Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar
Web: http://uep.edu.ph Email: [email protected]

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

IV THERAPY

Definition

 Intravenous therapy provides venous routes for administration of fluids, medications, blood and
other nutrients.

Purpose

 To correct and prevent fluid and electrolyte imbalance.

 It serves as route for medication administration, blood, and other nutrients.

Equipment

 Proper catheter for venipuncture (gauge will vary with body size and reason for intravenous
administration)
 Administration set (depends on type of solution and rate of administration)
 Disposable gloves
 Tourniquet
 Arm board/splint (optional)
 Non-allergenic tape/plaster
 IV stand (bed/rolling)
 Cotton balls with alcohol/alcohol swab
 Sterile gauze

PROCEDURE RATIONALE
1. Check physician’s written order for the  Physician’s order is a must before initiation of
type and amount of IV fluid. peripheral access and administration of an IV
solution.
2. Assess client’s previous experience with  Determine level of emotional status and the
IV therapy and arm placement need for further instructions.
preference.
3. Assess client’s vein, location, size and  Determine the accessible site of IV insertion.
condition.
4. Wash hands.  For infection control.
5. Prepare necessary equipment for the  Provides efficiency of the procedure and
initiation of IV. Check the sterility and ensures that no defective materials are used.
integrity of the IV solution, IV set and
other devices.
6. Prepare the client and the family by  Decreases anxiety and promotes cooperation.
explaining the procedure and the
purpose.
7. Assist client to comfortable position.  Provides comfort and prevents unnecessary
movement of client during IV insertion.
8. Open sterile packages using aseptic  Maintains sterility of equipment and reduces
technique. spread of microorganisms.
9. Check IV solution using the rights of drug  IV solutions are medications that should be
administration; then, open the seal. carefully checked to reduce risk of error.
10. Open the infusion set, push spike into the  Ensure complete connection of bottle/bag and
 bottle port. the tubing.
11. Fill drip chamber to at least half and  Eliminates introduction of air into tubing.
prime the tubing aseptically.
12. Wear gloves.  To prevent contact with blood spills.
13. Select the vein for IV placement; apply  Facilitates assessment of distal arm veins and
tourniquet 2-6 inches above the selected hand veins.
insertion site. Check for the presence of
radial pulse.
14. Clean the vein area with use cotton balls  Reduces bacteria on skin surfaces.
with alcohol, beginning at the vein and
circling outward in a 2-inch diameter.
Allow the site to dry for at least 60
seconds.
15. Encourage client to take a slow, deep  To facilitate relaxation.
breath as you begin.
16. Hold skin taut with one hand while the  To stretch the skin and inserting at the right
other hand holds the appropriate cannula; angle ensures catheter/cannula stability.
pierce skin with needle positioned on 15-
30 degrees angle.
17. When the needle enters the skin, lower it  Prevents penetration of both walls of the vein.
until it almost flushes with vein.
18. Push needle into the vein about ¼ inch  Permits the insertion of cannula/catheter
after the blood is noted. Slide the cannula without needle to prevent the puncture of
over needle and into vein before pulling other vein wall.
needle out of the vein and skin.
19. Slip the sterile gauze under the hub.  Removing the tourniquet prevents vein rupture
Release the tourniquet, remove the stylet from infusing fluid against wall closed vessel.
while applying the digital pressure over Applying pressure on the tip of the catheter
the catheter/cannula with one finger will prevent blood spills.
about ½ inch from the tip of inserted
catheter and connect the infusion tubing
aseptically to the IV catheter.
20. Open roller clamp/IV regulator slowly to  Determines if the catheter is in vein or wedge
allow fluid to flow freely for few seconds. against vessel wall; fluid infusion prevents clot
formation.
21. Anchor needle firmly in place with the use  Securing the catheter and tubing prevents
of transparent tape directly on the movement and tension on the device,
puncture site, using a chevron reducing mechanical irritation and possible
configuration or U-method. infection.
22. Tape a small loop of IV tubing for  Helps prevent the weight of the tubing from
additional anchoring, apply splint or arm pulling the needle out of place.
board if needle.
23. Regulate IV flow manually or set the  Right amount of IV fluid will be maintained
infusion device and its regulation. based on physician’s order.
24. Write on the IV label the date and time of  These are pertinent data in monitoring client’s
IV insertion and its regulation. intravenous therapy.
25. Review on the limitation in movement
with client to notify care provider for any
problem or discomfort.
26. Position the client for comfort with call  Promotes safety and comfort.
light within reach.
27. Dispose off used needles in appropriate  Reduces transmission of microorganisms and
sharp’s container. protect staff from injury.
28. Remove gloves and wash hands.  Decreases the incidence of cross-infection.
29. Document pertinent information.  Documentation contributes to continued data
necessary for the client’s care plan.
30. Check the client and site of IV every hour.  To determine if intravenous fluid is infusing
correctly.
Republic of the Philippines
 UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
Web: http://uep.edu.ph Email: [email protected]

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

PERFORMANCE EVALUATION CHECKLIST

IV THERAPY

PROCEDURE Able to Able to perform Not able to

perform with assistance perform
(2) (1) (0)

1. Check physician’s written order for the type and

amount of IV fluid.
2. Assess client’s previous experience with IV
therapy and arm placement preference.
3. Assess client’s vein, location, size and condition.
4. Wash hands.
5. Prepare necessary equipment for the initiation of
IV. Check the sterility and integrity of the IV
solution, IV set and other devices.
6. Prepare the client and the family by explaining the
procedure and the purpose.
7. Assist client to comfortable position.
8. Open sterile packages using aseptic technique.
9. Check IV solution using the rights of drug
administration; then, open the seal.
10. Open the infusion set, push spike into the bottle
port.
11. Fill drip chamber to at least half and prime the
tubing aseptically.
12. Wear gloves.
13. Select the vein for IV placement; apply tourniquet
2-6 inches above the selected insertion site. Check
for the presence of radial pulse.
14. Clean the vein area with use cotton balls with
alcohol, beginning at the vein and circling outward
in a 2-inch diameter. Allow the site to dry for at
least 60 seconds.
15. Encourage client to take a slow, deep breath as
you begin.
16. Hold skin taut with one hand while the other hand
holds the appropriate cannula; pierce skin with
needle positioned on 15-30 degrees angle.
17. When the needle enters the skin, lower it until it
almost flushes with vein.
18. Push needle into the vein about ¼ inch after the
blood is noted. Slide the cannula over needle and
into vein before pulling needle out of the vein and
skin.
19. Slip the sterile gauze under the hub. Release the
tourniquet, remove the stylet while applying the
digital pressure over the catheter/cannula with one
finger about ½ inch from the tip of inserted
catheter and connect the infusion tubing
aseptically to the IV catheter.
20. Open roller clamp/IV regulator slowly to allow fluid
 to flow freely for few seconds.
21. Anchor needle firmly in place with the use of
transparent tape directly on the puncture site,
using a chevron configuration or U-method.
22. Tape a small loop of IV tubing for additional
anchoring, apply splint or arm board if needle.
23. Regulate IV flow manually or set the infusion
device and its regulation.
24. Write on the IV label the date and time of IV
insertion and its regulation.
25. Review on the limitation in movement with client to
notify care provider for any problem or discomfort.
26. Position the client for comfort with call light within
reach.
27. Dispose off used needles in appropriate sharp’s
container.
28. Remove gloves and wash hands.
29. Document pertinent information.
30. Check the client and site of IV every hour.

Remarks:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Grade: _______

__________________________ ___________________________
Clinical Instructor Student’s Signature

Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES
 University Town, Northern Samar
Web: http://uep.edu.ph Email: [email protected]

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

PERFORMANCE EVALUATION CHECKLIST

INSERTING A BUTTERFLY (WINGED-TIP) NEEDLE

PROCEDURE Able to Able to perform Not able to

perform with assistance perform
(2) (1) (0)

1. Hold the needle, pointed in the direction of the blood

flow, at a 30 degree angle with the bevel up, and piere
the skin beside the vein about 1cm (½ inch) below the
site planned for piercing the vein.
2. Once the needle is through the ski, lower the needle
so that is almost parallel with the skin.
3. When blood flows back into the needle tubing, insert
the needle to its hub
4. Release the tourniquet, attach the infusion, and initiate
flow as quickly as possible.
Securing a Butterfly Needle
5. Tape the butterfly needle secured by the crisscross
(chevron) method. Place a small gauze square under
the needle, if required.

Remarks:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Grade: _______

__________________________ ___________________________
Clinical Instructor Student’s Signature

Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES
 University Town, Northern Samar
Web: http://uep.edu.ph Email: [email protected]

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

MONITORING AN INTRAVENOUS INFUSION

Preparation

1. Assess:
 Appearance of infusion site
 Patency of system
 Type of fluid being infused
 Rate of flow
 Response of the client
2. Determine:
 The type and sequence of solutions to be infused (from orders prescribed)
 The rate of flow and infusion schedule

Republic of the Philippines

 UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
Web: http://uep.edu.ph Email: [email protected]

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

PERFORMANCE EVALUATION CHECKLIST

MONITORING AN INTRAVENOUS INFUSION

PROCEDURE Able to Able to perform Not able to

perform with assistance perform
(2) (1) (0)

1. Ensure