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NCM 112 Lesson9
NCM 112 Lesson9
Planning
Disposable gloves
IV solution in a bag
Additives as ordered
IV tubing
Alcohol swab (if needed)
Expected 1. The ordered solution will be infused into the client's veins without
Outcomes: complications.
2. The IV catheter will remain patent.
3. The client will be able to discuss the purpose of the IV therapy.
4. The solution infused will not harm the client because of additive
incompatibilities or additive decomposition.
Client Education 1. Teach the client the rationale for the IV therapy and need to
Needed: change the solution.
2. Teach the client the type of solution and additives he or she is
receiving.
3. Instruct the client to report any leakage of the bag of IV solution.
4. Instruct the client to report if the solution is at a low level.
5. Be sure drip chamber is at least half 5. Prevents entry of air into IV tubing while
full (see Figure 8-7-3). bag is being changed.
6. Change IV solution: 6. Prevents fluid in drip chamber
from emptying while changing
Move roller clamp to stop flow solutions.
of fluid. Prepares equipment.
Remove old IV bag from IV pole Maintains sterility of solution.
and hang new bag. Prevents clotting of vein.
Spike new bag with tubing
(see Figure 8-7-4).
Re-establish prescribed flow
rate.
8. Empty remaining fluid from old IV if 8. Disposes of excess fluid. Reduces risk of
needed (see Figure 8-7-7). spilling large amounts of fluid in waste
can.
9. Remove gloves and dispose of all used 9. Reduces transmission of
materials. microorganisms.
10. Apply a label with date, time, and type 10. Allows for planning of next change.
of solution.
11. Wash hands. 11. Reduces transmission of
microorganisms.
Evaluation: The ordered solution infused into the client's vein without complications.
The IV catheter remained patent.
The client is able to discuss the purpose of the IV therapy.
The solution infused did not harm the client because of additive incompatibilities
or additive decomposition.
Nurses' Notes
Variations
Geriatric Variations: Pay special attention to assessing the IV insertion site. A good time for that
extra check is when you are changing the solution.
Pediatric Variations: Intravenous pump alarms can cause both anxiety and fear in
younger and older children. Changing the IV solution is a good
opportunity to teach children about the alarms. Remind children that
the alarm going off is not an emergency and does not mean that
they are in danger or becoming sicker.
Home Care Variations: An approved receptacle needs to be provided for used IV
bags and tubing.
The client or caregiver must be taught how to mix the IV
solution if additives are required.
The client or caregiver must be taught how to assess the
new IV solution for breaks in sterility or contaminants.
Possible Errors: The IV solution is not ready when the nurse needs it for a client.
Prevention: The nurse should anticipate when the new IV solution will be needed and be
sure it is ordered from the pharmacy. If this error does occur, slow the IV drip
rate so that the IV bag will not run dry, following institution protocol. Obtain
the new bag when ready and proceed to hang the IV solution.
Nursing Tips: Anticipate the need for the next bag of IV solution to avoid the risk of
an IV clotting because of the solution running out.
Keep in mind the client's laboratory results and need for fluid to be
sure the correct solution is given.