 A current individual concern or

NURSING DOCUMENTATION - is the behavior.

record of nursing care that is planned and
delivered to individual clients by qualified
nurses or other caregivers under the
direction of a qualified nurse. It contains
information in accordance with the steps of
the nursing process.
Types
Focus Charting
 Is a method for organizing health
information in the individual’s record.
 Example: nausea, chest pain,
pre-op teaching, hospital
admission
 A sign or symptom of (possible)
importance to the nursing and/or
medical diagnosis or treatment plan.
 Example: fever, constipation,
hypertension, incontinence,
lethargy

 It is a systematic approach to  An acute change in an individual’s

documentation, using nursing condition.
terminology to describe individual’s
health status and nursing action.  Example: Respiratory
distress, seizure, fever,
FDAR CHARTING discomfort.
F (FOCUS)
 A significant event in an individual’s
D (DATA) care

A (ACTION)  Example: begin treatment

regimen (oxygen), change in
R (REACTION) diet, catheterization

FOCUS  A key word or phrase indicating

compliance with a standard of care or
agency policy.
 A key word or diagnostic
category from a nursing  Example: Self-medication
diagnosis or collaborative teaching plan, transition
problem on the plan of
care (action plan). DATA
 Example: skin
integrity, coping,  Subjective and/or objective
activity tolerance, information supporting the stated
self-care deficit focus or describing observation the
time of significant events.

ANTE – BSN 2D 1|Page

EXAMPLES
DATA
– Complaining of continuous, sharp pain in
mid-abdominal incisional area.
-Crying “I need something for pain now!”
states pain is 9 on a scale of 10.
DATA
- Increase in body temperature above
normal range Temperature 39.8 degree
celcius/axilla.
- Flushed skin and warm to touched
ACTION
- Nursing interventions performed, planned
to be performed, and/or protocols and
procedures initiated.
EXAMPLES
ACTION
 Medicated with Nubain 5mg IVTT.
 Repositioned on Right side with
pillow to abdomen to help splint
wound.
ACTION
 Tepid sponge bath done
 Instructed significant others (SO) to
let patient wear loose clothing.
 Instructed SO to provide blanket to
patient when shiver.
 Instructed SO to let patient drink lots
of fluid.
 Instructed SO to include in his diet
ANTE – BSN 2D
foods rich in Vitamin C such as
orange, etc.
 Provide opportunity for patient to rest
 Due meds given
REACTION/RESPONSE
 Description of individual’s response to
medical and/or nursing care.
 Statement that the Action Plan of
Care outcomes have been attained or
are progressing toward attainment.
EXAMPLES
 REACTION/RESPONSE
 Patient stated pain was “much better”
30 mins. Later and rated it 3 on a
scale of 10.
 Patient was able to rest
 Patient temperature decrease to
temperature 37.8 degree
celcius/axilla.
EXAMPLE #1
 Needs/Focus
 Comfort (or relief of pain)
 Data
 Complaining of continuous,
sharp pain in midabdominal
incisional area.
 Crying “I need something for
pain now!” states pain is 9 on
a scale of 10.
2|Page
  Action
 Medicated with Nubain
5mg IVTT.
 Repositioned on Right side
with pillow to abdomen to
help splint wound.
 Response/Reaction
 Patient stated pain was “much
better” 30 mins.
 Later and rated it 3 on a scale
of 10.
EXAMPLE #2
 Received sitting on bed, awake,
responsive, coherent; with an IVF #4
PLR 1L @ 60 gtts/min; infusing well
at the right arm, with the following
vital signs: Bp – 110/70 mmHg, PR –
100bpm, RR – 26 cpm, T- 39.8
degree celcius/axilla.
 Focus – Hyperthermia
 Data
 Increase in body
temperature above normal
range Temperature 39.8
degree celcius/axilla;
Flushed skin and warm to
touched.
 Action
 Tepid sponge bath done;
Instructed significant others
(SO) to let patient wear loose
clothing; Instructed SO to
ANTE – BSN 2D
provide blanket to patient
when shiver; Instructed SO to
let patient drink lots of fluid;
Instructed SO to include in his
diet foods rich in Vitamin C
such as orange, etc; Provide
opportunity for patient to rest;
Due meds given.
 Response
 Patient was able to rest;
Patient temperature decrease
to temperature 37.8 degree
celcius/axilla.
POMR: Problem-Oriented Medical Record
narrative notes format
S-Subjective – what the patient tells you
O-Objective – what you observe or see
(may include lab results)
A- Assessment – what you think is going on
based on your data. An in-depth assessment
to determine the cause and effect of related
and underlying factors.
P- Plan – What you are going to do
3|Page
I- Intervention (specific interventions Disadvantages:
implemented)
 The concise approach to
E- Evaluation (patient’s response to documentation with these format may
interventions) cause nurses to feel restricted in the
information they want to share as
R- Revision (changes in the treatment) opposed to narrative charting.
It uses flow sheets to record routine care
SOAP entries are usually made at least
every 24 hours on any unresolved Example
problem
S- “I cannot eat, I feel bloated”. Pt stated.

O- Abdomen is distended but soft.

A- Third day post op. Passing flatus but

occasionally. Bowel sounds hypoactive in all
four quadrants. No BM since surgery.

P- Pt will evaluate /move bowel of feces

within next 2 hours in 6/18/18

I – Hold breakfast. Administer enema

according to doctor's order.
SOAPIE/ SOAP E- Client had moderate BM, soft and
formed. Stated “ Murag nakaginhawa na ko
Advantages:
ug lami.
 Problems can be quickly identified
from the prepared list

 All members of the team become

cognizant of the problems.

 They share in interventions,

implementation and evaluation of
outcomes.

Advantages

 Team collaboration determines

problem resolution and new strategy
development.

ANTE – BSN 2D 4|Page

ANTE – BSN 2D 5|Page
DRUG ADMINISTRATION
MEDICATION – substance administered for
the diagnosis, cure, treatment, or relief of a
symptom or for prevention of a disease.
- Given to exert specific physiologic
effects of the body.
- Important role in preventing, treating,
and curing illness their administration
has become one of the most
important complex and risk-laden
aspects of nursing care.
ROUTES OF DRUG ADMINISTRATION
Oral Route – per mouth
- Tablets, capsule, caplet, lozenge
(troche), pill, aqueous suspension,
elixir, syrup.
- Slower absorption through GI tract
o Tablet – compressed solid dosage
from certain therapeutic active
ingredients and excipients.
o Capsules – solid dosage where
therapeutic active ingredients
granules are enclosed within a hard
or soft soluble shell.
o Granules – solid dosage forms made
up of agglomeration of smaller
particles of powders.
o Sachets – small size spherical
granules packed into a small bag or
pouch pocket.
o Lozenges – dosage form that
dissolves slowly into the mouth.
Contain a drug with flavoring and
sweetening agents
o Chewables – are the solid dosage
form
ANTE – BSN 2D
Sublingual Route – under the tongue
- Faster absorption; bypasses GI tract
Buccal Route – against the cheek
Inhalation – aerosol spray; administered
through the mouth or nose
Instillation – urethral; instill liquid drugs
directly into the bladder
Suppository – vaginal and rectal
Parenteral Route – IV, IM, SC, ID,
intracardiac (heart), intrathecal (spinal cord),
intrapleural (pleural space), intraosseous
(bone marrow)
- Fast absorption; bypasses GI tract
Methods of Injection:
✔ Intradermal
- Into upper layer of skin
- Used for skin tests
- 0.1 ml
✔ Subcutaneous
- Provides slow, sustained released and
longer duration of action
- Rotate sites
- 0.5 – 1 ml
✔ Intramuscular
- More rapid absorption
- Less irritation of tissue
- Larger amount of drug
- Z- track method
- 1 – 3 ml
✔ Intravenous- into a vein
✔ Intracardial- heart tissue
✔ Intraperitoneal- peritoneal cavity
✔ Intraspinal- spinal canal
✔ Intraosseous- bone
Safety Risk:
- Rapid administration; rapid action
- Exposure to blood bones pathogens
✔ Sites for Intramuscular Injection
6|Page
 o Vastus Lateralis Site Topical Route - Skin, Eyes, Ear, Nose,
Rectum or Vagina
- Cream, gel or jelly, liniment, lotion,
ointment
Transdermal – use of medication patch will
release medication slowly and evenly.
● The effects are local and systemic
● Medication is prescribed by physician
● Medication order includes name of
drug, dose, route, frequency, date &
time.
o Deltoid Muscle Site

EFFECTS OF DRUGS

Therapeutic Effect – desired effect. It is also

reason drug is prescribed.
Side Effect – secondary effect
- May be harmless or harmful
- Unintended, usually predictable
Drug Toxicity – result from overdose
- Ingestion of external use
o Dorsogluteal Site
- Build up of drug in blood
Drug Allergy – immunologic reaction to drug
- Mild to severe (anaphylaxis)
Drug Tolerance – need increasing doses
to maintain therapeutic effect
Drug Interaction – one drug affecting
effect to another

ACTIONS OF DRUG ON THE BODY

o Ventrogluteal Site
Pharmacodynamics – process by which
drug changes the body (mechanism of
action)
Pharmacokinetics – study absorption,
distribution, biotransformation and
excretion
● Absorption – movement from
administration site into the
bloodstream

ANTE – BSN 2D 7|Page

 ● Distribution – transportation of drug
from its site to the site of action
● Metabolism – enzymes into a less
active form that can be excreted.
(Most drugs are metabolized in the
liver.)
● Excretion – elimination. (Kidneys
are the most important route.)
ADVERSE EFFECT OF MEDICATIONS
● LATROGENIC EFFECT DISEASE
caused unintentionally by medical
therapy
● ALLERGIC EFFECTS – immunologic
reaction to the drug
● TOXIC EFFETS
● DRUG INTERACTION

DRUG NOMENCLATURE
SIGNS AND SYMPTOMS OF DRUG
Chemical Name – describe the chemical ALLERGY
constituents of the drug ● Rash
Generic Name – assigned by the ● Urticaria
manufacturer that first develops the drug ● Fever
- Non-propriety name ● Diarrhea
● Nausea
Trade Name – brand name given by the ● Vomiting
company that sells the drug ● Anaphylactic reaction
MECHANISMS OF DRUG ACTIONS

Drug receptor interaction – interacts FACTORS AFFECTING MEDICATION

with one or more cellular structures to ACTION
alter cell function ● Developmental Considerations
Drug enzyme interaction – combines ● Weight
with enzymes to achieve desired effect ● Age
Acting on cell membrane or altering ● Gender
the cellular environment ● Diet
● Genetic and Cultural Factors
FACTORS AFFECTING DRUG ● Psychological Factors
ABSORPTION ● Illness & Disease
● ROUTE OF ADMINISTRATION ● Environment, timing of administration
● DRUG SOLUBILITY
● PH PREGNANCY CATEGORIES
● LOCAL CONDITIONS AT SITE OF ● Category A – No risk in human studies
ADMINISTRATION (studies in pregnant women have not
● DRUG DOSAFE demonstrated a risk to the fetus during
● SERUM DRUG LEVELS the first trimester).
● Category B - No risk in animal studies
(there are no adequate studies in
humans, but animal studies did not
demonstrate a risk to the fetus).

ANTE – BSN 2D 8|Page

 ● Category C - Risk cannot be ruled
out. There are no satisfactory studies
in pregnant women, but animal
studies demonstrated a risk to the
fetus; potential benefits of the drug
may outweigh the risks.
● Category D - Evidence of risk
(studies in pregnant women have
demonstrated a risk to the fetus;
potential benefits of the drug may
outweigh the risks).
- Check drug information sources for
pregnancy drug risk categories
● PATIENTS WHO ARE BREAST-
FEEDING
- Some drugs are excreted in breast
milk
- Can be dangerous because baby can’t
metabolize or excrete drugs

● Category X - Contraindicated - Check drug information sources for

(studies in pregnant women have contraindicating during lactation
demonstrated a risk to the fetus,
and/or human or animal studies have
shown fetal abnormalities; risks of the ● ELDERLY PATIENTS
drug outweigh the potential benefits).
- AGE RELATED CHANGES
EFFECTS
SPECIAL CONSIDERATIONS o Absorption
● PEDIATRIC PATIENTS o Metabolism
- Physiologic and immature body o Distribution
system may make the drug effects
less predictable o Excretion

- Require dosage adjustments and

careful measurements of doses - MAY HAVE INCREASED RISK OF
- Observe pediatric patients closely for o Drug toxicity
adverse effects and interactions
o Adverse Effects
- Administrations sites and techniques
may differ o Lack of therapeutic Effects
● PATIENTS FROM DIFFERENT
CULTURES
● PREGNANT PATIENTS
- Can affect patient’s understanding of
- Remember that you are caring for two drug therapy and compliance with it
patients
- Obtain drug information sheets in the
- Giving the mother a drug also gives it language that are commonly spoken
to the baby by patients

ANTE – BSN 2D 9|Page

 TYPES OF MED ORDER TEN RIGHTS OF DRUG
ADMINISTRATION
Standing Order – ongoing order or may
be given for a specific number of doses 1. Right Drug/Medication
or days
2. Right Dose
- May have special instructions to base
administrations on laboratory values; 3. Right Route
may include PRN orders. 4. Right Time
Single Order or One-Time Order – 5. Right Patient
given once and usually at a specific time
6. Right Information
Ex. Seconal 100mg HS before surgery
7. Right Evaluation
PRN Order – at client’s request and
nurse’s judgement concerning need and 8. Right to refuse
safety 9. Right Assessment
STAT Order – give once, immediately 10. Right Documentation
PARTS OF MEDICATION ORDER
● Patient’s Name UNDERSTANDING DRUG LABELS:
● Date and Time order is written ● Drug name – generic and brand name
● Name of drug ● Classification
● Dosage ● Medication from
● Route ● Dosage Strength
● Frequency ● Volume
● Signature of person writing the order ● Expiry Date
● Manufacturer
● Directions

TECHNIQUES FOR ADMINISTERING

DRUGS
Needles – available in different gauges – the
smaller the number, the larger the gauge
- Length – long enough to penetrate the
appropriate layers of tissue

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Syringes ASSESSMENT:
● Barrel 1. History
● Plunger a. Chronic Conditions
● With or without needle b. Drug Use
● Calibrated in milliliters or units c. Allergies
Parenteral Drug Packaging d. Level of education
Ampule – glass or plastic container e. Level of understanding of
that is sealed and sterile Disease and therapy
Cartridge – small barrel prefilled with f. Social Support
sterile drug
g. Financial Support
Vial – small bottle with rubber
diaphragm that can be punctured by needle h. Pattern of health care

COMFORT MEASURES: 2. Physical Assessment

● Placebo Effect a. Weight

● Managing Adverse Reactions (AR) b. Age

● Lifestyle Adjustment c. Physical Parameters

PATIENT AND FAMILY EDUCATION
1. Name, dose and drug action
2. Timing of administration
3. Special storage
preparation instructions
4. Specific OTC drugs or
alternative therapies to avoid.
5. Special comfort or
measures
6. Safety Measures
7. Specific points about drug
toxicity
8. Specific warning about drug
discontinuation
related to disease or
drug effects
3. Interventions
3 types:
and ● Drug Administration
● Provision of Comfort Measures
● Patient/Family Education
safety CRITERIA FOR CHOOSING
EQUIPMENT FOR INJECTIONS
● Route of administration
● Viscosity of the solution
● Quantity to be administered
● Body size
● Type of medication

ANTE – BSN 2D 11 | P a g e
Medical Record Documentation
● Document & sign each dose of
medication, as soon as it is given, and
the patient response
● Intentional or inadvertent omitted
drugs
● Refused drugs
Drug administration
● Medication errors
● Notify nurse manager and physician
● Write description or error on medical
record and remedial steps taken
● Complete special form for reporting
errors
- Always take appropriate body
substance isolation measures to
reduce your risk of exposure during
medication administration.
- Treat all blood and body fluids as
potentially infectious.

Types of Drug administration

Percutaneous Drug Administration - drug
applied to and absorbed through the skin or
mucous membranes.
TYPES OF MEDICATION ERRORS
Mucous Membrane - absorbed at a
● Inappropriate prescribing of the drug moderate to rapid rate.
● Extra, omitted, or wrong doses Eye Drop Administration - a medication
dropper to place the prescribed dosage on a
● Administration of drug to wrong
conjunctival sac.
patient
Aural Medication Administration -
● Administration of drug by wrong route
manually open the ear canal and administer
or rate
the appropriate dose.
● Failure to give medication within
Pulmonary Medication Administration - it
prescribed time
is administered via inhalation or injection.
● Incorrect preparation of drug
● Improper technique when
administering drug
● Giving a drug that has deteriorated
● Check patient’s condition
immediately; observe for adverse
effects

ANTE – BSN 2D 12 | P a g e
 and are not subject to hepatic alteration
Parenteral Drug Administration
- Drug administration outside of the
gastrointestinal tract
Kinds of Parenteral
 Drug Containers
 Glass ampules
 Single and multidose vials
 Nonconstituted syringes
 Prefilled syringes
 Intravenous medication fluids

Information on Drug Labels

 Name of medication
 Expiration date
 Total dose and concentration

Prefilled or Preloaded Syringes

 Confirm medication indications and
Endotracheal Tube - administered by patient allergies.

- Epinephrine  Confirm prefilled syringe label (name,

dose, and expiration date).
- Atropine
 Assemble the prefilled syringe.
- Naloxone Remove th pop-off caps and screw
together.
Enteral Drug Administration - medication
that is absorbed through the gastrointestinal  Reconfirm indication, drug, dose, and
tract route of administration.
Rectal Administration  Administer appropriately via the
indicated route.
- The rectum’s extreme vascularity promotes
rapid drug absorption.  Properly dispose of the needle and
syringe
- Medications do not travel through the liver,

ANTE – BSN 2D 13 | P a g e
Parenteral Routes  Gather any necessary equipment.
- Intradermal injection  Have patient sit upright when not
contraindicated.
- Subcutaneous injection
 Place the medication into your
- Intramuscular injection patient’s mouth. Allow self-
- Intravenous access administration; assist when needed.

- Intraosseous infusion  Follow administration with 4-8 ounces

of water and ensure that patient has
Oral Drug Administration - Any swallowed the medication.
medication taken by mouth and swallowed
into the GI tract. Be sure the patient has an
adequate level of consciousness to prevent Gastric Tube Administration
aspiration.
- Gastric tubes provide access directly
to the GI system.
Oral Drug Forms  Confirm proper tube placement.
 Capsules  Withdraw the plunger while
 Tablets observing for the presence of
gastric fluid or contents.
 Pills
 Instill the medication into the
 Enteric coated/time release gastric tube.
Capsules and Tablets
 Gently inject the saline.
 Elixirs
 Clamp off the distal tube
 Emulsions
 Lozenges
 Suspensions
 Syrups
Equipment for Oral Administration -
Soufflé cup, Medicine cup, Medicine
dropper, Teaspoon Oral syringe and Nipple

General Principles of Oral Administration

 Note whether to administer
medication with food or on empty
stomach.

ANTE – BSN 2D 14 | P a g e
 DOSAGE CALCULATION
Measurement Systems
- Metric
- Apothecaries
- Household
* Most doctors use the metric system.
Metric System
- Liter (L) - volume
- Grams (g) - weight
Apothecaries System
- Fluidounces, fluidram, pints, quarts -
volume WATER Adult has 45 liters two thirds of this
- Pounds - weight (30 liters) is found inside or within the cell
Household System while one third (15 liters) is outside the cell.
- drops, teaspoon, tablespoon, ounces,
cups, pints, gallons, quarts - volume 60% to 70% of total body weight so that
deprivation of water by as much as 10 %will
already result in illness and 20 % loss of body
Conversions between systems water may cause death.
– Approximate equivalents
– Charts
– Calculations OUTLINE
▪ Ratio method • Definition of IV therapy
▪ Fraction method • Indication of IV therapy

• Type of IV solution.
 Isotonic solution
 Hypertonic solution
 Hypotonic solution

• Categories of intravenous solutions

Work these problems:
1. The physician has ordered ampicillin
500 mg, on hand 250 mg capsules.
How much would you give? 2 capsules
2. You have 50 mg metropolol as a scored
tablet on hand and the doctor tells you
to give 25 mg. How much would you
give? ½ tablet
according to their purpose.
 Nutrient solutions
 Electrolyte solutions (Crystalloid)
 Volume expanders (Colloid)
• Parenteral Nutrition (PN)
• Clinical indications of parenteral nutrition.
• IV Infusion Method .
• Equipment of I.V. therapy.
• Nursing role in managing patient receiving
IV therapy

ANTE – BSN 2D 15 | P a g e
  Nursing assessment .
 Nursing diagnosis.
 Implementation
- Initiation phase
- Maintenance phase
- Discontinuing IV infusion
• Recoding and reporting,
• Evaluation

IV THERAPY
- It is an effective and efficient method
of supplying fluid directly into
intravenous fluid compartment
producing rapid effect with Hypertonic Solution
availability of injecting large volume
of fluid more than other method of - A higher salt concentration as the normal
administration. cells of the body and the blood

Indication of IV Therapy Examples:

- Maintain or Replace body store. - D5W in normal saline solution
- Restore acid base balance - D5W in half saline solution
- Restore the volume of blood component - D10W
- Administer of medication
- Provide nutrition
- Monitor CVP (Central Venous Pressure)

Types of IV Solution

Isotonic Solution
- it has the same salt concentration as the
normal cells of the body and the blood
Hypotonic Solution
Examples:
- 0.9% NaCl - A lower salt concentration as the normal
- Ringer Lactate cells of the body and the blood
- Blood Compotent
- D5W Examples:
- 0.45% NaCl
- 0.33% NaCl

ANTE – BSN 2D 16 | P a g e

CATEGORIES OF INTRAVENOUS
SOLUTIONS ACCORDING TO THEIR
PURPOSE:
1. Nutrient Solution
It contains some form of carbohydrate and
water.
• Water is supplied for fluid requirements
and carbohydrate for calories and energy.
• They are useful in preventing dehydration
and ketosis but do not provide sufficient
calories to promote wound healing, weight
gain, or normal growth of children.
• Common nutrient solutions are D5W and
dextrose in halfstrength saline.
2. Electrolyte Solutions (Crystalloids) -
consist of water and dissolve crystals
- used as maintenance fluids to
correct body fluids and electrolyte deficit.
- Commonly solutions are:
Normal saline (0.9% sodium chloride
solution).
ANTE – BSN 2D
-Ringer’s solutions (which contain
sodium, chloride, potassium, and
calcium.
-Lactated Ringer’s solutions (which
contain sodium, chloride,
potassium,calcium and lactate)
3. Volume Exapanders (Colloid) - increase
the blood volume following severe loss of
blood (haemorrhage) or loss of plasma
(severe burns)
• Expanders present in dextran, plasma, and
albumin.
Intracellular Fluid (30-40% of the body
weight) Extracellular Fluid (20-25%)
Interstitial (15%) Plasma (5%) Infant is
80% of body weight as water;
extracellular fluid is much higher in infant
than adult. Adult is about 50% TBW;
about 65% in children about 80% in
infants.
Parenteral Nutrition (PN) - nutritional
support that supplies protein, carbohydrates,
fat, electrolytes, vitamins, minerals, and fluids
via the IV route to meet the metabolic
functioning of the body.
CLINICAL INDICATIONS OF
PARENTERAL NUTRITION (PN)
* Client cannot tolerate internal nutrition as in
case of paralytic ileus, intestinal obstruction,
persistent vomiting.
* Client with hyper metabolic status in case of
burns and cancer.
* Client at risk of malnutrition because of a
recent weight loss of > 10%, NPO for >5 days,
and preoperative for severely depleted
clients.
17 | P a g e
 IV INFUSION METHOD
1. I.V BOLUS (I.V PUSH)
2. CONTINOUS DRIP INFUSION
3. INTERMITTEND INFUSION
EQUIPMENT OF I.V THERAPY
Solutions Container
I.V Administration Set
ANTE – BSN 2D
• Also, the nurse should assess the
patient for :
1- Any allergies and arm placement
preference.
2- Any planned surgeries.
3- Patient’s activities of daily living.
4- Type and duration of I.V therapy, amount,
and rate
Nursing Assessment:
- Assess the solution
✔ Sterile
✔ Clear and not expired
✔ No small particles
✔ No leakage
- Observe I.V Set
✔ Cracks
✔ Holes
✔ Missing Clamps
✔ Expired Date
Nursing Diagnosis:
✔ Anxiety related to threat regarding
therapy
✔ Fluid Volume Excess
✔ Fluid Volume Deficit
✔ Risk for infection
✔ Risk for Sleep pattern disturbance
✔ Knowledge Deficit related to I.V therapy
PLANNING
Identify expected outcomes which focus on:
• preventing complications from I.V therapy.
• minimal discomfort to the patient.
18 | P a g e
• restoration of normal fluid and electrolyte
balance .
• patient’s ability to verbalize complications.
IMPLEMENTATION
• I. Implementation during initiation phase
• A) Solution preparation: the nurse should:
• Label the I.V container.
• Avoid the use of felt-tip pens or
permanent markers on plastic bag.
• Hang I.V bag or bottle.
B) Site preparation:
1- Cleanse infusion site.
2- Excessive hair at selected
site should be clipped with scissor .
3- Cleanse I.V site with effective topical
antiseptic.
4- Made Venipuncture at a 10
to 30 degree angle.
II. Implementation during maintenance
phase
A) Monitoring I.V infusion therapy: the
nurse should:
 inspect the tubing.
 inspect the I.V set at routine intervals
at least daily.
 Monitor vital signs .
 recount the flow rate after 5 and
 15 minutes after initiation
B) Intermittent flushing of I.V lines
ANTE – BSN 2D
• Peripheral intermittent are usually flushed
with saline (2-3 ml 0.9% NS.)
• C) Replacing equipments (I.V container, I.V
set, I.V
dressing):
• I.V container should be changed when it is
empty.
• I.V set should be changed every 24 hours.
• The site should be inspected and palpated
for tenderness every shift or daily/cannula
should be changed every 72hours and if
needs.
• I.V dressing should be changed daily and
when needed
III. Implementation during phase of
discontinuing an I.V infusion
 The nurse never use scissors to
remove the tape or dressing.
 Apply pressure to the site for 2 to 3
minutes using a dry, sterile gauze
pad.
 Inspect the catheter for intactness.
 The arm or hand may be flexed or
extended several times.
RECORDING AND REPORTING:
• Type of fluid, amount, flow rate, and any
drug added.
• Insertion site.
• Size and type of I.V catheter or needle.
• The use of pump.
• When infusion was begun and
discontinuing.
• Expected time to change I.V bag or bottle,
tubing, cannula, and dressing.
• Any side effect.
• Type and amount of flush solution.
• Intake and output every shift, daily weight.
• Temperature every 4 hours.
• Blood glucose monitoring every 6 hours,
and rate of infusion.
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EVALUATION
• Produce therapeutic response to CALCULATE TOTAL INTAKE AND
medication, fluid and electrolyte balance. OUTPUT
• Observe functioning and patency of I.V
system.
 Example: Crystal has an IV infusing
• Absence of complications.
at KVO (10 mL/hr). She receives an
antibiotic in 22.5 mL q 8°
concurrently. One mL flush is given
after each antibiotic. She is given 30
IVF CALCULATIONS
mL of formula q 3°. She had diaper
weights of 17 mL, 33 mL, 55 mL, 45
1. cc/hr = Total Volume/ Running
mL, 52 mL, 50 mL, 15 mL, and 36
Hours mL.
Example:
The doctor ordered D5Water 1 Liter to run at  Calculate her I & O for the past 24
12 hours. Compute the cc/hr. hours.
1L=1000ml 1000ml/12hrs= 83.33 cc/hr
2. gtts/min INTAKE:
=total volume/hrs x drop factors/60 IV @ 10 mL/hr x 24 hr = 240 mL
min/hr Med of 22.5 mL x 3 (q8°) = 67.5 mL
Example: Flush of 1 mL x 3 = 3 mL
The doctor ordered PLR 1L to run at 10hours Formula of 30 mL x 8 (q 3°) = 240 mL
using a macro drop solutes. Compute for
240 mL + 67.5 mL + 3 mL + 240 mL
gtts/min.
=550.5 mL
1000ml/10hrs x 15 gtt/ml/60 min/hr
= 15000/600 = 25 gtts/ml Crystal's intake is 550.5 mL for the
past 24 hours.
 Macrodrop = 15 gtts/ml
WEIGH DIAPER
 Microdrop = 20 gtts/ml
- Gm and mL
- Weight of diapers, measurement
is "grams”
3. Running Hours= total
- Volume of urine output is "mL“
volume/cc/hour
- A 'gram' and a 'mL' are equivalent
Example: when measuring water.
The doctor ordered D5IMB 500cc to run at - In clinical setting, use grams and
50cc/hour. How long does it take for this IV mLs as equivalent when
to be consumed? measuring urine by diaper
500cc/50 cc/hours = 10 hours weights.

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 - Best noninvasive method
currently have and is close
enough for clinical decision
making.

- Process is to weigh diaper on a

gram scale and record output in
'mL (must account for weight of
dry diaper the same size used)

OUTPUT:
17 + 33 + 55 + 45 + 52 + 50 + 15 + 36
= 303 mL
Crystal's output is 303 mL for the
past 24 hours.

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