STARTING AN INTRAVENOUS INFUSION

RATIONALE:
1.
2.
3.
4.
5.

To supply fluid when clients are unable to take in 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.

EQUIPMENT:
Infusion set
Container of sterile parenteral solution
IV Pole
Adhesive or non allergic tape
Clean gloves
Tourniquet
Antiseptic swabs
Antiseptic ointment
Intravenous catheter
Sterile gauze dressing transparent occlusive dressing
Arm splint. If required

Towel or pad

Electronic infusion device or pump

STEPS
1. Prepare the client and perform hand
hygiene.
1. Open and prepare the infusion set.
Remove tubing from the
container and straighten it
out.
Slide the tubing clamp
along the tubing until it is
just below the drip
chamber.
Close the clamp
Leave the ends of the
tubing covered with the
plastic caps until the
infusion is started
2. Spike the solution container.
Remove the protective
cover from the entry site of
the bag
Remove the cap from the
spike, and insert the spike

RATIONALE
To gain cooperation and to maintain
aseptic technique.

To facilitate its access.

This will maintain the sterility of the

ends of the tubing

into the insertion site of the

bag or bottle. Follow the
manufacturers instruction.
3. Apply medication label to the
solution container. If a medication
was added
4. Apply a timing label on the
solution container.
5. Hang the solution container on the
pole.
Adjust the pole so that the
container is suspended
about 1m (3 feet) above the
clients head.
6. Partially fill the drip chamber with
solution.
Squeeze the chamber
gently until it is half full of
solution.
7. Prime the tubing.
Remove the protective cap,
and hold the tubing over a
container. Maintain the
sterility of the end of the
tubing and the cap.
Release the clamp, and let
the fluid run through the
tubing until all bubbles are
removed. Tap the tubing
with your fingers, if
necessary to help the
bubbles move.
Reclamp the tubing, and
replace the tubing cap,
maintain sterile technique.
For caps with air vents, do
not remove the cap when
priming this tubing.
8. Perform hand hygiene again just
prior to client contact.
9. Select the venipuncture site.
Unless contraindicated, use
the clients nondominant
arm.
Place a towel or bed
protector under the
extremity to protect linens.
10.Dilate the vein
Place the extremity in
dependent position(lower
than the clients heart)

To identify the medication added.

To identify when the solution was
started.
This height is needed to enable gravity
to overcome venous pressure and
facilitate flow of the solution.

The tubing is primed to prevent the

introduction of air into the client. Air
bubbles smaller than 0.5 ml usually does
not cause problems in peripheral lines.

To maintain aseptic technique.

Gravity slows venous return and distends

the veins. Distending the veins make it
easier to insert the needle properly.

Apply a tourniquet firmly

15-20 cm (6-8 inches)
above the venipuncture
site.
If the vein is not sufficiently
dilated: massage or
strokethe vein distal to the
site and in the direction of
venous flow toward the
heart.
Encourage the client to
clench and unclench her
fist.
Lightly tap the vein with
your fingertips.

It should be tight enough to obstruct

venous flow but not so tight to that it
occludes arterial flow. Obstructing
arterial flow inhibits venous filling.
This action helps fill the vein.

Contracting the muscles compresses the

distal veins, forcing blood along the
veins and distending them.
Tapping may distend the vein.
Heat dilates superficial blood vessels,
causing them to fill.

If the preceding steps fail to

distend the vein so that it is
palpable, remove the
tourniquet and apply heat
to the entire extremity for
10-15 minutes.
11.Put on gloves , and clean the
venipuncture site.

Clean the skin at the site of

entry with a topical
antiseptic swab, 2%
chlorhexidine, or alcohol.
Use a circular motion,
moving from the center
outward for several inches.
Permit the solution to dry
on the skin.
12.Insert the catheter, and initiate
the infusion.
Use the nondominant hand
to pull the skin taut below
the entry site.

Holding over the-needle

catheter at a 15-30 degree
angle with the bevel up,
insert the catheter through
the skin and into the veins
in one thrust.

Gloves protect the nurse from

contamination by the clients blood.
To disinfect the site.
This motion carries microorganisms away
from the site of entry.

This stabilizes the vein and makes the

skin taut for needle entry. It can also
make initial penetration less painful.

The catheter is advanced to ensure that

it, and not just the metal needle, is in the

Once blood appears in the

lumen of the needle, or you
feel the lack of resistance,
reduce the angle of the
catheter until it is almost
parallel with the skin, and
advance the needle and
catheter approximately 0.51cm (about inch) further.
Holding the needle portion
steady, advance the
catheter until the hub is at
the venipuncture site.

Release the tourniquet

Put pressure on the vein

proximal to the catheter to
eliminate or reduce blood
oozing out of the catheter.
Stabilize the hub with the
thumb or the index finger of
your nondominant hand.

Remove the protective cap

from the distal end of the
tubing, and hold it ready to
attach to the catheter,
maintaining the sterility of
the end.

Carefully remove the

needle, engage the needle
safety device and attach
the end of the infusion
tubing to the catheter hub.

Initiate the infusion

13.Tape the catheter.
Tape the catheter by the
U method. Using three
strips of adhesive tape,
each about 7.5 cm (3 in)
long.
Place one strip, sticky-side
up, under the catheters
hub.
Fold each end over so that
the sticky sides are against
the skin.

vein.

Place a second strip, stickyside down, over the

catheter hub.
Place a third strip, stickyside down, over the tubing
hub.
14.Dress and label the venipuncture
site and tubing according to
agency policy.
Unless there is an allergy, a
sterile, transparent
occlusive dressing is
applied.
Discard the tourniquet.
Remove the soiled gloves
and discard them
appropriately.
Loop the tubing, and secure
it with tape.

Looping and securing the tubing prevent

the weight of the tubing or any
movement from pulling on the needle.

Label the dressing with the

date and time of insertion,
type and gauge of needle or
catheter used, and your
initials.
15.Ensure appropriate infusion flow.
Apply a padded arm board
to splint the joint as
needed.
Adjust the infusion rate flow
according to the order.
16.Label the IV tubing
Label the tubing with the
date and time of
attachment, and your
initials.
17.Document relevant data. Record
Time of the start of the
infusion
Flow rate
Date and time of
venipuncture
Amount and type of
solution used, including
additives
Type and gauge of the
needle
Venipuncture site
Clientss general response

To ensure that it is changed at regular

intervals.

Monitoring an Intravenous
Infusion
RATIONALE:
To maintain the prescribed flow rate
To prevent complications associated with IV therapy.
STEPS

RATIONALE

1. Ensure that the correct solution is

being infused
2. Observe the rate of flow every
hour.
Compare the rate of flow
regularly.

If the rate is too fast, slow it

Infusions that are off schedule can be

harmful to a client.
Solution administered too quickly may
cause a significant increase in a
circulating blood volume(about 6L in an

so that the infusion will be

completed at the planned
time. Assess the client for
manifestations of
hypervolemia and its
complications (dysnea;
rapid, labored breathing;
cough; crackles (rales) in
the lung bases; tachycardia;
and bounding pulses.

If the rate is too slow, check

agency practice.

If the rate flow is 150 ml/hr

or greater , check the rate
of flow more frequently.

3. Inspect the patency of the IV

tubing and needle.
Observe the position of the
solution. If it is less than 1m
(3 feet) ablove the IVsite,
readjust to the correct
height or pole.

Observe the drip chamber.

If it is less than half full,
squeeze the chamber to
allow the correct amount of
fluid to flow in.

Open the drip regulator,

and observe for a rapid flow
of fluid from the solution
container into the drip
chamber. Then partially
close the drip regulator to
reestablish the prescribed
rate flow.

Inspect the tubing for

pinches, kinks, or
obstructions to flow.
Arrange the tubing so that
it is lightly coiled and under
no pressure.

Observe the position of the

tubing. If it is dangling

adult). Hypervolemia may result in

pulmonary edema and cardiac failure.

Solution administered too slowly can

supply insufficient fluid, electrolytes or
medication for a clients needs.

If the IV bag/bottle is too low, the

solution may not flow into the vein
because there is insufficient gravitational
pressure to overcome the pressure of the
blood within the vein.

Rapid flow of fluid into the drip chamber

indicates patency of the IV line. Closing
the drip regulator to the prescribed rate
of flow prevents fluid overload.

The solution may not flow upward into

the vein against the force of gravity.

below the venipuncture, coil

it carefully on the surface of
the bed.

Lower the solution

container below the level of
the infusion site, and
observe for a return flow of
blood from the vein.

Determine whether the

bevel of the catheter is
blocked against the wall of
the vein. If blocked, pull it
back gently, turn it slightly,
using a sterile gauze pad
underneath to protect the
skin and change the
position of the catheter
bevel.

A return flow of blood indicates that the

needle is patent and in vein. Blood
returns in this instance because venous
pressure is greater than the fluid
pressure in the IV tubing. Absence of
blood return may indicate that the
needle is no longer in the vein or that
the tip of the catheter is partially
obstructed by a thrombus, the vein wall,
or a valve in the vein.

If there is leakage, locate

the source. If the leak is at
the catheter connection,
tighten the tubing into the
catheter. If the leak cannot
be stopped, slow the
infusion as much as
possible without stopping it,
and replace the tubing with
a new sterile set. Estimate
the amount of solution lost,
if it was substantial.
4. Inspect the insertion site for fluid
infiltration.
Assess for infiltration at IV
site:
o Swelling
o Coolness
o Pallor
o Discomfort
If an infiltration is present,
stop the infusion and
remove the catheter.
Restart the infusion at
another site.
Apply a warm compress to
the site of the infiltration.

Warmth promotes comfort and

vasodilation, facilitating absorption of
the fluid from the interstitial tissues.

5. If the infiltration involves a

vesicant drug, it is called
extravasation, and other
measures might be indicated.
Stop the infusion
immediately. Disconnect
the tubing as close to the
catheter hub as possible
and attempt to aspirate any
drug remaining in the hub.
If an injectable antidote is
available, the catheter
should remain in place.
6. If infiltration is not evident, but
the infusion is not flowing,
determine whether the needle is
dislodged from the vein.
Gently pinch the IV tubing
adjacent to the needle site.
Use a sterile syringe of
saline to withdraw fluid
from the port near the
venipuncture site. If blood
does not return, discontinue
the intravenous solution.
The primary care provider
should be notified and , if
ordered, the antidote
administered.
The affected arm should be
elevated, and depending on
the drug, heat or cold
therapy should be
implemented.
7. Inspect the insertion site for
phlebitis.(inflammation of the
vein)
Inspect and palpate the site
at least every 8 hours.
If phlebitis is detected,
discontinue the infusion,
and apply warm compress
to the venipuncture site. Do
not use this injured vein for
further infusions.
8. Inspect the intravenous site for
bleeding.
Oozing or bleeding into the
surrounding tissues can
occur while the infusion is
flowing freely, but is more

It can cause severe tissue injury or

destruction and is considered as an
emergency.

likely to occur after the

needle has been removed
from the vein.
Observation of the
venipuncture site is
extremely important for
clients who bleed readily,
such as those receiving
anticoagulants.
9. Teach the client ways to maintain
the infusion system. For example:
Avoid sudden twisting or
turning movements of the
arm with the needle or
catheter.
Avoid stretching or placing
tension on the tubing.
Try to keep the tubing from
dangling below the level of
the needle.
Notify a nurse if:
o The flow rate
suddenly changes or
the solution stops
dripping
o The solution
container is nearly
empty
o There is blood in the
IV tubing.

Changing an Intravenous Container,

tubing and dressing
RATIONALE:
To maintain the flow of required fluids.
To maintain sterility of the IV system and decrease the incidence of
phlebitis and infection
To maintain patency of the IV tubing.
To prevent infection at the IV site and the introduction of
microorganisms into the bloodstream
STEPS

RATIONALE

1. Introduce yourself and verify the

clients identity. Explain to the
client what you are going to do,
why it is necessary, and how the
client can cooperate.
2. Perform hand hygiene and
observe other appropriate
infection control.
3. Provide for client privacy.
4. Set up the intravenous equipment
with the new container, and label
it.
Apply a timing label to the
container
Prime the tubing
Label the tubing
5. Prepare the IV needle or catheter
tape, and the dressing equipment
Prepare strips of tape as
needed for the type of
needle or catheter

Will be used to secure the needle or

catheter without covering the insertion
site.

Hang the pieces of tape

from the edge of a table.

This places the tape in readiness for use

without disrupting the adhesive

Open all equipment: swabs,

dressing and adhesive
bandage, and ointment

Facilitates access to supplies after gloves

are done.

Place a towel under the

extremity
Apply clean gloves
6. Remove the soiled dressing and all
tape, except the tape holding the
catheter or IV needle in place.
Remove the tape and gauze
from the old dressing one
layer at a time

Remove adhesive dressings

in the direction of the
clients hair growth, when
possible.

Prevents soiling of bed linens.

Prevents dislodgement of the catheter or

needle in case tubing becomes
entangled between layers of dressings.
This minimizes discomfort when
adhesive is removed from the skin.

Discard the used dressing

materials in the appropriate
container.
7. Assess the IV site
Inspect the IV site for the
presence of infiltration or
inflammation

Inflammation or infiltration necessitates

removal of the IV needle or catheter to
avoid further trauma to the tissues.

Discontinue and relocate

the IV site if indicated
8. Disconnect the used tubing
Place a sterile swab under
the hub of the catheter

Clamp the tubing. With the

4th and 5th finger of the
nondominant hand , apply
pressure to the vein above
the end of the catheter.

Holding the hub of the

catheter with the
nondominant hand, loosen
the tubing with the
dominant hand, using a
twisting, pulling motion
Remove the used IV tubing
Place the end of the tubing
in the basin or other
receptacle
9. Connect the new tubing, and
reestablish the infusion.
Continue to hold the
catheter, and grasp the new
tubing with the dominant
hand.

This absorbs any leakage that might

occur when the tubing is disconnected.
This helps prevent blood from coming
out of the needle during the change of
tubing.

Holding the catheter firmly but gently

maintains its position in the vein.

Remove the protective

tubing cap and, maintaining
sterility, insert the tubing
end securely into the
needle hub. Twist it to
secure it.
Open the clamp to start the
solution flowing.

10.Remove the tape securing the

needle or catheter.
When removing this tape,
stabilize the needle or
catheter hub with one hand.
11.Clean the IV site
Start with adhesive remover
or remove adhesive
residue.
Then, using alcohol swabs,
clean the site, beginning at
the catheter or needle and
cleaning outward in a 2-inch
diameter
12.Retape the needle or catheter
Apply the tape using the
U method
Apply a sterile gauze or
transparent dressing over
the site
Remove your gloves
13.Label the dressing, and secure the
IV tubing
14.Regulate the rate of flow of the
solution according to the order on
the chart
15.Document all relevant
information.

This prevents inadvertent dislodgement

of the needle or catheter.

Removal of adhesive residue facilitates

adherence of the new dressing.
Cleaning in this manner prevents
contamination of the IV site from
bacteria on the peripheral skin areas.
Antiseptics reduce the number of
microorganisms present at the site, thus
reducing the risk of infection.

Discontinuing an Intravenous Infusion

RATIONALE:
To discontinue an intravenous infusion when the therapy is complete or
when the IV site needs to be changed
EQUIPMENT
Clean gloves
Dry or antiseptic-soaked swabs
Small sterile dressing tape
STEPS

RATIONALE

1. Introduce yourself and verify the

clients identity. Explain to the
client what you are going to do,
why it is necessary, and how the
client can cooperate.
2. Perform hand hygiene and
observe other appropriate
infection control.
3. Provide for client privacy.
4. Prepare the equipment.
Clamp the infusion tubing

Loosen the tape at the

venipuncture site while
holding the needle firmly
and applying
countertraction to the skin.
Put on clean gloves, and

Clamping the tubing prevents the fluid

from flowing out of the needle onto the
client or bed.
Movement of the needle can injure the
vein and cause discomfort to the client.
Countertraction prevents pulling the skin
and causing discomfort.

hold sterile gauze above

the venipuncture site.
5. Withdraw the needle or catheter
from the vein.
Withdraw the needle or
catheter by pulling it out
along the line of the vein.
Immediately apply firm
pressure to the site, using
sterile gauze, for 2-3
minutes.
Hold the clients arm or leg
above the body. If any
bleeding persists.
6. Examine the catheter removed
from the client.
Check the catheter to make
sure it is intact.

Report a broken catheter to

the nurse in charge or
primary care provider
immediately.
If the broken piece can be
palpated, apply a
tourniquet above the
insertion site.
7. Cover the venipuncture site.
Apply the sterile dressing

Discard the IV solution

container properly. If
infusions are being
discontinued, discard the
used supplies appropriately.
8. Document all relevant
information.
Record the amount of fluid
infused on the intake and
output record and on the
chart.

Pulling it out in line with the vein avoids

injury to the vein.
Pressure helps stop the bleeding and
prevents hematoma formation.
Raising the limb decreases blood flow to
the area.

If a piece of tubing remains in the

clients vein it could move centrally
(toward the heart and lungs) and cause
serious problems.

Application of a tourniquet decreases the

possibility of the piece moving until a
primary care provider is notified.

The dressing continues the pressure and

covers the open area in the skin,
preventing infection.