MONITORING AN INTRAVENOUS INFUSION

Definition:

__________________________________________________________________________________________________________________________

Indications:

1. _______________________________________________________________________________________________________________________
2. _______________________________________________________________________________________________________________________

Assessment Focus

1. _______________________________________________________________________________________________________________________
2. _______________________________________________________________________________________________________________________
3. _______________________________________________________________________________________________________________________

Special consideration:

1. _______________________________________________________________________________________________________________________
2. _______________________________________________________________________________________________________________________
3. _______________________________________________________________________________________________________________________
4. ______________________________________________________________________________________________________________________
a. _________________________________________
b. _________________________________________
c. _________________________________________
d. _________________________________________
e. _________________________________________
 PROCEDURE RATIONALE 1 2 3 4 5

1. From the physician’s order determine he type and sequence of

solutions to be used.

2. Determine the rate of flow and infusion schedule.

3. Ensure that the correct solution is being infused. If the

solution is incorrect, slow the rate of flow to a minimum to
maintain the patency of the catheter.

4. Change the solution to correct one. Document and report the

error according to agency protocol.

5. Observe the rate of flow every hour. Compare the rate of flow
regularly.

6. If the rate is too fast, slow it so that the infusion will be

completed at the planned time.

PROCEDURE RATIONALE 1 2 3 4 5

7. Assess the client for the manifestations of hypervolemia and

its complications, including dyspnea; rapid, labored breathing;
cough; crackles in the lungs bases; tachycardia; and bounding
pulses.
8. Check if the rate is too slow.

9. Inspect the patency of the tubing and needle.

10. Observe the position of the solution container. If it is less than

1 m (3ft) above the IV site, readjust it to the correct height of
the pole.

11. Observe the drip chamber. If it is less than half full, squeeze
the chamber to correct amount of fluid to flow in.

12. Open the drip regulator and observe for a rapid flow of fluid
from the solution container into the drip chamber. Then
partially close the drip regulator to reestablish the prescribed
rate of flow.

PROCEDURE RATIONALE 1 2 3 4 5
13. Inspect tubing for pinches or kinks or obstructions to flow.
Arrange the tubing so that it is lightly coiled and under no
pressure. If it is dangling below the venipuncture, coil it
carefully on the surface of the bed.

14. Lower the solution container below the level of the infusion
site and observe for a return flow of blood from the vein.
15. Check for leakage. Locate the source. If the leak is at the
catheter connection, tighten the tubing into the catheter.

16. If the leak cannot be stopped, slow the infusion as much as

possible without stopping it, and replace the tubing with a new
sterile set.

PROCEDURE RATIONALE 1 2 3 4 5
17. Inspect the infusion site for fluid infiltration
a. Palpate the surrounding tissue for edema.

b. Feel the surrounding skin for changes in temperature

c. If the tubing does not have a backcheck valve, lower

the infusion bottle below the venipuncture site.

d. Use a sterile syringe of saline to withdraw fluid from

the rubber at the end of the tubing near the
venipuncture site. Discontinue the IV infusion if blood
does not return.
18. Try to stop the flow by applying a tourniquet 10-15 cm (4-6
in.) above the insertion site and opening the roller clamp.
19. Inspect for the presence of phlebitis. The clinical signs are
redness, warmth, and swelling at the IV site and burning pain
along the course of a vein.

PROCEDURE RATIONALE 1 2 3 4 5
20. Be alert to signs of circulatory overload.

21. Inspect for bleeding at the IV site.

22. If the client is able, teach him or her when to call for
assistance, e.g., if the solution stops dripping or the
venipuncture site becomes swollen.
 CHANGING AN INTRAVENOUS CONTAINER AND TUBING

Indications:

1. _______________________________________________________________________________________________________________________
2. _______________________________________________________________________________________________________________________
3. _______________________________________________________________________________________________________________________
4. _______________________________________________________________________________________________________________________
Assessment Focus:

1. _______________________________________________________________________________________________________________________
2. _______________________________________________________________________________________________________________________
3. _______________________________________________________________________________________________________________________
4. _______________________________________________________________________________________________________________________
5. _______________________________________________________________________________________________________________________

Special Considerations:

1. _______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
2. _______________________________________________________________________________________________________________________
3. _______________________________________________________________________________________________________________________
4. _______________________________________________________________________________________________________________________
5. _______________________________________________________________________________________________________________________
6. _______________________________________________________________________________________________________________________
7. _______________________________________________________________________________________________________________________
8. _______________________________________________________________________________________________________________________
9. _______________________________________________________________________________________________________________________
10. _______________________________________________________________________________________________________________________
11. _______________________________________________________________________________________________________________________

Patient Education:

Teach the client ways to maintain the infusion system, like:

1. ____________________________________________________________________________________________________________________
 2. ____________________________________________________________________________________________________________________
3. ____________________________________________________________________________________________________________________
4. ____________________________________________________________________________________________________________________
a. _______________________________________________________
b. _______________________________________________________
c. _______________________________________________________
d. _______________________________________________________
Equipments:

 Container with the correct kind and amount of sterile solution

 Administration set, including sterile tubing and drip chamber
 Timing label
 Sterile gauge square for positioning the needle
 Alcohol swab
 Clean glove
 Tape

PROCEDURE RATIONALE 1 2 3 4 5
A. Changing IV Container
1. Review physician’s order for changes in fluid
administration.

2. Obtain the correct solution container and make sure it is

properly labeled. Check for sterility and integrity.
3. Prepare to change solution when it only remains in the
neck of the bottle and make sure the drip chamber is half
full.

PROCEDURE RATIONALE 1 2 3 4 5
4. Wash hands.

5. Verify the physician’s order. Prepare all necessary

materials for changing IV solution and place it on an IV
tray.

6. Identify the patient and explain what you are going to do,
why is it necessary, and how he can cooperate.

7. Move the roller clamp to reduce flow rate.

8. Remove the protective cover from the entry site of the new
IVF bottle and disinfect rubber port with cotton and
alcohol.
 PROCEDURE RATIONALE 1 2 3 4 5
9. Remove old solution from IV pole.

10. Quickly remove spike from old IV solution, and without

touching tip, spike it to the new solution bottle while
kinking the tubing below the drip chamber.

11. Invert the IV bottle and hang to IV pole.

12. Check the tubing for air. If with air, remove air from the
tubing.

PROCEDURE RATIONALE 1 2 3 4 5
13. Regulate IV to prescribed rate.
14. Observe system for patency and the response of the client
to the therapy.
 PROCEDURE RATIONALE 1 2 3 4 5
B. Changing IV Tubing
1. Determine the need to change the IV tubing.
a. tubing should be changed 48-96 hours,
depending on agency protocol.

b. puncture of infusion tubing.

c. Contamination of tubing.

d. Occlusion of tubing.

2. Assemble the equipment.

3. Explain the procedure to the patient.

PROCEDURE RATIONALE 1 2 3 4 5
4. Do hand washing.
5. Open the administration set and attach it to the container,
using sterile technique.

6. Tighten the clamp and hang the container on the pole if it

is not already hung.

7. Remove the protective cap from the end of the tubing, and
prime the tubing. Clamp the tubing and replace the cap.

PROCEDURE RATIONALE 1 2 3 4 5
8. Don gloves. Remove the tape and the dressing carefully
from around the needle. Take care not to dislodge the
needle from the vein.
9. Place a sterile swab under the hub of the catheter to
absorb any leakage that might occur when the tubing is
disconnected. Clamp the old tubing.

10. While holding the hub of the needle with the fingers of one
hand, remove the tubing with the other hand, using a
twisting, pulling motion. Place the end of the tubing in the
kidney basin or other receptacle.

11. Continue to hold the needle, and grasp the new tubing with
the other hand. Remove the protective cap, and maintain
sterility, insert the tubing end tightly into the needle hub.

12. Open the clamp to start the solution flowing.

13. Clean the venipuncture site, working from the insertion

point outward in a circular manner.

14. Apply a sterile dressing over the site and tape the needle
in place. Apply a labeled tape over the dressing. The label
should include the date and time the dressing is applied;
the original date and time of the venipuncture; the size of
the catheter or needle; and your initials, as the nurse who
changed the dressing.
 15. Tape a label on the new tubing with the date and time of
the change and your initials.

16. Regulate the flow of the solution according to the order on

the chart.

17. Record the change of the tubing in the appropriate place

on the client’s chart.

EVALUATION FOCUS

1. Status of IV site.
2. Patency of IV system.
3. Accuracy of flow.
 DISCONTINUING AN INTRAVENOUS INFUSION

Definition:

_______________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________

Indications:

1. _______________________________________________________________________________________________________________________
2. _______________________________________________________________________________________________________________________
3. _______________________________________________________________________________________________________________________

Assessment Focus:

1. __________________________________________________________
2. __________________________________________________________
3. __________________________________________________________
4. __________________________________________________________

SPECIAL CONSIDERATIONS:
 1. __________________________________________________________
2. __________________________________________________________
3. __________________________________________________________
4. __________________________________________________________
5. __________________________________________________________

Equipment:

 Clean glove
 Waste receptacle tray
 Dry or antiseptic-soaked swabs
 Plaster
 Sterile dressing

PROCEDURE RATIONALE 1 2 3 4 5
1. Verify written doctor’s order to discontinue IV infusion.

2. Wash hands.

3. Prepare all necessary equipments.

4. Close the roller clamp of the IV administration set.

PROCEDURE RATIONALE 1 2 3 4
5. Put on the clean glove.

6. Moisten adhesive tapes around the IV catheter using

cotton balls with alcohol; remove plaster gently while
holding the needle firmly and applying counteraction to the
 skin.

7. Gently remove the needle or catheter by pulling it out

along the line of the vein.

8. Immediately apply pressure to the site, using the cotton

swab, for 2 to 3 minutes.

9. Hold the client’s arm or leg above the body if any bleeding
persists.

10. Hold the client’s arm or leg above the body if any bleeding
persists.

PROCEDURE RATIONALE 1 2 3 4 5
11. Inspect the catheter for completeness.

12. Report a broken catheter to the nurse in charge

immediately.

13. If a broken piece can be palpated, apply a tourniquet

above the insertion site.

14. Cover the venipuncture site by applying a sterile dressing.

 15. Discard the IV solution container, if infusions are being
discontinued, and discard the used supplies appropriately.

16. Document all relevant information

a. the amount of fluid infused
b. type of solution
c. container number
d. time of discontinuance
e. the client’s response to the procedure

STARTING AN INTRAVENOUS INFUSION

Definition:
 __________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________

Indications:

1. ____________________________________________________________________
2. ____________________________________________________________________
3. ____________________________________________________________________
4. ____________________________________________________________________
5. ____________________________________________________________________
6. ____________________________________________________________________
7. ____________________________________________________________________
8. ____________________________________________________________________
9. ____________________________________________________________________

Patient Education:

__________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

Preparation Of Patient:

1. _________________________________________________________________________________________
2. _________________________________________________________________________________________
3. _________________________________________________________________________________________
4. _________________________________________________________________________________________
 5. _________________________________________________________________________________________
6. _________________________________________________________________________________________
7. _________________________________________________________________________________________
8. _________________________________________________________________________________________

Special Considerations:

1. _________________________________________________________________________________________
2. _________________________________________________________________________________________
3. _________________________________________________________________________________________
4. _________________________________________________________________________________________
5. _________________________________________________________________________________________

Types of Solutions:

1. _______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
2. _______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
3. _______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Kinds of Needles and Catheters

 ______________________________________________________________
- _________________________________________
- _________________________________________
 ______________________________________________________________
- _________________________________________
- _________________________________________
 ______________________________________________________________
- _________________________________________
- _________________________________________
Site Selection Guidelines:

(Take into account available vein condition, patient comfort, and type and duration of IV therapy)

1. ______________________________________________________________________________________________________________________
2. ______________________________________________________________________________________________________________________
3. ______________________________________________________________________________________________________________________
4. ______________________________________________________________________________________________________________________
5. ______________________________________________________________________________________________________________________
- ___________________________________________
- ___________________________________________
- ___________________________________________

6. ______________________________________________________________________________________________________________________
a. ____________________________________________________________________________________________________
b. ____________________________________________________________________________________________________
 c. ____________________________________________________________________________________________________
d. ____________________________________________________________________________________________________
e. ____________________________________________________________________________________________________
7. _______________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________

Age-Related Considerations:

PEDIATRIC

1. _________________________________________________________________________________________________________________
2. _________________________________________________________________________________________________________________
3. _________________________________________________________________________________________________________________
4. _________________________________________________________________________________________________________________
5. _________________________________________________________________________________________________________________

GERIATRIC

1. _______________________________________________________________________________________
2. _______________________________________________________________________________________
3. _______________________________________________________________________________________

Equipments:

 Infusion set as ordered  IV pole

 Intravenous solution as prescribed by physician  IV tray containing
 Intravenous catheter - Adhesive or nonallergic tape
 - Clean glove - Sterile gauge dressing or transparent occlusive dressing

- Tourniquet - Arm splint, if required

- Antiseptic swab - Towel or pad

PROCEDURE RATIONALE 1 2 3 4 5
1. Verify the physician order for type and amount of solution to
use and the flow rate.

2. Observe the 10 rights in preparing and administering

medications.

3. Identify client and explain the procedure, secure consent if

necessary.

4. Do hand washing.

5. Prepare necessary materials for the procedure.

6. Check the sterility and integrity of the IV solution, IV set and

other devices.
 PROCEDURE RATIONALE 1 2 3 4 5
7. Place IV label on IVF bottle duly signed by RN who prepared it.
a. patient’s name
b. room number
c. IV solution
d. drug incorporation (if any)
e. bottle sequence
f. drop rate
g. time started
h. date started
8. Open and prepare the infusion set.
a. Remove the tubing from the container and straighten it
out. Slide the roller clamp along the tubing until it is
just below the drip chamber.

b. Move roller clamp to off position.

c. Leave the ends of the tubing covered with the plastic

caps until the infusion is started.
 PROCEDURE RATIONALE 1 2 3 4 5
9. Spike the solution container
a. Remove the protective cover from the entry site of the
IVF bottle and disinfect rubber port with cotton and
alcohol.

b. Remove the cap from the spike and insert the spike
into the insertion site of the IVF bottle.

10. Invert the IV bottle and hang to IV pole. Adjust the pole so
that the container is suspended about 1 m (3 ft.) above the
client’s head.

11. Fill the drip chamber with solution. Squeeze the chamber
gently until it is half full of solution.

PROCEDURE RATIONALE 1 2 3 4 5
12. Prime the tubing. Remove the protective cap and release the
roller clamp to allow the fluid to travel from drip chamber
through the tubing until all the bubbles are removed. Tap the
tubing if necessary with your fingers to help the bubbles
 move.

13. Reclamp the tubing and replace the tubing cap, maintaining
sterile technique.

14. Then prepare to assist the IV therapist in IV insertion.

 BLOOD TRANSFUSION

Definition:

__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________

Indications:

1. _______________________________________________________________________________________________________________________
2. _______________________________________________________________________________________________________________________
3. _______________________________________________________________________________________________________________________
4. _______________________________________________________________________________________________________________________

Special Considerations:

1. _______________________________________________________________________________________________________________________
2. _______________________________________________________________________________________________________________________
3. _______________________________________________________________________________________________________________________
4. _______________________________________________________________________________________________________________________
5. _______________________________________________________________________________________________________________________
6. _______________________________________________________________________________________________________________________
7. _______________________________________________________________________________________________________________________
8. _______________________________________________________________________________________________________________________
9. _______________________________________________________________________________________________________________________
10. _______________________________________________________________________________________________________________________
 11. _______________________________________________________________________________________________________________________
12. _______________________________________________________________________________________________________________________
13. _______________________________________________________________________________________________________________________
14. _______________________________________________________________________________________________________________________

Types Of Transfusion Reactions:

1. _______________________________________________________________________________________________________________________
2. _______________________________________________________________________________________________________________________
3. _______________________________________________________________________________________________________________________
4. _______________________________________________________________________________________________________________________
5. _______________________________________________________________________________________________________________________
6. _______________________________________________________________________________________________________________________

Blood Products For Transfusion:

1. _______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

2. _______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

3. _______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

4. _______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

5. _______________________________________________________________________________________________________________________
 _______________________________________________________________________________________________________________________

6. _______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

7. _______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

Assessment Focus:

1. _______________________________________________________________________________________________________________________
2. _______________________________________________________________________________________________________________________
3. _______________________________________________________________________________________________________________________
4. _______________________________________________________________________________________________________________________

Equipments:

 Unit of blood that has been correctly crossmatched  # 18 or # 19-guage needle or catheter (if one is not already in
 Blood administration set place)
 500 ml or 250 ml of normal saline solution for infusion  Alcohol swab
 IV pole  Plaster
 Clean glove
 Tourniquet

PROCEDURE RATIONALE 1 2 3 4 5
1. Verify doctor’s written order for blood transfusion.
2. Obtain client’s consent before the transfusion. Informed
consent involves explaining medical indications for transfusion,
benefits, risks, and alternatives.

3. Explain the procedure and its purpose to the patient. Instruct

the client to re[port promptly any sudden chills, nausea,
itching, rash, dyspnea, backpain, or other unusual symptoms.

4. If the client has an IV solution infusing, check whether the

needle and solution are appropriate to administer blood. The
needle should be gauge # 18 or # 19, and the solution must
be normal saline.

5. If the client does not have an IV solution infusing, you will

need to perform a venipuncture on a suitable vein and start an
IV infusion of normal saline.

6. Request prescribed blood/blood component from the blood

bank to include blood typing and X-matching result, the
expiration of the blood and blood result of transmissible
disease.

7. Using a clean tray, get the compatible blood from the

laboratory or blood bank.
8. With another nurse, compare the laboratory blood record with
a. The client’s name and identification number.
b. The serial # on the blood bag label.
c. The ABO group and Rh type on the blood bag label or
check crossmatching form.
9. Check blood bag for bubbles, cloudiness, dark color or
sediments.

10. Wrap blood with clean towel and keep it at room temperature
for no more than 30 minutes before starting the transfusion.

11. Verify the client’s identity by asking the full name and/or
checking the arm band for name and ID number.

12. Get the baseline V/S: BP, RR, Temperature before transfusion
and refer to M.D accordingly.
13. Give pre-med 30 minutes before transfusion as prescribed.

14. Do hand hygiene before ad after the procedure.

15. Prepare equipment needed for the procedure.

16. Set up the transfusion equipment.

a. Ensure that the blood filter inside the drip chamber is
suitable for whole blood or the blood components to be
transfused.

PROCEDURE RATIONALE 1 2 3 4 5
17. If the main line is with dextrose 5% initiate an IV line with
appropriate IV catheter with plain NSS on another site, anchor
catheter properly and allow a small amount of solution to
infuse to make sure there are no problems with the flow or the
venipuncture site.
18. Prepare the blood bag. Invert the blood bag gently several
times to mix the cells with the plasma.

19. Expose the port on the blood bag by pulling back the tabs.

20. Spike blood bag port carefully and hang the unit. Be sure
blood clamp is closed.

PROCEDURE RATIONALE 1 2 3 4 5
21. Gently squeeze the flexible sides of the drip chamber to
reestablish the liquid level with drip chamber one-third full.
Make sure filter is submerged in the blood.

22. Open the clamp and prime tubing and remove air bubbles if
any. Use needle G 18 or G 19 for side drip (for adults) or G 22
(for pediatrics).
23. Disinfect the Y-injection port of IV tubing (PNSS) and insert
the needle from BT administration and secure with adhesive
tape.

24. Shut off the primary IV and begin the blood transfusion.

25. Run the blood slowly for the first 15 minutes at 20 gtts/min.
Note adverse reactions, such as chilling, nausea, vomiting,
skin rash, or tachycardia.

PROCEDURE RATIONALE 1 2 3 4 5
26. Observe the client for the first 5 to 10 minutes of transfusion.

27. Remind the client to call a nurse immediately if any unusual

symptoms are felt during the transfusion.

28. Document relevant data. Record time blood was started, V/S,
type of blood, blood serial #, sequence # (e.g. #1 of three
ordered units), site of the venipuncture, size of the needle,
 and drip rate.

29. Swirl the bag hourly.

30. Check the V/S of the client 15 minutes after initiating

transfusion. If there are no signs of reaction, establish the
required flow rate.

31. Assess the client every 30 minutes or more often, depending

on the health status, until 1 hour post-transfusion.

PROCEDURE RATIONALE 1 2 3 4 5
32. If any untoward reaction or signs occur, stop the transfusion
immediately and notify the physician ASAP.

33. When blood is consumed, don glove, close the roller clamp of
BT set and disconnect from IV line. Flush the line with saline
solution by opening the mainline and adjust the drip to desired
rate.
34. Re-check Hgb, Hct, bleeding time, serial platelet count within
specified time as prescribed &/or per institution’s policy.
 PROCEDURE RATIONALE 1 2 3 4 5
35. Discard the administration set according to agency practice.
Needles should be placed in a labeled puncture-resistant
container designed for such disposal. Blood bags and
administration sets should be bagged and labeled before being
sent for decontamination and processing.

36. Remove glove.

37. Document the procedure, pertinent observations and nursing

intervention and endorse accordingly.

38. Remind the doctor about the administration of Calcium to maintain cardiac function and prevent hypocalcaemia
Gluconate if patient had several units of blood transfusion 93- that may lead to citrate toxicity.
6 or more units of blood).