FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020-2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

MODULE # 2 – INTRAVENOUS THERAPY

General Description: This topic aims to acquire knowledge and skills in the safe practice of
intravenous therapy especially in maintaining health, balance of fluids and
electrolytes.
Learning Outcomes:
1. Apply anatomy and physiology, intravenous complications, infection control,
documentation, and legal accountability theory to the nursing management of
Intravenous therapy and administration of medication.

2. To competently perform safe preparation, setting up, changing, and

discontinuing Intravenous infusion following demonstration and supervised
practice.

3. Demonstrate knowledge of numeracy and accurate drug calculations using

specific calculation formulas.

4. Indicate own accountability about infusion devices and compliance

5. Proper care for patients receiving Intravenous therapy

Intravenous therapy
Insertion of a needle through vein with a use of an IV cannula
based on a written doctor’s order. The IV cannula is attached to
sterile tubing and fluid container that deals with all aspects of
fluid and medication administration to compromised condition of
patients who cannot be treated effectively through oral medications
and nutrition.

1. Indications:
a. To maintain hydration and correct hydration in patients
unable to tolerate sufficient volumes of oral
fluids/medications
b. Parenteral nutrition

1 | P a g e
NUR1210- SKILLS LABORATORY (Mary Ann Bayani, MAN, RN)
Prepared by MCN FEU Faculty Lecturers January ,2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020-2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM
c. Administration of drugs
d. Transfusion of blood or blood components

2. Contraindications:
Administration of irritant fluids or drugs through peripheral access such as highly
concentrated, high osmolality solutions

Intravenous fluids:

There are two types of fluids that are used for intravenous drips:

1. Crystalloids – are aqueous solutions of mineral salts, or other water- soluble molecules.
The most common used is Normal Saline, a solution of sodium chloride at 0.9%
concentration, which is close to the concentration in the blood (isotonic). Next is the
Ringer’s lactate or Ringer’s acetate another isotonic solution often used for large
volume fluid replacement. Another fluid solution is the 5% Dextrose in water or called
D5W, this is often used for patent at risk or low blood sugar or high sodium.

Crystalloids are commonly

used for rehydration, and
electrolyte replacement.

2. Colloids – contain larger insoluble molecules such as gelatin, blood. Colloids preserve
high colloid osmotic pressure in the blood, such instances a parameter is decreased by
crystalloids due to hemodilution. This used to replace lost blood, maintain healthy blood
pressure and volume expansion. example of this is Albumin, Dextran. Colloids are high
in price than crystalloids.

2 | P a g e
NUR1210- SKILLS LABORATORY (Mary Ann Bayani, MAN, RN)
Prepared by MCN FEU Faculty Lecturers January ,2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020-2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM
Sites for Intravenous Infusion:

1. Dorsal metacarpal veins – dorsum of the hand, usually the common site

2. Cephalic vein – along radial bone of forearm

3. Basilic vein – runs up to the ulnar bone
4. Radial vein – back of the hand and the lateral aspect of
the forearm
5. Medial antecubital vein – anterior / flexor aspect of
the elbow joint
6. Accessory cephalic vein – back of the forearm,
it joins the cephalic below the elbow

Infection Control or Standard Precautions:

1. Hand hygiene – the most important measure

to prevent spread of infections before and after
procedure
2. Use of personal protective equipment/PPE
(ex: gloves, masks, eyewear) - PPE that is
appropriate for various types of patient
interactions and effectively covers personal
clothing and skin likely to be soiled with blood,
saliva, or other potentially infectious materials
should be available.

3 | P a g e
NUR1210- SKILLS LABORATORY (Mary Ann Bayani, MAN, RN)
Prepared by MCN FEU Faculty Lecturers January ,2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020-2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM
3. Respiratory hygiene/cough etiquette- infection prevention measures are designed to
limit the transmission of respiratory pathogens spread by droplet or airborne routes.
4. Sharps safety- All used disposable syringes and needles, scalpel blades, and other
sharp items should be placed in appropriate puncture-resistant containers located close

to the area where they are used. Sharps containers should be disposed of according to
state and local regulated medical waste rules.
5. Aseptic technique for doing the procedure
6. Sterile instruments and devices
7. Clean and disinfected surfaces - Cleaning removes large numbers of microorganisms
from surfaces and should always precede disinfection.

I.PREPARATION FOR INTRAVENOUS THERAPY:

1. Review Physician’s order:

This includes:
a. Type of solution
b. Route of administration
c. Exact amount (dose) of fluids to be infused
d. Rate of infusion
e. Duration of infusion or the time over which the infusion is to be completed
f. Physician’s signature
2. Patient assessment and psychological preparation
a. Introduce self and verify the client’s identity
b. Provide privacy
c. Explain the procedure and its importance
d. Evaluate patient’s preparedness for IV procedure
3. Perform hand hygiene
a. Wash hands with a non-antimicrobial soap and water
b. Do not wear artificial fingernails

II.SETTING UP AN IV INFUSION

4 | P a g e
NUR1210- SKILLS LABORATORY (Mary Ann Bayani, MAN, RN)
Prepared by MCN FEU Faculty Lecturers January ,2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020-2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

1. Assemble the articles needed for starting an IV infusion

2. Check the solution and set for sterility
a. IV bottles or plastic containers – hold up to light t look for cracks, clarity, expiration
date
b. Inspect administration set – closed, secured, sealed packs, clarity, expiration dates
Materials include:
o IV solution
o Macro set for adult
o Micro set for pediatrics
o IV catheters/cannulas
o Micropore tapes -1inch size
o Alcohol swabs
o Torniquet
o Clean gloves

PARTS OF INFUSION SET

5 | P a g e
NUR1210- SKILLS LABORATORY (Mary Ann Bayani, MAN, RN)
Prepared by MCN FEU Faculty Lecturers January ,2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020-2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM

Needless Injection port

3. Make an IV label / tag and computes for the rate of IV infusion.

4. Assesses client’s vein or IV site for complications

These are:

a. Infiltration – IV fluids leak into the surrounding tissues. This may cause improper
placement, patient’s movement that cause slip out of the catheter from the vein.
Signs and symptoms:
o Swelling
o Discomfort
o Burning feeling
o Tightness
o Cool skin and blanching
o Decreased or stopped flow rate

Management:
o Stop the infusion and remove the device
o Elevate the affected side to promote comfort,
6 | P a g e
NUR1210- SKILLS LABORATORY (Mary Ann Bayani, MAN, RN)
Prepared by MCN FEU Faculty Lecturers January ,2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020-2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM
o Apply warm compress to decrease swelling
o Check the site frequently
o Document your finding and interventions performed

b. Extravasation – is the leaking of vesicant drugs into surrounding tissues. This can
cause severe local tissue damage, possible leading to delayed tissue necrosis, loss
of function or worst amputation
Signs and symptoms:
o Blanching
o Burning sensation
o Discomfort at the IV site
o Cool skin around IV site
o Swelling at or above IV site
o Blistering

Management:
o Stop the IV flow and remove the IV line
o Elevate the extremity
o Perform frequent assessments of sensation, motor function and
circulation of affected extremity
o Record the extravasation site, symptoms, and treatment given

c. Phlebitis – inflammation of a vein. This can also occur as a result of vein trauma
during insertion, use of an appropriate IV catheter size for the vein or prolong used of
the same IV site
Signs and symptoms:
o Redness or tenderness at the site of the tip of the catheter or
along the path of the vein
o Puffy area over the vein
o Warmth around the insertion site
Management:
o Stop the infusion at the first sign
of redness or pain
o Apply warm. Moist compress
to the area
o Document your patient’s condition and interventions
o Insert a new catheter at a
different site

5. Maintain sterility of IV solution container while opening the port

7 | P a g e
NUR1210- SKILLS LABORATORY (Mary Ann Bayani, MAN, RN)
Prepared by MCN FEU Faculty Lecturers January ,2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020-2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM
6. Disinfects rubber port with cotton balls or alcohol swab.

7. Opens administration set (macro/micro set) aseptically and close first the roller clamp
8. Spikes the container without contaminating the port.
9. Hang the IV bottle using the IV stand or hook.
10. Fill the drip chamber at least half
11. Primes the tubing while maintaining sterility of the end of tubing.
12. Removes air from tubing’s then closed (ready for IV insertion

III. CHANGING AN IV INFUSION:

1. Check doctor’s order sheet

2. Perform handwashing
3. Obtain the correct solution container and check
for sterility, expiration and clarity
4. Prepare necessary materials and bring to bedside.
Put an IV tag /label at the IV solution with patient’s name, IV bottle, date and time
started with your signature
5. Introduce self and verify patient’s name
6. Explain the procedure
7. Open and disinfect the rubber port of the IV solution by alcohol swab
8. Closed roller clamp of infusion set – to avoid bubbles
9. Remove the old IV container then spike the infusion set to a new IV container without
touching the sterile port
10. Open the roller clamp and regulate the flow rate as ordered by the doctor
11. Remove bubbles or air if any.
12. Discard the used IV bottle and other materials used on proper waste disposal.
13. Document on the name of the IV bottle, date, time, and flow rate

IV. DISCONTINUING AN IV INFUSION:

1. Verify written doctor’s order,

2. Observe 12 rights of medication,
3. Prepare necessary materials such as cotton.
balls, micropore tape, and gloves)
4. Do handwashing,
5. Closed the roller clamp.
6. Put on clean gloves.
7. Loosen the tape using proper appropriate.

technique. Make it slow to avoid discomfort.

Be careful to avoid manipulating the device.
8 | P a g e
NUR1210- SKILLS LABORATORY (Mary Ann Bayani, MAN, RN)
Prepared by MCN FEU Faculty Lecturers January ,2021
 FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
SECOND SEMESTER – AY 2020-2021
NUR 1210 – NCM 109 CARE OF THE MOTHER AND CHILD AT RISK OR WITH PROBLEM
in the skin to prevent skin organism from entering the bloodstream. Never use alcohol
swab to clean the site.
8. Hold a cotton balls or sterile gauze above the venipuncture site. To control bleeding.
9. Withdraw the needle or IV cannula by pulling it out along the line of the vein. Check for
completeness.
10. Place a dressing over the venipuncture site. If the patient feels lingering tenderness t the
IV site, may apply warm moist packs.
11. Discard all waste materials including IV tubing’s, IV cannula, to proper waste disposal.
12. Remove gloves and dispose to proper waste disposal.
13. Document time discontinued, status of insertion site, and status of IV cannulas removed.

DOCUMENTATION:

Notes to take on to:

1. Document the procedure in the IV flow sheet, Kardex, and Nurses notes
2. Indicate time IV solution was started, changed, or terminated.
3. State reasons for doing this procedure.
4. Type of IV solution infused, amount infused, and the flow rate/regulation.
5. Effect of the procedure to patient
6. Any remarkable or pertinent observations on the patient

DRUG COMPUTATION:

Infusion flow Rate:

Always remember this formula:

Total fluids in ml x drop factor(gtts/ml ) = gtts /min (flow rate)

Time(min)

Example: 1500ml IV saline is ordered over 12 hours Using a drop factor of 15

drops/ml, how many drops er minute need to be delivered?

1500ml X 15(gtts/ml) = 31 gtts/minute

____________________________
12 X 60(give us total minutes)

9 | P a g e
NUR1210- SKILLS LABORATORY (Mary Ann Bayani, MAN, RN)
Prepared by MCN FEU Faculty Lecturers January ,2021