Intravenous fluid technique

Intravenous (IV) Therapy
Technique
Intravenoustherapy or IV therapy isthe givingof liquidsubstancesdirectlyintoavein.Itcanbe
intermittentorcontinuous; continuousadministrationiscalledanintravenousdrip.
The word intravenoussimplymeans“withinavein”,butismostcommonlyusedtorefertoIV therapy.
Therapiesadministeredintravenouslyare oftencalledspecialtypharmaceuticals.
Comparedwithotherroutesof administration,the intravenousroute isthe fastestwaytodeliverfluids
and medicationsthroughoutthe body.
Purposesof Intravenous(IV) Therapy
 To supplyfluidwhenclientsare unable totake inanadequate volume of fluidsby mouth
 To provide saltsandotherelectrolytes neededtomaintain electrolyteimbalance
 To provide glucose (dextrose),the mainfuel formetabolism
 To provide water-soluble vitaminsandmedications
 To establishalifelineforrapidlyneededmedications.
IntravenousFluids
SEE ALSO: IV Fluidsand Solution CheatSheet
There are twotypesof fluidsthat are usedforintravenousdrips; crystalloids andcolloids.
Crystalloidsare aqueoussolutionsof mineral saltsorotherwater-soluble molecules.The most
commonlyusedcrystalloidfluidis normal saline,asolutionof sodiumchloride at0.9% concentration,
whichisclose to the concentrationinthe blood(isotonic).Ringer’slactate orRinger’sacetate isanother
isotonicsolutionoftenusedforlarge-volume fluidreplacement.A solutionof 5% dextrose inwater,
sometimescalledD5W,isoftenusedinsteadif the patientisatriskfor havinglow bloodsugaror high
sodium.
The choice of fluidsmayalsodependonthe chemical propertiesof the medicationsbeing
given. Intravenousfluids mustalwaysbe sterile.Crystalloidsare commonlyusedforrehydration,and
electrolytereplacement.
Colloidscontainlargerinsoluble molecules,suchasgelatin;blooditself isacolloid.Colloidspreserve a
highcolloidosmoticpressure inthe blood,while,onthe otherhand,thisparameterisdecreasedby

crystalloidsdue tohemodilution.Anotherdifference isthatcrystalloidsgenerallyare much cheaperthan
colloids.Colloidshave large particlesinthemsotheyare not as easilyabsorbedintothe vascularbed.
Because of thispropertycolloidsare usedtoreplace lostblood,maintainhealthy bloodpressure,and
volume expansion.
Pre-CatheterizationorPreparation
1. ReviewPhysician’sOrder
A physician’sorderisnecessarytoinitiate IV therapy.The physician’sordershouldinclude:
 Type of solutionto be infused
 Route of administration
 Exact amount(dose) of anymedicationstobe addedtoa compatible solutioneitherhourlyor
24-hour volume
 Rate of infusion
 Durationof infusionorthe time overwhichthe infusionistobe completed
 Physician’s signature
2. Observe Hand Hygiene Procedures
Indicationsforhandwashingandhandantisepsis
 Wash handswitheitheranon antimicrobial soapandwateroran antimicrobial soapand water
whenhandsare visiblydirtyorcontaminatedwithbloodorotherbodyfluids.
 If hands are not visiblysoiled,use analcohol-basedhandrubtoavoidroutinelycontaminating
handsin all otherclinical situations.
 Decontaminate handsbeforehavingdirectcontactwithpatients
 Do not wearartificial fingernailsorextenderswhenhavingdirectcontactwithpatientsathigh
risk
3. GatherEquipment
Prepare andgather the equipment neededforstarting the IV.
Alwayscheckfor thefluid’s expiration date.
 Inspectsolutioncontainerforintegrity.

o Glasscontainers. Holdup to lighttolookfor cracks, clarity,particulate contamination,
and expirationdate.
o Plastic containers.Squeeze tocheckforpinholes,clarity,particulatecontamination,and
expirationdate.
 Inspectadministrationset
 Choose the appropriate set:ventedornonvented
 Gather venipunctureanddressingsupplies
 Catheter(22 g, 20 g, or 28 g mostcommon)
 Dressing(gauze orTSM)
 Tape:1-inch paper
 Preppingsolution
 Gloves2×2 gauze
4. PatientAssessmentand Psychological Preparation
It’simportantto alsoprepare the patientonthe procedure.
ADVERTISEMENTS
 Introduce self andverifythe client’sidentity.
 Provide privacy
 Explainthe procedure tothe client.A venipuncture cancause discomfortfora few seconds,but
there shouldbe nodiscomfortswhilethe solutionisflowing.
 Evaluate the patientpreparednessforIV procedure bytalkingwithpatientbefore assessing
veins
PatientInformation to Consider
 Patient’smedical diagnosis.
 Historyof chronicdisease thatplacespatientatriskforcomplications.
 Historyof vasovagal reactionsduringvenipuncture orwhenbloodisseen.
 Has the patienthad vascularaccessdevices?
 Will the patientbe goinghome withthe catheter?

 If cultural barrierexists,take more time;speakslowlyanddistinctlybutnotlouder.Use pictures.
Keepmessagessimple,anduse interpretertoimprove communication.
 Assessbotharmsand hand priorto choosingappropriate vein.
 Choose the lowestbestsite forsize catheterbeinginsertedandtype of therapythe patientwill
receive.
 Assessforanyallergies(e.g.,totape or povidone-iodine)
 Vital signsforbaseline data
 Skinturgor
 Allergy tolatex,tape oriodine
 Bleedingtendencies
 Disease orinjurytoextremities
 Statusof veinstodetermine appropriate venipuncturesite
5. Site Selectionand VeinDilation
There are several factorsyouneedtoconsiderbefore initiatingvenipunctures:
 Type of solutionto be infused. Hypertonicsolutionsandmedicationsare irritatingtovein.
 Conditionof vein. Use soft,straight,bouncyvein;if yourun yourfingerdownthe veinandit
feelslike acat’stail — avoid!Avoidveinsnearpreviouslyinfectedareas.
 Duration of therapy. Choose a veinthatcan supportIV therapyfor72–96 hours.
 Cathetersize.Hemodilutionisimportant.Thegauge of the cathetershouldbe assmall as
possible.
 Patientage. Elderly andchildrenneedadditionaltime forassessmentandmanagement
of insertion.
 Patientactivity. Ambulatorypatientsusingcrutchesorwalkerneedcatheterplacementabove
the wrist.
 Presence ofdisease or previous surgery. Patientswithvasculardiseaseor dehydration may
have limitedvenousaccess.If apatienthasa conditioncausingpoorvascularreturn
(mastectomy, stroke),the affectedside mustbe avoided.
 Presence ofshunts or graft. Do not use the arm or hand that hasa patentgraftor shuntfor
dialysis.

 Patientreceivinganticoagulationtherapy. Patientsreceivinganticoagulanttherapyhave a
propensitytobleed.Local ecchymosesandmajorhemorrhagiccomplicationscanbe avoidedif
the nurse is aware of the anticoagulanttherapy.
Precautions:Minimal tourniquetpressure;use the smallestcatheterthatisappropriate for
therapy;use care inremovingdressing.
 Patientwith allergies. Questionregardingallergiestomedications,foods,animals,and
environmental substances.Identifythe allergens:
 Iodine.Avoidpovidone-iodine asskinpreparation
 Latex. Setup latex allergy cart
Veindilationtechniques
Use the techniquesbelowtodilate the vein:
 Tourniquet.Latex or nonlatex usedmostfrequently.Placed6–8inchesabove the venipuncture
site.If BP high,move farther fromvenipuncture site.If BPlow,move asclose as possible
withoutriskingsite contamination.
 Gravity. Positionthe extremitylowerthanthe heart.
 Fist clenching.Instructpatienttoopenandclose his/herfist.
 Tapping vein.Using thumbandsecond finger,flickthe vein;thisreleaseshistaminesbeneath
the skinand causesdilation.Donotslapthe vein.
 Warm compresses.10 minutesmaximum.Donotuse microwave!
 Blood pressure cuff. Inflate to30 mmHg; great forfragile veins.
 Multiple tourniquettechnique.Use 2 to 3 latex tourniquets;applyone highonarmand leave
for 2 minutes;applysecondatmidarm below antecubital fossa;collateralveinsshouldappear;
applythirdif needed.
Tips for selectingveins
 Suitable veinshouldfeel relativelysmoothandpliable,withvalveswellspaced.
 Start withdistal veinsandworkproximally.
 Veinsthatfeel bumpy(like runningyourfingeroveracat’stail) are usuallythrombosedor
extremelyvalvular.Veinswill be difficulttostabilize inapatientwhohas recentlylostweight.
 Scleroticveinsare commonamongnarcoticaddicts.
 Dialysispatientsusuallyknowwhichveinsare goodforvenipunctures.

Catheterizationor Catheter Insertion
1. Needle Selection
The smaller the gaugenumber,thethickerthe catheter.
Cathetersvaryin sizescalledgauges.The smallerthe gauge number,the thickerthe catheterandthe
more rapidlymedicinecanbe administeredandbloodcanbe drawn.Furthermore,thickercatheters
cause more painful insertion,soit’sverynecessary nottouse a catheterthat’slargerthan youneed.
The tip of the cathetershouldbe inspectedforintegritypriortovenipuncture.Onlytwoattemptsat
venipuncture is recommended.
Recommendedgauges
Size Color Recommendeduse
14G Orange In massive traumasituations.
16G Gray Trauma, surgeries,ormultiple large-volume infusions
18G Green Bloodtransfusion,orlarge volume infusions.
20G Pink Multi-purpose IV;formedications,hydration,androutine therapies.
22G Blue Most chemoinfusions; patientswithsmallveins;elderlyorpediatricpatients
24G Yellow Veryfragile veins; elderlyorpediatricpatients
2. Don your gloves
Wearing glovesis NOToptional!
The possibilityof contactwitha patient’sbloodwhile startinganIV is highespeciallywithinexperienced
healthcare worker. Glovesmustalwaysbe presentandbe wornduring catheterization. Moreover,if the
riskof bloodsplatterishigh,suchas an agitatedpatient,the nurse shouldconsiderface
and eye protectionaswell asa gown.
It’simportantto observe properhand hygieneprocedures beforeputtingonsterile gloves.If atany
pointyourgloves’sterilitybecomescompromised,take themoff andputona new pair — it’sbetterto
be safe than sorry.
3. Site Preparation
Once you’ve donyourgloves, you’ll be now preparingthe site of insertion.

 Applyantimicrobial solution,workingfromcenteroutwardinacircularmotionfor2-3 inchesfor
20 seconds.Use enoughfriction.
 Do not shave site.Shavingcan cause micro abrasions; remove hairwithscissorsorclippersonly.
 Depilatoriesnotrecommended. Potential forallergicreaction.
 Do not apply70% isopropyl alcohol afterpovidone-iodinepreparation.Alcohol negatesthe
effectof povidone-iodine.
 Cleanse insertionsite withone of the followingsolutions:
 2% Chlorhexidinegluconate(preferred)
 Iodophor(povidone-iodine)
 70% Isopropyl alcohol
 Tincture of iodine 2%
4. Insertionof Catheterinto Vein
1Place the extremityina dependentposition(lowerthanthe client’sheart). Gravityslowsvenous
returnand distendsthe veins.Distendingthe veinsmakesiteasiertoinsertthe needle properly.
2Apply a tourniquetfirmly15 to 2 cm above the venipuncture site.Explainthat it will feel
tight. Tourniquetmustbe tightenoughtoocclude venousflow butnotsotightthat it occludesarterial
flow.Obstructingarterial flowinhibitsvenousfilling.If a radial pulse canbe palpated,the arterial flow is
not obstructed.
 Massage or stroke the veindistal tothe site andin the directionof venousflow towardthe
heart.Thisaction helpsfill the vein.
 Encourage the clientto andunclenchthe fist.Contractingmusclescompressesthe distal veins,
forcingbloodalongthe veinsanddistendingthem.
 Lighttap the veinwithyourfingertips.Tappingmaydistend the vein.
 If the precedingstepsfail todistendthe veinsothatitis palpable,remove the tourniquetand
wrap the extremityinawarm,moisttowel for10 to 15 minutes.Heartdilatessuperficial blood
vessels,causingthemtofill.Thenrepeatstep1.
3Put on cleanglovesand clean the venipuncture site. Glovesprotectthe nurse fromcontaminationby
the client’sblood.
ADVERTISEMENTS

 Cleanthe site withtopical antisepticswab.Some mayuse anti-infectivesolutionsuchas
povidone-iodine.Checkforallergies.
 Use a circular motion,movingfromthe centeroutwardforseveral inches.Thismotioncarries
microorganismsawayfromthe site entry.
 Permitsolutiontodryonthe skin.Povidone-iodine shouldbe incontactwiththe skinfor 1
minute tobe effective.
Insertthe catheterand initiate infusion.
4Use the nondominant hand to pull the skin taut belowthe entry site.
Thisstabilizesthe veinandmakesthe skintautfor needle entry.Itcan alsomake initial tissue
penetrationlesspainful.
5Hold the over-the-needle catheterata 15-to 30-degree angle withbevel up, insertthe catheter
through the skinand into the vein.
Suddenlackof resistance isfeltasthe needle entersthe vein.Jabbing,stabbingorquickthrusting
shouldbe avoidedbecause it maycause rupture of delicate veins.
6Advance the needle catheterapproximately1 cm.
Once bloodappearsinthe lumenor youfeel the lackof resistance,lowerthe angle of the catheteruntil
it almostparallel withthe skinandadvance the needle catheterapproximately1cm.
7Holding the needle portionsteady, advance the catheter until the hub is at the venipuncture site.
The catheteris advancedtoensure thatit, andnot justthe metal needle,isinthe vein.
8
Release the tourniquet.
9Apply pressure.
Put pressure onthe veinproximal tothe cathetertoeliminate orreduce bloodoozingoutof the
catheter.Stabilizethe hubwiththumbandindex fingerof the nondominanthand.
10Remove the protective cap from the distal end of the tubing.
Holdit readyto attach to the catheter,maintainingthe sterilitytothe end.
11Remove the needle.
Carefullyremovethe needle,engage the needle safetydevice,andattachthe endof the infusiontubing
to the catheterhub.
12
Initiate the infusion.
13 Tape the catheter. Tape the catheterby the “U” methodor accordingto the manufacturer’s
instructions.Usingthree stripsof tape (about3 incheslong).

14Dress and label the venipuncture site and tubingaccording to agency policy. Label shouldhave date
on whichadministrationsetmustbe changed. The venipuncture site shouldalsobe labeledwiththe
date and time,andtype and lengthof catheter.
15
Document the relevantdata, includingassessments.
5. CatheterStabilizationand DressingManagement
Cathetershouldbe stabilizedinamannerthatdoesnot interfere withvisualizationsoyoucan inspect
and do yourassessmentlater.Follow the stepsbelow onhow youcanachieve this:
 Tape the catheterbythe U, H, or the Chevronmethodoraccording to the manufacturer’s
instructions.Usingthree stripsof tape (about3 incheslong).
 Loop the tubingandsecure it withtape.Loopingandsecuringthe tubingpreventthe weightof
the tubingor any movementfrompullingonthe needle orcatheter.
 Dressthe venipuncture site andtubingaccordingtoagencypolicy.
Types ofdressingsacceptable for peripheral catheter
ADVERTISEMENTS
 Gauze dressingwithtape
 Transparentsemipermeable dressing(TSM)
Standards ofpractice
 Gauze dressingsshouldbe changedevery48hourson peripheral sites
 The use of non occlusive-typeadhesivebandage stripinplace of dressingnotrecommended
 TSM dressingcanbe changedwhencatheterischanged
Post-Catheterization
1. Labeling
Insertionsite
The venipuncture site shouldbe labeled:
 Date andtime
 Type and lengthof catheter

 Nurse’sinitials
Administrationset
 Label accordingto agencypolicy:label shouldhave date onwhichadministrationsetmustbe
changed
Solutioncontainer
 Place a time stripon all parenteral solutions
 Anyadditivesmusthave aclearlabel appliedtobag
2. EquipmentDisposal
 Needlesandstyletsshall be disposedof innonpermeable,tamper-proof containers.
 Dispose of all paperand plasticequipmentinabiohazardcontainer.
3. PatientEducation
Patientmustreceive informationonall aspectsof theircare.Aftercatheterisstabilized,dressingis
applied,andlabelingcomplete:
 Informregardinganylimitationsof movementormobility
 Explainall alarmsif EID isused
 Instructto call forassistance if venipuncture site becomestenderorsore or if rednessor
swellingdevelops
 Advise thatsite will be checkedeveryshiftbythe nurse
4. Rate Calculation
 Ensure appropriate infusionflow.
 Do not leave patientcare environmentuntil rate iscalculatedand adjustedaccordingly.
5. Documentation
Documentthe relevantdata,includingassessments.
 Recordthe start of the infusiononthe client’schart.
 Include the date andtime of the venipuncture
 The gauge andlengthof the device
 Specificname andlocationof the accessedvein

 Amountof solutionused,includinganyadditives
 Containernumber
 Flowrate
 Type,lengthandgauge of the needle orcatheter
 Venipuncturesite,howmanyattemptsweremade andlocationof eachattempt
 The type of dressingapplied
 The client’sgeneral response
 Your signature

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