1. Administering Intravenous Solutions and Medications
Chapter 36
Administering Intravenous Solutions and Medications
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

2. Lesson 36.1 Overview of IV Therapy: Types and Equipment Used
Theory
List four purposes for administering intravenous (IV) therapy.
Evaluate the advantages and disadvantages of using an infusion pump to deliver fluids or medications.
List three possible complications that can arise from the use of the IV route and the corrective actions you should take for each one.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

3. Lesson 36.1 Overview of IV Therapy: Types and Equipment Used
Clinical Practice
Prepare to give medications using each of the following methods:
a. Using an infusion pump to deliver a primary infusion
b. Using an infusion pump to deliver an IV piggyback
c. Using a controlled-volume device
d. Using an intermittent IV or a PRN (as-needed) lock
e. Giving the medication as a bolus
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

4. IV Therapy IVs are given to supply the body with:
Medications that are more effective when given by this route or cannot be given any other way
Fluids and electrolytes that the patient is unable to take orally in sufficient amounts
Blood, plasma, and other blood components
Nutritional formulas containing glucose, amino acids, and lipids
Intravenous fluids are given for a variety of reasons. Some intravenous medications are given when a patient cannot take medications orally or when rapid absorption is needed (e.g., an NPO patient returning from surgery).
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

5. Figure 36-2: Intravenous solution containers
Show the students IV solution containers.
Textbook figure 36-2
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

6. IV Therapy (cont’d)
The average adult needs 1500 to 2000 mL of fluids in each 24-hour period to replace those eliminated by the body
Fluids are lost by:
Hemorrhage
Severe or prolonged vomiting or diarrhea
Excessive wound drainage
Wounds (especially burn wounds)
Profuse perspiration
In order to maintain fluid balance, fluid loss will be replaced in order to prevent dehydration (vomiting and diarrhea) and shock (hemorrhage).
When the body has lost too much fluid, oral intake will not be adequate for replacement of fluids. Administering fluids intravenously provides a faster way of rehydrating a patient or increasing fluid volume.
A patient with severe blood loss will require blood transfusion.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

7. Types of IV Solutions Solutions most frequently used contain: Glucose
Saline
Electrolytes
Vitamins
Amino acids
Blood and blood products
The physician orders the type of solution to be given, the amount to be infused, and the rate of infusion.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

8. Types of IV Solutions (cont’d)
Isotonic solutions
Have the same concentration, or osmolality, as blood
Used to expand the fluid volume of the body
Hypotonic solutions
Contain less solute than extravascular fluid
May cause fluid to shift out of vascular compartment
Hypertonic solutions
Have a greater tonicity than blood
Replace electrolytes; when given as concentrated dextrose solutions, produce shift in fluid from intracellular to the extracellular compartment
Solutions that are given intravenously must be sterile and free from contaminating particles.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

9. Common IV Solutions and Tonicity
0.9% saline Isotonic
0.45% saline Hypotonic
5% dextrose in water Isotonic
10% dextrose in water Hypertonic
5% dextrose in 0.9% saline Hypertonic
5% dextrose in 0.45% saline Hypertonic
5% dextrose in 0.225% saline Isotonic
Ringer’s lactate Isotonic
5% dextrose in Ringer’s lactate Hypertonic
Trauma patients require isotonic solutions to maintain fluid volume as a result of hemorrhage (bleeding) and to correct hypotension (low blood pressure).
An elderly patient can become fluid overloaded with an isotonic solution; close monitoring of this patient population is necessary.
A patient who is dehydrated can benefit from hypotonic solution.
Hypertonic solutions are used to replace electrolytes.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

10. Administration Sets Primary intravenous set
Consists of bag of solution, regular tubing set, needleless connector, and IV stand
Secondary or piggyback intravenous set
Medications to be given intravenously often added to an existing IV line by using the piggyback method
Parallel, or Y, intravenous set
A Y-type administration set used to infuse certain blood products
Blood products require a special IV administration set.
When connecting an IV bag to IV tubing, care must be taken not to contaminate the system because this can result in infection.
Tubing size selection depends on the type of infusion. The standard drop size is 10 to 20 gtt/mL.
Snap-lock devices are safety mechanisms to decrease the use of needles, thus preventing needle sticks.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

11. Figure 36-3: Intravenous fluid and medication administration sets
Discuss intravenous fluid and medications sets and how they are used.
Textbook figure 36-3
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

12. Figure 36-4: Luer-Lok needleless intravenous syringe and port
Show students how snap-together intravenous equipment is used.
Textbook figure 36-4
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

13. Figure 36-5: Y-type blood administration setup
Why is a Y-type blood administration setup used? Blood products are never infused into the same IV line as medications or other fluids. A Y-type administration set is used to infuse certain blood products. The blood product is placed on one side, and a bag of normal saline is placed on the other side.
Textbook figure 36-5
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

14. Administration Sets (cont’d)
Controlled-volume set
Infusion pump administers small volumes of fluid or medication
Intermittent intravenous device (saline or PRN lock)
Established by applying Luer-lock cap or an extension set to the IV cannula
Filters
Trap small particles such as undissolved medication or salts that have precipitated from solution
An intermittent access device is preferred for patients who receive antibiotics, heparin, corticosteroids, antimetabolites, and some other drugs.
A 0.22-micron filter is used for most solutions. For solutions containing lipids or albumin, a 1.2-micron filter is used.
A special filter is needed for blood components.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

15. Figure 36-6: Controlled-volume set
What is a burette? tube-like chamber that holds 150 mL of fluid
Textbook figure 36-6
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

16. Figure 36-7: Intermittent intravenous device
Discuss the uses of an intermittent intravenous device.
Textbook figure 36-7
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

17. Infusion Pumps and Controllers
An added safety measure used in many agencies to regulate the flow of routine IV fluids
Use is mandatory when patients receive total parenteral nutrition or for medications that require critical accuracy
Programmed infusion pumps more accurate and provide better control over the amount of solution being infused
Controllers reduce risk of infusing fluid too quickly
Patient-controlled analgesia pumps used in most hospitals and in the home setting
What are the disadvantages of infusion pumps? Disadvantages of pumps include expense and special administration sets. There have also been incidents of pump failure.
Use of a pump does not replace or substitute for good nursing observation.
Rate controllers are not used for blood or viscous solutions because they are not as accurate as pumps.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

18. Figure 36-8: Intravenous infusion pump
Why should the nurse use an intravenous infusion pump? The pump can help prevent medication errors and regulate the flow routine of IV fluids.
Textbook figure 36-8
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

19. Infusion Pumps and Controllers (con’t)
Patient-controlled analgesia (PCA) pumps: used in both hospitals and home settings to allow patient to regulate administration of IV analgesics
Mini-infusion (syringe pump) uses an ordinary syringe to deliver small amounts of medication or fluid in a controlled time
Insulin pump is a small, self-contained pump device used to deliver doses of insulin
Review troubleshooting tips for IV pumps in Box 36-1
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

20. Venous Access Devices Intravenous needles and catheters
Winged-tip or butterfly needle
Meant for short-term therapy
Supplied in odd-numbered gauges (17, 19, 23, and 25)
Over-the-needle catheters
Consist of a needle with a catheter sheath over it
The needle is removed, leaving the flexible catheter in the vein
18-, 19-, 20- to 22-gauge needles
Although an arm board may be used to support and immobilize the arm during IV therapy, this is not desirable because the patient’s elbow or wrist movement may be severely restricted, causing discomfort. Newer ergonomic armboards can be safer and potentially reduce risks of injury
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

21. Figure 36-10: Placement of a PICC line
Discuss how to prevent complications of a PICC line.
Textbook figure 36-10
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

22. Figure 36-11: Placement of a subclavian central line
Textbook figure 36-11
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

23. Central Venous Catheters
May be left in place for 6 to 8 weeks
Positioned in right atrium or superior vena cava
Some are tunneled long-term catheters such as a Hickman, Broviac, Groshong catheter
PICC lines are the first choice in home IV therapy
Correct placement is verified by x-ray
Midline and PICC line catheters are used primarily in the home care setting for patients who require less than 8 weeks of IV therapy.
If a patient requires more than 8 weeks of IV therapy, a long-term catheter, such as a Broviac or Hickman, is used.
Central line catheters require x-ray verification before use. This is necessary to ensure that the catheter is properly placed and to prevent any adverse events.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

24. Things to Remember When giving IV medications:
Review the drug’s action before administration and know possible side effects and nursing implications
Assess for allergies and check for possible drug solution incompatibilities
Ensure that IV line is patent before attempting to administer medication, and verify flow rate IV solution
Always start with the Six Rights (right patient, right drug, right dose, right route, right time, right documentation).
Drug incompatibility must be checked in order to prevent drug- drug interaction. Not every drug precipitates when mixed. Mixing of an incompatible drug changes the composition and its effectiveness (e.g., Dilantin is compatible only with normal saline).
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

25. Question 1
The average adult needs how many mL of fluids in a 24-hour period to replace those eliminated by the body?
500 to 750
750 to 1000
1000 to 1500
1500 to 2000
Answer: 4
Rationale: The average adult needs 1500 to 2000 mL of fluid in a 24-hour period to replace those eliminated by the body. Patients whose fluid intake has decreased or who experience an excessive loss of body fluids will require fluid replacement.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

26. Question 2
Different types of tonicity are found in intravenous therapy solutions. Ringer’s lactate and 5% dextrose are what type of solution?
Hypotonic
Isotonic
Hypertonic
None of the above
Answer: 2
Rationale: Isotonic solutions have the same concentration or osmolality as blood and are used to expand the fluid volume of the body. Hypotonic solutions contain less solute than extravascular fluid and may cause fluid to shift out of the vascular compartment. Hypertonic solutions have a greater tonicity than blood and are used to replace electrolytes.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

27. Question 3
Richard is getting supplies ready to administer blood to his patient. Which type of administration set does he need?
Primary
Secondary
Y-type
Controlled-volume
Answer: 3
Rationale: A Y-type administration set is used to infuse blood products. The blood is placed on one side and saline is placed on the other side. A primary administration set consists of a bottle or bag of solution, a regular tubing set, a needle, and a stand to hold everything. A secondary set consists of a smaller medication to be administered with the primary continuing after the secondary is finished. A controlled-volume set is an infusion pump used to administer a very small volume of fluid or medication.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

28. Question 4
One difference between the peripherally inserted central catheter (PICC) and a midline (ML) catheter is:
you can take a blood pressure on the arm that has a midline.
only a PICC line can be used in children.
only a midline is placed in the patient under sterile technique.
the ML sits inside the subclavian vessel; the PICC may be advanced to the subclavian vessel.
Answer: 4
Rationale: The ML sits inside the subclavian vessel; the PICC may be advanced to the subclavian vessel. You may not take a blood pressure on the arm that has a PICC or ML catheter in place. Children can have either a PICC or ML. Both are placed under sterile technique.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

29. Lesson 36.2 IV Therapy Guidelines and Considerations
Theory
List three possible complications that can arise from the use of the IV route and the corrective actions you should take for each one. (Continued)
State at least seven guidelines related to IV therapy of fluids or medications.
Summarize special considerations for older adults who need IV therapy.
Recognize the signs and symptoms of a blood transfusion reaction and describe the steps you should take if one occurs.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

30. Lesson 36.2 IV Therapy Guidelines and Considerations
Clinical Practice
Devise a care plan with patient-specific data for a patient who needs IV fluid therapy.
Calculate the IV fluid flow rate from various IV orders.
Initiate IV therapy by performing venipuncture with an IV cannula (catheter over the stylet) using aseptic technique, and starting the ordered infusion.
Add a new bag of fluid to replace one from which the solution has infused.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

31. Lesson 36.2 IV Therapy Guidelines and Considerations
Clinical Practice
Discontinue an IV infusion and evaluate the site and surrounding tissue.
Safely monitor a patient receiving a blood transfusion; document your actions and the patient’s response to therapy.
Collect data on a patient who is receiving total parenteral nutrition; document your findings and the patient’s response to therapy.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

32. Complications of IV Therapy: Infiltration
Occurs when fluid or medication leaks out of the vein into the tissue
Often there will be edema around the site and the tissue will feel cool
Infusion is discontinued and another site is initiated to continue therapy
Fluid that is in the tissue will usually reabsorb within 24 hours
List two causes of infiltration, symptoms, and treatment. Dislodged or kinked catheter; IV improperly inserted in vein. Affected area will be swollen, cool to touch. Treatment requires removal of catheter, warm compress.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

33. Complications of IV Therapy: Phlebitis
Caused by irritation of the vein by the needle, catheter, medications, or additives in the IV solution
Signs: erythema, warmth, swelling, tenderness
IV must be discontinued and another site found
Warm compresses to the inflamed site will decrease discomfort
List two causes of phlebitis, symptoms, and treatment. Infused medication, infection. Symptoms include warm, tender, red, and hard area. Treatment requires removal of catheter and application of warmth.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

34. Complications of IV Therapy: Bloodstream Infection
Occurs when infectious pathogens introduced into the bloodstream
May occur from breaks in sterile technique during cannula insertion or any time the system is opened to change the bag or tubing
Signs and symptoms: fever, chills, pain, headache, nausea, vomiting, extreme fatigue
Blood cultures ordered and aggressive antibiotic therapy is started
IV site is immediately discontinued
List two causes of septicemia, symptoms, and treatment. Contaminated IV site or solution. Symptoms include fever, pain, and swelling to IV site. Remove IV catheter.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

35. Other Complications of IV Therapy
Catheter embolus
Occurs when a piece of the catheter breaks off and travels in the vein until it lodges
Air embolus
Can occur when changing bags, or when opening the line of a subclavian catheter
Speed shock
Occurs when fluids or medications given by bolus are administered too rapidly
Catheter embolus occurs if a portion of catheter breaks loose and travels through the system. Surgery may be required to remove dislodged pieces.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

36. Common Nursing Diagnoses for Patients Undergoing IV Therapy
Risk for deficient fluid volume
Imbalanced Nutrition: Less than body requirements, related to decreased oral intake
Ineffective tissue perfusion, related to loss of red blood cells or volume
List signs that you would observe for in a patient with dehydration.
List signs you would observe to determine if infection is present.
List signs you would observe for inadequate nutrition.
List signs you would observe to determine adequate tissue perfusion.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

37. Initiating IV Therapy Selection of the IV site Consider:
Accessibility of the vein, its general condition
Type of fluid to be given
Duration of IV therapy
Veins preferred for infusions and intermittent doses of medications are those distal to the antecubital area
Cephalic, basilic, and antebrachial veins of the lower arm and the veins on the back of the hand are the sites of choice for most adult patients
What are the most important components of preparing for IV insertion? Maintain sterility of equipment to prevent infection, aseptic technique must be used from preparation to administration, check IV bag for expiration date
Name two veins that are commonly used when starting an IV. Basilic and cephalic
Wearing gloves protects both the nurse and the patient.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

38. Administering IV Medications
All medications are administered using the Six Rights, with the addition of the right rate
Movement of the patient can affect the flow rate
Potassium is ALWAYS diluted and never given as a bolus
Sterile technique is used when medications are added to IV fluids
Most facilities require certification to administer chemotherapy drugs
Document IV site care and infusion rate on appropriate forms. Monitor IV site for signs of infection. IV site checks should be done hourly.
When a patient gets transported to a test, verify the IV rate because it can change as a result of patient movement. Monitor IV drip rate to ensure that IV fluid is infusing at correct rate. Fluid bag should be changed when 50 mL is left.
Aseptic technique must be used at all times when managing a patient with intravenous therapy. This will decrease the incidence of an infected IV site that could lead to a systemic infection.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

39. Calculation of Flow Rate
To calculate drops/minute:
Amount of solution in mL x number of drops/mL / time (in minutes)
You must know how many drops are contained in each milliliter as it passes through the drip chamber of the tubing
A standard set produces 10 to 20 gtt/mL, the pediatric or microdrip chamber produces 50 to 60 gtt/mL, and the macrodrip of the transfusion type sets gives 10 gtt/mL.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

40. Figure 36-13: Time tape label for an IV fluid container
Textbook figure 36-13
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

41. Application of the Nursing Process
Keeping the IV solution running
Assess:
The IV flow: the solution should drip into the chamber at regular intervals
The rate of the infusion
If a pump is used, check the programmed rate and volume; the dripping in the chamber will occur intermittently
The insertion site
Complaints from the patient
The level of the fluid remaining in the bag
The solution container is hung from an IV stand or pole. The tubing should be long enough to provide room for the patient to move about in bed, to turn over, or to carry out necessary activities.
Soft restraints are needed for children and confused patients who might pull out the IV or cause it to infiltrate.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

42. Implementation Administering IV medications Methods
Adding medications to the primary bag of fluids
Adding a secondary line or piggyback to the primary line
Using controlled-volume burettes
Directly injecting the medication into the vein
All medications are administered following the Six Rights and are documented on the medication administration record (MAR)
If a medication is administered too rapidly, speed shock may occur.
Some potent drugs and those causing irritation in concentrated strengths are diluted in 1000 mL of fluids.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

43. Implementation (cont’d)
Administering antineoplastic medications
Many are very irritating to tissue
Special precautions are used in preparing and administering these drugs
Discontinuing an IV infusion
When an infusion is to be discontinued, the flow is stopped and the catheter is removed
Discontinuation is documented on the IV flow sheet
Discuss what needs to be charted when discontinuing an IV infusion.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

44. Implementation (cont’d)
Administering blood and blood products
A consent to receive blood must be signed by the patient
If a reaction to the blood occurs with the Y administration system, the blood should be instantly shut off
Start the saline (with fresh tubing) to keep the IV access open, in case emergency drugs are needed
A transfusion is the IV administration of whole blood or one or more of its components.
Components frequently transfused include fresh or frozen plasma, packed red blood cells, and platelets.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

45. Implementation (cont’d)
Total parenteral nutrition
Mainly given through a central line
The nutritional status of patients who are NPO and on IV therapy must be assessed every day
IV solution contains dextrose but amount of calories supplied is below the total daily requirement
Lacks other essential nutrients and bulk
Supplemental calories may be provided by the use of amino acids and fat emulsions
Specially prepared solutions can be given peripherally, but these provide fewer calories because the dextrose content must be less.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

46. Evaluation Constant assessment of the patient
Evaluation of the effect of IV therapy relates to the reason it was given
If fluids are given to hydrate the patient, check for good skin turgor, adequate urine output, and moist mucous membranes
If TPN is given, assess patient’s weight gain and monitor blood glucose level
When a blood product is administered, monitor the blood count to see if values improve
Monitor for signs/symptoms of transfusion reaction
When IV antibiotics are administered, check the leukocyte count, temperature, and any wound to see if signs of infection are clearing; check for signs or symptoms of allergic reaction.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

47. Evaluation (cont’d) Documentation
Documentation of IV medication is done on the MAR
IV site is accessed every 1 to 2 hours according to agency policy and observations are entered on a flow sheet or in nurses’ notes
IV fluid counted as intake and recorded on I&O sheet
How is the administration of IV medications charted? IV fluid is counted as intake and recorded on the I & O sheet. Your documentation should reflect an absence of complications.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

48. Question 5
Which action by the nurse is incorrect when hanging intravenous therapy?
Hang the solution to run first at the lowest point.
Observe closely for transfusion reactions.
Keep the tubing free from air.
Keep IV fluids sterile.
Answer: 1
Rationale: Hang the solution to run in first at the highest level. You should always observe for transfusion reactions, keep the tubing free from air, and keep the IV fluids sterile.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.