Abbygail B.

Roderos  Nursing management of patients receiving IV therapy and

peripheral/central and parenteral nutrition in various
WEEK : (4-17-2023) setups(hospitals/home/others)
Maternal and Child Health Nursing  Adherence to established infection control practices
 Observation and assessment of all adverse reaction related to
TOPIC: IV Therapy IV therapy and initiation of appropriate nursing interventions
 Appropriate documentation relevant to the preparation,
IVF AND BLOOD administration and termination of all forms of IV Therapy

DEFINITION: 5. INDICATIONS OF IV THERAPY

• The insertion of a needle or catheter/cannula into a vein, based on the
physician’s written prescription.
• The needle or catheter/cannula is attached to a sterile tubing and a fluid
container to provide medication and fluids
 To maintain hydration and/or correct dehydration in patients
unable to tolerate sufficient volumes of oral fluids/medications
 Parenteral Nutrition
 Administration of Drugs
 Transfusion of Blood and blood components

OBJECTIVES: 6. CONTRAINDICATIONS OF IV THERAPY

• Serves as a guide for nurses in providing safe and quality nursing care to - Administration of irritant fluids or drugs through peripheral access
patients, relative to IV therapy (i.e. highly concentrated, high osmolarity solutions)

• Promote the application of principles underlying the administration of IV 7. COMMUNICATON SKILLS

Therapy - An IV therapy nurse shall possess verbal and written communication
skills in translating ideas and facts to patients, health care members
• Recognize the ethico-legal implications of IV Therapy and others.
1. ROLE DEFINITION
8. CLIENT EDUCATION
• The IV nurses are registered nurses committed to ensure the safety of all - An IV therapy nurse have the responsibility of educating patients and
patients receiving IV therapy. significant others on pertinent aspects of IV therapy

2. BASIS OF PRACTICE 9. CONTINUING EDUCATION

- Continuing education and staff development are vital to professional
• Legal therapeutic prescription of a licensed MD advancement. In this regard, the IV therapy nurse actively participate
• Thorough knowledge of the vascular system and share knowledge with other disciplines

• Recognition of holistic approach to patient care IV FLUIDS COME IN FOUR DIFFERENT FORMS:

• Individual profession accountability • Colloids

• Networking and linkages with external environment • Crystalloids

• Collaboration with members of health team • Blood and blood products

Utilization of Nursing Process, through: • Oxygen-carrying solutions

 Assessment
 Planning A. COLLOIDS
 Implementation
• Colloid solutions are IV fluids that contain solutes in the form of large
 Evaluation proteins or other similarly sized molecules.

3. CLINICAL SKILLS
• An IV therapy nurse shall be proficient and competent in all clinical
aspects of the IV Therapy
4. PROCEDURES
- an IV therapy nurse shall perform procedures that include but not
limited to the ff:
 Carry out MD’s prescription for IV therapy
 Perform peripheral venipuncture (except insertion of subclavian
and cut-down catheter)
 Prepare, initiate, monitor and terminate IV therapy
 Administer Blood and blood components as prescribed by MD
 Determine solution and medication incompatibilities
 Change IV site, tubings and dressings, according to IV therapy
standards
 Establish flow rates of solutions, medications, blood and blood
components as prescribed by the MD
• Accordingly, colloids remain in the blood vessels for long periods of time
and can significantly increase the intravascular volume.
• The proteins also have the ability to attract water from the cells into the
blood vessels. However, although the movement of water from the cells
into the bloodstream may be beneficial in the short term, continual
movement in this direction can cause the cells to lose too much water and
become dehydrated.
• Colloids are useful in maintaining blood volume, but their use in the field
is limited.
• Colloids are expensive, have specific storage requirements, and have a
short shelf life. This makes their use more suitable in the hospital setting.
• Commonly used colloid solutions include plasma protein fraction, salt
poor albumin, dextran, and hetastarch.
 B. CRYSTALLOIDS
• Crystalloid solutions are the primary fluid used for hospital IV therapy.
Crystalloids contain electrolytes (e.g.,sodium, potassium, calcium,
chloride) but lack the large proteins and molecules found in colloids.
• Crystalloids come in many preparations and are classified according to
their “tonicity.”
• TBW describes the entire amount of water contained within the body and
accounts for approximately 60% of body weight. It is distributed among the
intracellular and extracellular compartments.
• The intracellular space is the space within all the body cells (intra, within;
cellular, cell).
• The extracellular space is the space outside the cells (extra, outside;
cellular, cells). The extracellular compartment can be further divided into
the intravascular space (space within the blood vessels) and the interstitial
space (space between the cells but not within the blood vessels.
• When the crystalloid contains the same amount of electrolytes as the
plasma, it has the same concentration and is referred to as “isotonic”
• If a crystalloid contains more electrolytes than the body plasma, it is
more concentrated and referred to as “hypertonic”.
• When a crystalloid contains fewer electrolytes than the plasma, it is less
concentrated and referred to as “hypotonic”
• The different compartments are separated by membranes through which
the body water can easily pass. As a general rule, body water is pulled
toward the solution with a higher concentration of dissolved molecules.
• The movement of water across a semipermeable membrane that
selectively allows certain structures to pass while inhibiting others is
known as osmosis.
I. ISOTONIC CRYSTALLOIDS
• Isotonic crystalloids have a tonicity equal to the body plasma.
• When administered to a normally hydrated patient, isotonic crystalloids
do not cause a significant shift of water between the blood vessels and the
cells. Thus, there is no (or minimal) osmosis occurring
II. ISOTONIC FLUIDS
• Can be helpful in hypotensive or hypovolemic patients.
• Can be harmful. There is a risk of fluid overloading, especially in patients
with CHF and hypertension.
• Examples: Lactated Ringer's (LR), NS (normal saline, or 0.9% saline in
water)
III. HYPERTONIC CRYSTALLOIDS
• Hypertonic crystalloids have a tonicity higher than the body plasma.
• The administration of a hypertonic crystalloid causes water to shift from
the extravascular spaces into the bloodstream, increasing the
intravascular volume. This osmotic shift occurs as the body attempts to
dilute the higher concentration of electrolytes contained within the IV fluid
by moving water into the intravascular space
IV. HYPERTONIC FLUIDS
• Rarely used in the prehospital setting. Care must be taken with their use.
Dangerous in the setting of cell dehydration.
• Examples: D5.45% NaCl, D5LR, D5 NSS, blood products, and albumin
V. HYPOTONIC CRYSTALLOIDS
• Hypotonic crystalloids have a tonicity lower than the body plasma.
• The administration of a hypotonic crystalloid causes water to shift from
the intravascular space to the extravascular space, and eventually into the
tissue cells. Because the IV solution being administered is hypotonic, it
creates an environment where the extravascular spaces have higher
concentrations of electrolytes. The osmotic change results in the body
moving water from the intravascular space to the cells in an attempt to
dilute the electrolytes.
C. HYPOTONIC FLUIDS
• Can be helpful when cells are dehydrated such as a dialysis patient on
diuretic therapy. May also be used for hyperglycemic conditions like
diabetic ketoacidosis, in which high serum glucose levels draw fluid out of
the cells and into the vascular and interstitial compartments.
• Can be dangerous to use because of the sudden fluid shift from the
intravascular space to the cells. This can cause cardiovascular collapse
and increased intracranial pressure (ICP) in some patients.
• P Example: .45% NaCl, 2.5% dextrose
IVF COLOR CODING
COLOR IVF SOLUTION
PINK D5 in lactated Rnger’s
RED D5 water
ORANGE D5 NM
GREEN Plain Normal Saline Solution
DARK BLUE Plain Lactated Rnger’s
LIGHT BLUE D5 0.3% NaCl
YELLOW D5 NSS
YELLOW GREEN D5 NR
VIOLET D5 IMB
WHAT ARE THE DIFFERENT INTRAVENOUS (IV) FLUIDS COMMON IN
THE HOSPITAL?
• Plain Lactated Ringer’s Solution (PLR-Blue) is an isotonic crystalloid that
contains sodium chloride, potassium chloride, calcium chloride, and
sodium lactate in sterile water.
• 0.9% Sodium Chloride (0.9NaCl-Green) is an isotonic crystalloid that
contains 0.9% sodium chloride (salt) in sterile water.
• 5% Dextrose in water (D5W-Red) is packaged as an isotonic
carbohydrate (sugar solution) that contains glucose (sugar) as the solute.
• 5% Dextrose in Lactated Ringer's Solution (D5LR-Pink) is a hypertonic
solution which means it pulls fluid out of the cells into the intravascular
space (veins).
• Mannitol (Mossy Green) is an organic compound with the formula (C6H8
(OH)6), administered intravenously, to reduce acutely raised intracranial
pressure until more definitive treatment can be applied, e.g., after head
trauma. It is also used to treat patients with oliguric renal failure and as an
osmotic diuretic agent and a weak renal vasodilator.
• Dextrose 10% in Water (D10W-Blue Green) is a solution given by vein
(through an IV) used to supply water and calories to the body. It is also
used as a mixing solution (diluent) for other IV medications.
• Normosol-R (D5NR-Yellow Green) is a sterile, non-pyrogenic, isotonic 1. Administer the right drug
solution of balanced electrolytes in water for injection. The solution is
administered by intravenous infusion for parenteral replacement of acute 2. Administer to the right patient
losses of extracellular fluid
3. Administer the right dose
• Balanced Multiple Maintenance Solution with 5% Dextrose (D5IMBViolet)
4. Administer at the right route
is a solution that treats low potassium in the blood, supplies electrolytes,
dextrose (sugar) to the system 5. Administer at the right time
• 5% Dextrose Normal saline solution (D5NSS-Yellow) provides 6. Right documentation
electrolytes and is a source of water for hydration. They are capable of
inducing diuresis depending on the clinical condition of the patient 7. Teach patient about the drugs he’s receiving

STANDARDS OF NURSING PRACTICE 8. Take complete drug history

1. 9. Assess for drug allergies

10. Be aware of potential drug-drug or drug-food interactions

12 RIGHTS OF MEDICATION ADMINISTRATION

1. Right medication

2. Right patient

STANDARD POLICIES AND PROCEDURES:
A. Physician’s prescribed treatment
- Patient’s name
-Type and amount of solution
- Flow rate
-Type, dose and frequency of drugs
- Others affecting the procedures
- MD’s signature
B. Patient Assessments
- Clinical status of patient
- Patient’s diagnosis
- Patient’s age
3. Right time
4. Right route
5. Right dose
6. Right response
7. Right reason
8. Right documentation
9. Right assessment and evaluation
10. Right client education
11. Right to refuse medication
12. Right expiration date
- Type of solution
3. INITIATION OF IV THERAPY
- Duration of therapy
- Initiation of IV therapy shall be to provide peripheral intravascular access
for therapeutic indications

- Dominant arm - This requires physician’s prescription

- Condition of vein and skin 4. CHOICES OF CANNULA

- Cannula size For peripheral infusion:

C. IV set and equipment preparation - Purpose of infusion

- Check for expiration date - Type of infusion

- Check for clarity, sediments, packaging - Size and condition of the patient’s vein

- Check label against doctor’s written prescription - Duration of treatment

- Label for any medication that are added: (date, time, dose and amount; - Condition of patient
compatibility of drug with the solution)

- Functionality of infusion pump

2. MEDICATIONS
IV CANNULA
10 GOLDEN RULES FOR DRUG ADMINSTRATION
SIZE COLOR CATHETER CATHETER WATER
 (GAUGE) I.D O.D LENTGH FLOW Take note for:
mm mm (mm) RATE
(mL. - Patient’s condition
/min.)
14 Orange 1.7 2.1 45 270 - Patient’s age
16 Gray 1.3 1.7 45 180 - The size and vein condition
17 White 1.1 1.5 45 125
18 Green 0.9 1.3 45 80 - Type and duration of therapy
20 Pink 0.8 1.1 32 54
22 Blue 0.6 0.9 25 33 - Functional utilization of the hand
24 yellow 0.5 0.7 19 20
6. ANCHORING CANNULA AND TUBING

Good anchoring…

- Allows normal blood flow

- Prevents movement of cannula

- Prevents irritation of the vein

- Puncture site should not be covered with tape

7. IV CANNULA REMOVAL

- Peripheral IV cannulas and the site are routinely changed aseptically or

re-sited every 48-72 hrs or when necessary

8. QUALITY CONTROL OF IV SOLUTION

All IV fluids shall be inspected prior to use:

- Visible sediments

- Turbidity

- Leaks/cracks

- Expiration date

- Damaged caps

9. DOCUMENTATION OF IV THERAPY

Proper documentation provides:

- An accurate description of care that can serve as legal protection

- A mechanism for recording and retrieving info

- A record for health insurers and retrieving info documenting the insertion
or beginning of therapy

The ff. info. of care can serve as legal protection

- Size, type and length of cannula/needle

- Name of person who inserted the IV catheter

- Date and time of insertion

The ff. info. Is documented in the patient’s chart:

- Location and condition of insertion site

- Complications, pt. response & nursing interventions

- Pt. teaching and evidence of patient’s understanding

- Nurse’s signature

Policies on Documentation:

- Never chart ahead of time

– Chart properly

5. SELECTION OF VENIPUNCTURE SITE - Clearly identify who did the procedure

- Don’t leave space on charting Nsg. Intervention:

- Identify late entries - Remove IV

- Don’t criticize personnel on the chart - Check for bleeding

- Avoid error B. THROMBOSIS – an abnormal condition in which a clot (thrombus)

develops within a blood vessel
- Don’t tamper records
S/S:
- Document all reports to the doctor
- Tenderness
- Chart abbreviations properly
- Swollen vein
- Refusal of meds should be charted
- Reddened
- Don’t invent!!!
Nsg. Intervention:
10. INFECTION CONTROL
- D/C IV

- Restart new site

- Warm compress

Prevention:

- Proper venipuncture technique to reduce injury

C. PHLEBITIS – inflamed vein

S/S:
The ff. measures reduce patient’s risk:
- Redness
- Wash hands before and after a procedure
- Puffy area
- Use an approved antiseptic to clean the client’s skin
- Hard vein on palpation
- Cut/clip the hair of the venipuncture site. Don’t shave
- Increase body temp.
- Do not re-use catheter or needle
Nsg. Intervention:
Center for Disease Control:
- Removed IV
- IV should be changed 48-72 hrs
- Warm compress
- Site prep: tincture of iodine 1-2% (30 sec before venipuncture
- Notify MD
- Tubing should be change after 48 hrs
Prevention:
- Tubing should be changed after admin. of blood products
- Restart at large vein or use small gauge cannula
- Between changes of components, the IV system should be maintained
as a closed system as much as possible D. INFILTRATION – a process whereby fluid passes into the tissues

LOCAL COMPLICATIONS S/S:

11. COMPLICATIONS IN IV THERAPY - Swelling

- Discomfort
A. HEMATOMA – a collection of extravasated blood trapped in the
tissues of skin or in an organ. - Tightness at IV site
S/S: - Blanching at site
- Tenderness - Decrease temp at site
- Bluish - Absence of backflow
- Bruising around site - Continues fluid infusion even when vein is occluded although rate may
decrease
- Inability to advance catheter
Nsg. Intervention:
- Resistance during flushing
- Removed IV & restart new site
Prevention:
- Warm compress & elevate limbs
- Choose a good vein
- Check for pulse & numbness
- Release torniquet as soon as insertion is achieved
- Notify MD - Secure all connections

Prevention: - inspect fluids

- Restart at large vein or Nsg. Intervention:

use small gauge cannula - Notify MD

- Monitor IV site - Do C/S & Initiate Antibiotic

E. LOCAL INFECTION – an infection within a specific area - Monitor V/S

S/S: H. CIRCULATORY OVERLOAD – an elevation in blood pressure

caused by an increased blood volume, as by transfusion. It may lead
- Redness and swelling to heart failure or pulmonary edema
- Presence of exudates S/S:
- Inc. WBC count - Discomfort
Prevention: - Intake increase
- Good aseptic technique - Neck vein engorgement
Nsg. Intervention: - Decrease output
- D/C - Resp. distress
- Request for C/S - Increase BP
- Apply sterile dressing Prevention:
- Apply antibiotics - Use volume control set
SYSTEMIC COMPLICATIONS - Calculate rate
F. VENOUS SPASM – a spasmodic constriction of vein - Monitor infusion
S/S: - Do not “catch-up” infusion
- Sharp pain at IV site Nsg. Intervention:
Prevention: - High fowler’s position
- Check for allergies - Slow flow rate
Nsg. Intervention: - Admin. Oxygen as needed
- Warm compress flow rate - Admin. Furosemide as ordered
- Decrease the flow rate I. CATHETER EMBOLISM
- Restart is spasm is gone S/S:
G. SEPTICEMIA – systemic infection in which pathogens are present in - Sharp sudden pain @ IV site
the circulating blood, having spread from an infection in any part of
the body - Rough and uneven catheter noted

S/S: - Chest pain

- Fever & Chills - Tachycardia

- Hypotension Prevention:

- Body malaise - Don’t apply pressure

- Pain - Use radio opaque

- Contaminated IV site - Avoid joint flexion

- Nausea - Never re-insert stylet

Prevention: Nsg. Intervention:

- Hand hygiene - Tourniquet above elbow

- cover infusion site - Start new site

- follow SOP - Inform MD

J. ALLERGIC REACTION – an unfavorable physiologic response to an STANDARDS OF NURSING PRACTICE PROCEDURES
allergen to which a person has previously been exposed and to
which a person has developed antibodies A. SETTING UP AN IV

S/S: 1. Verify doctor’s order & make I.V. label. - An order requiring the
initiation of IV must be made by the physician prior to the
- Itching
implementation of this procedure.
- Wheezing 2. Observe 12 R’s in Drug Admin. - For legal purposes
3. Explain Procedure to Client and secure consent if necessary - To
- Bronchospasm decrease anxiety and foster cooperation
4. Assess client’s vein; choose appropriate vein: location, size,
- Anaphylactic reaction condition. - Good condition of the vein will facilitate easier insertion of
- Urticarial rash the needles.
5. Hand hygiene before and after the procedure - To reduce
- Edema transmission of microorganisms and to prevent infection.
6. Prepare the necessary materials for procedure
- Bronchospasm
- Organization saves nursing time.
Prevention:
- IV tray w/ IV solution
- Obtain allergic history
- Cotton balls w/ alcohol
- Monitor client
- Administration set
- Test dosing (slow rate)
- Plaster and gloves
Nsg. Intervention:
- IV cannula with IV solution
- STOP!!! – Flush w/ PNSS
- Tourniquet and splints
- Notify MD
- Forceps soaked in antiseptic solution
- Admin. Antihistamine as ordered
- Sterile gauze or dressing
12. PROCEDURAL PROBLEMS ASSOCIATED WITH IV THERAPY
 Fluctuating flow rate 7. Check the sterility & integrity of the IV solution, IV set & other
 Runaway IV devices. - Break in the integrity of the materials can lead to infection.
 Sluggish IV 8. Place IV label on the IV fluid bottle (client’s name, room number,
 tubing/ loose connection / disconnection solution, drug incorporation, bottle sequence and duration) - To
 IV line obstruction/kinking of IV tubing ensure that the correct client will receive the IVF, and for
documentation purposes.
 Clogged filter
9. Open the seal of the IV solution and disinfect port with cotton balls
 Break in aseptic technique
with alcohol. - To reduce number or microorganisms residing in the
 leaks due to inappropriate device
port.
10. Open the administration set (IV set) aseptically and close the IV
13. RISK ASSOCIATED WITH IV THERAPY
clamp. - Closing the IV clamp prevents the solution from spilling
 Infectious organism exposure unintentionally after insertion to the solution bottle.
 Needle stick injury 11.
 Chemical exposure

14. OUTCOME CRITERIA

 The desired outcome criteria of these IV Nursing standard shall be
to:

- To deliver safe and quality IV Therapy care

- Protect the patient and the IV nurse therapist

- Protect the IV therapy nurse’s practice

Spike container aseptically
 All nurses are responsible for quality, utilizing IV nursing process of: 12. Fill drip chamber to at least half and prime the tubing aseptically
13. Remove air bubbles if any and put back the cover to the distal end of
- Assessment the IV tubing (get ready for IV insertion). - To remove air along the
tubing and to prevent air embolism.
- Planning
B. INSERTING IV W/ DUMMY ARM
- Implementation
1. Verify doctor’s written prescription for IV therapy, check prepared IVF
- Evaluation
and other things needed.
 Deviation from optimal care in the IV therapy nursing practice
- An order requiring the initiation of IV must be made by the physician prior
requires corrective care
to the implementation of this procedure.
INTRAVENOUS THERAPY 2. Observe 12 Rs in Drug Admin.
- For legal purposes 17. Label on I.V. Tape near the I.V. site to indicate the date of insertion.

3. Explain Procedure to Client and secure consent if necessary
- To decrease anxiety and foster cooperation
4. Assess client’s vein; choose appropriate vein: location, size, condition.
- Good condition of the vein will facilitate easier insertion of the needles.
5. Hand hygiene before and after the procedure
- To reduce transmission of microorganisms and to prevent infection.
6. Apply tourniquet 5-12cm (2-6in) above injection site depending on
condition of client
- To distend the veins and facilitates easier insertion
7. Check for radial pulse below tourniquet
. Tourniquet must be tight enough to occlude venous flow but not so tight
that it occludes arterial flow. Obstructing arterial flow inhibits venous filling.
If a radial pulse can be palpated, the arterial flow is not obstructed.
16. Regulate flow of infusion according to duration. - Improper calibration
can lead to under dosage or over dosage.
18. Label with plaster on the I.V. tubing to indicate the date when to
change the I.V. 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 Mgt
C. DISCONTINUING AN IV
1. Verify doctor’s order to discontinue IV including IV medications
2. Assess & inform the client of the discontinuation of IV infusion and of
any medication.
- Decreases anxiety and foster cooperation.

8. Prepare site with effective topical antiseptic according to hospital policy 3. Prepare the necessary materials.
or cotton balls with alcohol in circular motion and allow 30 seconds to dry.
(No touch technique). - Saves time and effort

- To reduce number of microorganisms in the area and to prevent - IV tray

infection.
- Cotton balls w/ alcohol
9. Using the appropriate I.V. cannula, pierce skin with needle positioned
- Plaster
on a15-30-degree angle; upon backflow visualization decrease the angle,
advance the catheter and stylet (1/4 inch) into the vein. - Forceps soaked in antiseptic solution
10. Position the I.V. catheter parallel to the skin. Hold stylet stationary the -Sterile gauze or dressing
slowly advance the catheter, until the hub is 1mm to the puncture site.
- kidney basin
11. Slip a sterile gauze under the hub. Release the tourniquet, remove the
stylet while applying digital pressure over the catheter with one finger 4. Hand hygiene before and after the procedure
about 1-2in. from the tip of the inserted catheter
- To reduce transmission of microorganisms and to prevent infection.
12. Connect the infusion tubing of the prepared IVF aseptically to the
5. Close the clamp of the IV administration set.
catheter.
– To prevent spilling of solution.
- To initiate flow of solution into the vein.
6. Moisten adhesive tape around the I.V. catheter with cotton ball with
When steel-winged needle (butterfly) is used:
alcohol; remove plaster gently.
A. Connect the I.V. tubing to the steel-winged needle connector & prime
- It facilitates easier removal of the plaster.
the needle with I.V. fluid.
7. Use pick-up forceps to get cotton ball with alcohol and without applying
B. Using the steel-winged needle, pierce skin with the needle bevels up,
pressure, remove needle or IV catheter then immediately apply pressure
positioned on a 5–10-degree angle.
over the venipuncture site
C. With steel-winged needle, parallel on the skin, enter the vein directly
8. Inspect IV catheter for completeness.
and advance needle ¼ inch after successful venipuncture. Check for
backflow. Remove tourniquet. - Make sure that the entire length of the catheter is complete. If not, inform
the physician immediately.
13. Open the clamp, regulate the flow rate and reassure the client.
11. Place dressing over the venipuncture site
- To initiate flow of solution into the vein.
- Make sure that the entire length of the catheter is complete. If not, inform
14. Anchor needle firmly w/ the use of
the physician immediately.
a. transparent tape/dressing directly on the puncture site.
10. Discard sharps and waste according to Health Care Waste Mgt
b. tape (approp. anchoring style).
11. Document time of discontinuance, status of insertion and integrity of IV
- To secure the needle in place. catheter and endorse accordingly

15. Tape a small loop of I.V. tubing for additional anchoring; apply splint (if
needed).

- To secure the needle in place.

D. CHANGING AND IV SOLUTION
1. Verify doctor’s prescription in doctor’s order sheet, countercheck IV
label, IV card, infusion sequence, type, amount additives (if any) and
duration of infusion
2. Observe 12 Rs in Drug Admin. - For legal purposes
3. Explain Procedure to Client and assess IV site for redness, swelling and
pain… - To decrease anxiety and foster cooperation
4. Change IV tubings & cannula if 48- 72hrs. Has lapsed after IV insertion
- Prolonged used of needle is the primary source of infection in IVF.
5. Hand hygiene before and after the procedure - To reduce transmission
of microorganisms and to prevent infection.
6. Prepare necessary materials. - To save time and effort
- IV tray
- Cotton balls w/ alcohol
- New IV bottle w/ IV label
- Forceps soaked in antiseptic solution
7. Check sterility and integrity of IV solution. - Break in the integrity of the
materials can lead to infection.
8. Place IV label on the IV bottle
9. Calibrate the new IV bottle according to duration of infusion. Place IV
label on the IV bottle. - Improper calibration can lead to underdosage or
overdosage.
10. Open and disinfect rubber port of IV solution to follow
11. Close the IV clamp or kink tubing and spike the container aseptically. -
Closing the IV clamp prevents the solution from spilling unintentionally
after insertion to the solution bottle
12. Regulate the flow rate based on duration of infusion. Remove air
bubbles (if any). - Improper calibration can lead to underdosage or
overdosage. Air in the tubings can lead to air embolism.
13. Reassure client and significant others
14. Discard sharps and waste according to Health Care Waste Mgt.
15. Document in the patient’s chart and endorse to incoming shift.
E. INCORPORATION INTO IV BOTTLE
1. Verify written medication card against MD prescription; observe hospital
policy on drug administration - To make sure that correct medication will
be administered.
2. Observe 12 Rs in Drug Admin. - For legal purposes
3. Explain Procedure (medication & action) and check patency and IV site
- To decrease anxiety and foster cooperation
4. Verify for skin test of drug for IV incorporation (if skin testing is
necessary)
5. Hand hygiene before and after the procedure - To reduce transmission
of microorganisms and to prevent infection.
6. Prepare necessary materials needed for the procedure such as:
- IV tray
- Cotton balls w/ alcohol
- syringes needed
- Forceps soaked in antiseptic solution
-Sterile gauze or dressing
- kidney basin
7. Disinfect the injection port of the vial and the ampule before breaking
then aspirate the right drug to be incorporated either in vial or ampule
8. Remove the cover of the airway of the administration set, maintain the
sterility and incorporate prepared drug into the airway. Recap airway after.
*** If the administration set has no airway, put down the bottle, kink the IV
tubing, remove the administration set from the bottle aseptically; disinfect
the bottle’s rubber stopper; incorporate the right drug to the IVF bottle;
return the administration set to IVF bottle aseptically;
10. Swirl the IV bottle to mix the drug, with IVF and regulate the flow rate
accordingly.
10. Observe for 5-10mins for any drug interaction while reassuring the
patient; monitor V/S
11. Document in the patient’s chart
12. Discard sharps and waste according to Health Care Waste Mgt
F. IV PUSH THROUGH THE IV PORT
1. Verify written medication card against MD prescription; observe hospital
policy on drug administration - To make sure that correct medication will
be administered.
2. Observe 12 Rs in Drug Admin. - For legal purposes
3. Explain Procedure (medication & action) and check patency and IV site
- To decrease anxiety and foster cooperation
4. Hand hygiene before and after the procedure - To reduce transmission
of microorganisms and to prevent infection.
5. Check patency and other reactions 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 necessary materials needed for the procedure such as:
- Right drug - IV tray
- Right diluent - syringes needed
- Cotton balls w/ alcohol - etc….
8. Disinfect the injection port of the diluent vial or ampule as appropriate
9. Aspirate right amount of diluent for the drug (if drug needs to be
diluted.)
10. Aspirate the right drug dose; disinfect the Yinjection port of the IV
administration set
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 the same syringe aspirate 1-2cc of IVF to flush the medicine
given.
13. Regulate the rate of IV fluid infusion as prescribed
14. Reassure the patient and observe for signs and symptoms of adverse
drug reaction.
15. Discard sharps and waste according to Health Care Waste Mgt.
G. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER
1. Verify written medication card against MD prescription; observe hospital 9. If using Hep lock device with 3- way stop cock with luer-lock, rotate the
policy on drug administration - To make sure that correct medication will stop cock so that the line going to the patient is closed (this will prevent
be administered. backflow of blood)

2. Observe 12 Rs in Drug Admin. - For legal purposes
3. Explain Procedure (medication & action) and check patency and IV site
- To decrease anxiety and foster cooperation
4. Hand hygiene before and after the procedure - To reduce transmission
of microorganisms and to prevent infection.
5. Prepare necessary materials needed for the procedure such as:
- Right drug and dose - Right diluent needed
- IV injection tray - Syringes and needle
6. Check present IV fluid label, level and the incorporated medicine in the
Volumetric chamber or IV bottle if w/ incorporated medicine, check for
drug-drug incompatibility and if the on-going IV fluid in the volumetric
chamber is to be consumed in 6-8 hrs. Request a prescription for IVF to
be used solely for drug administration and keep the whole set sterile.
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 to flush Heparin
solution
12. Close the IV line and remove saline syringe and insert medication
syringe into the port.
13. Open the IV line & inject medication into the vein, timing the flow rate
according to doctor’s order of drug manufacturer’s instructions.
14. Observe client for any adverse reactions and 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.

7. Aspirate prepared right drug and with correct dose. 17. Close & remove saline syringe.

8. Add desired IVF diluent into volumetric chamber by opening the sliding 18. Close the IV saline, remove syringe and return the cover of the
clamp from the bottle then close the clamp. injection port aseptically.

9. Disinfect rubber injection port of the volumetric chamber and 19. Document in the patient’s chart, IVF sheet and Kardex
incorporate the drug. Mix gently
20. Discard sharps and waste according to Health Care Waste Mgt.
10. Open the clamp of the airway at the volumetric chamber

11. Regulate the flow rate of IVF infusion accordingly

12. Place IV label on volumetric chamber indicating the drug incorporated

and flow rate

13. Reassure/monitor client when incorporated medicine is consumed,

close airway of VC and IVF and regulate flow rate of main IVF as
prescribed

14. Discard sharps and waste according to Health Care Waste Mgt.

15. Document in the patient’s chart, IVF sheet and Kardex

H. IV PUSH- HEPARIN LOCK

1. Verify written medication card against MD prescription; observe hospital

policy on drug administration - To make sure that correct medication will
be administered.

2. Observe 12 Rs in Drug Admin. - For legal purposes

3. Explain Procedure (medication & action) and check patency and IV site
- To decrease anxiety and foster cooperation

4. Hand hygiene before and after the procedure - To reduce transmission

of microorganisms and to prevent infection.

5. Prepare necessary materials needed for the procedure such as:

- heparin solution - Normal saline

- 3cc syringe (3pcs) - tuberculin syringe 1pc)

- IV tray - cotton balls with alcohol

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

a syringe

7. Fill the tuberculin syringe with Heparin solution. (heparin solution is

usually prepared with 0.1cc heparin plus 0.9cc Normal saline solution

8. Fill the 3cc syringe with Isotonic solution or Normal saline 1cc each