INFUSION ADMINISTRATION

BY : TANTI ANGGREINI BOTI

Infusion solution
kidney basin
drape
alcohol swab
tray
gloves
infusion administration set
Aims and learning outcomes

By the end of this lesson you will be able to:

● assist a patient to increase their oral fluid intake
● accurately complete a fluid intake and output chart
● discuss factors that affect fluid balance
● identify common intravenous fluids and their uses
● prepare equipment for an intravenous infusion,
monitor its
progress and discontinue when appropriate
● recognize complications of IV therapy and take
appropriate
actions to prevent or relieve complications
● discuss the precautions that are used during a
blood transfusion to
ensure a safe transfusion.
 Fluid and electrolyte concept
I. Fluid function :

1. Termo regulator ( adjust the body

temperature ) / regulate the body temperature
2. Detoxication
3. Eliminate the waste product
4. Essential for elimination process
5. Need in respiratory process
 II. Compartment / types
1. Intra cells fluid
2. Extra cells fluid
a. intra vascular
b. interstitial fluid
c. trans cellular fluid
- synovial
- pleural
- CFS ( cerebral vascular fluid )
- pericardial fluid
- intra orbital fluid
 Fluid transportation mechanism
1. Active transportation
need ATP energy ( adenosine tryphospate )
example : Sodium Potassium Pump

2. Passive transportation
doesn’t need ATP energy ( adenosine
tryphospate )
Example : diffusion, osmosis
 Fluid and electrolyte problems
1. Fluid volume excess ( FVE )
2. Fluid volume deficit ( FVD )
 DEHIDRATION
DEFINITION : LACK OF BODY’S FLUID

SIGN AND SYMPHTOM :

1. WEAK
2. PALLOR
3. RAPID PULSE
4. RAPID RESPIRATION
5. PERSPIRATION
6. BREATHING DIFFICULTY
7. SUNKEN EYE LIDS
8. BAD SKIN TURGOR
9. DRY LIPS
10.DRY MOUTH MUCOUS
11.SUNKEN FONTANEL
12.THIRSTY
13.MILD TO MODERATE FEVER
 CAUSED / ETIOLOGY
1. EXCESSIVE BLEEDING
2. PROLONGED VOMIT
3. LACK OF FLUID INTAKE
4. LONG TERM DIARHEA
5. BURN WOUND
6. POST OPERATION
 NURSING DIAGNOSE
DEHIDRATION RELATED TO LACK OF FLUID
INTAKE INDICATED BY :
PROBLEMS ETIOLOGY SYMPTOM
DEHIDRATION 1. EXCESSIVE BLEEDING 1. WEAK
2. PROLONGED VOMIT 2. PALLOR
3. LACK OF FLUID INTAKE 3. RAPID PULSE
4. LONG TERM DIARHEA 4. RAPID RESPIRATION
5. BURN WOUND 5. PERSPIRATION
6. POST OPERATION 6. BREATHING
DIFFICULTY
7. SUNKEN EYE LIDS
8. BAD SKIN TURGOR
9. DRY LIPS
10. DRY MOUTH MUCOUS
11. SUNKEN FONTANEL
12. THIRSTY
13. MILD TO MODERATE
FEVER
KOMPOSING NURSING DIAGNOSES
PROBLEMS + RELATED TO + ETIOLOGY +
INDICATED BY SIGN / SYMPHTOM

EXAMPLE :
DEHIDRATION RELATED TO LONG TERM VOMIT
INDICATED BY WEAK, RAPID PULSE,
PERSPIRATION, THIRSTY, BAD SKIN TURGOR
 INTERVENTION
1. Assess the client’s need
2. Encourage the client to take plenty of water
3. Limit the client’s activity
4. Collaborate with nutritionist for suitable diet
5. Administer the infusion.
6. Increase the water intake
7. Close monitoring the vital sign
8. Note the fluid balance
 implementation
1. Assessing the client’s need
2. Encouraging the client to take plenty of water
3. Limiting the client’s activity
4. Collaborating with nutritionist for suitable diet
5. Administering the infusion.
6. Increasing the water intake
7. Closing monitoring the vital sign
8. Noting the fluid balance
 infusion
Indication :
1. Hydration
2. Replace fluid lost / blood lost
3. Transfusion of blood / blood components
4. During surgery
5. Ready access for emergency / emergency care
6. Intravenous drug medication
7. Other situation / direct access to blood vein is
needed
 Contraindication
• Infection
• Phlebitis
• Schlerosed veins
• Previous intravenousinfiltration
• Burn
• Traumatic injury / proximal to insertion site
• Arteriovenous fistula
• Surgical procedure effecting exremities
 contraindication
1. Edema ( beware )
2. Heart problems (beware )

Procedure : Critical point :

Principe : sterile
 Difficult access
• Dehydration ( severe dehydration )
• Shock
• Chemotherapy
• Intravenous substances abuse
 Potential complication
• Bleeding
• Bruising
• infection
 Standard precaution
• Washing hands
• Wearing gloves
• Using eyes protection
 Ideal vein selection
1. Round
2. Firm
3. Flexible
4. full
 Site selection consideration
1. Intended use of the intravenous catheter
2. Accessibility of the vein
3. Patient’s age
4. Comfort
5. Urgency of the situation
 Upper extremity are prefered
because ?
• More durable
• Fever complication

Risk of lower extremity :

1. Risk of thrombosis
2. embolism
 Location of insertion site
1. Upper extremity :
a. Cephalic vein
b. Basilic vein

2. Lower extremity :
c. Dorsal venous arch

3. Scalp Vein : for young infant , neonate

 Types of IV Catheter
1. Over The needle
2. Butterfly
 Size IV cath
from 14 G to 24 G
The bigger the number the smaller the catheter
size.
Small catheter should be used because :
1. less resistance
2. fever complication
 Large IV catheter should be used
no 14 – 16 G
1. For acute situation
2. Fluid recusitation
3. Hypovolemia
4. Severe dehydration
Factor influence the selection of IV
cath :
1. Age related to vessel size
2. Pressurized boluses
3. Viscosity of the fluid to be infused
 instruments
1. Infusion administration set / GIVING SET ; Set infus
2. Infusion stand : Tiang infus
3. Infusion solution : Cairan infus
4. Intravenous catheter : Aboquet / IV Catheter
5. Tourniquet
6. penetrating drape / Drape : duk bolong / duk
7. Galipot / Kom kecil
8. Plaster / adhesive tape
9. 4x4 gauzes / Qassa lipat ukuran 4 x 4
10. 2 x 2 gauze / 2 by 2 gauze ; qassa 2x2
11. Arm board / spalk tangan
12. Transparent occlusive dressing
11. instrument’s tray : bak instrument
12. Bandage scissors : Gunting Verban
13. Betadine
14. Alcohol swab in container
15. Tray ; baki
16. Under cover / blue sheet / under pad ;
pengalas
17. Kidney basin / kidney disk / kidney receiver :
bengkok
19. Gloves : surgical gloves ; handscoen
20.
 INSTRUCTION
1. FOLLOW ME THIS WAY
2. LAY DOWN ON YOUR BED
3. ROLL YOUR SLEEVE UP
4. GIVE ME YOUR RIGHT HAND
5. MAKE A FIST / CLENCH YOUR FINGERS
6. IF YOU FEEL PAIN PLEASE TAKE A DEEP BREATHING
7. UNCLENCH YOUR FINGER SLOWLY
8. WELL, IT’S FINISHED ALREADY
9. IF YOU HAVE ANY COMPLAINT, PLEASE CALL ME/
PLEASE LET ME KNOW
 Steps of communication
1. Step 1 : permission
2. Step 2 : Salutation
3. Step 3 : Self introduction
4. Step 4 : patient Concern
5. Step 5 : Feed back and clarification
6. Step 6 : Procedure Explanation and require
agreement
7. Step 7 : Procedure Explanation and require
agreement
8. Step 8 : INSTRUCTION
9. Step 9 : closing and encouragement / compliment
 DIALOGUE
A. Permission

1. EXCUSE ME, ( SIR, MADAM, MISS )

2. MAY I COME IN ? / CAN I COME IN

B. Salutation :
GOOD MORNING / AFTERNOON / EVENING
( SIR, MADAM, MISS )
C. Self Introduction :

5. LET ME INTRODUCE MYSELF , MY NAME IS

………………I AM THE NURSE ON DUTY , THIS
MORNING SHIFT FROM 7 AM TO 3 PM

D. Patient’s Concern :
6. HOW ARE YOU THIS MORNING,
( SIR, MADAM, MISS )?
7. DO YOU HAVE ANY COMPLAINT ?
E. Feed back and clarification :
8. How long ave you got It ? How does it feel ?
Severe ? Moderate or mild ? Or continuous ?
9. I SEE, LET ME INFORM YOUR DOCTOR LATTER

F. Procedure Explanation and require agreement

9. IT’S TIME FOR ME TO GIVE YOU INFUSION /
I AM GOING TO GIVE YOU INFUSION,
I NEED TO TO GIVE YOU INFUSION
• BECAUSE YOU HAVE LOST AND ELECTROLYTE
BESIDE IT IS YOUR THERAPEUTIC REGIMENT/
YOUR DOCTOR ORDER

10. DO YOU AGREE ?

11. IF SO PLEASE SIGN HERE FOR INFORM
CONSENT
 G. INSTRUCTION
1. FOLLOW ME THIS WAY
2. LAY DOWN ON YOUR BED
3. ROLL YOUR SLEEVE UP
4. GIVE ME YOUR RIGHT HAND
5. MAKE A FIST / CLENCH YOUR FINGERS
6. IF YOU FEEL PAIN PLEASE TAKE A DEEP BREATHING
7. UNCLENCH YOUR FINGER SLOWLY
8. WELL, IT’S FINISHED ALREADY
9. IF YOU HAVE ANY COMPLAINT, PLEASE CALL ME/
PLEASE LET ME KNOW
 H. closing.
11. Well it’s finished already
12. Well it’s done
13. If you have any complaint, please inform me
14. If you have any complaint, please press this
button to call me in
15. If you have any complaints or problems, I will
be at the nurse station.
17. Keep the insertion site dry
16. Thank you for your good cooperation,Sir,
madam, Miss
 dialogue

Nurse : good Morning, Mr. C. Did you sleep well last night ?

Mr. C : No, I didn’t. I’ve got headache

Nurse : mr. C. from the physical examination we noticed

that you have lost much fluids and electrolyte. I’m
going to administer the infusion on your vein, now.
Do you agree ?

Mr. C : yes, I do,…..

Nurse : If you agree, please sign here ! For inform consent

Nurse C : follow me this way. Lay down on your
bed please,.. Give me your right hands.
Roll your sleeve up. Make fist, please. I
will insert this needle, now. If you
feel pain please take a deep breathing
well it’s finished already. If you have
any complaint, please call me.
Thank you for your good cooperation.
 documentation
What to report :
1. patient’s name
2. Doctor in charge
3. Diagnose
4. Date and time of administration
5. Location of insertion
6. Type of fluid has been used
7. Additional medication
8. Drop factors
9. Complaints
10. Tense in used : past tense ( active or passive )
11. Future for further planning
 documentation

Name : Mr. C. O’neil room : 2 C

Age : 53 years old Dx : gastritis
Ward : male internist ward
Date / time Note Name /
signature
Monday, Administered Infusion for mita
november 27th normal saline for 20 drops
2012 per minutes drip
aminophilin 1 CC ( N/S : 20
10.00 Am gtt/I ). On radial vein, right
hands. Running well . No
Discomfort
Roll your sleeve up