Name: Gallemit, Justin Patrick W.

Date: 12/15/2021

Evaluator/Signature: Queenie Jane Ramel RN, MAN Grade: _____________

ASSISTING A PERIPHERAL VENOUS ACCESS IV INFUSION

Description:

Administering and monitoring IV fluids is an essential part of routine patient care. The primary care provider often orders IV therapy to prevent or correct problems in fluid and
electrolyte balance. For IV therapy to be administered, an IV must be inserted.

Purpose:

Peripheral venous access allows sampling of blood, as well as administration of fluids, medications, parenteral nutrition, chemotherapy, and blood products.

Equipment:

• IV solution, as prescribed • IV securement/stabilization device, as appropriate

• Medication administration record • Clean gloves
• Towel or disposable pad • Additional personal protective equipment (PPE), as indicated
• Nonallergenic tape • IV pole
• IV administration set • Local anesthetic (if ordered)
• Label for infusion set (for next change date) • IV catheter (over the needle, Angiocath) or butterfly needle
• Transparent site dressing • Short extension tubing
• Electronic infusion device (if appropriate) • End cap for extension tubing
• Tourniquet • Alcohol wipes
• Time tape and/or label (for IV container) • Skin protectant wipe (e.g., SkinPrep)
• Cleansing swabs (chlorhexidine preferred) • Prefilled 2-mL syringe with sterile normal saline for injection
 PERFORMED
ACTION RATIONALE REMARKS
YES NO
1. Verify the IV solution order on the patient’s This ensures that the correct IV solution and rate of infusion, and/or
chart with the medical order. Clarify any medication will be administered. This knowledge and skill is essential for
inconsistencies. Check for color, leaking, and safe and accurate IV and medication administration.
expiration date. Know techniques for IV
insertion, precautions, purpose of the IV
administration, and medications if ordered.

2. Gather, prepare and place the following Having equipment available saves time and facilitates accomplishment of
materials and equipment on the IV tray: procedure.
clean gloves, tourniquet, IV tag/label,
cleansing swabs (chlorhexidine preferred), IV
catheter or butterfly needle, and alcohol
wipes; bring to the bedside.

3. Perform hand hygiene and put on PPE, if

indicated. Hand hygiene and PPE prevent the spread of microorganisms.
PPE is required based on transmission precautions.

4. Identify the patient by asking the patient’s

name or reading the Identification bracelet. Identifying the patient ensures the right patient receives the intervention and
helps prevent errors.

5. Close curtains around bed and close the door

to the room, if possible. Explain what you are This ensures the patient’s privacy.
going to do and why you are going to do it to Explanation relieves anxiety and facilitates cooperation.
 the patient. Ask the patient about allergies to Possible allergies may exist related to medications, tape, or local
medications, tape, or skin antiseptics, as anesthetic. Injectable anesthetic can result in allergic reactions and tissue
appropriate. If considering using a local damage.
anesthetic, inquire about allergies for these
substances as well.

PERFORMED
ACTION RATIONALE REMARKS
YES NO
6. Compare the IV container label with the
doctor’s order. Remove IV bag from outer Checking the label with MAR/CMAR ensures the correct IV solution will be
wrapper, if indicated. Check expiration dates. administered.
Alternately, prepare and label the IV tag
Identifying the patient ensures the right patient receives the medications
specifying patient’s name, room number, and helps prevent errors.
name and type of IV solution, additives, drop
rate, date and time of IV insertion, estimated Labelling the container allows a quick visual reference by the nurse to
date & time to be consumed & name of IV monitor infusion accuracy
Therapist.
7. Maintain aseptic technique when opening Asepsis is essential for preventing the spread of microorganisms.
sterile packages and IV solution. Remove Labeling tubing ensures adherence to facility policy regarding administration
administration set from package. Apply label set changes and reduces the risk of spread of microorganisms.
In general, IV tubing is changed every 72 to
to tubing reflecting the day/date for next set
96 hours.
change, per facility guidelines.
8. Close the roller clamp or slide clamp on the Clamping the IV tubing prevents air and fluid from entering the IV tubing at
IV administration set. Invert the IV solution this time.
container and remove the cap on the entry
Inverting the container allows easy access to the entry site.
site, taking care not to touch the exposed
entry site. Remove the cap from the spike on Touching the opened entry site on the IV container and/or the spike on the
the administration set. Using a twisting and administration set results in contamination and the container/administration
pushing motion, insert the administration set set would have to be discarded.
spike into the entry site of the IV container.
 Inserting the spike punctures the seal in the IV container and allows access
to the contents.
9. Hang the IV container on the IV pole. Suction causes fluid to move into drip chamber. Fluid prevents air from
Squeeze the drip chamber and fill at least moving down the tubing.
halfway.
10. Open the IV tubing clamp, and allow fluid to This technique prepares for IV fluid administration and removes air from the
move through tubing. Allow fluid to flow until tubing. If not removed from the tubing, large amounts of air can act as an
all air bubbles have disappeared and the embolus.
Touching the open end of the tubing results in contamination and the
entire length of the tubing is primed (filled)
administration set would have to be discarded.
with IV solution. Close the clamp. After fluid
has filled the tubing, recap the end of the
tubing.

PERFORMED
ACTION RATIONALE REMARKS
YES NO
11. After the IV therapist successfully inserted the Promotes patient comfort and safety.
IV catheter, remove equipment and return the
patient to a position of comfort. Lower bed, if
not in lowest position.
12. Return to check flow rate and observe IV site Continued monitoring is important to maintain correct flow rate.
for infiltration 30 minutes after starting Early detection of problems ensures prompt intervention.
infusion which include: Swelling, discomfort,
burning, and/or tightness, cool skin and
blanching & decreased or stopped flow rate
and at least hourly thereafter. Ask the patient
if he or she is experiencing any pain or
discomfort related to the IV infusion.
 13. Document the location where the IV access
was placed, as well as the size of the IV To ensure continuation of the plan of care.
catheter or needle, the type of IV solution,
and the rate of the IV infusion.

Learner’s Reflection: (What did you learn most of the activity? What is its impact to Instructor’s Comments:
you?)
The importance of these skills is that I will be able to apply the theories I learned in
real life situations. I feel like it will be fulfilling if I will be able to perform it soon. Also,
it helps the nurses practice their health assessment and communication skills to
gather relevant data for documentation. Since this looseleaf does not have a video
provided as it was an extra looseleaf, I just looked up on YouTube for a video
explaining the steps. It helped me in understanding the process well and the steps
were well explained

Evaluation:
The expected outcome is met when the IV access is initiated on the first attempt; fluid flows easily into the vein without any sign of infiltration; and the patient verbalizes minimal
discomfort related to insertion and demonstrates an understanding of the reasons for the IV

References:
Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3rd Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses’ Guide to Clinical Procedures. 5th Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursing Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4th Edition. Philadelphia: LWW