Clinical Procedures For Safer Patient Care: Chapter 8. Intravenous Therapy

Clinical Procedures for Safer Patient Care
Chapter 8. Intravenous Therapy
8.1 Introduction
The use of intravenous (IV) therapy is common in the health care setting. IV therapy is a treatment that
infuses fluids, nutrients, blood, blood products, or medication directly into a vein. It is a fast, efficient way to
infuse fluids and medications into the body.
This chapter will review how to care for a patient with peripheral intravenous therapy and central venous
catheters. It will cover how to prepare IV infusions, and how to assess, maintain, and prevent complications
related to intravenous therapy.
Learning Objectives
 Define patient conditions

 Discuss how to prevent infections related to IV therapy, general guidelines, and complications
associated with IV therapy
 Compare the benefits and complications related to a peripheral IV for administering IV therapy
 Identify common types of central venous catheters and the benefits and complications associated
with them
 Demonstrate how to flush a saline lock, start a continuous IV infusion, discontinue a continuous
infusion, and discontinue a peripheral IV
 Describe how to change IV solution and IV tubing, and how to calculate IV rates
 Discuss indications for blood and blood product transfusions
 Describe how to prepare, administer, and monitor blood and blood products and manage transfusion
reactions according to Canadian standards
 Define total parenteral nutrition (TPN), explain how to care for a patient receiving TPN, and identify
potential complications
 Explain how to administer TPN

8.2 Intravenous Fluid Therapy

Intravenous therapy is treatment that infuses intravenous solutions, medications, blood, or blood products
directly into a vein (Perry, Potter, & Ostendorf, 2014). Intravenous therapy is an effective and fast-acting
way to administer fluid or medication treatment in an emergency situation, and for patients who are unable
to take medications orally. Approximately 80% of all patients in the hospital setting will receive intravenous
therapy.
The most common reasons for IV therapy (Waitt, Waitt, & Pirmohamed, 2004) include:
1. To replace fluids and electrolytes and maintain fluid and electrolyte balance: The body’s fluid
balance is regulated through hormones and is affected by fluid volumes, distribution of fluids in the
body, and the concentration of solutes in the fluid. If a patient is ill and has fluid loss related to
decreased intake, surgery, vomiting, diarrhea, or diaphoresis, the patient may require IV therapy.
2. To administer medications, including chemotherapy, anesthetics, and diagnostic reagants: About
40% of all antibiotics are given intravenously.
3. To administer blood or blood products: The donated blood from another individual can be used in
surgery, to treat medical conditions such as shock or trauma, or to treat a failure in the production of
red blood cells. The infusion restores circulating volumes, improving the ability to carry oxygen and
replace blood components that are deficient in the body.
4. To deliver nutrients and nutritional supplements: IV therapy can deliver some or all of the nutritional
requirements for patients unable to obtain adequate amounts orally or by other routes.
Guidelines Related to Intravenous Therapy

The following are general guidelines for peripheral IV therapy:
 IV fluid therapy is ordered by a physician or nurse practitioner. The order must include the type of
solution or medication, rate of infusion, duration, date, and time. IV therapy may be for short or long
duration, depending on the needs of the patient (Perry et al, 2014).
 IV therapy is an invasive procedure, and therefore significant complications can occur if the wrong
amount of IV fluids or the incorrect medication is given.
 Aseptic technique must be maintained throughout all IV therapy procedures, including initiation of
IV therapy, preparing and maintaining equipment, and discontinuing an IV system. Always perform
hand hygiene before handling all IV equipment. If an administration set or solution becomes
contaminated with a non-sterile surface, it should be replaced with a new one to prevent introducing
bacteria or other contaminants into the system (Centers for Disease Control [CDC], 2011).
 Understand the indications and duration for IV therapy for each patient. Practice guidelines
recommend that patients receiving IV therapy for more than six days should be assessed for an
intermediate or long-term device (CDC, 2011).
 If a patient has an order to keep a vein open, or “TKVO,” the usual rate of infusion is 20 to 50 ml per
hour (Fraser Health Authority, 2014).
 Complications may occur with IV therapy, including but not limited to localized infection, catheter-
related bloodstream infection (CR-BSI), fluid overload, and complications related to the type and
amount of solution or medication given (Perry et al., 2014).
 For an infusing peripheral IV, the site must be assessed every 2 hours and p.r.n.
 A saline lock site must be assessed every 12 hours and p.r.n.
Types of Venous Access

Safe and reliable venous access for infusions is a critical component of patient care in the acute and
community health setting. There are a variety of options available, and a venous access device must be
selected based on the duration of IV therapy, type of medication or solution to be infused, and the needs of
the patient. In practice, it is important to understand the options of appropriate devices available. This
section will describe two types of venous access: peripheral IV access and central venous catheters.
Peripheral IV
A peripheral IV is a common, preferred method for short-term IV therapy in the hospital setting. A
peripheral IV (PIV) (see Figure 8.1) is a short intravenous catheter inserted by percutaneous venipuncture
into a peripheral vein, held in place with a sterile transparent dressing to keep the site sterile and prevent
accidental dislodgement (CDC, 2011). Upper extremities (hands and arms) are the preferred sites for
insertion by a specially trained health care provider. If a lower extremity is used, remove the peripheral IV
and re-site in the upper extremities as soon as possible (CDC, 2011; McCallum & Higgins, 2012). The hub
of a short intravenous catheter is usually attached to IV extension tubing with a positive pressure cap (Fraser
Health Authority, 2014).
PIVs are used for infusions under six days and for solutions that are iso-osmotic or near iso-osmotic (CDC,
2011). They are easy to monitor and can be inserted at the bedside. CDC (2011) recommends that PIVs be
replaced every 72 to 96 hours to prevent infection and phlebitis in adults. Most agencies require training to
initiate IV therapy, but the care and preparation of equipment, and the maintenance of an IV system can be
completed each shift by the trained health care provider. For more information on how to initiate IV therapy,
see the resources at the end of the chapter.
Figure 8.1 Peripheral intravenous (IV) catheter (PIV)
PIVs are prone to phlebitis and infection, and should be removed (CDC, 2011) as follows:
 Every 72 to 96 hours and p.r.n.

 As soon as the patient is stable and no longer requires IV fluid therapy
 As soon as the patient is stable following insertion of a cannula in an area of flexion
 Immediately if tenderness, swelling, redness, or purulent drainage occurs at the insertion site
 When the administration set is changed (IV tubing)
Several potential complications may arise from peripheral intravenous therapy. It is the responsibility of the
health care provider to monitor for signs and symptoms of complications and intervene appropriately.
Complications can be categorized as local or systemic. Most complications are avoidable if simple hand
hygiene and safe principles are adhered to for each patient at every point of contact (Fraser Health
Authority, 2014; McCallum & Higgins, 2012). Table 8.1 lists the potential local and complications and
treatment.
Table 8.1 Potential Local Complications of Peripheral IV Therapy

Complication Signs, Symptoms, and Treatment
Phlebitis is the inflammation of the vein’s inner lining, the tunica intima. Clinical
indications are localized redness, pain, heat, and swelling, which can track up the vein
leading to a palpable venous cord.
Mechanical causes: Inflammation of the vein’s inner lining can be caused by the cannula
rubbing and irritating the vein. It is recommended to use the smallest gauge possible to
deliver the medication or required fluids.
Phlebitis
Chemical causes: Inflammation of the vein’s inner lining can be caused by medications
with a high alkaline, acidic, or hypertonic solutions. To avoid chemical phlebitis, follow
the Parenteral Drug Therapy Manual (PDTM) guidelines for administering IV
medications for the appropriate amount of solution and rate of infusion.
Treatment: Immediately remove cannula. May elevate arm or apply a warm compress.
Document findings in chart. Initiate a new peripheral IV if necessary.
Infiltration Infiltration occurs when a non-vesicant solution (IV solution) is inadvertently
administered into surrounding tissue. Signs and symptoms include pain, swelling, redness,
skin surrounding insertion site is cool to touch, change in quality or flow of IV, tight skin
around IV site, IV fluid leaking from IV site, and frequent alarms on the IV pump.
Treatment: Stop infusion and remove cannula. Follow agency policy related to infiltration.
Always secure peripheral catheter with tape or IV stabilization device to avoid accidental
dislodgement. Avoid areas of flexion and always assess IV site prior to giving IV fluids or
IV medications.
Extravasation occurs when vesicant solution (medication) is administered and
inadvertently leaks into surrounding tissue, causing damage to surrounding tissue.
Characterized by the same signs and symptoms as infiltration but also includes burning,
Extravasation stinging, redness, blistering, or necrosis of the tissue.
Treatment: Stop infusion and remove cannula. Follow agency policy for extravasation for
specific medications. For example, toxic medications have a specific treatment plan.
Hemorrhage is defined as bleeding from the puncture site.
Hemorrhage
Treatment: Apply gauze to the site until the bleeding stops, then apply a sterile transparent
dressing.
Local infection is indicated by purulent drainage from site, usually two to three days after
an IV site is started.
Local infection at
IV site
Treatment: Remove cannula and clean site using sterile technique. Monitor for signs and
symptoms of systemic infection.
Data source: Fraser Health Authority, 2014; McCallum & Higgins, 2012
Systemic complications can occur apart from chemical or mechanical complications. To review the systemic
complications of IV therapy, see Table 8.2.
Table 8.2 Systemic Complications of Peripheral IV Therapy

Safety considerations:
 Cardiac and renal patients have increased risk of systemic complications.

 Pediatric patients, neonates, and elderly people have increased risk of systemic complications.
Complication Signs, Symptoms and Treatment

Pulmonary edema, also known as fluid overload or circulatory overload, is a
condition caused by excess fluid accumulation in the lungs, due to excessive fluid in
the circulatory system. It is characterized by decreased oxygen saturation, increased
respiratory rate, fine or coarse crackles at lung bases, restlessness, breathlessness,
Pulmonary edema
dyspnea, and coughing up pinky frothy sputum. Pulmonary edema requires prompt
medical attention and treatment. If pulmonary edema is suspected, raise the head of the
bed, apply oxygen, take vital signs, complete a cardiovascular assessment, and notify
the physician.
Air embolism Air embolism refers to the presence of air in the vascular system and occurs when air
is introduced into the venous system and travels to the right ventricle and/or pulmonary
circulation. An air embolism is reported to occur more frequently during catheter
removal than during insertion, and the administration of up to 10 ml of air has been
proven to have serious and fatal effects. Small air bubbles are tolerated by most
patients.
Signs and symptoms of an air embolism include sudden shortness of breath, continued
coughing, breathlessness, shoulder or neck pain, agitation, feeling of impending doom,
lightheadedness, hypotension, wheezing, increased heart rate, altered mental status, and
jugular venous distension.
Treatment: Occlude source of air entry. Place patient in a Trendelenburg position on

the left side (if not contraindicated), apply oxygen at 100%, obtain vital signs, and
notify physician promptly.
To avoid air embolisms, ensure drip chamber is one-third to one-half filled, ensure all
IV connections are tight, ensure clamps are used when IV system is not in use, and
remove all air from IV tubing by priming prior to attaching to patient.
A catheter embolism occurs when a small part of the cannula breaks off and flows
Catheter embolism into the vascular system. When removing a peripheral IV cannula, inspect tip to ensure
end is intact.
Catheter-related bloodstream infection (CR-BSI) is caused by microorganisms that
are introduced into the blood through the puncture site, the hub, or contaminated IV
tubing or IV solution, leading to bacteremia or sepsis. A CR-BSI is a nosocomial
preventable infection and an adverse event.
CR-BSI is confirmed in a patient with a vascular device (or a patient who had such a
Catheter-related
device in the last 48 hours before the infection) and no apparent source for the infection
bloodstream
other than the vascular access device with one positive blood culture.
infection
Treatment: IV antibiotic therapy
To avoid CR-BSI, perform hand hygiene prior to care and maintenance of an IV

system, and use strict aseptic technique for care and maintenance of all IV therapy
procedures.
Data source: Fraser Health Authority, 2014; Fulcher & Frazier, 2007; McCallum & Higgins, 2012; Perry et
al., 2014
Central Venous Catheters
A central venous catheter (CVC) (see Figure 8.2), also known as a central line or central venous access
device, is an intravenous catheter that is inserted into a large vein in the central circulation system, where the
tip of the catheter terminates in the superior vena cava (SVC) that leads to an area just above the right
atrium. CVCs have become common in health care settings for patients who require IV medication
administration and other IV treatment requirements. CVCs can remain in place for more than one year.
Some CVC devices may be inserted at the bedside, while other central lines are inserted surgically. Central
lines are inserted by a physician or specially trained health care provider, and the use of ultrasound guided
placement is recommended to reduce time of insertion and complications (Safer Healthcare Now, 2012).
A CVC has many advantages over a peripheral IV line, including the ability to deliver fluids or medications
that would be overly irritating to peripheral veins, and the ability to access multiple lumens to deliver
multiple medications at the same time (Fraser Health Authority, 2014). Central venous catheters can be
inserted percutaneously or surgically through the jugular, subclavian, or femoral veins, or via the chest or
upper arm peripheral veins (Perry et al., 2014). Femoral veins are not recommended, as the rate of infection
is increased in adults (CDC, 2011; Safer Healthcare Now, 2012). To have a CVC inserted or removed, an
order by a physician or nurse practitioner must be obtained. Site selection for a CVC may be based on
numerous factors, such as the condition of the patient, patient’s age, and type and duration of IV therapy.
The majority of patients in an ICU will have a CVC to receive fluids and medications. A chest X-ray is
given to determine correct placement before inserting, or to confirm a suspected dislodgement (Fraser
Health Authority, 2014). An IV pump must be used with all CVCs to prevent complications.
CVCs are typically inserted for patients requiring more than six days of intravenous therapy or who:
 Require antineoplastic medications

 Are seriously or chronically ill
 Require vesicant or irritant medications
 Require toxic medications or multiple medications
 Require central venous pressure monitoring
 Require long-term venous access or dialysis
 Require total parenteral nutrition
 Require medications with a pH greater than 9 or less than 5, or osmolality of greater than
600mOsm/L
 Have poor vasculature
 Have had multiple PIV insertions/attempts (e.g., two attempts by two different IV therapy
practitioners)
Figure 8.2 Central venous catheter (CVC) with three lumens
Figure 8.3 Peripherally inserted central catheter (PICC) with

one lumen
A central line is made up of lumens. A lumen is a small hollow channel within the CVC tube. A CVC may
have single, double, triple, or quadruple lumens (Perry et al., 2014). Depending on the type of CVC, it may
be internally or externally inserted, and may have an open-ended or valved tip. Open-ended devices are
those in which the catheter tip is open like a “straw.” These have a higher risk for complications, such as
hemorrhage, air embolism, and occlusion from fibrin or clots. Valved devices are those in which the tip is
configured with a three-way pressure-activated valve (Perry et al., 2014). It is important to know what type
of central line is being used, as this will impact how to care for and manage the equipment for specific
procedures. Table 8.3 lists various types of central lines.
Table 8.3 Types of Central Venous Catheters (CVCs)

 CVC care and maintenance requires specialized training to prevent complications.

 Central lines heighten the risk for patients to develop a nosocomial infection. Strict adherence to
aseptic technique is required for all CVC care.
Type Location and Additional Information

Tip location: The tip of the catheter is located in the SVC. The entry site is the exit site.
Can be inserted at the bedside by specially trained physician or nurse. The

percutaneous CVC is inserted directly through the skin. The internal or external
jugular, subclavian, or femoral vein is used.
Most commonly used in critically ill patients. Can be used for days to weeks, and the
patient must remain in the hospital. Usually held in place with sutures or a
manufactured securement device.
Percutaneous
central venous
catheter (CVC)
Central venous catheters
Internal jugular venous catheter (upper CVC)

Peripherally Tip location: The tip is located in the SVC.
inserted central
catheter (PICC) A PICC (see Figure 8.3) may be inserted at the bedside, in a home or radiology setting.
The line is inserted through the antecubital fossa or upper arm (basilic or cephalic vein)
and is threaded the full length until the tip reaches the SVC. Can provide venous access
for up to one year. The patient may go home with a PICC. PICCs can easily occlude
and may not be used with dilantin IV. It is held in place with sutures or a manufactured
securement device.
PICC line inserted in the upper arm
(through the basilic vein)
A tunnelled CVC, also known as a Hickman, Broviac, or Groshong, is a long-term
CVC with a proximal end tunnelled subcutaneously from the insertion site and brought
out through the skin at an exit site. Insertion is a surgical procedure, in which the
catheter is tunnelled subcutaneously under the skin in the chest area before it enters the
SVC. A tunnelled catheter may remain inserted for months to years. These CVCs have
a low infection rate due to a Dacron cuff, an antimicrobial cuff surrounding the
catheter near the entry site, which is coated in antimicrobial solution and holds the
catheter in place after two to three weeks of insertion.
Subcutaneous or
tunnelled central
venous catheter
Tunnelled CVC
Implanted central The implanted central venous catheter (ICVC) is inserted into a vessel, body cavity,
venous catheter or organ and is attached to a reservoir or “port,” located under the skin. The ICVC is
(ICVC, port a cath) also referred to as a port a catheter or port a cath. A surgical procedure is required to
insert the device, which is considered permanent. The device may be placed in the
chest, abdomen, or inner aspect of the forearms. It is often better for body image. The
ICVC can be accessed using a non-coring needle. A patient may return home with this
type of CVC.
Chest with ICVC inserted
ICVC under the skin

Data source: Fulcher & Frazier, 2011; Perry et al., 2014
CVCs have specific protocols for accessing, flushing, disconnecting, and assessment. All health care
providers require specialized training to care for, manage complications related to, and maintain CVCs as
per agency policy. Never access or use a central line for IV therapy unless trained as per agency policy. For
more information on CVC care and maintenance, see the suggested online reference list at the end of this
chapter.
Health care providers should assess a patient with a central line at the beginning and the end of every shift,
and as needed. For example, if the central line has been compromised (pulled or kinked), ensure it is
functioning correctly. Each assessment should include:
 Type of CVC and insertion date: reason for CVC

 Dressing: is it dry and intact?
 Lines: secure with stat-lock, sutures, or Steri-Strips?
 Review: patient still requires a CVC?
 Insertion site: free from redness, pain, swelling?
 Positive pressure cap: attached securely?
 IV fluids: running through an IV pump?
 Lumens: number of lumens and type of fluids running through each?
 Vital signs: fever?
 Respiratory/cardiovascular check: any signs and symptoms of fluid overload?
See Table 8.4 for a list of complications, signs and symptoms, and interventions.
Table 8.4 Potential Complications with Central Venous Catheters

Complication Signs and Symptoms Interventions
Also known as fluid overload (circulatory Accurate fluid balance assessments,
overload); characterized by decreased oxygen monitor electrolytes and vital signs,
Pulmonary
saturation, increased respiratory rate, fine or coarse provide chest auscultation, elevate
edema
crackles at lung bases, restlessness, breathlessness, head of bed, administer oxygen and
dyspnea, coughing up pinky frothy sputum. diuretic therapy
A mechanical complication that mainly occurs
during insertion of the CVC due to failure to
correctly place the catheter, which may lead to
Mechanical Treatment will be specific to the
asystolic cardiac arrest, bleeding, subcutaneous
complications complication.
hematoma, hemothorax, catheter mal-position, or
pneumothorax. These complications are usually
detected at the time of insertion.
Infection is a common complication of indwelling
CVCs in patients with a vascular device and no
apparent source for the bloodstream infection other
than the device. Confirmed with one positive blood
culture in patients who have had a vascular device
Strict hand-washing, aseptic
implanted within the last 48 hours.
technique for all procedures, close
monitoring of vital signs, strict
Catheter-related Catheter-related bloodstream infection (CR-BSI) is
protocols for dressing, tubing and cap
bloodstream caused by microorganisms that are introduced into
changes, blood cultures as required,
infection the blood through the puncture site, the hub, or
IV antibiotic therapy, remove/replace
contaminated IV tubing or IV solution, leading to
catheter, prevent contamination of
bacteremia or sepsis. A CR-BSI is a nosocomial
hub
preventable infection and an adverse event.
Systemic: elevated temperature, flushed, headache,

malaise, tachycardia, decreased BP, and additional
signs and symptoms of sepsis
Notify physician, clean area using
Insertion site may become red, tender, swollen, or
Infection at strict aseptic technique, send C & S
have purulent drainage. Monitor blood work and
insertion site swab (swab for bacterial wound
temperature.
culture) as per policy
Catheter-related thrombosis (CRT) is the
development of a blood clot related to long-term
CVC use. It mostly occurs in the upper extremities
Routine flushing with positive
and can lead to further complications, such as
pressure, vital signs, repositioning, IV
pulmonary embolism, post-thrombotic syndrome,
Catheter-related bolus, notify physician, venogram/X-
and vascular compromise. Symptoms include pain,
thrombosis rays likely; will require anticoagulant
tenderness to palpation, swelling, edema, warmth,
therapy and possible removal of the
erythema, and development of collateral vessels in
CVC
the surrounding area. Most CRTs are
asymptomatic, and prior catheter infections
increase the risk for developing a CRT.
Air embolism An air embolism is the presence of air in the Occlude source of air entry. Place
vascular system and occurs when air is introduced patient in a Trendelenburg position on
into the venous system and travels to the right the left side (if not contraindicated),
ventricle and/or pulmonary circulation. An air apply oxygen at 100%, obtain vital
embolism can occur during CVC insertion, while
catheter is in place, or at time of
removal. Administration of up to 10 ml of air has
been proven to have serious effects, and is
sometimes fatal. Tiny air bubbles are tolerated by signs, and notify physician promptly.
most patients.
To avoid an air embolism, ensure drip
Signs and symptoms of an air embolism include chamber is one-third to one-
sudden shortness of breath, continued coughing, half filled, ensure all IV connections
breathlessness, shoulder or neck pain, agitation, are tight, ensure clamps are used
feeling of impending doom, lightheadedness, when IV system is not in use, and
hypotension, wheezing, increased heart rate, altered remove all air from IV tubing by
mental status, and jugular venous distension. The priming prior to attaching to patient.
effects of air embolism depend on the rate and
volume of air introduced.

Occlusions may be mechanical (pinch-off
syndrome, due to an internal pinching of the
central line between the first rib and clavicle),
caused by medication (unplanned/accidental
Follow agency-specific guidelines for
precipitation in the IV line), or from parenteral
managing various types of occlusions.
nutrition (may leave a lipid residue inside the
Thrombolytic therapy may be
catheter). Thrombus formation (fibrin sheath
Occlusions of initiated.
around the tip of the catheter) may occur as soon as
CVC (mechanical
24 hours after CVC is inserted. Thrombotic
or thrombus) Do not flush against resistance, flush
occlusions are responsible for approximately 58%
well between medications, and
of all occlusions. In addition to causing catheter
always flush using positive pressure
dysfunction, thrombotic occlusions can lead to
through a positive pressure cap.
catheter-related thrombosis. Signs include sluggish
flow rate, inability to flush or infuse medications,
and frequent downstream occlusion alarms on the
EID.
Clamp immediately and seal with a
CVCs may become broken or cracked. Assess for
sterile, occlusive dressing to prevent
pinholes, cracks, or tears during routine care.
an air embolism, bleeding, or a CR-
Assess for drainage after routine care.
Damage to CVC BSI. The CVC may be repaired or
line replaced. Notify health care provider
Avoid using sharp objects around CVCs, and only
promptly. Repair should only be
use a needleless device when accessing a central
completed by a trained CVC
line.
specialist.
Call physician and stop all fluid
infusions. You may need to pull back
on tubing and X-ray CVC again for
Patient may experience dysrhythmias caused by tip
placement confirmation.
of the catheter moving from original position to an
Catheter unwanted position. Migration may occur due to
Tape catheter securely using tape and
migration increased intrathoracic pressure due to coughing,
devices.
change in body position, or physical movement (of
the arms), sneezing, or weightlifting.
Do not pull on central lines; prevent
IV lines from being caught on other
equipment.
Data source: Baskin et al., 2009; BCIT, 2015a; Brunce, 2003; Fraser Health Authority, 2014; Perry et al.,
2014; Prabaharan & Thomas, 2014
Critical Thinking Exercises
1. What is the difference between a non-tunnelled (percutaneous) catheter and a tunnelled catheter?

8.3 IV Fluids, IV Tubing, and Assessment of an IV

System
Patients are prescribed an IV solution (fluids) based on their electrolyte and fluid volume status. IV fluids
are commonly categorized as colloids and crystalloids. Colloid solutions contain large molecules that
cannot pass through semi-permeable membranes and are used to expand intravascular volume by drawing
fluid from extravascular space via high osmotic pressure. Examples of colloid solutions are albumin,
dextrans, and hydroxyethyl starches (Crawford & Harris, 2011). Crystalloid solutions contain solutes such
as electrolytes or dextrose, which are easily mixed and dissolvable in solution. Crystalloids contain small
molecules that flow easily across semi-permeable membranes, which allows for transfer from
the bloodstream into the cells and tissues (Crawford & Harris, 2011). They may increase fluid volume in
interstitial and intravascular space. Examples of crystalloid solutions are isotonic, hypotonic, and hypertonic
solutions.
Isotonic solutions have an osomolality of 250 to 375 mOsm/L. Isotonic solutions have the same osmotic
pressure as plasma, creating constant pressure inside and outside the cells, which causes the cells to remain
the same (they will not shrink or swell) and does not cause any fluid shifts within compartments. Isotonic
solutions are useful to increase intravascular volume, and are utilized to treat vomiting, diarrhea, shock, and
metabolic acidosis, and for resuscitation purposes and the administration of blood and blood products.
Examples of isotonic solutions include normal saline (0.9% sodium chloride), lactated Ringer’s solution, 5%
dextrose in water (D5W), and Ringer’s solution. It is important to monitor patients receiving isotonic
solutions for fluid volume overload (hypervolemia) (Crawford & Harris, 2011).
Hypotonic solutions have a lower concentration, or tonicity, of solutes and have an osomolality equal to or
less than 250 mOsm/L. The infusion of hypotonic solutions lowers the osmolality within the vascular space
and causes fluid to shift to the intracellular and interstitial space. Cells will swell but may also delete fluid
within the vascular space. Examples of hypotonic solutions include 0.45% sodium chloride, 0.33% sodium
chloride, 2.5% dextrose in water, and 0.2% sodium chloride. Monitor for hypovolemia and hypotension
related to fluid shifting out of the vascular space, and do not administer to patients with increased
intracranial pressure (ICP), as it may exacerbate cerebral edema. Use cautiously in patients with burns, liver
failure, and traumas (Crawford & Harris, 2011).
Hypertonic solutions have a higher concentration, or tonicity, of solutes and have an osomolality equal to
or greater than 375 mOsm/L. The osmotic pressure gradient draws water out of the intracellular space into
the extracellular space. Examples of hypertonic solutions include D5W and 0.45% sodium chloride, D10W,
and 3% sodium chloride. Hypertonic solutions may cause intravascular fluid volume overload and
pulmonary edema, and they should not be used for an extended period of time. Hypertonic solutions should
not be used in patients with heart or renal disease who are dehydrated (Crawford & Harris, 2011).
Read the article IV fluids: what nurses need to know for more in-depth information regarding colloid and
crystalloid solutions.
Although all IV fluids must be administered carefully, hypertonic solutions are additionally risky.
An order for IV fluids may be continuous or as a bolus, depending on the needs of the patient. IV solutions
are available in 25 ml to 1000 ml bags. The frequency, duration, amount, and additives to solution must be
ordered by a physician or nurse practitioner; for example, an order may be “give NS at 125 ml/hr.”
The most common types of solutions include normal saline (NS) and D5W. Patients may also have
medications, such as potassium chloride, thiamine, and multivitamins, added to IV solutions. To discontinue
an IV infusion, an order must be obtained from the physician or nurse practitioner (Perry et al., 2014).
IV Administration Equipment
When a peripheral vein has a cannula inserted, an extension tubing is connected to the hub on the cannula
and flushed with normal saline to maintain patency of the cannula. Most peripheral intravenous cannulas
will have extension tubing, a short, 20 cm tube with a positive fluid displacement/positive pressure cap
attached to the hub of the cannula for ease of access and to decrease manipulation of the catheter hub
(Vancouver Coastal Health, 2008). The extension tubing must be changed each time the peripheral catheter
is changed. When the peripheral cannula is not in use, the extension tubing attached to the cannula is called
a saline lock.
Intravenous fluids are administered through thin, flexible plastic tubing called an infusion set or primary
infusion tubing/administration set (Perry et al., 2014). The infusion tubing/administration set connects to
the bag of IV solution. Primary IV tubing is either a macro-drip solution administration set that delivers 10,
15, or 20 gtts/ml, or a micro-drip set that delivers 60 drops/ml. Macro-drip sets are used for routine primary
infusions. Micro-drip IV tubing is used mostly in pediatric or neonatal care, when small amounts of fluids
are to be administered over a long period of time (Perry et al., 2014). The drop factor can be located on the
packaging of the IV tubing.
Primary IV tubing is used to infuse continuous or intermittent fluids or medication. It consists of the
following parts:
 Backcheck valve: Prevents fluid or medication from travelling up the IV

 Access ports: Used to infuse secondary medications and give IV push medications
 Roller clamp: Used to regulate the speed of, or to stop or start, a gravity infusion
 Secondary IV tubing: Shorter in length than primary tubing, with no access ports or backcheck valve;
when connected to a primary line via an access port, used to infuse intermittent medications or fluids.
A secondary tubing administration set is used for secondary IV medication.
Figure 8.4 IV Primary and secondary tubing set up

IV solution bags should have the date, time, and initials of the health care provider marked on them to be
valid. Add-on devices (e.g., extension tubing or dead-enders) should be changed every 96 hours, if
contaminated when administration set is replaced, or as per agency policy. Intravenous solution and IV
tubing should be changed if:
 IV tubing is disconnected or becomes contaminated by touching a non-sterile surface

 Less than 100 ml is left in the IV solution bag
 Cloudiness or precipitate is found in the IV solution
 Equipment (date and time) is outdated
 IV solution is outdated (24 hours since opened)
Primary and secondary administration sets (see Figure 8.4) should be changed regularly to minimize risk and
prevent infection (CDC, 2011; Fraser Health Authority, 2014). Change IV tubing according to agency
policy. Table 8.5 lists the frequency of IV tubing change.
Table 8.5 Frequency of IV Tubing Changes

 All IV tubing must be changed using sterile technique.

 IV tubing is changed based on the type of tubing, time used, and the type of solution.
 If possible, coordinate IV tubing changes with IV solution changes.
Frequency of IV
Type of IV Tubing and Solution
Tubing Change
Primary tubing with hypotonic, isotonic, or hypertonic continuous solution, when
Every 72 -96 hours insertion site is changed, or when indicated by the type of solution or medication
being administered.
Secondary or intermittent IV solution or medication. Rationale: When an
intermittent infusion is repeatedly disconnected and reconnected for infusion, there
Every 24 hours
is increased risk of contamination at the catheter hub, needleless connector, and the
male Luer end of the administration set, potentially increasing risk for CR-BSI.
Infusions containing fat emulsions (IV solutions combined with glucose and amino
Every 24 hours acids infused separately or in a 3 in 1 admixture). Example: Total parenteral
nutrition (TPN).
4 hours or 4 units,
whichever comes first, Blood and blood products
or between products
Data source: CDC, 2011
Infusing IV Fluids by Gravity or an Electronic Infusion Pump

(EID)
To ensure therapeutic effectiveness of IV fluids, a constant, even flow is necessary to prevent complications
from too much or too little fluid. A physician must order a rate of infusion for IV fluids or for medications.
The rate of infusion for medications (given via a secondary or primary infusion) can be found in the
Parenteral Drug Therapy Manual (PDTM). If an order for IV fluids is “to keep vein open” (TKVO), the
minimum flow rate is 20 to 50 ml per hour, or according to physician’s orders (Fraser Heath Authority,
2014).
A health care provider is responsible for regulating and monitoring the amount of IV fluids being infused.
IV fluid rates are regulated in one of two ways:
1. Gravity. The health care provider regulates the infusion rate by using a clamp on the IV tubing,
which can either speed up or slow down the flow of IV fluids. An IV flow rate for gravity is
calculated in gtts/min.
2. Electronic infusion device (EID) (see Figure 8.5). The infusion rate is regulated by an electronic
pump to deliver the fluids at the correct rate and volume. All IV pumps regulate the rate of fluids in
ml/hr. An IV pump (EID) is used for many types of patients, solutions, and medications (Vancouver
Coastal Health, 2008).
An IV pump must be used for:
 All CVC devices

 All opioid infusions (use a patient-controlled analgesia)
 All pediatric patients
 All medication as described in the PDTM
 Infusion rates below 60 ml/hr
Figure 8.5 Electronic infusion device (EID)
To calculate the drops per minute for an infusion by gravity, follow the steps in Table 8.6.
Table 8.6 Calculating the Drops per Minute (gtts/min) for an Infusion by Gravity
Steps Additional Information
An order may read:
1. Verify the physician
Example 1. Give NS IV 125 ml/hr
order.
Example 2. Give 1000 ml of NS IV over 8 hours.
2. Determine the drop The drop factor is the amount of drops (gtts) per minute. IV tubing is either macro
factor on the IV tubing (10, 15, or 20 gtts/min) or micro tubing (60 gtts/min). The drop factor (or
administration set. calibration of the tubing) is always on the packaging of the IV tubing.
Use the formula:
Infusion rate (ml/hr) X IV drop factor (gtts/min)
= drops per minute
60 (Administration time is always in minutes)
3. Complete the To calculate ml/hr, divide 1000 ÷ 8 = 125 ml/hr.
calculation using the
formula. Example: Infuse IV NS at 125 ml/hr. IV tubing drop factor is 20 gtts/min
125 X 20 = 41.6 gtts/min, round up to 42 gtts/min (Round down or

60 up to the nearest whole number)
Observe and count the drips in the drip chamber and regulate for 42 gtts/min (one
full minute). Alternatively, divide 42 by 4 (rounded down from 10.4 to 10 gtts/min)
to count for 15 seconds. The gtts/min should be assessed regularly to ensure the IV is
infusing at the correct rate (e.g., every 1 to 2 hours, if the patient accidentally bumps
the IV tubing, or if a patient returns from another department).
4. Regulate IV
infusion using the
roller clamp.
Regulate IV tubing by using a roller clamp

Take the IV calculations quiz for more practice with IV fluid dose calculation.
When an infusion is by gravity, there are several factors that may alter the flow/infusion rate (Fulcher &
Frazier, 2007). In addition to regulating the flow rate, assess the IV system to ensure these factors are not
increasing or decreasing the flow of the IV solution. These factors are listed in Table 8.7.
Table 8.7 Factors Influencing the Flow Rate of Infusions

Factors Additional Information
May occur if the tubing is kinked or bent. Tubing may become kinked if
Tube occlusion
caught under the patient or on equipment, such as beds and bed rails.
Irritating or chilled fluids (fluids stored in the fridge) may cause a reflex
action that causes the vein to go into spasm at or near the intravenous
Vein spasms
infusion site. If fluids or medications are chilled, bring to room
temperature prior to infusion.
The IV tubing drip chamber should be approximately 3 feet above IV
Height of the fluid container
insertion site.
If the cannula is located in an area of flexion (bend of an arm), the IV
Location/position of IV cannula flow may be interrupted when the patient moves around. To avoid this
issue, replace IV cannula.
If the cannula punctures the vein, the fluid will leak into the surrounding
Infiltration or extravasation
tissue and slow or stop the flow, and swelling will develop.
Instruct the patient not to touch the roller clamp and to take care not to
Accidental touching/bumping of
bump the clamp, as this may accidentally change the flow rate. Instruct
the control clamp or raising arm
patient to keep hand/arm below heart level; an elevated hand/arm will
above heart level
slow or stop an infusion running by gravity.
Needle or cannula gauge/diameter The smaller the needle or cannula, the slower the fluid will flow.
Assessing an IV System
All patients with IV fluid therapy (PIV and CVC) are at risk for developing IV-related complications. The
assessment of an IV system (including the IV site, tubing, rate, and solution) (see Figure 8.6) often depends
on what is being infused, the patient’s age and medical condition, type of IV therapy (PIV or CVC), and
agency policy. Generally, an IV system should be assessed as described in Checklist 65.
Figure 8.6 Assess IV site prior to use

Checklist 65: Assessing an IV System
Disclaimer: Always review and follow your hospital policy regarding this specific skill.
 IV systems must be assessed every 1 to 2 hours or more frequently if required.

 An IV system should be assessed at the beginning of a shift, at the end of a shift, if the electronic
infusion device alarms or sounds, or if a patient complains of pain, tenderness, or discomfort at the
IV insertion site.
 Review the patient’s chart to determine insertion date and type of solution ordered.
 A peripherally inserted catheter is usually replaced every 72 to 96 hours, depending on agency
policy.
 If the peripheral catheter or central venous catheter is not in use, or is being used intermittently,
flushing is required to keep the site patent. Refer to agency policy for flushing guidelines.
 A not-in-use peripheral IV site is generally flushed every 12 hours with 3 to 5 ml of normal saline.
 Review the in-and-out sheet to determine expected amount in the IV solution bag.
 Patients with cardiac or renal disease, as well as pediatric patients, are at a higher risk for IV-related
complications.
 Elderly patients often have fragile veins and may require closer monitoring.

This step reduces the transmission of
1. Perform hand hygiene.
microorganisms.
2. Introduce yourself and explain the purpose of the This builds trust with patient and allows time for the
assessment. patient to ask questions.
This step ensures you have the correct patient and
complies with agency standard for patient
identification.
3. Confirm patient ID using two patient identifiers

(e.g., name and date of birth), and compare the MAR
printout with the patient’s wristband.
Compare MAR with patient

wristband
4. Apply non-sterile gloves (optional). This reduces the transmission of microorganisms.
5. Assess the IV insertion site and transparent Check IV insertion site for signs and symptoms of
phlebitis or infection. Check for fluid leaking,
redness, pain, tenderness, and swelling. IV site should
be free from pain, tenderness, redness, or swelling.
dressing on IV site.
Ensure patient is informed to alert the health care
provider if they experience pain or notice swelling or
redness at the IV site. If patient is unable to report
pain at IV site, more frequent checks are required.
6. Inspect the patient’s arm for streaking or venous Assess complications on hand and arm for signs and
cords; assess skin temperature. symptoms of phlebitis and infiltration/extravasation.
Kinks or bends in tubing may decrease or stop the
flow of IV fluids. Ensure tubing is not caught on
equipment or side rails on bed.
7. Assess IV tubing for kinks or bends.
Tubing should be properly labelled with date and
time.
If IV solution is on gravity, calculate and count the
drip rate for one minute.
If solution is on an IV pump, ensure the rate is correct

8. Check the rate of infusion on the primary and
and all clamps are open as per agency protocol.
secondary IV tubing. Verify infusion rate in physician
orders or medication administration record (MAR).
If secondary IV medication is infusing, ensure clamp
on secondary IV tubing is open. The EID is unable to
distinguish if the primary bag or secondary bag is
infusing.
IV solutions become outdated every 24 hours.
Ensure the correct solution is given.
If 100 ml of solution or less is left in the bag, change

9. Assess the type of solution and label it on bag. the IV solution and document on in-and-out sheet.
Check volume of solution in bag.
If an IV pump is used, ensure it is plugged into an
outlet.
Ideally, the IV solution should be 90 cm above

patient heart level.
10. Assist patient into comfortable position, place call
bell in reach, and put up side rails on bed as per These precautions prevent injury to the patient.
agency policy.
11. Perform hand hygiene. This step prevents the spread of microorganisms.
12. Document procedure and findings as per agency Timely and accurate documentation promotes patient
policy. safety.
1. What are the signs and symptoms of phlebitis?
2. Name three advantages and three disadvantages of a central line.

8.4 Priming IV Tubing and Changing IV Fluids

and Tubing
Primary and secondary IV tubing and add-on devices (extension tubing) must be primed with IV solution to
remove air from the tubing. Priming refers to placing IV fluid in IV tubing to remove all air prior to
attaching the IV tube to the patient. IV tubing is primed to prevent air from entering the circulatory system.
An air embolism is a potential complication of IV therapy and can enter a patient’s blood system through cut
tubing, unprimed IV tubing, access ports, and drip chambers with too little fluid (Perry et al., 2014). It is
unknown how much air will cause death, but deaths have been reported with as little as 10 ml of air. The
best way to avoid air bubbles in IV tubing is to prevent them in the first place (Perry et al., 2014). New IV
tubing may also be required if leaking occurs around the tube connecting to the IV solution, if the tubing
becomes damaged, or if it becomes contaminated. Checklist 66 outlines the process of priming IV tubing.
Checklist 66: Priming IV Tubing

 Primary IV tubing can be macro-drip or micro-drip tubing. The drop factor of the IV tubing is
required to complete the IV drip rate calculation for a gravity infusion.
 Remember to invert all access ports and backcheck valve.

This step prevents the transmission of
microorganisms.
This ensures IV solution is correct and helps prevent
2. Check order to verify solution, rate, and frequency.
medication error.
You will need IV solution, primary IV tubing, time
label, change label, alcohol swab, and basin or sink.
3. Gather supplies.
Sterile IV solution
Tear the perforated corner of the outer packaging;
check colour, clarity, and expiration date.
4. Remove IV solution from outer packaging and

gently squeeze.
Remove IV solution from packaging

5. Remove primary IV tubing from outer packaging.
IV tubing
6. Move the roller clamp about 3 cm below the drip

chamber and close the clamp.
Move roller clamp

Be careful and do not contaminate the spike.
7. Remove the protective cover on the IV solution

port and keep sterile. Remove the protective cover on
the IV tubing spike.
Remove protective cover from spike

on IV tubing
8. Without contaminating the solution port, carefully

insert the IV tubing spike into the port, gently
pushing and twisting.
Insert IV spike into sterile solution using
sterile technique
The IV bag should be approximately one metre above
9. Hang bag on IV pole.
the IV insertion site.
Filling the drip chamber prevents air from entering
the IV tubing.
10. Fill the drip chamber one-third to one-half full by

gently squeezing the chamber. Remove protective
cover on the end of the tubing and keep sterile.
Fill drip chamber

11. With distal end of tubing over a basin or sink, Inverting and tapping the access ports and backcheck
slowly open roller clamp to prime the IV tubing. valve helps displace and remove air when priming the
Invert backcheck valve and ports as the fluid passes IV tubing.
through the tubing. Tap gently to remove air and to
fill with fluid.
Invert IV tubing when priming

with solution
12. Once IV tubing is primed, check the entire length
This step confirms that air is out of the IV tubing.
of tubing to ensure no air bubbles are present.
13. Close roller clamp. Cover end with sterile dead-
Keep the distal end sterile prior to connecting IV to
ender or sterile protective cover. Hang tubing on IV
patient.
pole to prevent from touching the ground.
Label IV solution bag as per agency policy. Do not
write directly on the IV bag.
14. Label tubing and IV bag with date, time, and

initials.
Labelled IV bag
This reduces the transmission of microorganisms.
Hand hygiene with ABHR

Data source: Fulcher & Frazier, 2007; Perry et al., 2014.
Watch a video or demonstration to learn how to prime IV tubing.
IV solutions are considered sterile for 24 hours. An IV solution may be changed if the physician’s order
changes, if an IV solution infusing at TKVO is expired after 24 hours, or if the IV solution becomes
contaminated. To change an IV solution bag, follow Checklist 67.
Checklist 67: Changing an IV Solution Bag

1. Verify and select correct IV solution bag and IV solutions are considered a medication and must be
compare to the medication administration record checked using the SEVEN RIGHTS x 3, as per
(MAR) or physician orders. agency policy.
Sterile IV solution
Proper identification of a patient prevents medication
2. Introduce yourself, identify patient, and explain
errors. Explaining the procedure provides an
procedure.
opportunity for the patient to ask questions.
Hand hygiene prevents the transmission of
microorganisms.
This ensures the correct IV solution is used.
4. Remove outer plastic packaging and squeeze bag

to test for leaks and expiration date. Assess for
precipitates or cloudiness. Hang new IV solution on
IV pole.
Remove IV solution from packaging

5. Pause the EID or close the roller clamp on a Stops the infusion to prevent air bubbles from
gravity infusion set. forming in IV tubing.
Keep IV tubing port sterile at all times. If IV tubing
6. Remove protective plastic cover from the new IV
port becomes contaminated, dispose of it immediately
solution tubing port.
and replace.
Removing old solution from IV pole prevents spilling
7. Remove the old IV solution bag from the IV pole. of solution.
Turn IV bag upside down, grasping the tubing port.
Ensure IV tubing spike remains sterile during
With a twisting motion, carefully remove IV tubing removal to avoid contaminating IV tubing.
spike from old IV solution bag.

This ensures that a sterile technique is used during the
process.
8. Using a gentle twisting motion, firmly insert the

spike into the new IV bag.
Spike new IV solution

9. Fill the drip chamber by compressing it between Fluid in the drip chamber helps prevent air from
your thumb and forefinger. Ensure the drip chamber being introduced into IV tubing.
is one-third to one-half full. Check IV tubing for air
bubbles.
Fill drip chamber
IV tubing label
Once rate is set, count the drops per minute on the
gravity set or ensure the EID is running at the correct
rate as per physician orders.
10. Open clamp and regulate IV infusion rate via

gravity, or press start on the EID as per physician
orders.
Regulate IV tubing with a roller

clamp
Labelling IV solutions provides easy viewing of
infusing solutions and additives.
11. Label new IV solution bag as per agency policy.

Time tape gravity IV solutions as per agency policy
Labelled IV bag
12. Dispose of used supplies, perform hand hygiene,
Document time, date, type of solution, rate, and total
and document IV solution bag change according to
volume.
agency policy.
Data source: Fulcher & Frazier, 2007; Perry et al., 2014.
Watch a video or demonstration to learn how to change IV solution.
Checklist 68 describes how to change the IV tubing administration set and IV solution at the same time.
Checklist 68: IV Tubing Administration Set and IV Solution Change

1. Verify physician orders for the type of solution, This step verifies the patient’s need for IV
rate, and duration. Collect necessary supplies. fluids/medications. It also confirms the correct rate
and solution for patient safety.
Hand hygiene prevents the transmission of
microorganisms.
Proper identification of patient prevents errors.
3. Identify yourself, identify the patient using two

identifiers, and explain the procedure to the patient.

wristband
IV solutions are considered a medication. Prime as
per Checklist 66. Keep distal protective cap attached
to IV tubing to ensure sterility of distal end. Label IV
solution and IV tubing as per agency policy.
4. Prime new administration set using a new IV

solution bag and new IV tubing.
Keep distal end sterile

with sterile cap
5. Hang new administration set (primed primary line This prepares the equipment and adheres to the
and IV solution) on IV pole. principles of aseptic technique.
6. Clamp old IV administration set. Remove IV Stop the flow of infusion during tubing and solution
tubing if on an EID. change.
Proper disinfection of equipment decreases bacterial
load and prevents infections.
7. Clean the connection between the distal end of old

IV tubing and the positive pressure cap. Scrub the
area for 15 seconds and let it dry for 30 seconds.
Scrub the connection

between the IV tubing and positive pressure cap
8. Remove the protective cap on the distal end of the

new IV administration set.
Remove sterile cap
9. Carefully disconnect the old tubing from the

positive pressure cap and insert the new IV tubing
into the positive pressure cap attached to the
extension tubing. Disconnect IV tubing from
hub
This step ensures the IV solution is infusing at the
correct rate.
10. Open the roller clamp on the new tubing to

regulate flow rate, or insert new tubing into the EID
and restart IV rate.
Regulate IV tubing using a

roller clamp
IV site should be free from redness, swelling, and
pain. Dressing on IV site should be dry and intact.
11. Check IV site for patency, and signs and
symptoms of phlebitis.
Assess IV site for patency

This step prevents the spread of microorganisms.
12. Discard old supplies and perform hand hygiene.
Perform hand hygiene

Document the date and time of IV tubing and solution
13. Document procedure as per agency policy.
change.
Data source: BCIT, 2015b; Fulcher & Frazier, 2007; Perry et al., 2014
1. How long can IV solution be used?

2. What is the purpose of removing air from IV tubing?

8.5 Flushing a Saline Lock and Converting a

Saline Lock to a Continuous IV Infusion
A saline lock (SL), also known as a heparin lock, is a peripheral intravenous cannula connected to extension
tubing with a positive pressure cap (see Figure 8.7). This device allows easy access to the peripheral vein for
intermittent IV fluids or medications (Perry, et al., 2014). The saline lock is “flushed” or filled with normal
saline to prevent clotting when not in use. To use an SL, the cannula is flushed with 3 to 5 ml of normal
saline to assess patency. After the saline lock is used, the cannula is flushed again with 3 to 5 ml of normal
saline or heparin to “lock” the saline in the cannula in order to keep it patent. Once the saline lock is
inserted, it can be left in a vein for up to 72 hours or as per agency policy. Saline locks are usually inserted
in the arm or hand. If a saline lock is removed, the extension tubing and positive pressure cap are also
changed (Vancouver Coastal Health, 2012).
Figure 8.7 Saline lock with positive pressure cap (Max Plus)
A saline lock can be used for continuous and intermittent short-term IV therapy. Flushing is performed:
 Before and after administering IV fluids or medications to assess placement and patency of PIV
 After blood sampling
 After each infusion to prevent mixing of incompatible medications and solutions
 Every 12 hours when the saline lock is not in use
A saline lock must be flushed in a specific manner to prevent blood being drawn into the IV catheter and
occluding the device between uses. Checklist 69 describes the process of flushing an SL.
Checklist 69: Flushing a Saline Lock

 Poor standards of aseptic technique are the primary cause of health care infections. Be diligent with
disinfecting and sterile technique. Sterile technique must be used with all IV procedures.
 An alcohol swab (70% isopropyl alcohol) must be used to clean the hub prior to access. The hub is
scrubbed for 15 seconds and allowed to dry completely (30 seconds).
 Never attempt to flush a “blocked” saline lock. If unable to flush, remove the SL.
 Never use a needle to access a positive pressure cap. Attach a Luer lock syringe to the positive
pressure cap to flush.

You will need alcohol swabs, 3 to 5 ml syringe
prefilled with 0.9% normal saline, clean gloves.
1. Perform hand hygiene; gather supplies.

2. Compare MAR to patient’s wristband, identify Follow agency policy for proper patient
patient using two identifiers, and explain procedure to identification.
patient.
Compare MAR with
patient wristband
3. Clean work surface with CaviWipes and let dry. This prevents the spread of microorganisms.
This prevents and minimizes the spread of
microorganisms.
4. Perform hand hygiene and apply clean gloves.
Apply non-sterile gloves

If IV site is red, tender, or swollen, the SL needs to be
discontinued; do not flush.
5. Assess IV site for signs and symptoms of phlebitis.
Assess site for phlebitis

Aseptic technique is required for all IV procedures.
All access ports must be disinfected to decrease the
bacterial load prior to use.
6. Scrub the top of the positive pressure cap for 15

seconds and let dry for 30 seconds.
Clean the positive

pressure device (Max Plus) prior to use
Clamp must be open to flush the saline lock.
7. Open clamp on extension tubing.
Open clamp on saline lock

8. If using a prefilled normal saline syringe for Purging the air prevents it from being injected into
flushing, the air must be “purged” from the syringe. the patient. Air should never be injected into a
To remove air from a syringe, apply gentle pressure patient.
to the syringe plunger until a click, snap, or pop
sound is heard.
Next, remove the sterile dead-ender on the Luer lock

end of the syringe, and remove the air by gently
pushing the plunger upwards, keeping the syringe
Apply pressure to the
plunger until a click, snap, or pop sound is heard
vertical.
Purge a prefilled syringe

Turbulent stop-start flush ensures full flushing of the
catheter.
Bottoming out the saline syringe with the plunger can

cause reflux of fluid back into the catheter.
9. Attach NS prefilled Luer lock syringe by twisting
the syringe onto the positive pressure cap. Undo If resistance is felt, do not force flush.
clamp on extension tubing. Inject 3 to 5 ml of
solution using turbulent stop-start technique. Flush
until visibly clear. Do not bottom out syringe (leave
0.2 to 0.5 ml in the syringe).
Flush the saline lock

Always clamp after removing syringe from the
positive pressure cap. Positive displacement occurs
when the syringe is disconnected from the positive
pressure cap.
10. Remove syringe from positive pressure cap;

THEN clamp the extension tubing.
Close clamp on saline

lock
Clamp the extension tubing as close to the IV site as

possible to prevent negative fluid displacement and
accidental aspiration of blood at the catheter tip.
11. Wipe top of the positive pressure cap with an Moisture promotes the growth of microorganisms.
alcohol swab to remove fluid residue.
Wipe top of pressure cap
Properly secured extension tubing prevents accidental
dislodgement of SL.
12. Ensure dressing is dry and intact, and the

extension tubing is properly secured with tape.
Dry and intact dressing

Proper disposal of equipment prevents the spread of
microorganisms.
13. Remove gloves; discard supplies and perform

hand hygiene.
Hand hygiene with

ABHR
Document IV site assessment, location of PIV,
14. Document procedure.
procedure, date, and time.
Data source: Perry et al., 2014; Vancouver Coastal Health, 2008
An SL can be converted to a continuous or intermittent IV to infuse fluids or medications. Prior to

converting an SL to a continuous infusion, review the physician’s orders for type of solution, infusion rate,
additives, and duration. IV solutions are considered a medication. Follow the seven rights x 3 when
preparing IV solution. To convert a saline lock to a continuous IV, review Checklist 70.
Checklist 70: Converting a Saline Lock to a Continuous IV Infusion

 If at any time you think a piece of equipment has been contaminated, dispose of it immediately and
obtain a new sterile piece.
 Always assess IV site and flush SL prior to initiating an IV infusion.
 Always follow the safety seven rights x 3 for IV fluids and medications.
 Educate the patient on signs and symptoms of phlebitis and when to call for assistance (unexpected
or adverse reactions).
 IV solutions must be recorded on the in-and-out sheet or patient chart.
 Patients on continuous IV solutions are at risk for fluid overload, especially patients with renal or
cardiac conditions. Monitor output and input when patients are on a continuous infusion.

1. Verify physician orders and collect supplies. You will need clean gloves, 3 to 5 ml prefilled 0.9%
normal saline syringe, IV solution, IV pump if
indicated.
Verify the rate and duration of solution.
Review the rationale/reason for the IV fluids to

provide an explanation to the patient.
Prime IV tubing with correct IV solution as per
Checklist 66. Ensure IV tubing and IV solution bag
are labelled.
2. Perform hand hygiene and prime IV tubing with IV

solution.
Prime IV tubing
Identifying patient correctly prevents errors and
enhances safe practices.
3. Enter room and identify patient using two

identifiers.

wristband
Educate patient about why IV fluids are being
initiated.
Hand hygiene prevents the spread of microorganisms.
4. Explain procedure, clean work surface and let dry,

and perform hand hygiene.

Appropriately disinfecting the positive pressure cap
decreases the bacterial count and adheres to the
principles of infection control.
5. Apply gloves, scrub the top of the positive pressure

cap for 15 seconds, and let dry for 30 seconds.
Clean positive pressure

cap (Max Plus) with alcohol swab
6. Open clamp on extension tubing and assess IV site.
Open clamp on saline
lock
Clamp must be released to flush the extension tubing.

Purging the air prevents it from being injected into
the patient. Air should never be injected into a
patient.
7. If using a prefilled normal saline syringe for

flushing, the air must be “purged” from the syringe.
To remove air from a syringe, apply gentle pressure
to the syringe plunger until a click, snap, or pop
sound is heard. Push up gently on
plunger until a click is heard
Next, remove the sterile dead-ender on the Luer lock
end of the syringe, and remove the air by gently
pushing the plunger upwards.
To purge air, remove

the sterile dead-ender and push up gently on the
plunger until all air is removed
catheter.

8. Attach NS prefilled Luer lock syringe by twisting If resistance is felt, do not force flush.
the syringe to the positive pressure cap. Inject 3 to 5
ml of solution using turbulent stop-start technique.
Flush until visibly clear. Do not bottom out syringe
(leave 0.2 to 0.5 ml in the syringe).
Flush with normal

saline
Proper disposal of equipment decreases the spread of
9. Remove syringe and discard.
microorganisms.
10. Scrub the top of the positive pressure cap for 15 Appropriately disinfecting the positive pressure cap
seconds and let dry for 30 seconds. decreases the bacterial count and adheres to the
principles of infection control.
Clean positive
pressure cap (Max Plus) with alcohol swab
Do not let the positive pressure cap touch any non-
sterile surface prior to attaching the IV tubing. If
required, place the positive pressure cap on sterile
gauze while preparing tubing.
11. Without breaking sterile technique, remove the

cap on the distal end of the IV tubing. Using a
twisting motion, connect Max Plus end to IV tubing.
Connect IV tubing to saline
lock Continuous IV infusion

Adjust IV infusion rate by gravity or IV pump as per
physician’s orders. Monitor for factors that may
affect flow rate.
12. Initiate IV infusion.
Adjust IV rate
Properly secured extension tubing prevents accidental
dislodgement of tubing.
13. Secure IV tubing to patient with tape.
Secure IV tubing with

tape
14. Document procedure and monitor expected Chart type of solution, rate, date, and time of infusion
response to IV fluids. as per agency policy.

1. A continuous infusion is started on your patient. As you leave the room, your patient complains of
pain at the insertion site. What should you do?
2. When flushing a positive pressure cap, when do you clamp the extension tubing?

8.6 Converting an IV Infusion to a Saline Lock and

Removal of a Peripheral IV
A peripheral IV may be converted to a saline lock when a prescribed continuous IV therapy is switched to
intermittent IV or a saline lock for future use. A physician’s order is required to stop a continuous infusion.
Checklist 71 describes how to convert an infusion to a saline lock.
Checklist 71: Converting an IV Infusion to a Saline Lock

1. Verify physician orders to convert IV infusion to a
Ensures correct order is being implemented.
saline lock.
This prevents the transmission of microorganisms.
2. Perform hand hygiene; collect supplies.

Proper identification prevents errors. Explaining the
procedure educates the patient and allows time for
patient to ask questions.
3. Identify yourself; identify the patient using two

identifiers and comparing the MAR to the patient’s
wristband; explain the procedure to the patient.

wristband
This step prevents the transmission of
microorganisms.
This prevents fluid from escaping from tubing when
5. Stop IV infusion with clamp or turn off EID. Apply
disconnecting tubing from positive pressure cap
clean gloves.
(hub).
6. Scrub the connection area between the hub and IV
tubing for 15 seconds and let dry for 30 seconds.
Scrub the connection
between the IV tubing and positive pressure cap
7. Disconnect primary tubing from the extension

tubing; ensure the positive pressure cap remains on
the extension tubing. Place a sterile cap on end of IV
tubing if tubing will be reconnected for later infusion.
Disconnect IV tubing
from saline lock
Aseptic technique is required for all IV procedures.
All access ports must be disinfected to decrease the
bacterial load prior to use.
8. Scrub the hub for 15 seconds and let dry for 30

seconds.
Clean positive
pressure cap (Max Plus) with alcohol swab
catheter.

9. Attach 10 ml syringe prefilled with 0.9% normal If resistance is felt, do not force flush. Assess IV site
saline and flush saline lock to clear the positive for pain, redness, or swelling.
pressure cap. Do not bottom out syringe.
Flush saline lock

Proper disposal of equipment prevents the spread of
microorganisms.
10. Remove syringe and discard.
Discard syringe
11. Clamp extension tubing. Clamping the extension tubing as close to the IV site
as possible prevents negative fluid displacement and
accidental aspiration of blood at the catheter tip.
Close clamp on saline lock
Saline lock
12. Wipe top of positive pressure cap with alcohol Removal of excess fluid prevents bacterial growth on
swab to remove fluid residue. the hub.
13. Document procedure as per agency policy. Document date, time, and IV site assessment.
Watch a video or demonstration to learn how to convert a running IV to a saline lock.
A peripheral IV (saline lock) may be discontinued if ordered by a physician or nurse practitioner; if the
patient is discharged from a health care facility; if signs of phlebitis, infiltration, or extravasation occur; or if
the saline lock is no longer required for fluids or medication (Fulcher & Fraser, 2007). Peripheral IV’s
should be removed promptly when no longer needed to avoid a catheter-related bloodstream infection (CR-
BSI), as well as unnecessary pain and trauma (Infusion Nurses Society, 2012). In general, saline locks are
changed every 72 hours. If a patient has a peripheral IV in an area of flexion, the IV site should be replaced
within 24 hours, or when the patient is stable. Other research shows that peripheral IV cannulas should not
be routinely changed but replaced based on whether the site is functioning, the saline lock is required, the
insertion site is patent, and/or the insertion site is a source of infection (CDC 2011; Infusion Nurses Society,
2011).
At times, a physician may order IV fluids to be discontinued but request to have the IV converted to saline
lock. Be sure to assess the order for discontinuing an IV. Before removing an IV, consider the following:
 Is the patient drinking enough fluids?

 Is the patient voiding, passing gas, and having bowel sounds?
 Is there a need for the IV (IV meds)?
 Are the lab values within normal limits (Hgb, K)?
 Is the patient using an epidural/PCA?
 Do you have a physician order?
Review the steps in Checklist 72 for removing a peripheral IV.
Checklist 72: Removing a Peripheral IV

 Assess the patient and be sure they are medically stable prior to removing SL. Check the following:
lab values, ongoing need for fluids or IV medications, inability to eat or drink, presence of nausea or
vomiting.
 If patient has ongoing medical concerns requiring an IV, alert the physician.

1. Confirm physician’s order or the reason to remove This step prevents errors in the health care setting.
the IV cannula.
You will need sterile gauze (two 2x2s), clean gloves,
2. Perform hand hygiene and collect supplies. tape, alcohol swab as required, C & S swab if
purulent drainage present.
Proper identification prevents errors. Explaining the
procedure educates the patient and allows patient to
ask questions.
3. Identify yourself; identify the patient using two

identifiers and comparing the MAR to the patient’s
wristband; explain the procedure to the patient.

wristband
4. Perform hand hygiene and apply clean gloves.
Preparing gauze allows for easy access once cannula
Open up sterile gauze for easy access and place close
is removed.
by.
5. Remove tape on extension tubing. Tape must be removed prior to removing cannula.
6. Remove transparent dressing:
 Stabilize the IV cannula.

 Loosen one edge of transparent dressing Removing transparent
toward the IV site by stretching the dressing
in the direction of loosened edge.
 Loosen the other edge of the dressing and
repeat previous step.
dressing Completely remove
dressing from IV site
7. If purulent drainage is present, perform C & S
This provides follow-up data for potential infection.
swab and clean area with alcohol swab.
Applying pressure to the IV site upon removal of the
catheter is painful for the patient. Remove catheter
first, then apply pressure.
8. Hold sterile gauze above the insertion site; do not

apply pressure. Keeping the cannula parallel to the
skin, pull out in a straight, slow, steady motion.
Assess catheter tip and discard cannula as per agency Gauze over cannula
policy.
Remove saline lock

9. Place sterile gauze over insertion site and apply If patient is on coagulation therapy, extended pressure
gentle pressure until bleeding stops, usually for 2 to 3 will be required to stop bleeding at IV site for 5
minutes. minutes.
10. Apply new sterile gauze and tape to create This prevents bacteria from entering the old IV site.
occlusive dressing on old IV site.
Apply sterile gauze over

IV insertion site
These steps prevent the spread of microorganisms.
11. Discard supplies, remove gloves, and perform

hand hygiene.

Document date, time, condition of cannula,
12. Document procedure as per agency policy.
appearance of IV site, and type of dressing applied.
Data source: ATI, 2015; Perry et al., 2014; Phillips, 2005
Watch a video or demonstration to learn how to discontinue an IV (removal of a peripheral IV).
1. What is the purpose of applying pressure to the site after the cannula has been removed?
2. Name five factors to consider prior to discontinuing an IV.

8.7 Transfusion of Blood and Blood Products

All health care practitioners who administer blood or blood products must complete specific training for safe
transfusion practices and be competent in the transfusion administration process. Always refer to your
agency policy for guidelines for preparing, initiating, and monitoring blood and blood product transfusions.
These guidelines apply to adult patients only.
The transfusion of blood or blood products (see Figure 8.8) is the administration of whole blood, its
components, or plasma-derived products. The primary indication for a red blood cell (RBC) transfusion is to
improve the oxygen-carrying capacity of the blood (Canadian Blood Services, 2013). A health care provider
order is required for the transfusion of blood or blood products. RBC transfusions are indicated in patients
with anemia who have evidence of impaired oxygen delivery. For example, individuals with acute blood
loss, chronic anemia and cardiopulmonary compromise, or disease or medication effects associated with
bone marrow suppression may be candidates for RBC transfusion. In patients with acute blood loss, volume
replacement is often more critical than the composition of the replacing fluids (Canadian Blood Services,
2013). Transfusions can restore blood volume, restore oxygen-carrying capacity of blood with red blood
cells, and provide platelets and clotting factors. The most common type of blood transfusion is blood that is
donated by another person (allogeneic). Autologous transfusion is the transfusion of one’s own blood (Perry
et al., 2014).
Figure 8.8 Red blood cells and blood IV tubing
Transfusion therapy is considered safe, and stringent precautions are followed in the collection, processing,
and administration of blood and blood components. However, transfusions still carry risks such as
incompatibility, human error, and disease transmission, and blood transfusion must be taken seriously at all
times. Incompatibility can be decreased by using irradiated red blood cells or leukocyte-reduced blood. The
majority of blood transfusion complications are a result of human error (Perry et al., 2014).
Compatibility testing is vital for all recipients of blood or blood products. Recipients must be transfused
with an ABO group specific to their own blood type or ABO group-compatible. There are three types of
blood typing systems: ABO, Rh, and human leukocyte antigen (HLA). For more information on these, refer
to the online resources at the end of this chapter. It is vital to understand what types of blood groups are
compatible for transfusions (Canadian Blood Services, 2013).
When administering blood and blood products, it is important to know the patient’s values and beliefs
regarding blood products. Some groups of individuals, mainly Jehovah Witnesses, will refuse blood
transfusions or blood products based on religious beliefs. These individuals will refuse transfusion of whole
blood and primary blood components but may accept transfusion of derivatives of primary blood
components such as albumins solutions, clotting factors and immunoglobulins. Always assess each
individual preference to establish if a blood component is an acceptable treatment to manage their illness or
condition (Canadian Blood Services, 2007).
When managing blood transfusions, it is important to prevent complications from occurring and to identify
issues promptly to manage reactions effectively. Transfusion reactions (mild to life-threatening) may occur
despite all safety measures taken. All transfusion reactions and transfusion errors must be reported to the
hospital’s transfusion services (blood bank). It is imperative to know what signs and symptoms to look for,
and to educate your patient on what to report and when to report potential transfusion reactions. Mild to
severe reactions may include (Canadian Blood Services, 2011):
 Temperature ≥ 38.0 C or change of 1°C from pretransfusion value within 15 minutes after initiation
of transfusion
 Acute or delayed hemolytic transfusion reaction
 Hypotension/shock
 Rigors
 Anxiety
 Back or chest pain
 Nausea/vomiting
 Shortness of breath (dyspnea)
 Hemoglobinuria
 Bleeding/pain at IV site
 Tachycardia/arrhythmia
 Generalized flushing
 Rash ≥ 25% of body
 Urticaria and other anaphylaxis reactions
 Hemolysis after transfusion
 Cytopenias after transfusion
 Virus, parasite, and prion infections
 Non-immunological reactions including infection
 Circulatory overload
 Hypothermia
For more information on types of reactions, signs and symptoms, and treatments, review the article adverse
events related to blood transfusions, or see the online resources at the end of this chapter. If patient has a
blood transfusion reaction, always follow agency policy to manage mild to severe blood reactions. In
general, if a reaction occurs, follow the steps outlined in Checklist 73.
Checklist 73: Managing a Blood or Blood Product Transfusion Reaction

 Always review your agency’s algorithm for managing mild to severe reactions. If a reaction is mild
(e.g., fever), and without any other complications, a patient may continue the transfusion if
monitored closely. Most other transfusion reactions require the transfusion to be stopped
immediately.
 A blood transfusion reaction may occur 24 to 48 hours post-transfusion.
 Each separate unit presents a potential for an adverse reaction.
 Follow emergency transfusion guidelines when dealing with an emergency blood or blood product
transfusion.
 Be aware of which types of blood or blood products cause the most types of transfusion reactions.
 Be aware of the types of patients at high risk for blood or blood product transfusion reactions.
 Always have emergency equipment and medications available during a transfusion. For example,
epinephrine IV should always be readily available.

The severity of a blood transfusion reaction is related
1. Stop transfusion immediately. to the amount of product infused and the amount of
time it has been infusing.
Keeps IV site patent for emergency medications if
2. Keep IV line open with 0.9% saline.
required.
Assessment monitors the type and severity of
reaction. In addition to assessment:
 Maintain good urinary output.

 Avoid fluid overload.
3. Complete cardiovascular and vital signs
 Manage DIC (disseminated intravascular
assessment.
coagulation) or hemorrhage if clinically
indicated.
 Provide supportive measures as required
(oxygen, etc.).
4. Contact physician for medical assessment and to The physician responsible for the patient must be
inform about reaction. informed of all transfusion reactions.
Vital signs must be monitored to identify improving
5. Check vital signs every 15 minutes until stable.
or worsening condition.
6. Obtain blood and urine samples as soon as Blood and urine samples can help identify the type of
possible. blood transfusion reaction.
7. Check all labels, tags, forms, blood order, and
Clerical errors account for the majority of blood
patient’s identification band to determine if there is a
transfusion reactions.
clerical discrepancy.
All blood products and IV tubing are investigated by
8. Keep all blood and IV tubing for further testing by the transfusion services and reported to Canadian
the blood bank for verification of blood product and Blood Services and Public Health Agency of Canada.
patient identification. These professional bodies are responsible for
reporting and recording incidents of reactions.
Notify blood bank when an adverse reaction occurs,
9. Notify blood bank.
even if transfusion is continued.
Document time, date, signs and symptoms, type of
product, notification to the physician and
management of reaction, and patient response to
management of reaction.
Documentation includes, but is not limited to:

10. Document as per agency policy.
 Transfusion reaction form
 Patient chart
 Report for transfusion services (blood bank)
 Adverse event form (Patient Safety Learning
System or PSLS)
Data source: Alberta Health Services, 2015a; Canadian Blood Services, 2011; Perry et al., 2014; Vancouver
Coastal Health, 2008
In preparation for a blood or blood product transfusion (Alberta Health Services, 2015a, 2015b; Perry et al.,
2014; Vancouver Coastal Health, 2008), the steps listed in Checklist 74 must be completed. These steps
must be completed before obtaining the blood or blood product from the blood bank.
Checklist 74: Preparing for a Blood or Blood Product Transfusion

 If there is any discrepancy between patient information, group and screen, product ordered, etc., do
not proceed. Stop and verify any discrepancies.
 Be diligent when preparing to infuse blood. Distractions may lead to errors when verifying
information.

1. Verify the physician’s order for the specific blood Order must be verified for the type of product; the
or blood product. amount, date, time, and rate and duration of infusion;
any modifications to a blood component (e.g.,
irradiation); specific transfusion requirements; and
possible sequence in which multiple components are
to be transfused.
Physician orders for a
blood transfusion
2. Verify the health care provider’s orders for any
Some patients may require Benadryl IV or Tylenol
pre- or post-transfusion medications to be
pretransfusion or Lasix post-transfusion.
administered.
3. Obtain the patient’s transfusion history, and notePast complications may require patient to have pre-
any known allergies and previous transfusion and post-transfusion medications to prevent further
reactions. transfusion reactions.
Verification allows for the identification of any newly
4. Verify that type and cross-match (also known as a developed antibodies, and ensures current
G & S) have been completed within the past 96 compatibility between donor red blood cells and
hours. recipient’s plasma. If G & S is outdated or not
available, initiate process for new G & S sample.
The patient’s IV cannula must be patent and without
complications, such as infiltration or phlebitis. The
size of cannula (#18 to #20) must match the
guidelines set by Canadian Blood Services.
5. Verify patency of IV site.
Assess patency of IV site

6. Ensure appropriate patient identification band is To complete all safety identification checks, proper
available and legible. identification must be on the patient.
7. Assess laboratory values, such as hematocrit, This ensures the transfusion is appropriate for the
coagulation values, and platelet count. patient.
All blood products must have a consent form signed
prior to the transfusion.
8. Check that the patient has properly completed and

signed the transfusion consent form.
Assess patient’s understanding of the procedure and

its rationale. Consent is required for the transfusion of
blood and blood components and products. Example of a consent form
Consent is mandatory for all blood and blood product

transfusions. Follow agency policy if patient is unable
to sign or consent to blood or blood product
transfusions.
9. Know the indications for the transfusion. Know why the patient is receiving the transfusion.
10. Obtain and record the patient’s pretransfusion Pretransfusion vital signs are a mandatory component
baseline vital signs, including temperature, pulse, of blood administration.
respiration, blood pressure, and oxygen saturation
level. If the patient is febrile, which means the
patient’s temperature is higher than 37.8°C (100°F),
notify the health care provider before initiating the
transfusion.
Pre-assessment of vital signs

Be prepared for potential complications, as prompt
intervention may be required to prevent serious
complications.
11. Have emergency equipment available at the

bedside (oxygen, suction, etc.).
Emergency equipment
check at bedside
Proper documentation provides evidence that all
12. Complete all documentation as required per
required procedures have been followed to prepare
agency policy.
for a transfusion.
Data source: Alberta Health Services, 2015b; Canadian Blood Services, 2011; Perry et al., 2014; Vancouver
Coastal Health, 2008
Checklist 75 provides steps to administering blood and blood products safely in the acute care setting.
Checklist 75: Transfusion of Blood and Blood Products

 No medications may be added to blood units or through IV tubing.

 Specific blood administration tubing is required for all blood transfusions. Blood tubing is changed
every 4 hours or 4 units, whichever comes first.
 See agency policy for using EID for the administration of blood products.
 Intravenous immunoglobulin (IVIG) is only compatible with D5W.
 All blood products taken from the blood bank must be hung within 30 minutes and administered
(infused) within 4 hours due to the risk of bacterial proliferation in the blood component at room
temperature.

1. Verify physician orders and all preparation steps as
listed in Checklist 74.
2. Assess or initiate venous access. Appropriate needle gauge is based on clinical status
of patient, urgency of transfusion, and venous access:
 #18 gauge for trauma/surgery

 #20 to #22 for elective medical/geriatric
Transfusion set must be Luer-locked to a 2.0 ml

maximum extension tubing, either directly to cannula
or through a Max Plus positive pressure cap.
Saline lock
Prime an IV line following Checklist 66.
 0.9% NS for RBC

 D5W for IVIG
Refer to blood product fact sheets for all other

products.
3. Initiate primary infusion at TKVO.
Normal saline IV solution

Document any clinical sign or symptom that may be
4. Complete and document cardiovascular
confused with a transfusion reaction (e.g., existing
assessments and initial vital signs.
fever).
Plan for pickup or delivery of blood and blood
5. Obtain products from the transfusion areas within
products. Do not request blood or blood products if
30 minutes of planned transfusion.
Steps 1 to 4 are not complete.
Assess blood bag for any signs of leaks or
contamination, such as clumping, clots, gas bubbles,
or a purplish discoloration. Return to blood bank if
blood bag contains any of the above signs.
6. Complete visual inspection of product.
Visual inspection of the

blood bag
7. Initial verification: All verification numbers/information must match
exactly.
a. Compare the transfusion medical services (TMS)
documentation with the patient record to verify: Must be completed by two trained staff members
competent in blood transfusion administration
 Patient first and last name and unique process as set out by the agency.
identifier number
 Physician order Confirm the patient blood type and Rh are compatible
 Consent with the donor blood type and Rh.
 Patient ABO grouping (G & S)
If there are any discrepancies, stop the process and
b. Compare the TMS documentation with the product contact the TMS for resolution and direction. Do not
label attached to the product tab and verify: proceed.
 Patient first and last name and unique Ensure the blood product matches the physician’s
identifier number orders (red blood cells or platelets).
 Type of blood product and ABO blood
grouping
 11-digit serial number
 Product expiry date and time
 Special requirements (e.g., irradiated)
 G & S expiry date
TMS record
Medications must be administered through an IV
8 Administer pre-medications as ordered.
infusion set, and the IV site cleared with 0.9% NS.
All verification numbers must match exactly. If there
9. Final verification (must be completed by the same are any discrepancies, stop the process and contact
two staff members as noted in Step 7). the TMS for resolution and direction. Do not proceed.
Compare the patient’s first and last name and unique

identifier number using all of the following:
 Patient identification band or equivalent ID

process as approved by the TMS (Ask the
patient to spell first and last name and state Identify patient
date of birth.)
 TMS documentation Patients who are alert and oriented should be asked
 Compatibility tag and label attached to blood to:
product
 Spell first and last name
Only after recipient identification and product check  State their date of birth
is confirmed, invert product 5 to 10 times and insert
spike of the blood administration set into the blood All identifying information attached to the blood bag
product container. must remain attached at least until completion of
transfusion.
Do not remove the product from the presence of the
patient; prime at bedside. If product is removed from
bedside, the final verification process must be
10. Perform hand hygiene. Prime the blood product completed again.
administration set:
 Close clamp. Completely cover the filter with

product.
 A straight blood administration set is used for
all transfusions.
 A Y-type blood administration set should only
be considered in clinical situations where
additional fluid volume may be required.
Prime blood tubing

11. Initiate transfusion: Adults: Initiate red cells slowly (25 ml in the first 15
minutes). For all other blood transfusions, refer to the
 Obtain vital signs immediately prior to blood and product sheet as per your agency policy.
Some agencies use an EID to administer blood
transfusions. Always check agency policy prior to
transfusion.
For each and every unit:
 Remain with the patient for the first 5 minutes

and assess for clinical signs of transfusion
reaction.
transfusion, then 15 minutes after initiation,
then every hour until transfusion is complete.  Complete transfusion within 4 hours of
removal from the blood bank.
 Maintaining asepsis, disconnect the NS
infusion and connect blood administration set
Most transfusion reactions occur within first 15
and start transfusion.
minutes of a transfusion. Infusing small amounts of
 Advise patient on the signs and symptoms of
blood component initially minimizes volume of blood
transfusion reaction and what and when to
to which patient is exposed, thereby minimizing
report.
severity of reaction.
Infusion of packed red

blood cells
Vital signs must be monitored:
 Immediately prior to infusion

 Within 10 to 15 minutes
12. Monitor:  Every hour until transfusion is complete
 Assess and observe for clinical signs and
symptoms of reactions up to 24 hours post-
transfusion.
 Complete all appropriate clinical
documentation.
Vital signs
 Manage transfusion reactions as per protocol.
 Complete required transfusion reaction form.
13. In the event of a transfusion reaction, stop the
infusion.  Return remaining blood to blood bank for
further investigation.
14. For additional units, repeat steps 6 to 12. Follow the same process to ensure patient safety.
15. Flush administration set with maximum of 50 ml Flushing displaces any blood or blood product from
of normal saline and re-establish IV or SL as per the administration set. It is not necessary to flush
physician orders. between units of the same blood product.
16. Discard waste in biohazard waste container. This prevents the spread of biohazard waste.
17. Complete all documentation as required by Documentation may include:
 Transfusion record form
 All vital signs and reactions
agency.  Any significant findings, initiation and
termination of transfusion
 Record of transfusion on the in-and-out sheet
Data source: Alberta Health Services, 2015a, 2015b; Perry et al., 2014; Vancouver Coastal Health, 2008
Watch a video or demonstration to learn how to transfuse blood or blood products.
1. How many units of blood can be transfused through one blood administration set?
2. What are the steps to managing a blood transfusion reaction?

8.8 Total Parenteral Nutrition (TPN)

Total parenteral nutrition (TPN), also known as parenteral nutrition (PN) is a form of nutritional support
given completely via the bloodstream, intravenously with an IV pump. TPN administers proteins,
carbohydrates, fats, vitamins, and minerals. It aims to prevent and restore nutritional deficits, allowing
bowel rest while supplying adequate caloric intake and essential nutrients, and removing antigenic mucosal
stimuli (Perry et al., 2014).
TPN may be short-term or long-term nutritional therapy, and may be administered on acute medical floors
as well as in critical care areas. The caloric requirements of each patient are individualized according to the
degree of stress, organ failure, and percentage of ideal body weight. TPN is used with patients who cannot
orally ingest or digest nutrition (Triantafillidis & Papalois, 2014). TPN may be administered as peripheral
parenteral nutrition (PPN) or via a central line, depending on the components and osmolality. Central veins
are usually the veins of choice because there is less risk of thrombophlebitis and vessel damage (Chowdary
& Reddy, 2010). According to Chowdary & Reddy (2010), candidates for TPN are:
 Patients with paralyzed or nonfunctional GI tract, or conditions that require bowel rest, such as small
bowel obstruction, ulcerative colitis, or pancreatitis
 Patients who have had nothing by mouth (NPO) for seven days or longer
 Critically ill patients
 Babies with an immature gastrointestinal system or congenital malformations
 Patients with chronic or extreme malnutrition, or chronic diarrhea or vomiting with a need for
surgery or chemotherapy
 Patients in hyperbolic states, such as burns, sepsis, or trauma
TPN is made up of two components: amino acid/dextrose solution and a lipid emulsion solution (see Figure
8.9). It is ordered by a physician, in consultation with a dietitian, depending on the patient’s metabolic
needs, clinical history, and blood work. The amino acid/dextrose solution is usually in a large volume bag
(1,000 to 2,000 ml), and can be standard or custom-made. It is often yellow in colour due to the
multivitamins it contains. The ingredients listed on the bag must be confirmed by the health care provider
hanging the IV bag. The solution may also include medication, such as insulin and heparin. The amino
acid/dextrose solution is reviewed and adjusted each day based on the patient’s blood work. Lipid emulsions
are prepared in 100 to 250 ml bags or glass bottles and contain the essential fatty acids that are milky in
appearance. At times, the lipid emulsion may be added to the amino acid/dextrose solution. It is then called
3 in 1 or total nutrition admixture (Perry et al., 2014).
TPN is prepared by a pharmacy, where the calories are calculated using a formula, and is usually mixed for
a 24-hour continuous infusion to prevent vascular trauma and metabolic instability (North York Hospital,
2013). TPN orders should be reviewed each day, so that changes in electrolytes or the acid-base balance can
be addressed appropriately without wasting costly TPN solutions (Chowdary & Reddy, 2010).
Figure 8.9 Types of TPN (amino acids and lipids)
Figure 8.10 TPN tubing with special filter
TPN is not compatible with any other type of IV solution or medication and must be administered by itself.
TPN must be administered using an EID (IV pump), and requires special IV filter tubing (see Figure 8.10)
for the amino acids and lipid emulsion to reduce the risk of particles entering the patient. Agency policy may
allow amino acids and lipid emulsions to be infused together above the filters. TPN tubing will not have any
access ports and must be changed according to agency policy. Always review agency policy on setup and
equipment required to infuse TPN.
A physician may order a total fluid intake (TFI) for the amount of fluid to be infused per hour to prevent
fluid overload in patients receiving TPN. It is important to keep track of all the fluids infusing (IV fluids, IV
medications, and TPN) in order to avoid fluid overload (Perry et al., 2014). Do not abruptly discontinue
TPN (especially in patients who are on insulin) because this may lead to hypoglycemia. If for whatever
reason the TPN solution runs out while awaiting another bag, hang D5W at the same rate of infusion while
waiting for the new TPN bag to arrive (North York Hospital, 2013). Do not obtain blood samples or central
venous pressure readings from the same port as TPN infusions. To prevent severe electrolyte and other
metabolic abnormalities, the infusion rate of TPN is increased gradually, starting at a rate of no more than
50% of the energy requirements (Mehanna, Nankivell, Moledina, & Travis, 2009).
Complications Related to TPN

There are many complications related to the administration of TPN (Perry et al., 2014). Table 8.8 lists
potential complications, rationale, and interventions.
Table 8.8 TPN Complications, Rationale, and Interventions

Complication Rationale and Interventions
CR-BSI, which starts at the hub connection, is the spread of bacteria through the
bloodstream. There’s an increased risk of CR-BSI with TPN, due to the high
dextrose concentration of TPN. Symptoms include tachycardia, hypotension,
elevated or decreased temperature, increased breathing, decreased urine output,
Catheter-related
and disorientation.
bloodstream infection
(CR-BSI), also known as
Interventions: Strict adherence to aseptic technique with insertion, care, and
sepsis
maintenance; avoid hyperglycemia to prevent infection complications; closely
monitor vital signs and temperature. IV antibiotic therapy is required. Monitor
white blood cell count and patient for malaise. Replace IV tubing frequently as
per agency policy (usually every 24 hours).
Due to poor aseptic technique during insertion, care, or maintenance of central
line or peripheral line
Localized infection at exit
or entry site Interventions: Apply strict aseptic technique during insertion, care, and
maintenance. Frequently assess CVC site for redness, tenderness, or drainage.
Notify health care provider of any signs and symptoms of infection.
A pneumothorax occurs when the tip of the catheter enters the pleural space
during insertion, causing the lung to collapse. Symptoms include sudden chest
pain, difficulty breathing, decreased breath sounds, cessation of normal chest
Pneumothorax movement on affected side, and tachycardia.
Interventions: Apply oxygen, notify physician. Patient will require removal of

central line and possible chest tube insertion.
An air embolism may occur if IV tubing disconnects and is open to air, or if part
of catheter system is open or removed without being clamped. Symptoms
include sudden respiratory distress, decreased oxygen saturation levels,
shortness of breath, coughing, chest pain, and decreased blood pressure.
Air embolism
Interventions: Make sure all connections are clamped and closed. Clamp
catheter, position patient in left Trendelenburg position, call health care
provider, and administer oxygen as needed.
Related to sudden increase in glucose after recent malnourished state. After
starvation, glucose intake suppresses gluconeogenesis by leading to the release
of insulin and the suppression of glycogen. Excessive glucose may lead to
hyperglycemia, with osmotic diuresis, dehydration, metabolic acidosis, and
ketoacidosis. Excess glucose also leads to lipogenesis (again caused by insulin
stimulation). This may cause fatty liver, increased CO2 production, hypercapnea,
Hyperglycemia
and respiratory failure.
Interventions: Monitor blood sugar frequently QID (four times per day), then
less frequently when blood sugars are stable. Follow agency policy for glucose
monitoring with TPN. Be alert to changes in dextrose levels in amino acids and
the addition/removal of insulin to TPN solution.
Refeeding syndrome Refeeding syndrome is caused by rapid refeeding after a period of malnutrition,
which leads to metabolic and hormonal changes characterized by electrolyte
shifts (decreased phosphate, magnesium, and potassium in serum levels) that
may lead to widespread cellular dysfunction. Phosphorus, potassium,
magnesium, glucose, vitamin, sodium, nitrogen, and fluid imbalances can be
life-threatening. High-risk patients include the chronically undernourished and
those with little intake for more than 10 days. Patients with dysphagia are at
higher risk. The syndrome usually occurs 24 to 48 hours after refeeding has
started. The shift of water, glucose, potassium, phosphate, and magnesium back
into the cells may lead to muscle weakness, respiratory failure, paralysis, coma,
cranial nerve palsies, and rebound hypoglycemia.
Interventions: Rate of TPN should be based on the severity of undernourishment

for moderate- to high-risk patients. TPN should be initiated slowly and titrated
up for four to seven days. All patients require close monitoring of electrolytes
(daily for one week, then usually three times/week). Always follow agency
policy. Blood work may be more frequent depending on the severity of the
malnourishment.
Signs and symptoms include fine crackles in lower lung fields or throughout
lung fields, hypoxia (decreased O2 sats).
Interventions: Notify primary health care provider regarding change in

Fluid excess or pulmonary
condition. Patient may require IV medication, such as Lasix to remove excess
edema
fluids. A decrease or discontinuation of IV fluids may also occur. Raise head of
bed to enhance breathing and apply O2 for oxygen saturation less than 92% or as
per agency protocol. Monitor intake and output. Pulmonary edema may be more
common in the elderly, young, and patients with renal or cardiac conditions.
Data source: Chowdary & Reddy, 2010; Mehanna et al., 2009; O’Connor, Hanly, Francis, Keane, &
McNamara, 2013; Perry et al., 2014
A patient on TPN must have blood work monitored closely to prevent the complications of refeeding
syndrome. Blood work may be ordered as often as every six hours upon initiation of TPN. Most hospitals
will have a TPN protocol to follow for blood work. Common blood work includes CBC (complete blood
count), electrolytes (with special attention to magnesium, potassium, and phosphate), liver enzymes (total
and direct bilirubin, alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline
phosphatase [ALP], gamma-glutamyl transferase [GGT], total protein, albumin), and renal function tests
(creatinine and urea). Compare daily values to baseline values, and investigate and report any rapid changes
in any values (Chowdary & Reddy, 2010; Perry et al., 2014). Table 8.9 outlines a plan of care when a patient
is receiving TPN.
Table 8.9 Assessment of a Patient with TPN

Assessment Additional Information
Intravenous line should remain patent, free from infection.
CVC/peripheral IV
Dextrose in TPN increases risk of infection. Assess for signs and symptoms of
line
infections at site (redness, tenderness, discharge) and systemically (fever, increased
WBC, malaise). Dressing should be dry and intact.
Daily or biweekly Monitor for evidence of edema or fluid overload. Over time, measurements will
weights reflect weight loss/gain from caloric intake or fluid retention.
QID (4 times a day) capillary blood glucose initially to monitor glycemic control, then
Capillary or serum reduce monitoring when blood sugars are stable or as per agency policy. May be done
blood glucose levels more frequently if glycemic control is difficult. Indicates metabolic tolerance to
dextrose in TPN solution and patient’s glycemic status.
Monitor and record every eight hours or as per agency policy. Monitor for signs and
symptoms of fluid overload (excessive weight gain) by completing a cardiovascular
and respiratory assessment. Assess intakes such as IV (intravenous fluids), PO (oral
Monitor intake and
intake), NG (nasogastric tube feeds). Assess outputs: NG (removed gastric content
output
through the nasogastic tube), fistula drainage, BM (liquid bowel movements),
colostomy/ileostomy drainage, closed suction drainage devices (Penrose or Jackson-
Pratt drainage) and chest tube drainage.
Review lab values for increases and decreases out of normal range. Lab values include
Daily to weekly
CBC, electrolytes, calcium, magnesium, phosphorus, potassium, glucose, albumin,
blood work
BUN (blood urea nitrogen), creatinine, triglycerides, and transferrin.
Most patients will be NPO. Proper oral care is required as per agency policy. Some
Mouth care
patients may have a diet order.
Vital signs Vital signs are more frequently monitored initially in patients with TPN.
Data source: BCIT, 2015a; Perry et al., 2014
TPN may be administered in the hospital or in a home setting. Generally, patients receiving TPN are quite ill
and may require a lengthy stay in the hospital. The administration of TPN must follow strict adherence to
aseptic technique, and includes being alert for complications, as many of the patients will have altered
defence mechanisms and complex conditions (Perry et al., 2014). To administer TPN, follow the steps in
Checklist 76.
Checklist 76: TPN Administration

 Compare the patient’s baseline vital signs; electrolyte, glucose, and triglyceride levels; weight; and
fluid intake and output with treatment values, and investigate any rapid change in such values.
 To identify signs of infection early, be aware of the patient’s recent temperature range.
 Use strict aseptic technique when caring for central venous catheters and PICC lines.
 Do not use TPN solution if it has coalesced, as evidenced by formation of a thick, dense layer of fat
droplets on its surface. If the solution appears abnormal in any way, request a replacement from the
pharmacy.
 Never try to catch up with a delayed infusion.

Check date and time of last TPN tubing change, lab
values, and expiry date of TPN to prevent medication
error.
1. Review physician’s orders and compare to MAR
and content label on TPN solution bag and for rate of Assess CVC, WBC, and patient for malaise.
infusion. Each component of the TPN solution must
be verified with the physician’s orders. Medications may be added to the TPN.
Ensure the rate of infusion is verified in the doctor’s

order each time new TPN bag is initiated.
Generally, new TPN tubing is required every 24
hours to prevent catheter-related bacteremia. Follow
agency policy.
2. Collect supplies, prepare TPN solution, and prime Ensure tubing is primed correctly to prevent air
IV tubing with filter as per agency protocol. TPN embolism.
requires special IV tubing with a filter.
TPN tubing with

special filter
3. Perform hand hygiene, identify yourself, and Hand hygiene prevents the spread of microorganisms.
identify patient using two patient identifiers.
Compare the MAR to the patient’s wristband. Explain Proper identification prevents patient errors.
the procedure to the patient.
Compare MAR to
patient wristband
4. Complete all safety checks for CVC as per agency This adheres to safety policies related to central line
policy. care.
5. If changing TPN solution, pause EID and remove
old TPN administration set. Disinfect connections Change TPN IV tubing as per agency policy. Use
and change IV tubing as per agency policy. strict aseptic technique with IV changes as patients
with high dextrose solutions are at greater risk of
If starting TPN for the first time, flush and disinfect developing infections.
CVC lumens as per agency policy.
6. Insert new TPN solution and IV tubing into EID. EID must be used with all TPN administration.
7. Start TPN infusion rate as per physician orders. Prevents medication errors.
8. Discard old supplies as per agency protocol, and
These steps prevent the spread of microorganisms.
perform hand hygiene.
9. Monitor for signs and symptoms of complications See Table 8.8 for list of complications related to
related to TPN. TPN.
10. Complete daily assessments and monitoring for See daily and weekly assessments in Table 8.9. Flow
patient on TPN as per agency policy. rate may be monitored hourly.
Note time when TPN bag is hung, number of bags,
and rate of infusion, assessment of CVC site and
11. Document the procedure in the patient chart as
verification of patency, status of dressing, vital signs
per agency policy.
and weight, client tolerance to TPN, client response
to therapy, and understanding of instructions.
Data source: North York Hospital, 2013; Perry et al., 2014
1. Describe refeeding syndrome and state one method to reduce the risk of refeeding syndrome.
2. A patient receiving TPN for the past 48 hours has developed malaise and hypotension. What
potential complication are these signs and symptoms related to?

8.9 Summary
Infusion therapy is a common treatment in the hospital setting, and vital for patient recovery. The safe
management of IV equipment and procedures related to IV therapy is an essential skill for safe patient care.
This chapter reviewed the skills necessary to care for a patient receiving IV therapy, and the benefits and
complications related to peripheral intravenous therapy, central venous catheters, blood and blood products,
and TPN.
Key Takeaways
 Use strict aseptic technique when preparing and maintaining all IV solutions and equipment. Most
complications related to IV therapy can be prevented.
 Be alert and vigilant, and assess for complications as per agency policy.
 Keep up to date with recommendations for safe care with IV therapy from the Centers for Disease
Control and Canadian Patient Safety Institute.
 There are many types of equipment and procedures related to IV therapy. Educate yourself on the
various types of equipment and devices to care for your patient safely.
 Receive the appropriate training for initiating IVs, CVC care and maintenance, and blood and blood
product transfusions.
 Remember that patients on IV therapy are at an increased risk for fluid overload. These patients
include the elderly, young, and those with cardiac and renal disease.
 Follow all transfusion policies to avoid transfusion errors. Be alert to the potential complications of
blood and blood product transfusions.
 Complete all daily assessments related to a patient receiving TPN. These patients are generally quite
ill and have a diminished ability to tolerate complications.
Suggested Online Resources

1. ATI Nursing Education: Blood administration. This module provides comprehensive information about
blood administration, including practice questions and step-by-step videos.
2. ATI Nursing Education: Intravenous therapy. This American-based online module covers all topics
related to IV therapy including definitions, a review of equipment, step-by-step videos, evidence-based
research, frequently asked questions, and quizzes.
3. Canadian Blood Services: Clinical guide to transfusion. These educational materials provide guidelines
for the care of patients receiving blood or blood products. This information includes blood administration,
adverse reactions, blood components, emergency transfusions, pediatric and neonatal transfusions, and
more.
4. Drug calculations. This medication calculation website reviews how to calculate the dosages for
parenteral and non-parenteral medications, and IV fluids. It also includes metric conversions and IV drop
rate calculations.
5. Fraser Health: Central venous catheters in adult patients. This self-learning online module is designed for
health care professionals and covers central venous catheter (CVC) care and maintenance.
6. Fraser Health: Peripheral intravenous initiation. This self-study online module covers initiating
intravenous (IV) therapy.
7. Intravenous fluid selection. This sample chapter from a textbook describes the selection of IV fluids and
solutions, and includes study questions as well.
8. Mosby’s Nursing Video Skills – Advanced. These Canadian-based online module with various videos and
procedure checklists related to IV therapy, central lines, blood and blood product transfusions, and TPN.
9. Nursing Made Incredibly Easy: The nurse’s quick guide to IV drug calculations. This article provides a
simple and concise way to perform accurate IV drug calculations.
References
Alberta Health Services. (2015a). Transfusion of blood and blood components. Retrieved on July 15, 2015,
from https://extranet.ahsnet.ca/teams/policydocuments/1/clp-prov-transfusion-blood-product-policy-ps-
59.pdf
Alberta Health Services. (2015b). Transfusion of blood and blood components — Acute adult. Retrieved on
July 15, 2015, from https://extranet.ahsnet.ca/teams/policydocuments/1/clp-prov-transfusion-blood-product-
adult-acute-procedure-ps-59-01.pdf
ATI. (2015). Discontinuing a peripheral intravenous line. ATI Nursing Education. Intravenous Therapy.
Retrieved on Oct 10, 2015 from http://atitesting.com/ati_next_gen/skillsmodules/content/iv-
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x?WT.mc_id=HPxADx20100319xMP
Fraser Health. (2007). Central venous catheters in adult patients. A self-learning module. Retrieved on Oct
10, 2015, from https://www.fraserhealth.ca/media/CentralVenousCatheters.pdf
Fraser Health Authority. (2014). Clinical practice guidelines: Intravenous therapy. Retrieved on July 2,
2015, from http://physicians.fraserhealth.ca/media/2014%2005%2015%20IV%20Therapy%20CPG
%20FINAL.pdf
Fulcher, E. M., & Fraser, M. S. (2007). Introduction to intravenous therapy for health professionals. St
Louis, MO: Elsevier.
Infusion Nurses Society. (2011). Infusion nursing standards of practice. Journal of Infusion Nursing, 34(1).
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short peripheral catheter site. Journal of infusion nursing, 35(5), 290 -292.
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prevention and management. Head and Neck Oncology, 1(4). doi: 10.1186/1758-3284-1-4
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O’Connor, A., Hanly, A. M., Francis, E., Keane, N., & McNamara, D. (2013). Catheter associated blood
stream infections in patient receiving parenteral nutrition: A prospective study of 850 patients. Journal of
Clinical Medical Research, 5(1),18-21. doi: 10.4021/jomr1032w
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2014). Clinical skills and nursing techniques (8th ed.). St
Louis, MO: Elsevier-Mosby.
Phillips, L. D. (2005). Manual of IV therapies. Philadelphia, PA: F.A. Davis Company.
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Chapter 8. Intravenous Therapy

 Define patient conditions