Initiate and manage an intravenous infusion
Dehydration - when oral replacement is inadequate or impossible
To replace blood and blood products
To maintain or replace electrolytes
Administer medications and dilute poisons in the blood
To provide a source of nutrients
To administer water-soluble vitamins
(1) Whole blood
(2) Packed red blood cells
(3) Fresh frozen plasma
(4) Colloids - contain protein or other high molecular weight molecules
(a) Plasma Protein Fraction
(b) Salt-poor albumin
(c) Dextran
(d) Hetastarch
(5) Crystalloids
(a) Isotonic solutions - Will not cause a significant fluid or electrolyte shift
(b) Hypertonic solutions
(i) Higher solute concentration
(ii) Tend to cause fluid shift out of intracellular compartment into extracellular compartment
(c) Hypotonic solutions
(i) Less solute concentration when compared to plasma
(ii) Tend to cause movement from extracellular compartment into the intracellular compartment
(1) Normal saline solution (NS, 0.9% NaCl)
(a) Description
(i) Isotonic solution (contains same amounts of sodium and chloride found in plasma)
(ii) Contains 90 grams of sodium chloride per 100 ml of water
(b) Indications
(i) Solution of choice to be used in conjunction with a blood transfusion
(ii) Indicated for restoring the loss of body fluids
(2) Ringer's Solution or Lactated Ringer's (LR)
(a) Description
(i) Isotonic solution (replaces electrolytes in amounts similarly found in plasma)
(ii) Contains sodium chloride, potassium chloride, calcium chloride, and sodium lactate.
(b) Indications
(i) Solution of choice for burns
(ii) Most cases of dehydration
(iii) Supportive treatment of trauma
(3) Five percent dextrose and water (D5W)
(a) Description
(i) Isotonic solution (the glucose is metabolized quickly, leaving a solution of dilute water)
(ii) Contains 5 grams of dextrose per 100 ml of water
(c) Indications
(i) Provide a source of calorie replacement
(ii) Solution of choice when glucose is needed for metabolism (hypoglycemia)
Accumulation of fluid in the tissue surrounding an IV needle site
(1) Cause - penetration of the vein wall by the needle/catheter or later dislodgment
(2) Signs and symptoms
(a) Flow rate may or may not be slow or no flow of solution
(b) Infusion site is cool and hard to the touch
(c) Infusion site or extremity is pale and swollen
(d) Patient complaints of pain, tenderness, burning, or irritation at infusion site
(e) Fluid leaking around infusion site
(3) Corrective action
(a) Stop IV infusion immediately and remove needle or catheter
(b) Elevate extremity with IV
(c) If noticed within 30 minutes of onset, apply ice to swelling
(d) If noted later than 30 minutes of onset, apply warm compresses to encourage absorption
(e) Notify supervisor of infiltration
(f) Document observations and actions
(g) Restart IV in another location, if directed
(4) Preventive measures
(a) Tape catheter hub and tubing securely to limb
(b) Stabilize extremity in use by applying arm board if necessary
Inflammation of the wall of the vein
(1) Causes
(a) Injury to the vein during puncture
(b) From later needle movement
(c) Irritation to vein as result of
(i) Long-term therapy (vein overuse)
(ii) Irritating or incompatible additive
(iii) Using large-bore catheters
(iv) Using lower extremities as IV sites
(v) Infection
(2) Signs and symptoms
(a) Sluggish flow rate
(b) Swelling around the infusion site
(c) Patient complaints of pain and tenderness
(d) Redness and warmth along the vein
(3) Corrective action
(a) Stop IV infusion immediately
(b) Report observations to supervisor
(c) Treat affected limb like an infiltration
(d) Document observations/actions
(4) Preventive measures
(a) Keep infusion flowing at prescribed rate
(b) Select large vein when irritating drugs/fluids are given
(c) Change tubing every 24 to 48 hours or IAW local SOP
(d) Change solutions and dressings every 24 to 48 hours or IAW local SOP
(e) Change IV site PRN or IAW local SOP
The obstruction of a blood vessel (usually occurring in the lungs or heart) by air carried via the bloodstream
WARNING: The minimum quantity of air that may be fatal to humans is not known. Animal experimentation indicates that fatal volumes of air are much larger than the quantity present in the entire length of IV tubing. Average IV tubing holds about 5 ml of air, an amount not ordinarily considered dangerous.
(1) Causes
(a) Failure to remove air from the tubing
(b) Allowing the solution to run dry
(c) Disconnected IV tubing
(2) Signs and symptoms
(a) Abrupt drop in blood pressure
(b) Weak, rapid pulse
(c) Cyanosis
(d) Chest pain
(3) Corrective action
(a) Notify supervisor and physician immediately
(b) Immediately place patient on left side with feet elevated to allow the pulmonary artery to absorb small air bubbles
(c) Administer oxygen as needed
(4) Preventive measures
(a) Clear all air from tubing before attaching it to the patient
(b) Monitor solution levels closely and change before they are empty
(c) Check to see that all connections are secure
Circulatory overload
Is an increased blood volume resulting from excessive IV fluid being infused too rapidly into the vein
CAUTION: Use extreme caution when administering IV fluid to pediatric or geriatric patients and to patients experiencing CHF, pulmonary edema or head trauma. All of these types of patients are at increased risk of circulatory overload.
(1) Causes
(a) Fluid delivered too fast
(b) Reduced kidney function
(c) Congestive heart failure or cardiac insufficiency
(2) Signs and symptoms
(a) Elevated blood pressure
(b) Distended neck veins
(c) Rapid breathing, shortness of breath, tachycardia
(d) Fluid intake is much greater than urinary output
(3) Corrective action
(a) Decrease flow rate to keep vein open (TKO)
(b) Place the patient in the semi-Fowler's position to facilitate breathing
(c) Notify supervisor immediately
(d) Record observations and actions taken
(4) Preventive measures - frequently check flow rate to maintain desired rate
(1) Causes
(a) Use of contaminated equipment
(b) Poor aseptic venipuncture technique
(c) Contaminated site or IV equipment not changed regularly
(2) Signs and symptoms
(a) Redness, swelling, and soreness around IV site
(b) Sudden rise in temperature and pulse
(c) Drainage from IV site
(3) Corrective action
(a) Notify supervisor immediately
(b) Discontinue IV by removing the catheter tip and take a culture of wound to identify pathogens present
(c) Use strict aseptic technique when cleaning and dressing the wound
CAUTION: If a culture of the site is ordered, it must be done before cleaning the site.
(d) Document all corrective actions taken
(4) Preventive measures
(a) Use complete aseptic technique when starting an IV
(b) Clean site thoroughly when IV is initiated and then periodically IAW local SOP to prevent infection
(c) Anchor catheter and tubing securely
(d) Check site at least daily for signs of inflammation IAW local SOP
(1) Obtain a physician's order. May be standing order if in combat unit.
(2) Perform a patient care hand wash
(3) Gather equipment
(a) Correct IV solution and amount (bag or bottle)
(b) IV administration set and needle or catheter
(i) Size of the catheter or needle varies from a 28 g to a 14 g
(ii) Size will depend on the size of the vein or the amount and rate of fluid administration, the viscosity (thickness) of the solution to be administered, and the size and condition of the patient. (e.g., administration of blood requires a large bore catheter, 18 g or larger due to the thickness of blood)
(c) Tape, constricting band, sterile gauze, antiseptic sponges (Betadine is commonly used for cleaning the skin)
(d) Latex gloves
(4) Identify patient and explain the procedure (ask about known allergies such as betadine, alcohol, medications, ask if they have had an IV before)
(5) Inspect and assemble equipment
(a) IV bag - Expiration date, clarity, leaks
CAUTION: Any doubt regarding clarity, leaks, defect or contamination of any equipment or supplies, check with supervisor prior to starting the IV.
(b) Packages (gloves, gauze) - tears or rips, water marks
(c) Tubing - remove infusion set from box. Inspect for any holes, cracks or other signs of defects and tighten the clamp 6 to 8 inches below the drip chamber.
(d) Remove protective covers from the spike of the drip chamber and from the outlet (long spout) of the IV container without contaminating them.
(e) Needle or catheter - inspect for barbs or nicks and discard in sharps container if flawed
(f) Insert the spike into the container
(i) If using a bag, push the spike firmly into the container's outlet tube
(ii) If using a bottle, push the spike firmly through the container's diaphragm
(6) Hang the container at least 2 feet above the level of the patient's heart if possible and squeeze the drip chamber until it is half full of solution.
(7) Remove air from tubing as follows
(a) Hold end of tubing above the level of the bottom of the IV container
(b) Loosen protective cover on needle adapter to allow air to escape
(c) Release the clamp on tubing
(d) Gradually lower the tubing until the solution reaches the end of the needle adapter
CAUTION: If small air bubbles remain in tubing, tap tubing with finger from bottom to top allowing air bubbles to rise.
(e) Clamp the tubing
(f) Retighten protective cover
(g) Loop tubing over IV stand
(8) Cut several strips of tape and hang them in a readily accessible location
(9) Select the infusion site
(a) Choose the most distal and accessible vein of an uninjured arm or hand
(b) Avoid veins that are infected or injured and irritated areas
WARNING: Use lower extremities only if there is no accessible site in upper extremity.
(c) Avoid sites over joints because the catheter is difficult to stabilize. Dislodgment and infiltration can occur and flow may increase or decrease with joint movement.
(d) Use the nondominant hand or arm, whenever possible
(e) Select a vein large enough to accommodate the size of needle/catheter to be used
(10) Prepare infusion site
(a) Apply constricting band about 2 inches above venipuncture site, tight enough to stop venous flow but not so tight that the radial pulse cannot be felt.
CAUTION: Do not leave the constricting band in place for more than 2 minutes.
(b) Instruct patient to open and close his/her fist several times to increase circulation
(c) Select and palpate a prominent vein
(d) Clean skin with antiseptic sponge in a circular motion from the center outward
(e) Inspect IV catheter and loosen catheter/needle by rotating catheter
CAUTION: If patient is allergic to betadine, use only the alcohol pad.
(11) Put on gloves for self-protection against transmission of contaminants
(12) Hold the catheter with your dominant hand and remove protective cover without contaminating the needle
(13) Hold flash chamber with thumb and forefinger directly above the vein or slightly to one side of the vein
(14) Draw the skin below the cleaned area downward to hold the skin taut over the site of venipuncture
(15) Position the needlepoint, bevel-up, parallel to the vein and about 2 inch below the site of venipuncture
(16) Hold the needle at approximately a 20-30 degree angle and pierce skin
CAUTION: Ensure that thumb-holding skin taut does not contaminate catheter/needle or recontaminate cleansed skin area.
(17) Decrease the angle until almost parallel to skin surface and direct it toward the vein. Continue advancing the needle/catheter until the vein wall is pierced.
CAUTION: A faint "give" will be felt as the vein wall is pierced.
(18) Check for blood in the flash chamber
(a) If blood is not noted in the flash chamber, pull needle back slightly (but not above skin surface) and attempt to redirect the needlepoint into the vein.
(b) If still unsuccessful, release the constricting band, withdraw catheter/needle, and use the alcohol swab or a small sterile gauze to put pressure on the site.
(c) Notify your supervisor before attempting a venipuncture at another site
CAUTION: If constricting band is not released, patient will bleed excessively when needle is removed.
(19) Advance catheter/needle units approximately 1/8 inch further to ensure placement of catheter is into the vein
(20) Stabilize flash chamber with dominant hand, grasp catheter hub with nondominant hand and thread catheter into vein, to catheter hub
CAUTION: Pressing lightly on skin over catheter tip is necessary to decrease or stop blood flow from catheter hub after needle is removed.
(21) Remove flash chamber/needle and lay aside (dispose of needle properly after IV site has been secured)
CAUTION: After removal of stylet needle - Never reinsert stylet needle into catheter; a portion of the catheter sheath could be sheared off causing an embolus.
(22) With dominant hand, remove the protective cover from needle adapter on tubing and quickly connect adapter into the catheter hub, while maintaining stabilization of the hub with nondominant hand.
(23) Tell the patient to unclench the fist and then release the constricting band
(24) Unclamp IV tubing and adjust flow rate to appropriate drip rate (TKO or per doctor's orders)
(a) TKO or KVO means to keep vein open
(b) Maintained at a flow rate of 30 ml's per hour or about 7-10 drops per minute
(25) Examine infusion site for infiltration and discontinue if infiltration is present
(26) Clean the area of blood if necessary and secure hub of catheter with tape, leaving hub and tubing connection visible
CAUTION: Do not release hold on catheter hub/catheter connection until secured with at least one piece of tape.
(27) Apply a sterile dressing over the puncture site or IAW local SOP
(28) Loop the IV tubing on extremity and secure with tape
(29) Splint the arm loosely on a padded splint, if necessary, to reduce movement
(30) Print the date, gauge of the catheter, time the IV was started and initials of the person initiating the IV on a piece of tape. Secure the tape to the dressing.
(31) Print patient's identification, drip rate, date, time the IV infusion was initiated and initials of the person initiating the IV on a piece of tape. Secure the tape to the IV container.
(32) Print the date and time the tubing was put in place and the initials of the person initiating the IV on a piece of tape and wrap the tape around the tubing, leaving a tab.
(33) Re-examine site for infiltration
(34) Remove gloves and perform a patient care hand wash
(35) Record the procedure on the appropriate form
(1) Indication - no suitable peripheral veins can be accessed
(2) Site
(a) Medially adjacent to pulsation of femoral artery
(b) Find midpoint of line drawn between the symphysis pubis and superior iliac crest
(3) Complications
(a) Hematoma from vein or adjacent femoral artery
(b) Thrombosis
(c) Phlebitis
(d) Thrombosis or phlebitis may extend to iliac veins or inferior vena cava
Intraosseous infusion
(1) Indications
(a) The pediatric or adult patient who is in cardiac arrest and in whom you cannot quickly obtain peripheral venous access
(b) Hypovolemic pediatric patient who faces a prolonged transport time and in whom you cannot quickly and easily start a peripheral IV
(2) Site - proximal tibia, one fingerbreadth below the tibial tuberosity either midline or slightly medial to the midline
(3) Steps in the procedure
(a) Prep the skin with betadine (very important)
(b) Prepare bone marrow needle or 16 gauge spinal needle for proper depth during insertion. Insert needle pointing away from epiphyseal plate, advancing to periosteum
(c) Use a screwing motion to penetrate the bone until decreased resistance is felt (see diagram 5)
(d) Once you have penetrated the bone and decreased resistance in the bone marrow cavity
(e) Remove the stylet (see diagram 6 and 7)
(f) Aspirate bone marrow into a saline filled syringe. (Bone marrow may not always be aspirated)
(g) Infuse saline by syringe to ensure placement and to remove clots
(h) Secure needle with tape, although the needle is usually well stabilized by bone
(i) Attach standard IV tubing and fluids to infuse under gravity or pressure as prescribed by medical control
(4) Complications
(a) Epiphyseal plate injury
(b) Osteomyelitis
(c) Sepsis
(d) Tibial fracture if needle too large
(e) Marrow damage
(f) Fat embolism
Replace the solution container (only). Every 24 hours when running a slow infusion.
CAUTION: Do not allow solution container to run completely out before changing containers.
(1) Perform a patient care hand wash
(2) Select or prepare the new solution container by removing the protective cover from the outlet tube
(3) Clamp IV tubing shut
(4) Remove the used container from the IV hanger, and remove the spike from it
CAUTION: The old tubing is connected to the catheter. Care must be taken to maintain sterility. To prevent the back flow of blood, keep the spike and tubing elevated.
(5) Insert the IV spike into new IV container
(6) Hang the new container
(7) Adjust the infusion rate
(8) Label the solution container and prepare a timing label
(9) Record the amount of solution received from the previous container, and time, type, and amount of new solution.
(1) Perform patient care hand wash and don gloves
(2) Remove the tape and the old dressing without dislodging the catheter
NOTE: Tubing should remain taped in place to reduce the chance of accidental dislodgment of the catheter.
(3) Clean the area around the infusion site IAW local SOP
(4) Examine the site for signs and symptoms of infiltration
(5) Cover the infusion site with sterile gauze and secure with tape, or dress IAW local SOP
(6) Secure the dressing to the site without encircling the wrist or arm
(7) Label the dressing
CAUTION: Changing the tubing should coincide with the time the solution container will be changed.
(1) Perform patient care hand wash
(2) Spike the new tubing into a new solution container and hang it from the IV pole
(3) Prime the tubing and clamp it
(4) Clamp old tubing shut
(5) Connect the new tubing to the catheter hub
WARNING: Wear gloves for self-protection and to protect the patient against transmission of contaminants whenever handling body fluids.
(a) Loosen the tape on the old tubing without dislodging the catheter
(b) Place sterile gauze pad under the catheter hub to provide a small sterile field for the catheter hub
(c) Grasp new tubing between the fingers of one hand
(d) Grasp catheter hub with a sterile gauze pad and carefully disconnect the old adapter. (Press fingers over catheter tip to help prevent back flow of blood).
(e) Remove the protective cap from the new tubing adapter and quickly connect it to the catheter hub
CAUTION: Do NOT remove the protective cap with your teeth.
(f) Remove the gauze pad from under the catheter hub and clean the site, if necessary
(g) Secure the tubing to the arm and reinforce the dressing as necessary
(h) Adjust the infusion rate
NOTE: If replacing catheter, discontinue IV, select new IV site proximal to old IV site (if using same limb), and start new IV.
Perform patient care handwash
Put on exam gloves
Clamp the IV tubing
Remove the tape and dressing without dislodging the catheter
Place a sterile gauze pad over the injection site
Smoothly pull out the catheter, following the course of the vein
WARNING: Do not twist, raise, or lower the catheter.
Apply pressure to the site with the gauze
Examine the catheter to ensure that it was removed intact
Apply an adhesive bandage to the site, if necessary
Dispose of used equipment IAW local SOP
Record the procedure on the appropriate form
Manage an IV (Demo)
1. Replace the solution container (only). Every 24 hours when running a slow infusion
2. Change the dressings every 24 hours or IAW local SOP
3. Replace the solution container and tubing every 48 hours or IAW local SOP
Discontinue (DC) and IV (Demo)
1. Perform patient care handwash
2. Put on exam gloves
3. Clamp the IV tubing
4. Remove the tape and dressing without dislodging the catheter
5. Place a sterile gauze pad over the injection site
6. Smoothly pull out the catheter, following the course of the vein
7. Apply pressure to the site with the gauze
8. Examine the catheter to ensure that it was removed intact
9. Apply an adhesive bandage to the site, if necessary
10. Dispose of used equipment IAW local SOP
11. Record the procedure on the appropriate form