INTRAVENOUS INFUSIONS –
Nurse’s Responsibility, Preparation,
Procedure and After Care of the Patient
INTRAVENOUS INFUSIONS
The introduction of a large amount of fluid into the body via veins is termed as I.V. infusions. It has the following purpose:
1. To restore the fluid volume that is lost from the body due to haemorrhage, vomiting, diarrhea, drainage etc.
2. To meet the patient’s basic requirements for calories, water, minerals and vitamins.
3. To prevent and treat shock and collapse.
4. To supply the body with adequate amounts of fluids, electrolytes and other nutrients when the patient is unable to taken inadequate amount by mouth or oral intake in contraindicated or impracticable.
5. To administer medicines.
Indications for I.V. Infusions
I.V. infusions are indicated in the following situations:
1. To save patient in life threatening situations e.g., patients having haemorrhage, shock, extensive burns etc.
2.To supply fluids and nutrients to the patients who may have nothing by mouth or who are unable to ingest oral liquids owing to prolonged nausea, vomiting, diarrhea, peritonitis, paralytic ileus, fistulas etc.
3. To supply fluids and nutrients to the patients who are unable to digest or absorb a diet administered by mouth or through the nasal tube. E.g., patients who do not have an anatomically intact intestinal tract or the patients with septicaemia etc.
4. To dilute toxins in case of toxaemia or septicaemia.
5. To administer medications which are destroyed by the gastric juices or which will not be absorbed by the gastro-intestinal tract, if administered orally.
Solutions Used
1. Nutrient solutions e.g., dextrose 5%, 10%, 20%, 25%, 50% etc.
2. Electrolyte solutions available in isotonic, hypotonic and hypertonic concentrations, e.g., normal saline, dextrose saline, lactated Ringer’s solution, 1/6 molar solution sodium lactate solutions etc.
3. Alkalinizing and acidifying solutions, e.g., sodium lactate solution, sodium bicarbonate, potassium chloride, etc.
4. Blood volume expanders. These are plasma substitutes and contain large molecular substances which will not escape through the vessel walls and tend to prevent the circulating fluid from leaking into the tissues. E.g., dextran, lomodex, haemocoele etc.
An Isotonic solution is one which has an electrolyte content approximately 310 MEq/L.
A Hypotonic solution is one in which the total electrolyte content is below 250 MEq/L.
A Hypertonic solution has a total electrolyte content of 375 MEq/L or greater.
In general, isotonic solutions are used for extracellular volume replacement e.g., in prolonged vomiting. Depending on the specific electrolyte imbalance, hypertonic or hypotonic solutions may be used.
Certain additives are frequently instilled into I.V. solutions such as vitamins, potassium chloride, etc. clients with normal kidneys who are kept Nil orally should have potassium added to I.V. solution. The body has no conservation mechanism for potassium and even when the serum level falls, the kidneys continue to excrete potassium. Hypokalemia can develop quickly, if there is no intake of potassium orally or parenterally.
Equipments Used
Correct selection and preparation of equipment assist in safe and quick placement of an I.V. line. Because fluids are instilled into the blood stream, sterile techniques are necessary while doing this procedure. Standard equipment include (i) I.V. solution and tubing. (ii) Needle or catheter (iii) antiseptic (iv) Tourniquet (v) Gloves and Dressing (vi) Arm board.
Other I.V. Equipment include:
1. solution containers
2. various types of tubing
3. volume control devices
Different types of tubings are used to administer a medication. Macrodip tubing which delivers large drops is needed to infuse a drug rapidly. I.V. extension tubings may be used to facilitate changes in position or to increase mobility.
Volume control devices are used for children, for clients with renal or cardiac failure and for critically ill clients to prevent sudden, uncontrolled rapid infusion of large volumes.
Venipuncture Sites
A venipuncture is a technique in which a vein is punctured transcutaneously by a sharp rigid stylet (e.g. needle or metal needle) partially covered by a plastic catheter (over – the needle catheter or O N C) or by a needle attached to a syringe. The general purpose of a venipuncture is:
1. To collect a blood specimen
2. Instill a medication
3. Start an I.V. infusion
4. Inject a radio-opaque or radio-active tracer for special examination
When selecting a site for administration of I.V. fluids, it is essential to consider the following factors:
1. Conditions of veins (collapsed or too small)
The characteristics of tissues over the vein (oedematous, injured, diseased, inflamed etc)
2. Purpose and the duration of infusions
3. The type and the amount of I.V. fluid ordered
4. The diagnosis and the general conditions of the patient
5. Age of the client (very young and old clients have fragile veins)
6. Mobility of the limb: avoid sites that are easily moved or bumped such as the dorsal surface of the fluid.
Common I V Puncture Sites
The most convenient veins for venipuncture in the adult are the ‘basilic’ and the ‘median cubital vein’ in the antecubital fossa because these veins are large and superficial. However, for prolonged infusions, these veins cannot be used without limiting the movements at the elbow joints by the use of splints. If the person is right handed, use of the left arm allows more independence and vice versa. The most commonly used veins in the order of their frequency of use are as follows:
1. veins of the forearm (basilic and cephalic veins)
2. veins in the antecubital fossa (median cubital, cephalic and basilic vein)
3. veins in the radial area (radial vein)
4. veins in the hand (dorsal metacarpal veins)
5. veins in the foot
6. veins in the thigh (femoral and saphenous veins)
7. veins in the scalp (for infants)
GENERAL INSTRUCTIONS FOR I.V. INFUSIONS
1. Follow strict aseptic technique throughout the procedure. The I.V. bottles, the I.V. fluids, the drip set etc. should be sterile. These should be handled under aseptic technique.
2. I.V. fluids are administered only with a clearly written prescription. The order should specify the type of solution, the concentration, the amount to be administered and the total time of infusion.
3. Maintain the specified rate of flow to prevent circulatory overload.
4. Watch the patient constantly for any unfavorable symptoms and if found any, report them to the physician or atleast to the senior nurses. Early detection of complications saves the patient from unnecessary sufferings. Sometimes the life of the patient may be endangered during I.V. infusions.
5. The solution used for infusions should correspond to the osmolality of the blood plasma (isotonic); hypotonic and hypertonic solutions are to be used with great care.
6. The following observations are made throughout the procedure:
a. Flow rate, dislodgement of needle etc
b. Signs of circulatory overload
c. Urinary output
d. The needle site for infiltration and thrombophlebitis
e. Fluid level in the bottle
f. Patency of the I.V. tubing and presence of kinks in the tubing. Sometimes the patient may lie on the tube and block the flow of fluid.
g. The blood circulation at the infused site; use of arm board and tight bandages used to fix the arm board may occlude the circulation
h. Intake and output chart for 24 hours. A fluid balance chart shows on one side the amount and the type of fluid administered and on the other side the amount lost by kidneys, stomach etc
i. Fluid and electrolyte balance; regular estimation of the electrolytes of blood is necessary.
7. When electrolyte are used (e.g. potassium) the rate of flow should be very low; otherwise a cardiac arrest may occur.
8. Observe the ‘five right’ rule – the right patient, the right medicine, the right dose, the right time, and the right method of administration.
9. Always check the expiry date of the fluid before opening the bottles; never use the fluid which has crossed the expiry date.
10. Shake the fluid and look for the suspended articles; fluids that are discolored, cloudy in appearance or contain suspended articles should not be used for infusion.
11. Make sure that the drip is sterile and is in good working order.
12. Select a proper site for infusions. Do not use any site that is tender, red, oedematous and inflamed for infusions.
13. Patients who are on long term I.V. fluids, the amount of fluid administered should meet the caloric requirement of the patient. Electrolytes are introduced in the form of sodium chloride and potassium chloride. Vitamins B and C are usually added to the drip. The protein requirements are also met partly.
14. If the flow of fluid is slowed or stopped, find out the cause. One of the following reasons may be found.
a. Spasm of the vein; stroking the vein gently above the needle entry may relieve the spasm.
b. Displacement of the needle; this characterized by local swelling. The flow must be stopped and restarted elsewhere.
c. Kinking or external pressure on the tube. The tubing may be obstructed by the patient lying on the tube or by a kink.
d Minor displacement of the needle has occurred within the vein. The bevel of the needle may be pressed against the wall of the blood vessel. Slight lifting of the needle mount, by placing a cotton ball under the needle, changing the position of the arm or elevating the forearm on a pillow also can help to correct the position of the needle and to restore the flow of fluid.
e. Low pressure within the I.V. fluid; elevating the height of the infusion bottle a few inches can increase the rate of flow by creating more pressure within the bottle.
15. Never allow the bottle to get empty completely to prevent the entry of air into the tissues. Change the I.V. bottle or discontinue the I.V. infusion when a small amount of solution is in the neck of the bottle and before the drip chamber is empty.
16. If I.V. infusions are to be given immediately before or after the blood transfusion, always use physiologic saline (0.9%) to prevent haemolysis of the blood cells in the tubing.
17. Keep the patient warm and comfortable with blankets, if necessary.
18. Immobilize the joints with splints when the needle is placed near the joint.
19. If the temperature of the solution is to be maintained near to the body temperature, apply hot water bottles at a moderate temperature around the I.V. tubing or bottle.
20. Frequent observation of the vital signs throughout the procedure will help to detect many complications.
21. Offer bed pan or urinal before the I.V. infusions are started.
NURSE’S RESPONSIBILITY IN THE ADMINISTRATION OF I.V. INFUSIONS
Preliminary Assessment
1. Check the patient’s name, bed number and other identifications.
2. Check the diagnosis and the age of the patient
3. Check the purpose of infusion
4. Check the physician’s orders for the type of infusion fluid, the strength, the amount and the duration of infusion.
5. Check the consciousness of the patient and his ability to follow the instructions.
6. Check the general condition of the patient, whether overhydrated or dehydrated.
7. Check the site of infusion – note the condition of the veins and tissue at the infusion site.
8. Check the abilities and limitations of the patient.
9. Check the need for additional restraints.
10. Check the patient’s previous experience with infusions.
11. Check the articles available in the patient’s unit.
12. Check the articles for their working order, the sterility of drip sets and the fluid. Check the expiry date of the fluid. Check the fluid for discoloration, suspended particles etc.
PREPARATION OF ARTICLES
Articles
A tray containing:
1. I.V. solutions (sterile and clear) in required number of bottles for a day.
Purpose: to administer fluid without interruption
2. Sterile I.V. tubing with attached drip chamber and clamp.
Purpose: to supply the fluid into the patient.
3. Sterile butterfly or scalp vein needle with a protective cap on its needle.
Purpose: it can be used for unstable vein and also allow maximum freedom of movement.
4. Sterile syringes (2 or 5 ml) with needles no. 20 and 22.
Purpose: to take blood specimens, if necessary; to add medications to the I.V. drip; or to initiate the procedure.
5. Sterile transfer forceps in a jar.
Purpose: to handle sterile supplies.
6. Sterile cotton swabs and gauze pieces in sterile containers.
Purpose: to clean the skin at the site of infusion and also to cover the needle after the venipuncture.
7. Methylated spirit in a container.
Purpose: to clean the skin.
8. Kidney tray and paper bag.
Purpose: to receive the wastes.
9. Bowl with water
Purpose: to receive the used syringes and needles.
10. Tourniquet
Purpose: to occlude venous return and to make the veins visible.
11. Adhesive plaster with scissors
Purpose: to secure the needle and the tubing.
12. Covered arm splint with roller bandages.
Purpose: to immobilize the part in order to prevent the needle dislodging from the site.
13. Specimen bottles
Purpose: to collect blood specimens, if ordered.
14. Mackintosh and towel
Purpose: to protect the bed and the garments.
15. I.V. pole
Purpose: to hang the bottle at the required height.
Preparation of the Patient and the Environment
1. Explain the procedure to the patient to win his confidence and co-operation. Explain the sequence of the procedure and tell how he can co-operate in the procedure.
2. Tactfully send the visitors out of the patient’s room.
3. If the general conditions allows, ask the patient to wash hands with soap and water
4. Provide privacy with curtains and drapes.
5. Restraint the site, in case of children.
6. Offer the bedpan or urinal as needed.
7. See that the patient has taken food or drinks, if allowed.
8. Check the vital signs and record it in the nurse’s record for the future reference.
9. Divert the attention of the patient away from the infusion procedures by friendly conversations and by curious articles.
10. If any sedation is ordered, it may be given to quiet the patient.
11. Adjust the height of the bed for comfortable working of the nurse.
12. Clear the bedside table or overbed table and arrange the articles conveniently.
13. Place the patient in a comfortable and relaxed position suitable for the infusion site.
14. Select a site on the non-dominant arm to give maximum freedom for the patient.
15. Keep the I.V. stand in position
16. Place the mackintosh and towel under the area where the infusion is to be given.
17. Provide a good source of light if the lighting in the room is inadequate.
18. Call for assistance if necessary.
PROCEDURE
Steps of Procedure
1. Wash hands
Reason: to prevent cross infection.
2. Prepare the I.V. solution:
a. Carefully remove the bottle seal from the top of the bottle. Clean the top with a spirit swab; holding the bottle upright, insert the drip set and the air vent into the bottle openings.
Reason: every step of the procedure requires aseptic technique to prevent contamination of the whole apparatus.
b. Close the screw clamp
Reason: to prevent the drip chamber completely filled with the fluid, and also to prevent the fluid loss from the drip set.
c. Hang the bottle on the I.V. pole about 18 to 24 inches high
Reason: sufficient height needed for gravity to overcome venous pressure and to facilitate the flow of solution into the vein.
d. Connect the butterfly or needle to the I.V. tubing and remove the protective covering.
e. Open the clamp and flush the I.V. fluids through the tubing and needle into the kidney tray until all air is removed. Clamp the tubing and reapply the protective cap over the needle.
Reason: air, if left in the tubing, may enter the vein and cause air embolism.
3. Prepare few strips of adhesive tapes and keep ready for use.
Reason: to stabilize the I.V. needle once it is inserted into the vein.
4. Prepare the venipuncture site:
a. Place the extremity in a dependent position (lower than the patient’s heart)
Reason: gravity impedes venous return and distends the vein.
b. Apply a tourniquet firmly 6 to 8 inches proximal to the venipuncture site.
Reason: the tourniquet obstructs the venous flow and distends the vein. Care to be taken that the tourniquet is not applied too tightly to occlude the arterial flow.
c. Massage the or stroke the vein distal to the knot and in the direction of the venous flow (towards the heart)
Reason: this helps to fill the vein with the blood and the vein becomes visible.
d. Encourage the patient to clench and unclench the fist rapidly.
Reason: contracting muscles compresses the distal veins, forcing blood along the veins and distending them to the point of tourniquet.
e. Lightly tap the vein with your finger tips.
Reason: helps to distend the vein.
f. If the veins are not visible by the above steps, remove the tourniquet and apply heat to entire extremity for 10 to 15 minutes. Then apply tourniquet.
Reason: heat dilate the superficial blood vessels (if locating a vein has taken more than two to three minutes, releasing tourniquet and reapply. Prolonged obstruction causes numbness and discomfort in the extremity)
g. Clean the area with a spirit swab
Reason: helps to remove surface bacteria.
h. Dry the area with a sterile dry swab
Reason: if alcohol enters the vein, it can cause reactive vasospasm. (do not touch the area after cleaning and drying to ensure asepsis)
5. Insert the needle into the vein
a. Grasp the arm distally to the point of entry of the needle. Place left thumb one inch below the expected point of entry. Pull the skin taut.
Reason: taut skin will help to locate and maintain the vein in position. It also makes initial tissue penetration less painful.
b. Holding the needle at a 30 degree angle with the bevel up. Pierce the skin lateral to the vein. Once the needle enter the skin, lower the angle of the needle, so it becomes parallel with the skin. Follow the course of the vein and pierce the side of the vein.
Reason: lowering the angle, limits the chances of puncturing both sides of a vein.
c. When backflow of blood occurs into the needle and tubing, insert the needle further up, into the vein about ¾ to 1 inch.
Reason: back flow of blood ensures that the needle is in the vein. Pushing the needle further up in the vein, prevents dislodging of the needle from the vein.
d. Release the tourniquet and open the clamp to allow the fluid to run in.
6. Secure the needle and tubing in place:
a. Secure the scalp vein needle either by the ‘H’ method or by the ‘criss cross’ method. Apply two strips of adhesive tape to the wings of needle parallel to the needle. Apply another piece of tape across the previous two tapes in the shape of an ‘H’
Or
Apply one strip of the adhesive over the wings of the butterfly. Another strip is brought beneath the needle and cross to the opposite sides over the wings.
Reason: to ensure that the needle may remain in place.
b. Secure the scalp vein tubing to the skin by forming a loop.
Reason: this prevents pulling on the needle when patient moves in bed.
c. Secure the I.V. tubing to the skin.
Reason: further prevents accidental withdrawal of the needle.
d. Cover entry site with sterile gauze piece
Reason: prevents environmental contamination.
e. Use arm board to immobilize the nearest joint
Reason: armboard reduces the mobility of the arm thereby preventing dislodging of the needle from its site.
After Care of the Patient and the Articles
1. Maintain the specified rate of flow throughout the procedure.
2. Remove the mackintosh and towel.
3. Make the patient comfortable in bed. Tidy up the bed.
4. If the patient is conscious, instruct the patient not to move the hand.
5. Collect all articles used for infusion and take them to the utility room; clean them first with cold water and then with warm soapy water and rinse them thoroughly with clean water. Dry them and replace them in their proper places.
6. Send the blood specimens, if any, to the lab.
7. . Record the following information on the nurses record with date and time
a. Type of fluid administered
b. The concentration of the solution
c. the amount of fluid
d. the rate of flow of fluid
e. any medicines added to the bottle (if medicines are added to the I.V. bottle, it should be clearly written on the I.V. bottle also)
f. any reaction noticed in the patient
8. Return to the bedside to assess the comfort of the patient and to observe any complications developing in the patient. Stay with the patient and observe the patient constantly in order to prevent accidents and complications. Watch for any unfavorable signs such as headache, chills, nausea, restlessness, dyspnoea etc. watch the infusion site for swelling, pain etc.
9. If appropriate, teach the family members to observe and report the following conditions and request nursing assistance.
a. The fluid chamber is not dripping
b. Bottle or bag of fluid nearly empty
c. Backflow of blood into the tubing
d. Needle or connections in the tubing is disconnected
e. Increasing pain and discomfort at the needle site or along the vein
f. Swelling the tissues around the needle insertion site
g. Any unusual symptoms such as chills, restlessness etc.
10. When leaving the ward, the nurse should report the following to the relieving nurse.
a. The name and bed number of the patient getting the I.V. drip
b. The time at which the drip has started
c. The type of fluid that is given
d. The amount of fluid that is administered and how much more to be administered
e. Any specific precautions to be followed
f. The specified rate of flow
g. The general condition of the patient
11. To change the intravenous bottles:
a. Prepare the new bottle prior to the old one running out completely. Remove the bottle seal and clean the top with a spirit swab
b. Clamp the intravenous tubing. Remove the air inlet by the I.V. tubing. Hang up the new bottle, release the clamp and re-establish the infusion in the specified rate of flow.
c. Chart the amount and type of fluid infused or added each time
12. When the prescribed volume of fluid has been infused, it is discontinued. To discontinue it:
a. Clamp the infusion tubing. Loosen all the adhesive tapes that have been used to fix the needle and the tubing.
b. Withdraw the needle by pulling on the needle hub in line with the vein. At the same time hold a dry sterile swab over the needle site.
c. When the needle is out, apply firm pressure to the site for 2 or 3 minutes, to prevent bleeding.
d. Apply a small sterile dressing over the needle site which can be removed on the following day.
e. Discard the bottle and tubing as desired.
f. Record the total amount of fluid infused, the amount of fluid discarded if any, and the time at which the infusion is stopped.
g. Watch for the general, condition of the patient after the fluids have been discontinued. If the condition deteriorates, inform the doctor and restart the infusion.