Intravenous (IV) Therapy by Kimberly Napper

IV Therapy: A method used to administer fluids, electrolytes, and medications directly into the blood stream.

Orders for IV therapy:

Client’s Name

Date & Time (that order is written)

Name of Drug (or Fluid)

Dose of Drug (or Fluid)

Route of Administration

Frequency of Administration

Signature of person writing order

Why Use the IV Route?

Treat Fluid and Electrolyte Imbalances

Administer Medications

Sedation

Anesthetics & Analgesics

Safety/ Emergencies

Contrast Agents for Diagnostic Tests

Blood Products

Provide Nutrition if unable to obtain enterally (ex. Total Parenteral Nutrition (TPN))

Advantages of IV Route

Medications & fluids when enteral route is contraindicated

Rapid onset & rapid action

Purest form of medicine enters directly into the blood stream

If pain med, pain relieved almost instantly

Can achieve precise dosage and flow rates

Can be discontinued immediately if needed

Promotes client comfort

Less pain and irritation than with IM injections

Administration without waking client

Patient Controlled Analgesia (PCA)

Disadvantages of the IV Route:

Once the medication is administered……... there is no getting it back.

Requires skill to initiate and maintain.

Client fear or pain when initiating treatment

Risk of IV- related complications (Brunner 13th p 298)

Allergic reactions ~15 minutes

Infiltration

Extravasation

Fluid volume overload.

Fluid/drug incompatibilities

The nurse has to start an IV on a client. Which are the reasons for IV therapy? Select all that apply.

A. To replace or maintain fluid balance.

B. To administer medications
C. To draw arterial blood gases NO
D. For blood transfusions.
E. To deliver nutrients
F. To increase body weight.NO

Complications of IV Therapy

Incompatible Solutions/ Precipitation -chemical reaction resulting in crystal formation in IV fluid

If you see crystallization, clamp the IV immediately using the slide clamp closest to the client.

Throw away the tubing. Do not attempt to flush through!

Complications of IV Route

Systemic: Circulatory overload, Air embolism, Febrile reactions, Infection (sepsis)

Local: Hematoma, Infiltration, Extravasation, Phlebitis, Thrombophlebitis, Clot in Catheter, Site Infection,
Hematoma/Bruising

Infiltration- The movement of a needle or cannula from within a vessel into the surrounding tissue.

Typical symptoms: a slowed flow of fluids, swelling, pallor, coolness of the skin, discomfort in the area

Severity of the symptoms depends on the amount and type of fluid

Extravasation- The inadvertent administration of a vesicant into the tissues (a severe type of infiltration)

Intensity of the irritating action is so severe that plasma escapes from the extracellular space and blisters are
formed. Large extravasations of some medications may lead to contractures, with the need for debridement and
grafting and in severe cases amputation.
Phlebitis-inflammation of vein

Thrombophlebitis- clot & inflammation in vein

Site Infection- localized infection but may lead to

Cellulitis- Spreading bacterial infection of the skin and tissues beneath the skin.

Staphylococcus and Streptococcus are usually responsible, although many types of bacteria can cause
the condition.

Symptoms and signs: Redness, Tenderness, Swelling, Warmth at site, Not contagious, Treated with oral
or intravenous antibiotics

A client receiving intravenous fluids should be monitored most closely by the nurse for which type of medication that has
the potential for causing severe tissue damage?

A. Irritants.
B. Vesicants.
C. Nonvesicants.
D. Crystalloids.

An infant less than nine months old requires IV fluids. Which site is acceptable for the nurse to access exclusively related
to the age of this client?

A. Feet.
B. Scalp.
C. Forearms.
D. Intraosseous.

Common Peripheral IV sites (13th Brunner Fig. 13-7 p. 274) look at Advantages & Disadvantages

The prudent nurse should be aware that which client’s IV site is more difficult to determine infiltration?

A. Feet.
B. Hands.
C. Forearms.
D. Antecubital.

Venous Access/ Venipuncture: List equipment for IV insertion & discontinuation.

Topical (for the skin) Cleansing Agents: Antibacterials used to clean the skin to prevent infection that may be caused by
surgery, injection, or skin injury

Chloraprep (chlorhexidine gluconate)

Included in most IV “start kits”

Current topical antibacterial of choice

Alcohol (isopropyl alcohol)

may be used initially to cleanse & improve visualization

Betadine (povidone iodine) - was the antibacterial agent of choice before chlorhexidine
Intravenous Catheters

Procedure for Initiating an IV Brunner 13th Ed Chart 13-3 p. 275

Sterile dressing first! Secure & label.

Saline Lock or INT (intermittent)

Do not touch the sharps container! Just drop the needle in the hole!

Procedure for Discontinuing an IV Brunner 13th Ed p. 279

Remove tape & holder carefully. May need alcohol to loosen adhesive.

Remove catheter & examine the tip to be sure the bevel is intact.

Apply direct pressure to site to promote hemostasis.

Dispose of catheter in sharps container

Document procedure.

Caution!! Scissors are dangerous around IV lines. Severing the catheter can cause embolism.

IV Equipment: List the various types of tubing sets & pumps used for IV therapy.

Port on IV Bag for Adding or Removing Fluids

“Spiking” the Bottle (or Bag) (sterile technique)

Prime the Drip Chamber (before you “prime” the tubing to prevent air from being in tubing)

Hang Bag from IV Pole

Note Color of Fluid (should be clear) before you use it

Check Orders First!

IV start kit

Catheter (correct size)

Bag of Fluid with Label

LABEL Expiration dates on bag of fluid, tubing, & IV site

Sterile dressing on IV site

Site secured with holder &/or tape (watch for allergies to tape/adhesive)
Adjusting IV rate by gravity

Calculate correct gtts/min (drops per minute) rate (Will need to know gtts/mL on tubing)

Count drops in drip chamber

Start by counting the number of drops that fall in the drip chamber in 6 seconds. (One tenth of 60 seconds)

Example: 2 drops/6 sec. = 20 drops/min.

Adjust the flow by using the “wheel” on the primary tubing

Types of Solutions: Define the following & give examples of each. (See Brunner 13th Ed. P. 248 Table 13-5)

Crystalloids

Isotonic

Hypotonic

Hypertonic

Colloids- fluids with complex molecules & proteins (like albumin & whole blood)

Brunner 13th Ed. Definitions on page 237

Crystalloid Solutions (See list in Brunner 13th Ed. P. 248 Table 13-5)

contain small molecules that pass freely through cell membranes and vascular system walls

are useful as fluid expanders

are stored at room temperature

are a useful source for electrolytes and a temporary source of fluid volume

flow out of the vascular system rather quickly

Lactated Ringer's is an example of a crystalloid solution.

Taylor Chapter 40: Crystalloids & Tonicity to Cells

(the ability of the solute to cause water movement from one compartment to another)

Osmolarity (don’t try to memorize these numbers)

“Iso-osmotic “ or isotonic.

When all body fluids have an osmolarity near 300 mOsm/L, the osmotic pressure of the two fluid
compartments are equal, so no net water movement occurs.

Isotonic solutions 270-300 mOsm/L ex: 0.9% Sodium Chloride (NS)

Hypertonic solutions >300 mOsm/L

ex: Dextrose 5% 0.9%Sodium Chloride (D5NS)

Hypotonic solutions <270 mOsm/L

 ex: Dextrose 2.5% in Water (D2.5W)

Isotonic (Brunner 13th Ed. P. 248 Table 13-5)

Used to maintain fluid intake and reestablish water volume

Stays in the vascular compartment, therefore, it expands the vascular volume.

Ex: treatment for vomiting, diarrhea, and fever

Normal Saline (0.9% NaCl)

Lactated Ringer’s Solution (LR) (see contraindications)

Dextrose 5% in Water (D5W)

*When glucose is metabolized, it produces free water. So, it starts as isotonic but becomes hypotonic.

Hypotonic (Brunner 13th Ed. P. 248 Table 13-5)

Used to provide free water and treat cellular dehydration.

0.45% NaCl (1/2 NS) half strength normal saline

0.33% NaCl (1/3 NS) one third strength normal saline

2.5% Dextrose in water (D2.5)

Hypertonic (Brunner 13th Ed. P. 248 Table 13-5)

Draws fluids from the intracellular fluid (ICF) causing cells to shrink and extracellular fluid (ECF) to expand.

Given to patients with hyponatremias (Na+ deficits) with edema

D5 NS(5% Dextrose in normal saline)

D5 ½ NS (5% Dextrose in in 0.45% NaCl)

D5LR (5% Dextrose in Lactated Ringer's Solution)

D10W (10% Dextrose in water)

D50W50 (50% Dextrose in 50 ml of water)

Examples of different fluids (quiz in class)

 0.45% Saline (1/2 NS) Hypotonic

 0.9% Saline (NS) Isotonic
 5% Dextrose in Water (D5W) Isotonic
 5% Dextrose in 0.225% Saline (D5 1/4 NS) Isotonic (because it’s such a small amount of sodium)
 Lactated Ringer's solution (LR) Isotonic
 5% Dextrose in lactated Ringer's solution Hypertonic
 5% dextrose in 0.45% saline (D5 1/2 NS) Hypertonic
 5% dextrose in 0.9% saline (D5 NS) Hypertonic
 10% Dextrose in Water (D10W) Hypertonic
Colloid Solutions (See list in Brunner 13th Ed. P. 248 Table 13-5)

contains molecules that are frequently very complex and much larger than those in the crystalloid solutions

are needed when a solution is required to remain in the vascular system

generally require refrigeration and can be stored for a limited period.

A solution that contains protein is colloidal.

Whole human blood and Hetastarch are examples of colloid solutions.

http://nursing411.org/Courses/MD0564_Blood_Electrolytes_ItraV/2-09_Blood_Electrolytes.html

Colloidal Solutions

Plasma expanders

Hetastarch (Hespan)

Blood or blood products

Albumin

Whole Blood

Packed RBCs

Other Intravenous Solutions

TPN (Total Parenteral Nutrition)

Electrolytes (ex. Potassium, Magnesium, Calcium)

Carbohydrates: Dextrose: large concentrations require a “central IV”

Proteins: Given as amino acids

Fats/lipids

Multivitamin Infusion

A client is receiving an intravenous (IV) infusion of 5% dextrose in 0.45% normal saline (D5 ½ NS).

Which type of IV solution is infusing? (Select all that apply.)

A. Isotonic
B. Hypotonic
C. Hypertonic
D. Colloid
E. Crystalloid
An 80-year-old client admitted for dehydration is receiving IV fluids. The nurse should assess more frequently for which
complication?

A. Phlebitis.
B. Air emboli.
C. Infiltration.
D. Respiratory distress. (a symptom of fluid volume overload!)

A client receiving a hypertonic solution has a B/P of 170/100, jugular vein distention and respiratory distress.
The nurse should suspect that the client may be experiencing

A. circulatory overload. (aka: fluid volume overload)

B. allergic reaction.
C. systemic infection
D. air embolism.

A client with dry skin and mucous membranes is weak, has orthostatic blood pressure changes, and has decreased urine
output. The client’s serum osmolality is normal. Which IV fluids would the nurse anticipate being prescribed for this
client?

A. Normal saline.
B. ½ normal saline
C. 5% dextrose in water.
D. 10% dextrose in water.

Answer A: Normal Saline because….

The client has clinical manifestations of dehydration

(Isotonic because the serum levels are normal) so the client has hypovolemia or isotonic dehydration.

A: Normal Saline was the only isotonic solution on the list.

B: ½ normal saline and C: 5% dextrose are hypotonic solutions.

C: When the Dextrose burns off, it become hypotonic and will cause fluid shifts causing cellular edema. This is not
needed because client’s cells are normal size.

D: 10% dextrose is hypertonic and will cause fluid shifts causing cellular dehydration.
A client involved in a motor vehicle accident presents to the ED with severe internal bleeding, is severely hypotensive and
unresponsive. The nurse is aware that which prescription for IV fluids should be questioned?

A. Hetastarch.
B. Albumin.
C. 0.45% normal saline.
D. 5% dextrose in Lactated Ringers.

Answer C: 0.45% NaCl because…

The goal of IV therapy in this client is to expand the intravascular volume as quickly as possible.

0.45% saline is hypotonic and can cause shifts away from the intravascular space into the cells and further hypotension.

You need a hypertonic solution to expand the intravascular space and get the BP up.

The client is receiving 5% dextrose and 0.45 sodium chloride IV and is complaining of pain at the IV site. The nurse
assesses the site and notes erythema and edema. Which would be the appropriate intervention?

A. Slow the infusion rate.

B. Apply antibiotic ointment to the IV site.
C. Discontinue the IV and apply a warm compress to the IV site.
D. Gently pull back the IV access device to reposition it in the vein.

As a nurse, you frequently care for postsurgical patients in your hospital unit.

Most of the medical–surgical patients are admitted and have IV fluids infusing during their admission.

Due to the frequent use of IV fluids on your floor, understanding fluid balance and electrolyte function is primary to your
nursing practice.

What conditions might lead to the development of hypovolemia?

How would the amount of patient fluid loss be determined?

Describe how hypovolemia and third-space fluid shift correlate.

Outline the major difference between hypovolemia and third-space fluid shift.

Which conditions can result in third spacing?

Assessing and monitoring IV Therapy: Include the six (6) rights.

1) Client
2) Medication (or Fluid)
3) Dosage
4) Route
5) Time
6) Documentation
Assessments R/T IV Therapy

I & O – can do without an order

Intake should equal output. If treating dehydration, urine output will increase as hydration status
improves. Make sure not to overhydrate & cause fluid volume overload! Watch urine color as an
indicator of hydration status, too.

VS – take as often as needed

Skin turgor and mucous membranes

Urine Specific Gravity –( need MD order) (will study with Diagnostic Tests lecture)

Lab values – electrolytes

List the most common complications of IV therapy & how to distinguish between the complications, and nursing
interventions for each.

Medications via IV route:

IV push

IVPB

Patient Controlled (PCA) (sort of IV push, but client does it using a push button & machine)

IVP (intravenous push)

Check Orders

Prepare medication

Contingencies

Compatabilities

Swab lowest port with antimicrobial solution

Flush with saline before & after medications that are incompatible with IVF

Use correct mL/min rate!

Observe client!!

Document
IVPB Intravenous Piggyback

Check Orders

Prepare medication

Contingencies

Compatibilities

Hang IVPB above primary IVF using highest port

If incompatible solution, do NOT piggyback!!!

Infuse at correct mL/hr rate!

Observe client!!

Document

Adjusting rate by gravity

Calculate correct gtts/min (drops per minute) rate

Count drops in drip chamber of piggyback

Adjust the flow by using the “wheel” on the primary tubing

You will have to readjust the flow rate of the primary fluid after the piggyback is complete

Patient Controlled Analgesia (PCA)

Allows client to self-administer IV pain med

Programmed according to physician’s orders Ex. 2 mg/10 min, 5 mg/hour, with 20 mg/4 hour “lockout”

NEVER allow family to “help”. Overdose likely!

Must be “Y-ed” in at closest port with compatible IVF

IV Medication Administration

What safety issues must be considered when administering a medication using the intravenous route?

Nursing Diagnoses

Risk for Impaired Skin Integrity

Excess fluid volume R/T excessive fluid or sodium intake

Risk for pulmonary edema R/T hypervolemia

Knowledge deficit R/T signs and symptoms of fluid volume excess

Risk for injury related to fluid and electrolyte imbalance or trying to go to the bathroom

Our goal is to return client’s to optimal health!