INSERTING IV CANNULA UTILIZING A DUMMY

1. Verify the written prescription for IV therapy check prepared IVF and other things needed.
2. Explain procedure to reassure the patient & significant others and observe the 10Rs.
3. Do hand hygiene before and after the procedure.
4. Choose site for IV.
5. Apply tourniquet 5 to 12 cm. (2-6inches) above injection site depending on condition of patient.
6. Check for radial pulse below tourniquet.
7. Prepare site with effective topical antiseptic according to hospital policy or cotton balls with alcohol in
circular motion and allow 30 seconds to dry.
(No touch technique.)

Note: CDC Universal Precaution: Always wear gloves when doing any venipuncture.

8. Using the appropriate IV cannula, pierce skin with needle positioned on a 15-30 degree angle.
9. Upon flashback visualization decrease the angle, advance the catheter and stylet (1/4 inch) into the vein,
check if tip of catheter can be rotated freely inside the vein.
10. Position the IV catheter parallel to the skin. Hold stylet stationary and slowly advance the catheter until
the hub is 1mm to the puncture site.
11. Slip a sterile gauze under the hub. Release the tourniquet, remove the stylet while applying digital
pressure over the catheter with one finger about 1-2 inch from the tip of the inserted catheter. 12.
Connect the infusion tubing of the prepared IVF aseptically to the IV catheter.

Note: When steel-winged needle (butterfly) is used:

A. Connect the IV tubing to the steel-winged needle connector & prime the needle with IV fluid.
B. Using the steel-winged needle, pierce skin with the needle bevel up , positioned on a 5-10
degree angle.
C. With steel-winged needle, parallel on the skin, enter the vein directly and advance needle ¼
inch after successfully performing venipuncture. Check for backflow. Remove tourniquet.

12. Connect the infusion tubing of the prepared IVF aseptically to the IV catheter
13. Open the clamp, regulate the flow rate. Reassure patient.
14. Anchor needle firmly in place with the use of:

A. Transparent tape/dressing directly on the puncture site.

B. Tape (using any appropriate anchoring style) :U method H method Chevron method
C. Band-Aid

Note: Never place unsterile tape directly on IV insertion site, instead place a small piece of sterile
OS & then secure it with adhesive tape.

15. Tape a small loop of IV tubing for additional anchoring; apply splint (if needed).
16. Calibrate the IVF bottle & regulate flow of infusion according to prescribed duration.
17. Label on IV tape near the IV site to indicate the date of insertion, type and gauge of IV catheter and
countersign.
18. Label with plaster on the IV tubing to indicate the date when to change the IV tubing. 19. Observe
patient and report any untoward effect.
19. Observe patient and report any untoward effect.
20. Document in the patient’s chart and endorse to incoming shift.
21. Discard sharps and waste according to Health Care Waste Management(DOH/DENR)

SETTING UP AN IV INFUSION

1. Verify written prescription and make IV label.

2. Observe ten (10) Rs when preparing & administering IVF.

10 Golden Rules for Administering Drug Safely (from Nursing 88 Vol. 18, August 1988):
A. Administer the RIGHT DRUG.
B. Administer the right drug to the RIGHT PATIENT.
C. Administer the RIGHT DOSE.
D. Administer the right drug by the RIGHT ROUTE.
 E. Administer the right drug at the RIGHT TIME.
F. DOCUMENT each drug you administer.
G. TEACH your client about the drugs he is receiving.
H. Take a complete patient DRUG HISTORY. (There is a risk of adverse drug reactions
when a number of drugs are taken or when patient is taking alcohol drinks.)
I. Find out if the patient has any DRUG ALLERGIES.
J. Be aware of potential DRUG – DRUG or DRUG – FOOD INTERACTIONS. To
protect your patient and your license, follow these guidelines for avoiding medication
errors.

3. Explain procedure to reassure patient and/or significant others, secure consent, if necessary
4. Assess patient’s vein; choose appropriate site location, size and condition.
5. Do hand hygiene before and after the procedure.
6. Prepare necessary materials for procedure

IV tray with IV solution

IV Administration Set
IV cannula
Forceps soaked in antiseptic solution
Alcohol swabs or cotton balls soaked in alcohol with cover (this should be exclusively used for IV)
 Plaster
 Tourniquet
 Gloves
 Splint
 IV hook
 Sterile 2x2 gauze or transparent dressing.
7. Check the sterility and integrity of the IV solution, IV set and other devices.

8. Place IV label on IVF bottle duly signed by RN who prepared it (patient’s name, room no., solution,
drug incorporation, bottle sequence, and duration, time, and date.
9. Open the seal of the IV infusion aseptically and disinfect rubber port with cotton ball with alcohol.
10. Open the IV administration set aseptically and close the roller clamp and spike the infusate container
aseptically.
11. Fill drip chamber to at least half and prime it with IV fluid aseptically.
12. Expel air bubble if any and put back the cover to the distal end of the IV set (get ready for IV insertion).

CHANGING AN IV SOLUTION

1. Verify doctor’s prescription in doctor’s order sheet; countercheck

 IV label,  Amount,
 IV card,  Additives (if any),
 Infusate sequence,  Duration of infusion.
 Type,

2. Observe ten (10) Rs.

3. Explain procedure to reassure patient & significant others & assess IV site for redness, swelling, pain,
etc.
4. Change IV tubings and cannula if 48-72 hours lapsed after IV insertion.
5. Wash hands before and after the procedure.
6. Prepare necessary materials; place on IV tray.
7. Check sterility and integrity of IV solution.
8. Place IV label on the IV bottle.
9. Calibrate new IV bottle according to duration of infusion as per prescription.
10. Open and disinfect rubber port of IV solution to follow.
11. Close the roller clamp and spike the container aseptically.
12. Regulate the flow rate based on the prescribed infusion rate of infusion. Expel air bubbles (if any).
13. Reiterate assurance to patient and significant others.
14. Discard all waste materials according to Health Care Waste Management.
15. Document and endorse accordingly.
 DISCONTINUING AN IV INFUSION

1. Verify written doctor’s order to discontinue IV including IV medicines.

2. Observe ten (10) Rs.
3. Assess and inform the patient of the discontinuation of IV infusion & of any medicine.
4. Prepare the necessary materials: IV tray or injection tray with sterile cotton balls with alcohol, plaster,
pick-up forceps in antiseptic solution, kidney basin, Band-Aid.
5. Wash hands before and after procedure.
6. Close the roller clamp of the IV administration set.
7. Moisten adhesive tapes around the IV catheter with cotton ball with alcohol; remove plaster gently.
8. Use pick-up forceps to get cotton ball with alcohol and without applying pressure, remove needle or IV
catheter then immediately apply pressure over the venipuncture site.
9. Inspect IV catheter for completeness.
10. Place dressing over the venipuncture site.
11. Discard all waste materials including the IV cannula according to Health Care Waste Management
(DOH/DENR).
12. Reassure patient.
13. Document time of discontinuance, status of insertion site and integrity of IV catheter and endorse
accordingly.

ADMINISTERING IV DRUGS
INCORPORATION OF DRUG INTO IVF BOTTLE/BAG

1. 1Verify the written medication card against the MD prescription; observe hospital policy on drug
administration.
2. Observe ten (10) Rs when preparing and administering medication.
3. Explain procedure (medication and action) to reassure patient & significant others and check patency
and IV site.
4. Verify for skin test of drug for IV incorporation (if skin testing is necessary).
5. Do hand hygiene before and after the procedure.
6. Prepare necessary materials needed for the procedure such as: injection tray, syringes needed, right drug
to be incorporated either in vial or ampule.

7. Disinfect injection port of the vial & the ampule before breaking then aspirate the right dose aseptically.
8. Remove the cover of the administration set, maintain sterility and incorporate prepared drug into the
airway aseptically. Recap airway after.
Note: if the administration set has no airway, pull out the set and incorporate the prepared the
drug and re-spike the IV set to the bottle then place the label. (All these should be done
aseptically).

9. Swirl the IV bottle to mix the drug with IVF and regulate the flow rate accordingly.
10. Observe for 5-10 mins. for any drug interaction while reassuring the patient; monitor VS.
11. Document in the patient’s chart.
12. Discard sharp and other wastes according to Health Care Waste Management (DOH/DENR).

ADMINISTERING IV DRUGS
IV PUSH THROUGH THE IV PORT

1. Verify medication card against the written doctor’s prescription.

2. Observe ten (10) Rs when preparing and administering medication.
3. Explain procedure to reassure patient & significant others (the name of medicine and action/interaction of
medication) before administration.
4. Do hand hygiene before and after the procedure. (Use gloves especially for chemotherapeutic & other vesicant
drugs.)
5. Check patency and other reaction signs of swelling, redness, phlebitis, etc… do not give the drug.
6. Check for skin test result of drug for IV push, drug-drug, drug IV fluid incompatibility, dosage (computation).
7. Prepare the necessary materials for the procedure such as: right drug, right diluent needed, IV injection tray,
syringes and needles, alcohol, etc.
8. Disinfect injection port of the diluent, vial or ampule as appropriate.
9. Aspirate right amount of diluent for the drug (if the drug needs to be diluted).
10. Aspirate the right drug dose; disinfect the Y-injection port of the IV administration set/catheter IV port.
11. Close the roller clamp of the IV tubing from the bottle and push IV drug aseptically and slowly or according to
the manufacturer’s recommendation.
12. Using same syringe aspirate 1-2 cc of IVF to flush medicine given.
13. Regulate rate of IV fluid infusion as prescribed. (if needed)
14. Reassure patient and observe for signs and symptoms of adverse drug reaction.
15. Discard sharps and other waste according to Health Care Waste Management (DOH/DENR).

ADMINISTERING IV DRUGS
IV PUSH through the HEPARIN LOCK DEVICE

1. Check medication card against the written doctor’s prescription.

2. Observe ten (10) Rs when preparing and administering medication.
3. Explain procedure to the patient (name of the medicine and action) before administration.
4. Do hand hygiene before and after the procedure (use gloves especially for chemo drugs).
5. Gather equipment to include/but not limited to the following:

 IV tray
 Heparin solution
 Normal saline diluent
 or Isotonic solution
 2.5 cc syringes (3 pcs.)
 Tuberculin/TB syringe 1 pc.

6. Prepare medication to be administered e.g., antibiotic and draw it up into a syringe.

7. Fill a tuberculin syringe with Heparin solution. N.B. Heparin solution is usually prepared with 0.1 cc Heparin plus
0.9 cc Normal saline or Isotonic solution.
8. Fill the 2.5 cc syringe with Isotonic solution or Normal saline 1 cc each.
9. If using Hep. Loc device with 3-way stop cock with Luer-lock, rotate the stop cock so that the line going to the
patient is closed (this will prevent backflow of blood).
10. Remove the cover of the injection port aseptically and keep the sterility of the cover.
11. Check the patency, open the IV line inject NSS or Isotonic solution to flush the Heparin solution.
12. Close the IV line & remove saline syringe and insert medication syringe into port.
13. Open the IV line & inject medication into the vein, timing the flow rate according to doctor’s prescription or drug
manufacturer’s instructions.
14. Observe patient for any adverse reactions & do nursing intervention accordingly.
15. Close the IV line & remove medication syringe.
16. Insert the saline syringe, open the line & flush catheter tubing /IV cannula to flush the line.
17. Close & remove saline syringe.
18. Close the IV line, remove syringe and return the cover of the injection port aseptically.
19. Document in the patient’s chart and Kardex.
20. . Discard waste according to Health Care Waste Management (DOH/DENR).

Note: Normal saline can take the place of Heparin. Studies have shown the efficacy of NSS. Heparin
solution can be used if normal saline or Isotonic solution is not available.
BLOOD TRANSFUSION

1. Verify doctor’s written prescription and make a treatment card according to hospital policy.
2. Observe ten (10) Rs when preparing and administering any blood or blood components.
3. Explain the procedure/rationale for giving blood transfusion to reassure patient and significant others
and secure consent. Get patient’s history regarding previous transfusion.
4. Explain the importance of the benefits on Voluntary Blood Donation (RA 7719 – National Blood
Service Act of 1994).
5. Request prescribed blood/blood components from blood bank to include blood typing and X-matching
and blood result of transmissible disease.
6. Using a clean lined tray, get compatible blood from hospital blood bank.
7. Wrap blood bag with clean towel and keep it at room temperature.
8. Have a doctor and a nurse assess patient’s condition. Countercheck the compatible blood to be
transfused against the X-matching sheet noting ABO grouping and Rh, serial no. of each blood unit, and
expiry date with the blood bag label and other laboratory blood exam as required before transfusion
(Hgb and Hct).
9. Get the baseline vital signs – BP, RR, temperature before transfusion. Refer to MD accordingly.
10. Give pre-med 30 minutes before transfusion as prescribed.
11. Do hand hygiene before and after the procedure.
12. Prepare equipment needed for BT:

13. If main IVF is with dextrose 5% initiate an IV line with appropriate IV catheter with Plain NSS on
another site, anchor catheter properly and regulate IV drops.
14. Open compatible blood set aseptically and close roller clamp. Spike blood bag carefully; fill the drip
chamber at least half full; prime tubing and remove air bubbles (if any). Use needle G 18 or 19 for side
drip (for adults) or of 22 for pedia (if blood is given through the Y-injection port, the gauge of needle is
disregarded).
15. Disinfect the Y-injection port of IV tubing (Plain NSS) and insert the needle from BT administration set
and secure with adhesive tape.
16. Close roller clamp of IV fluid of Plain NSS and regulate to KVO while transfusion is going on.
17. Transfuse the blood via the injection port and regulate at 10-15 gtts initially for 15 minutes and then at
the prescribed rate (usually based on the patient’s condition).
18. Observe patient for 10-15 minutes for any immediate reaction.
19. Observe patient on an ongoing basis for any untoward signs and symptoms such as flushed skin, chills,
elevated temperature, itchiness, urticaria and dyspnea. If any of these symptoms occurs stop the
transfusion, open the roller clamp of the IV line with Plain NSS, and report to doctor immediately.
20. Swirl the bag hourly to mix the solid with the plasma. N.B. one BT set should be used for 1-2 units of
blood.
21. When blood is consumed, close the roller clamp of BT, and disconnect from IV lines then regulate the
IVF of plain NSS as prescribed.
22. Continue to observe and monitor patient post transfusion for delayed reaction could still occur.
23. Re-check Hgb and Hct, bleeding time, serial platelet count within specified hours as prescribed &/or per
institution’s policy.
24. Discard blood bag and BT set and sharps according to Health Care Waste Management (DOH/DENR).
25. Document the procedure, pertinent observations and nursing intervention and endorse accordingly.
26. Remind the doctor about the administration of Ca gluconate if patient had several units of blood
transfusion (3-6 or more units of blood).
TPN UTILIZING PERIPHERAL ACCESS
1. Verifies doctor’s prescription.
2. Explains the procedure to reassure patient and significant others (benefits, risks, duration, changes in
volume and flow rate, etc.)
3. Secures consent form from patient and/or authorized member of the family.
4. Prepares parenteral solution and all other devices needed for the parenteral administration taking into
consideration the mode of administration such as:

a. Peripheral Access
b. Central Access

5. Assesses patient and choose suitable vein, location, and get baseline vital signs
6. Checks the integrity and functionality of the parenteral solution and IV devices.
7. Observes the ten (10) Rs in safe drug administration.
8. Do hand hygiene and maintain asepsis throughout the procedure.
9. Prepare TPN solution (follow procedure of Setting Up).
10. Inserts the IV catheter aseptically (large, bore catheter. Follow procedure I in IV insertion).
11. Connects the tubng to the prepared parenteral solution and regulate flow rate as prescribed.
12. Dresses IV site as per IV standard.
13. Labels IV site and solution as per IV standard.
14. Continue to reassure patient and do pertinent health education.
15. Disposes waste materials according to Health Care Waste Management (DOH/DENR).
16. Documents procedure and observations with corresponding nursing intervention in the patient’s chart
like I&O, weight daily, etc.
17. Monitors patient periodically and report unusual findings if any: such as signs of infection, hyper &
hypoglycemia, change of color and consistency of solution, etc.
18. Document observation and intervention as necessary.
19. Reassure patient.

TPN UTILIZING CENTRAL VASCULAR ACCESS

1. Follow procedure in Procedure of Peripheral Access from steps 1-9.
2. Assist surgeon in Open or Closed Central
3. Connects the IV administration set to the central vascular access catheter aseptically and regulate flow
rate as prescribed.
4. Assess dressing over central vascular access for swelling, redness, pain and foul smelling discharges.
Change dressing aseptically, everyday.
5. Monitor/reassure patient.
6. Document observations and circumstances as necessary.
7. Discard waste materials according to Health Care Waste Management (DOH/DENR).

DISCONTINUING PARENTERAL SOLUTION ADMINISTRATION

1. Verify written prescription (Discontinues upon completion of TPN requirements (e.g. 24hrs, 12hrs or in
the occurrence of any adverse reaction.)
2. Observe ten (10) Rs.
3. Explain procedure to the patient and significant others
4. Prepare the necessary materials to be used in discontinuing TPN utilizing Peripheral/Central Vascular
Access. (Prepare sterile dressing set and stitch scissor for Open Central Vascular Access).
5. Follow doctor’s prescription (e.g. electrolyte; weight; blood laboratory monitoring)
6. Monitor patient closely and document observations and intervention.
7. Refer M.D. for any unusual observations.
8. Discard waste materials according to Health Care Waste Management (DOH/DENR).