriate location.
• Document the procedure.

Types of IV Access

• Peripheral vein access via a catheter.
• Jugular or subclavian vein access via a central venous access device.

Guidelines for Safe IV Medication Administration

• Infusion pumps should be used for medications that can cause serious adverse reactions, like potassium chloride, and these medications should never be administered via IV bolus.
• IV medications should not be administered through tubing infusing blood, blood products, or parenteral nutrition solutions.
• Medication references should be reviewed for recommended concentration and administration rate prior to administration.
• IV placement should be verified before medication administration.
• The compatibility of medications with IV solutions should be verified before infusing a medication through tubing infusing another medication or IV fluid.

Needlestick Prevention

• Be familiar with IV insertion equipment.
• Avoid needles if needleless systems are available.
• Use protective safety devices when available.
• Dispose of needles immediately in designated puncture-resistant receptacles.
• Do not break, bend, or recap needles.

Preventing IV Infections

• Perform hand hygiene before and after handling IV systems.
• Use standard precautions.
• Change IV sites according to facility policy, usually every 72 hours.
• Replace the administration set based on the infusion type.
• Change continuous infusion sets (with or without secondary fluids) every 96 hours.
• Intermittent infusions should be changed every 24 hours.
• Change blood or propofol administrations more frequently, according to facility policy.
• Remove catheters as soon as there is no clinical need.
• Replace catheters if a break in surgical aseptic technique is suspected (during emergency insertions).
• Use a sterile needle or catheter for each insertion attempt.
• Avoid writing on IV bags with pens or markers for risk of contaminating the solution.
• Change tubing immediately for potential contamination.
• Do not allow fluids to hang longer than 24 hours unless in a closed system (pressure bags for hemodynamic monitoring).
• Wipe all ports with alcohol or an antiseptic swab before connecting IV lines or inserting a syringe to prevent microorganism introduction.
• Never disconnect tubing for convenience or to reposition the client.

Complications of IV Therapy

• Complications require notification of the provider and documentation; new tubing and catheters should be used for restarting IV infusions after detecting complications.

Infiltration or Extravasation

• Infiltration. IV solution or medication leaks into the subcutaneous tissue (non-vesicant).
• Extravasation. IV solution or medication leaks into the subcutaneous tissue (vesicant - can damage tissues).
• Findings include pallor, local swelling, decreased skin temperature, damp dressing, or slowed infusion rate.
• For extravasation, withdraw solution from client's IV catheter and administer antidote prior to discontinuing IV access.
• To treat Stop infusion and remove catheter, elevate extremity, encourage active ROM, apply warm or cold compress (depending on solution infusing), and restart infusion proximal to the site or in another extremity.
• Prevent by carefully selecting site and catheter, and securing the catheter.

Phlebitis or Thrombophlebitis

• Phlebitis or Thrombophlebitis. Edema; throbbing, burning, or pain at the site; increased skin temperature, erythema; a red line up the arm with a palpable band at the vein site; slowed rate of infusion
• Treatment: Promptly discontinue infusion and remove catheter, elevate extremity, apply warm compresses 3–4 times daily, Restart infusion in different vein proximal to site or in another extremity, and obtain culture specimen if drainage is present.
• Prevent by changing the IV site at least every 72 hours, avoiding lower extremity insertion, and practicing hand hygiene and surgical aseptic technique.

Fluid Overload

• Fluid Overload includes distended neck veins, increased blood pressure, tachycardia, shortness of breath, crackles in lungs, and edema
• Additional findings varying with IV solution.
• Treatment includes decreased IV flow rate; and notify provider of change, elevate head of bed, measure vital signs and oxygen saturation, adjust rate after correcting fluid overload, administer diuretics.
• Prevention involves use of an infusion pump, and monitor I&O.

Cellulitis

• Includes Pain, warmth, edema, induration, red streaking, fever, chills, and malaise.
• Treatment includes discontinuing infusion, remove catheter, elevate extremity, apply warm compresses 3 to 4 times/day, obtain a specimen for culture, administer analgesics, antibiotics and antipyretics.
• Prevent by rotating sites at least every 72 hr, avoid inserting an IV into the lower extremities, use hand hygiene and surgical aseptic technique.

Catheter Embolus

• Missing catheter tip upon removal; severe pain at the site with migration, absence of findings without migration.
• Treatment includes place a tourniquet high on extremity to limit venous flow, prepare for removal under x-ray or surgery, same catheter after removal to determine the cause.
• Prevent by not reinserting the stylet into the catheter.