1-6. Procedures to Follow in Managing a Patient with an Intravenous Infusion

The following are some procedures you will perform as you manage the patient with an IV.

a. Replace the Intravenous Solution Container. Adhere to strict aseptic techniques throughout the replacement procedure.

(1) Perform a patient care hand wash.

(2) Select and prepare the new solution. Check the provider's orders or check with the supervisor.

(3) Clamp the tubing shut to prevent air from entering the tubing during the replacement procedure.

(4) Remove protective cover from the port of the new container.

(5) With the old container upside down, remove the spike from the nearly empty bag.

(6) Insert the spike in the new container and hang it on the IV stand.

(7) Adjust the flow rate according to the directive.

(8) Document solution container according to the procedures provided in Section I.

b. Replace the Intravenous Tubing. Tubing should be changed every 48 hours IAW local policy. It is advisable to change the tubing at the same time you are changing the bag/bottle. The more often you open the closed system, the greater the chance for contamination.

(1) Perform a patient care hand wash and don gloves.

(2) Use the clamp to turn off the infusion.

(3) Disconnect the old tubing from the bottle, cover the open end, and hang it on the IV pole hook or tape it to the pole. Hanging the tubing on the hook will help to prevent backflow into the tubing.

(4) Spike and prime the new tubing.

(5) Attach the new tubing to the catheter/needle using the following procedures.

(a) Place sterile gauze under the catheter/needle hub. The sterile gauze is used to prevent contamination of the catheter and tubing during the procedure.

(b) Remove the protective cap from the new tubing adapter and grasp the new tubing between the fingers on one hand. Be careful not to contaminate the adapter during the process.

(c) Grasp the catheter hub with a sterile gauze pad between the thumb and forefinger and carefully disconnect the old tubing adapter with the other hand.

(d) Quickly, connect the adapter to the needle hub.

(6) Secure the tubing and dressing to the arm.

(7) Clean the area of any contamination and dispose of equipment and used tubing. Remove gloves and discard.

c. Change the Dressing. Follow the procedures below to change the dressing. (Dressings should be changed every 24 hours or IAW local policy.)

(1) Obtain the following equipment:

(a) Adhesive tape.

(b) Antiseptic swab.

(c) Some 2-inch by 2-inch sterile gauze pads.

(2) Perform a patient care hand wash and don gloves.

(3) Hold the needle hub steady while loosening and removing the old dressing. Discard the old dressing. To help prevent catheter/needle dislodgement, ask the patient not to move until the new dressing has been secured.

(4) Clean the skin around the infusion site with an antiseptic swab. Check for infection and inflammation.

(5) Secure the hub and new dressing to the arm.

(6) Remove and discard gloves.

(7) Label the dressing and document your actions.

d. Discontinue the Infusion. Follow the procedures below to discontinue an infusion.

(1) Obtain the following equipment:

(a) Waterproof pad.

(b) Adhesive tape and 2 x 2 inch sterile gauze pads or a self-adhesive bandage.

(2) Place the pad under the patient's arm.

(3) Perform a patient care hand wash and don gloves.

(4) Remove the tape and dressing. When removing the tape and dressing, take care not to dislodge the needle.

(5) Clamp the tubing. This stops the flow of solution and keeps it from leaking into the tissue as the needle is removed or from soiling the bed linens after removal.

(6) Place an antiseptic sponge over the injection site and pull the needle out smoothly without hesitation, following the course of the vein. If the needle is removed by twisting, raising, or lowering it, it could damage the vein.

(7) Immediately apply pressure with gauze for approximately one minute and then apply a small, dry pressure dressing. A self-adhesive bandage may be used or use the 2 x 2 inch gauze secured in place with a piece of tape.

(8) Remove the equipment. Dispose of the bottle/bag tubing and needle according to SOP.

e. Check for Complications of Intervenous Therapy.

(1) Infiltration. Infiltration is an accumulation of fluids in the tissue surrounding the venipuncture site.

(a) Cause of the infiltration. Infiltration is caused when the catheter/needle becomes dislodged or penetrates through the vein allowing IV fluid to leak into surrounding tissue.

(b) Signs and symptoms of infiltration.

  1. Solution is flowing at a sluggish rate or not at all.
  2. Infusion site is cool and pale.
  3. Infusion site or extremity is swollen.
  4. Patient complains of pain, tenderness, burning, or irritation at the infusion site.
  5. Fluid leaking around infusion site.
  6. Absence of blood backflow, when IV bag/bottle is lowered below IV site.

(c) Intervention measures for infiltration.

  1. If flow is sluggish, pullback on the catheter a bit and rotate it or elevate and depress the catheter a bit. If elevating the catheter helps, a small piece of gauze may be placed under the needle to hold it in position. The level of the catheter may be resting against the side of the vein and this will help to free it.
  2. If this does not correct the flow, or if infiltration has occurred, stop infusion and notify supervisor. You may be directed to remove the IV and restart it in an alternate location.
  3. Apply cold pack to site if infiltration has occurred within one-half hour. A cold pack will help reduce the pain and swelling.
  4. Apply warm, wet compresses to promote absorption if infiltration has occurred more than thirty minutes earlier. A warm, wet compress stimulates circulation, promoting the absorption of the infiltrated solutions into surrounding tissues.
  5. Document observations and actions for future reference.

(d) Preventive measures against infiltration.

  1. Use splint for stability and to prevent dislodging of the IV catheter/needle.
  2. Tape the catheter/needle securely.

(2) Phlebitis. Phlebitis is an inflammation of the wall of the vein.

(a) Associated problems. Problems associated with phlebitis include thrombophlebitis and thrombosis.

1 Thrombophlebitis is an inflammation of the vein accompanied by the formation of a clot.
2 Thrombosis is a formation of a clot in a blood vessel without accompanying inflammation.

(b) Phlebitis can be caused by the following:

1 Injury to vein during venipuncture or from later needle movement.
2 Irritation to vein caused by:
a Long-term therapy.
b Infusion of irritating or incompatible additive.
c Use of vein that is too small to handle the amount or type of solution.
d Sluggish flow rate which allows clot to form at end of needle. e Infection.

(c) Signs and symptoms of phlebitis.

1 Swelling and redness around venipuncture site.
2 Tenderness of tissue around venipuncture site.
3 A yellowish, foul-smelling discharge from venipuncture site. 4 A sluggish flow rate.

(d) Intervention measures against phlebitis.

1 When phlebitis is noted, report your observations to the supervisor. Trained personnel will then remove the IV and restart it in an alternate location and initiate proper care for the inflammation.
2 Document observations and actions.

(e) Prevention measures against phlebitis.

1 Keep the infusion flowing at the prescribed rate.
2 Stabilize the catheter/needle with correct taping and a splint.
3 Select a large vein when irritating drugs and fluids are given.
4 Maintain strict aseptic techniques.
5 Change catheters and tubing every 48 to 72 hours or IAW local policy.
6 Change bags, bottles, and dressings every 24 hours or IAW local policy.

(3) Circulatory overload. Circulatory overload is a state of increased blood volume.

(a) Causes of circulatory overload.

1 Fluid is infused too fast.
2 Too much fluid is infused.
CAUTION: Circulatory overload can occur in any patient who receives an excess of fluid. It is not confined to elderly, pediatric, or debilitated patients.

(b) Signs and symptoms of circulatory overload.

  1. Rise in blood pressure.
  2. Dilation of veins with neck veins sometimes visibly engorged.
  3. Rapid pulse, rapid breathing, shortness of breath, and rales. Rales is an abnormal crackling or rattling sound heard upon listening to sound within the chest.
  4. Wide variance between fluid input and urine output.

(c) Intervention measures for circulatory overload.

  1. Slow the infusion to keep open (TKO).
  2. Raise the head of the patient's bed to assist with respiratory effort.
  3. Notify your supervisor, immediately.

(d) Preventive measures against circulatory overload.

  1. Monitor the urine output. An I&O Worksheet (DD Form 3630) is required for all IV patients. A record of liquid input and output (including IV therapy) is maintained on this worksheet.
  2. Check the flowrate at frequent intervals to ensure the desired rate is being maintained.

(4) Air embolism. Air embolism is an obstruction of a blood vessel by air carried via the bloodstream.

(a) Causes of air embolism.

  1. 1 Allowing the solution to run dry.
  2. 2 Air bubbles in the IV tubing.
  3. 3 Disconnected tubing.

(b) Signs and symptoms of air embolism.

  1. Abrupt drop in blood pressure.
  2. Chest pain.
  3. Weak, rapid pulse.
  4. Cyanosis. (A blue-gray discoloration of the skin caused by inadequate perfusion of oxygen.)
  5. Loss of consciousness.

(c) Intervention measures for air embolism.

  1. Notify supervisor immediately.
  2. Administer oxygen if allowed.
  3. Turn the patient on his left side and lower the head of the bed so the air bubbles can float to and remain in the right atrium. The risk of serious effects of an air embolism increases if the embolism passes to the left side of the heart.

(d) Preventive measures against air embolism.

  1. Clear all air from tubing before attaching it to the patient.
  2. Monitor solutions closely and change before they are empty.
  3. Check to see that all connections are secure.

(5) Infection. Infection is the state or condition in which the body or a part of it is invaded by a pathogenic agent (microorganism or virus), which under favorable conditions, multiplies and produces effects which are injurious. Localized infection is usually accompanied by inflammation, but inflammation may occur without infection.

(a) Causes of infections.

1 Poor aseptic techniques.

  1. Unsterile venipuncture techniques.
  2. Contamination of equipment during manufacture.
  3. Failure to keep the site clean or to change IV equipment regularly.

2 Transmission from another infected part of the body to the infusion site.

3 Introduction of contaminants while irrigating or manipulating an occluded, leaking, or infiltrated catheter.

(b) Signs and symptoms of infection.

1 Swelling, redness, and soreness around the infusion site.

2 A yellowish, foul-smelling discharge from the venipuncture site.

3 Rise in temperature and pulse.

(c) Intervention measures for suspected infection.

1 Report observations to the supervisor.

2 Save IV equipment for possible laboratory analysis IAW local policy.

3 Document all observations and actions.

(d) Preventive measures against infection.

1 Use rigid aseptic techniques when initiating and maintaining an IV infusion.

2 Anchor the catheter/needle firmly with tape.

3 Check vein at least once each shift for evidence of tenderness or signs of inflammation.

(6) Disturbance of infusion. This is any disturbance or failure of the infusion apparatus to deliver proper prescribed solution infusion rate.

(a) Signs of disturbance in the infusion.

1 Flow rate slowing down or speeding up.
2 Solution flow stopping.

(b) Intervention measures for a disturbance of infusion.

1 Frequent observations of flow rate and equipment.

2 If flow rate disturbance is noted, attempt to locate the following causes and follow-up action.

  1. Solution container is empty. Stop flow and notify supervisor.
  2. Drip chamber is less than half-full. Squeeze drip chamber until half full.
  3. Control clamp is closed. Readjust clamp to restore prescribed drip rate and notify supervisor.
  4. Defect in equipment. Report defect immediately to supervisor.
  5. Tubing is kinked or caught under patient. Untangle the line or reposition patient so that the solution flows through the tube at the prescribed rate. Monitor for correct flow and rate.
  6. Catheter is bent or compressed in the vein. Reposition the extremity and splint area if necessary.