ASSISTING IV INSERTION,

BLOOD TRANSFUSION
AND
TIME TAPING
 DEFINITION OF TERMS

1. Intravenous Therapy
-intravenous therapy requires parenteral fluids
(solutions) and special equipment: administration set,
IV pole, filter, regulators to control flow rate and an
established venous route.

2. Parenteral
- administered by means other than through the
alimentary tract (as by intramuscular or
intravenous injection)
3. Parenteral fluids
- are intravenous solutions that are
sterile and usually packed in plastic bags
or in glass containers.

4. IV pole
-a metal pole wherein intravenous
solutions are placed or hanged.
5. Drip chamber
- comes in two types, first is Macro drip
which releases 10-20 drops per milliliter
of solution and Micro drip, which
releases 60 drops per milliliter.

6. Regulator
- is a roller clamp which compresses the
plastic tubing to control the flowrate.
8. Injection port
- a specific site in the IV administration
set wherein parenteral medications are
introduced.

9. IV catheter
- are specialized needles that initiates
access to the venous system.
7. Micro drip
- Micro drip releases 60 drops per milliliter.
Usually indicated for pediatrics.

8. Macro drip
- Macro drip which releases 10-20 drops per
milliliter of solution.

9. Volume control chamber

- a special control chamber that is used to
regulate the fluid amount administered in a
specific time.
Spike

IV Tubing

Drip Chamber
Y – Port /
Injection Port
Needle

Regulator
Micro drip

Macro drip
 IV
CATHETERS/
IV CANNULAS
10. Blood Transfusion
- The introduction of blood or blood plasma into
a vein or artery.

11. Blood administration set

- tubing with in lined filter and Y for saline
administration.

12. Blood Typing

- is a laboratory examination to determine a
persons blood type.
13. Cross-matching
- is the process of determining compatibility
between blood types.

14. Rh factor
- an inherited antigen in human blood.

15. Hepatitis
-inflammation of the liver.
16. RBC
- Red Blood Cells

17. Antigen
- any substance (as a toxin or enzyme) that
stimulates an immune response in the body
(especially the production of antibodies)

18. Agglutinin
- an antibody that causes agglutination of a
specific antigen.
TYPES OF
SOLUTIONS
1. HYPOTONIC SOLUTION
- lowers osmotic pressure and
makes fluid move into cells.
-Used to treat cellular
dehydration and establish renal
function
Ex
- 0.25% NaCl
-0.45% NaCl
-- 2.5% dextrose
2. ISOTONIC SOLUTION
- increases only extracellular
fluid volume .

Ex
.9% NaCl (normal saline)
Lactated Ringer's solution
D5W (acts as a hypotonic solution in body)
Hypertonic fluid
-increases osmotic pressure and
draws fluid from the cells
Ex
D5NaCl
D5 in Lactated Ringer's
D5 0.45% NaCl
TYPES OF SOLUTION ACCDG TO
PURPOSE

1. Nutrient solution
• It contains some form of CHO (dextrose
and glucose) and water.
• CHO are used for calorie and energy
while water is for fluid requirements of the
body
• Ex 5% Dextrose in water (D5W)
5% Dextrose 0.45 Na Cl
2.Electrolyte solution
• Primarily to replace electrolyte loss
• Ex Normal saline ( 0.9 Na Cl)
• Ringers Solution
3. Saline + Balanced electrolyte solution
• It is used to restore vascular volume
particularly after trauma and surgery.
• It is also used to replace fluid and
electrolyte for clients with continuing losses
like in gastric suctioning or wound drainage.
• Ex 5% Dextrose in Normal Saline (
D5NSS)
4. Volume expanders
• It is used to increase the blood volume
follow severe loss of blood or loss of plasma
like burns which withdraw large amounts of
plasma from the bloodstream to the burn
site.
• Ex Dextran, Plasma and Albumin
PURPOSES OF IV THERAPY
 To supply fluid when clients are unable
to take in an adequate volume of fluids by
mouth

 To provide salts needed to maintain

electrolyte balance

 To provide glucose (dextrose), the

main fuel for metabolism
 To provide water-soluble vitamins
and medications

 To establish a lifetime for rapidly

needed medications
TYPES OF NEEDLE CATHETERS/
NEEDLE CANNULAS
1. BUTTERFLY NEEDLES

- (scalp vein or wing-tipped)

- are short, beveled needles with plastic

wings attached to the shaft.
2. VASCULAR ACCESS DEVICES (VAD)

- include various cannulas, catheter and

infusion ports that allow long term IV
therapy or repeated access to the
central venous system.

Eg.
- CVC (Central Venous Catheter)
- Implantable port
3. Intracath
- refers to a plastic tube inserted into a
vein.
 Word about Gauges
• Catheters (and needles) are sized by
their diameter, which is called the
gauge
• The smaller the diameter, the larger
the gauge
• The greater the diameter, the more
fluid can be delivered. To deliver
large amounts of fluid, you should
select a large vein and use a 14 or
16-gauge catheter
Materials used in IV therapy

1. Infusion set
2. Container of sterile parenteral solution
3. IV pole
4. Adhesive or hypoallergenic tape
5. Clean gloves
6. Tourniquet
7. Antiseptic swabs
8. Antiseptic ointment, such as povidone-iodine
9. Intravenous catheter
10. Sterile gauze dressing or transparent occlusive
dressing
11. Arm splint, if required
IV STARTER KIT
KEY POINTS PRIOR TO INITIATION
OF IV THERAPY
1. Physician’s prescribed treatment.
This should be of a written
prescription in the doctor’s order
sheet
- Patient’s name
- Type and amount of solution
- The flow rate
- The type, dose and frequency of
medications to be incorporated/
pushed
- Others affecting the procedures (X-rays, treatments to
the extremities, etc.)
2. Patient Assessment
- Patient’s diagnosis
- Patient’s age
- Dominant arm (Non)
- Condition of the vein/ skin-
a. use distal veins of arms first;
b. select a vein that is the most easily palpated and feels
soft and full
c. Select a vein large enough to allow adequate
circulation around the catheter
d. Select a vein naturally splinted by a bone
e. Avoid veins that are previously used and
damaged
f. Avoid veins of a surgically compromised or
injured extremity
3. IV set and equipment preparation
• Check for expiry date
• Check for clarity; any presence of holes on
plastic cover(packaging); plastic container
(bag) for presence of sediments or insects
• Check label against the physician’s written
prescription
• Label for any medication that are added:
date, time, dose of medication and
amount; compatibility of drug with the
solution
• Functionality of Infusion Pump, Patient
controlled analgesia (Pt CA)
• Peripheral IV cannulas and the site are
routinely changed aseptically or re-sited
every 48-72 hours or when necessary
 ROLES OF NURSES
NOTE: Assist only; except when you are a
licensed IV Nurse
Before starting an infusion:
- Determine the doctor’s order
- Determine if the patient has any allergies
or sensitivities to medications (use
hypoallergenic plasters)
- Determine the site of insertion (for hairy
areas)
• Inform the patient about the
procedure
• Keep patient in a comfortable position
• Prepare the materials needed
• Closely monitor the rate of flow
• Do not let the bottle empty; follow
another bottle as ordered by the
physician
• Remove bubbles and air inside the tubing
- If air is in line and goes to line of vein, open the
chamber (air chamber)
• Careful/ regular monitoring of intravenous access sites is
recommended
• If with presence of obstruction or blood clot:
- Pushing when there’s a clot is not advisable
- Get a syringe, kink the mainline to stop flow while doing
suction
 FACTORS AFFECTING FLOW

• Position of patient
• Height of tube – the higher, the faster it flows
• Tubing length
• Size of the vein
• Gauge of catheter
• Presence of obstruction
• Temperature and viscosity of fluid
WARM FLUIDS FLOW BETTER THAN COLD
 DOCUMENTATION
• The date and time you inserted the venous access
device
• The specific vein chosen
• The gauge and length of the inserted device
• The brand and style of the device
• The solution that’s infusing
• Whether the solution is infusing by gravity or pump
 PROBLEMS WITH IV THERAPY
• Sepsis – infection of the blood
• Hematoma – accumulation of blood in the
tissue of injury
• Cellulitis- bacterial infection of the skin and
tissues immediately beneath the skin
• Thrombosis- a clot
• Catheter fragment embolism
Cellulitis
• Infiltration – the catheter is dislocated
to the surrounding tissues rather that
directly to the vein
• Air embolism
• Phlebitis- inflammation of the vein
 BLOOD
TRANSFUSION
 The 4 main blood types

RECIPIENT DONOR

O A B AB
AB √ √ √ √
B √ √
A √ √
O √

AB= Universal Recipient

O= Universal Donor
Things to remember
in doing
blood transfusion:

 Blood should be typed and cross-

matched before the administration.

 Not all blood types are compatible to

each other.
Blood donors must
be chosen with care,
according to the
following criteria:

1. They must be free from disease such as

type A or B hepatitis.

2. They must be free from allergies or a

history of chronic diseases
• 3. They must not
• have been immunized
• recently to avoid
• possible allergic
• reaction to the blood.

• 4. Heart & chest sounds, blood count,

temperature, pulse and respiratory rate
and blood pressure should be within
normal range.
 Recipients may not
need all the constituents
of whole blood.

 Blood transfusion is
basically the same as starting on intra-
venous infusion, only the vein and the
needle should be larger in diameter
because of the viscosity of the blood.
PURPOSES
OF
BLOOD
TRANSFUSION
Blood transfusion is given for the
following reasons:

 Red Blood Cell loss

 Major cut

 When the body is not adequately

producing cells such as platelets.
Equipments needed in Blood transfusion:

1. Properly typed and cross-matched

blood

2. Filter set or blood set

3. G16, G18, G20 needle or catheter

4. Normal saline solution

 TYPES OF BLOOD
COMPONENTS
1. RED BLOOD CELLS (RBC)
- Are blood products used to replace red
blood cells (erythrocytes)
- Are usually supplied in 25-400ml.
Always check the unit for volume of
blood component
2. WHOLE BLOOD
- Used to resolve hypovolemic (decreased
fluid volume)shock resulting from
hemorrhage
- Contains RBC, plasma and plasma
proteins
3. PLATELETS
- Used to treat thrombocytopenia (decreased platelet
count) and platelet dysfunctions
- May vary from 50-400 ml per unit
- Administered rapidly; usually 15-30 minutes
4. FRESH FROZEN PLASMA
- May be used to provide clotting factors or volume
expansion; it contains no platelets
5. ALBUMIN
- Is prepared from plasma
- Albumin is a protein
- Used to treat shock and hypoproteinemia
6. CRYOPRECIPITATES
- Are prepared from fresh frozen plasma and can be
stored for 1 year
- Can be used to replace clotting factors, especially factor
VIII and fibrinogen
PRECAUTIONS AND NURSING
RESPONSIBILITIES
1. No solution other than PNSS or normal
saline should be added to blood
components
2. Medications are never added to blood
components or piggybacked into a blood
transfusion
3. To avoid the risk of septicemia, infusions
(1 unit) should not exceed 4 hours
4. Always check the blood bag for the date
of expiration
5. Inspect the blood for leaks, abnormal
color, clots and bubbles
6. Blood must be administered as soon as
possible (within 20-30 minutes) from its
being received at the blood bank, as this
is the maximal allowable time out of
monitored storage
7. Never refrigerate blood in refrigerators
other than those used in blood banks; if
the blood is not administered within 2-0-
30 minutes, return it to blood bank
8. The nurse should measure vital signs and assess lung
sounds before the transfusion and again after the first
15 minutes and every hour after the transfusion is
completed
9. Two registered nurses need to check the
physician’s order, the client’s identity, and the
client’s identification band or bracelet and number,
verifying that the name and number are identical to
those on the blood bag component tag
10. At the bedside, the nurse asks the
client to state his or her name, the nurse
compares the name with the name on
the identification band or bracelet
11. The nurse checks the blood bag tag,
label, and blood requisition form to
ensure that ABO and Rh types are
compatible
12. If the nurse notes any inconsistencies
when verifying client identity and
compatibility, the nurse notifies the blood
bank immediately
13. A Jehovah’s witness cannot receive
blood or blood products
14. Ensure that an informed consent has
been obtained
15. Check the client’s vital signs: if the
temperature is elevated, notify the
physician before beginning the
transfusion
16. If a reaction occurs(chills, heavy
sweating, muscle aches, back pain,
chest pain, rashes, itching, swelling,
rapid pulse, dyspnea, cough,
wheezing, pallor, cyanosis, apprehension,
headache, nausea, vomiting, abdominal
cramping, diarrhea), stop the trasfusion,
change the IV tubing down to the IV site,
keep the IV line open with normal saline,
notify the physician and blood bank, and
return the blood bag and tubing to the
blood bank
17. Do not leave the patient alone, and
monitor the client for any life threatening
symptoms
 BLOOD TRANSFUSION
COMPLICATIONS

1. Transfusion reactions
2. Circulatory overload- is caused by
infusion of blood at a rate too rapid
for the client to tolerate
3. Iron overload- is a delayed
transfusion complication that
occurs in chronically dependent on
blood transfusions, such as clients
with anemia or thrombocytopenia
4. Disease transmission- such as Hepatitis
C, Hepatitis B, AIDS, malaria, etc.
5. Hypocalcemia (low level of calcium in the
blood)
6. Hyperkalemia (high level of potassium in
the blood)
Possible negative effects when there is
negligence in the part of the IV therapist would
include:

 Hypervolemia
- an abnormal increase in blood volume
or strictly speaking, an abnormal
increase in the volume of blood plasma
 Infiltration
- the diffusion or accumulation in a tissue
or cells of substances not normal to it or
in amounts in excess of the normal; also,
the material so accumulated.

 Extravasation
- seeping of blood, lymph, or serum into
tissues.
 Phlebitis
- inflammation of a vein.
- with phlebitis there is infiltration of the
walls of the vein and usually, the
formation of a clot (thrombus) in the vein
(thrombophlebitis).
 TIME TAPPING
IVF CALCULATION
1. Flow rate= total volume of IVF x drop(gtts) factor
no. of hours to infuse x 60

DROP FACTOR:
Macro drip (gtt) = 15
Micro drip (ugtt) = 60
Example: Compute the rate of flow of D5 0.3 NaCl 250 ml
to be consumed in 8 hours
MACRO DRIP:
250 cc/mlx15 = 3750 = 7.8 or 8 gtts/min
8 x 60 480

MICRO DRIP:
250 cc/ml x 60 = 1500 = 31 ugtts/min.
8 x 60 480
2. VOLUME PER HOUR
Volume per hour = Total vol. of IVF in ml/cc
no. of hours to consume
Example: 250 cc = 31.25 cc/hour
8 hours
Short cut: rate per minute x 4 for MACRO DRIP
rate per minute x 1 for MICRO DRIP

3. NUMBER OF HOURS TO CONSUME

Number of hours = Total vol. of IVF
ml/ hour
Example: 250 cc = 8 hours
31 cc/hour
SITUATION: D5LR 1 liter to be infused
in 10 hours
a. Compute to rate of low in macro
drops
b. Compute the flow of rate in micro
drops
c. Compute the volume per hour in
macro set and micro set
d. Compute the number of hours to
last
1. MACRO DROPS
1000 mlx15 = 15000 = 25 gtts/min
10 x 60 600
2. MICRO DROPS
1000 cc/ml x 60 = 60000 = 100 ugtts/min.
10 x 60 600
3. Volume per hour
1000 cc = 100 cc/hour
10 hours
MACRO DRIP: 25 gtts/min. x 4 = 100 ml/ hour
MICRO DRIP: 100 gtts/ min. x 1 = 100 ml/ hour
4. NUMBER OF HOURS TO CONSUME
1000 cc = 10 hours
100 cc/hour

2. BLOOD CALCULATION
Flow rate= total volume of IVF x drop(gtts) factor
per minute no. of hours to infuse x 60
DROP FACTOR= 10 gtts/ cc
Example: Transfuse reconstituted PRBC 250 ml for 4
hours
250 mlx10 = 2500 = 10.41 or 10 gtts/min
4 x 60 240
 Time Taping
Hourly rates of infusion can be
calculated by dividing the total
infusion volume by the total
infusion time in hours.

Formula:
Total infusion volume
= ml per hour
Total infusion time
 SAMPLE IVF FLUID TIME TAPE
Cebu (VELEZ) General Hospital
Name of patient: ________ Date: _______
Ward/RM/ Bed no: ____________________
Venoclysis: ____________________________
Additives: _____________________________
Rate of flow per minute: ________________
No. of hours to consume: _______________
Vol. / hour: _____________________________
TIME FLUID LEVEL
7 am 250 ml
8 am 219 ml
9 am 188 ml
10 am 157 ml
11 am 126 ml
12 nn 95 ml
1 pm 64 ml
2 pm 33 ml
3 pm 2 ml
 TIME FLUID LEVEL

12 NOON 1000 ml
1 PM 900 ml
2 PM 800 ml
3PM 700 ml
4PM 600 ml
5PM 500 ml
6PM 400 ml
7PM 300 ml
8PM 200 ml
9PM 100 ml
10 PM 0 ml
 MEASURING INTAKE AND
OUTPUT
Equipment:
Calibrated glass or cup
Intake and output bedside form with fluid
conversions
Intake and output record chart
Commode/ bedpan/ urinal for urine and other
output measurements
Clean gloves
Guidelines:
1. Assess if strict measurement of intake
and output is ordered
2. Assess patient’s ability to assist in
keeping intake and output record.
3. Instruct patient to keep record of all fluids
taken orally. Keep an I&O record at the
bedside for patient to document intake
4. Assess all potential sources of intake
(IVF, oral fluids, NGT) and output (
e.g.vomitus, stool, urine, drainage from
tubes)
5. Instruct patient to void into bedpan or
urinal, not into toilet
6. Instruct patient not to place toilet tissue in
bedpan or defecate in bedpan
7. Empty urinal, bedpan, or Foley drainage
bag into measuring container
8. Record time and amount of output on
bedside I&O record. Record all urine,
drainage from nasogastric tubes,
drainage tubes, etc.
9. Observe color, clarity, and odor of urine
10. Determine all forms where
documentation of I&O occur
11. Assess for signs of dehydration or
overhydration
12. Evaluate weight changes
13. Record all forms of fluid intake except
blood and blood products in the total
amount column of the 24 hour record
(IVFs and Oral fluids). These are
recorded separately
13. Transfer all intake and output to graphic sheet or 24
hour I&O record
14. Complete 24 hour output record by adding together all
three intake and output totals and place total on graphic
sheet
15. Use clean gloves in transferring and measuring the
intake and output
16. Accurately measure all sources of fluid intake and
output
 EQUIVALENTS
15 gtts (drops) 1 ml
1 tsp 5 ml
1 tbsp 15 ml
1 cup 180 ml
1 glass 240 ml
1 pint 480-500 ml
1 quart 960 ml
1 galloon 3840 ml or 5 liters
1 liter 1000 ml
1 deciliter 1000 ml
1 ml 1 cc
 Frozen

Blood

Plasma
Packed
Red
Blood
Cells

(PRBC)
 PLATELET
APHERESIS
The role of the nurse in assisting IV
insertion:

The role of the nurse in maintaining

an infection free IV site is very crucial. It
is because they are the one’s who is
constantly monitoring the patient from
time to time. Negligence on the part of
the nurse would result on the negative
effects that would be detrimental on the
health of the patient.
 It is also very important for the
nurse assisting the doctor in IV
insertion to anticipate the needs of
the doctor that the procedure will be
done efficiently and for the
convenience on the part of the
patient.