RETURN DEMONSTRATION (NCMA 113)

IVT INFUSION 1. How long client is likely to have IV

Note: Before preparing infusion, verify 2. Kinds of fluid to be infused
primary care provider’s order: 3. Medication client is receiving
- Type of solution to be administered - Review clients record regarding
- Rate of flow/time the infusion to be previous infusion. Note for any
completed complications and how it is
- Any client’s allergies managed.
- Consider using local anesthetics to
PURPOSE reduce pain & discomfort during
- Supply fluid for clients unable to catheter insertion.
take adequate fluid volume orally
- Provide salts & other electrolytes to EQUIPMENT
maintain electrolyte balance - Substitute appropriate equipment for
- Provide water-soluble vitamins & clients with tape, iodine or latex
medication allergies
- Provide dextrose for metabolism ● Infusion set
- Establish lifeline for rapidly needed ● Extension tubing (optional)
medications ● Sterile parenteral solution
● IV pole
ASSESSMENT ● Non Allergenic tape
- Vital signs for baseline of data ● Clean gloves (Sterile is needed for
(RR,PR, & BP) site palpation after skin antisepsis)
- Allergies to latex, tape or iodine ● Single-used and latex free tourniquet
- Bleeding tendencies ● Antiseptic swab (10%
- Disease/injury of extremities povidone-iodine, 2% chlorhexidine
- Status of veins gluconate with alcohol [preferred for
Note: Avoid recently used sites because it is its residual effect lasting for 48hr], or
prone to complications & discomfort. 70% isopropyl alcohol
- Determine client’s dominant hand ● IV catheter with passive system
Note: If venous sites are not found do not do mechanism
blind venipuncture or use vascular Rationale: automatically retracts
visualization method needle to avoid needlestick injury.
- Agency policy about hair clipping #20&#24 gauge for adult clients.
the area before a venipuncture Choose appropriate type and size
Note: It is not recommended for possible based on size of the vein and purpose
scratch or following infection. of IV. Always have extra catheter
with ones in different sizes available
PLANNING ● Stabilization device
Factors that may affect choice of vein & size ● IV protection device
of catheter
 RETURN DEMONSTRATION (NCMA 113)

● Sterile gauze dressing/Transparent limb site to be used still providing

semipermeable membrane dressing privacy.
(preferred) 4. Apply a medication label to the
● Towel/bed protector solution bottle if medication is
● Local anesthetics (optional & per needed. If not applied, put it upside
agency policy) down on the container.
● Splint (if required) Rationale: can be easily read when
● Vein visualization device (if needed) the container is hanging up.
● Electronic infusion device or pump 5. Open & prepare the packaging of the
(if applicable) infusion set & straighten it out. Slide
tubing clamp below drip chamber &
IMPLEMENTATION close the clamp. Leave ends of
PREPARATION tubing covered with plastic caps until
1. Select time to perform venipuncture the infusion starts.
convenient to the client. If urgent, Rationale: Keep the sterility of
provide scheduled care before both ends of tubing
infusion establishment to minimize 6. Spike solution container by
excessive movement of affected removing the protective cover of the
limb. bag, removing the cap of the spike
Rationale: Moving affected limb after and insert the spike at the insertion
infusion establishment can remove site
catheter. 7. Hang the solution in the pole and
2. Make sure client’s gown or clothing adjust the pole for about 1 cm (3ft)
can be removed over the IV above client’s head.
apparatus. Rationale: enable gravity to
3. Visitors/family members may be overcome venous pressure and
asked to leave if desired by nurse or facilitate flow of the solution into
client. the vein.
8. Partially fill drip chamber by
PERFORMANCE squeezing the chamber until half full
1. Introduce self, verify client’s solution.
identity, explain procedure, why it is Rationale: prevent air from
necessary and how client will moving down the tubing.
participate. If possible, explain how 9. Prime tubing by removing the
long the IV will remain & how it will protective cap holding tubing over a
be used container and releasing the clamp.
2. Hand hygiene & other infection Let the fluid run through the tubing
prevention procedures until all bubbles are removed. Tap
3. Place client in a comfortable position the tubing if necessary with fingers
whether sitting or lying. Expose the
 RETURN DEMONSTRATION (NCMA 113)

to help the bubbles move. Reclamp 15. Apply clean gloves and clean the
the tubing and replace tubing cap venipuncture site.
Rationale: prevent the introduction of air Rationale: Gloves protect the nurse from
into the client contamination by the client’s blood.
10. Hand hygiene - Clean the skin with soap and water if
11. Select venipuncture site visibly soiled. Remove excess hair if
- Use non dominant arm, look for necessary using scissor or surgical
relatively straight and palpable veins, clippers.
site sufficiently distal to the wrist or - chlorhexidine solution (preferred),
elbow such that the tip of the use a backand-forth motion for 30
catheter will not be at a point of seconds to scrub the insertion site
flexion and surrounding area. Allow the site
Rationale: Joint flexion can increase risk to completely air dry before inserting
of irritation of vein walls by the catheter. the catheter. Do not fan, blow on, or
- Choose the site most likely to last the wipe the skin
full length of the IV therapy, which - povidone-iodine, apply using
most likely will be using a vein in applicator and allow to remain on the
the forearm skin for 1.5 to 2 minutes or longer to
- Check agency protocol about completely dry for adequate
shaving if the site is very hairy antisepsis
12. Dilate the vein by placing extremity 16. Reapply a tourniquet or use vein
in a dependent position (lower than visualization technology, if needed.
the client’s heart). - If vein palpation is necessary after
Rationale: Gravity slows venous return application of skin antiseptic, apply
and distends the veins. Distending the sterile gloves.
veins makes it easier to insert the needle 17. Insert the catheter and initiate the
properly infusion.
- Apply a tourniquet 15 to 20 cm (6 to - Remove the catheter assembly from
8 in.) above the venipuncture site. its sterile packaging. Review
Rationale: The tourniquet must be tight instructions. Remove the cover of the
enough to obstruct venous flow but not needle (stylet).
too much that it obstructs arterial flow. - Use the nondominant hand to pull
Obstructing arterial flow inhibits venous the skin taut below the entry site
filling. If a radial pulse can be palpated, Rationale: stabilizes the vein and makes
the arterial flow is not obstructed. the skin taut for needle entry, make initial
13. Remove the tourniquet while tissue penetration less painful.
preparing the insertion site - Holding the over-the-needle catheter
14. Minimize insertion pain as much as at a 15- to 30-degree angle with
possible by Transdermal analgesic needle (stylet) bevel up, insert the
creams
 RETURN DEMONSTRATION (NCMA 113)

catheter through the skin and into the the hub with the thumb and index
vein finger of the nondominant hand.
- Once blood appears (backflow) - Remove the protective cap from the
lower the angle of the catheter until distal end of the tubing and hold it
it is almost parallel with the skin, and ready to attach to the catheter
advance the needle (stylet) and - Stabilize the catheter hub and apply
catheter approximately 0.5 to 1 cm pressure distal to the catheter with
(about 1/4 in.) farther into the vein your finger
Rationale: catheter is advanced to ensure Rationale: This prevents excessive blood
that it, and not just the stylet, is in the flow through the catheter
vein - remove the stylet, engage the needle
- No backflow, try redirecting the safety device if it does not engage
catheter assembly again toward the automatically, and attach the end of
vein. If the stylet has been the infusion tubing to the catheter
withdrawn from the catheter even a hub
small distance, or the catheter tip has - Initiate the infusion or flush the
been pulled out of the skin, must be catheter with sterile normal saline.
discarded and a new one used. Rationale: Blood must be removed from
Rationale: Rationale: Reinserting can Otherwise, the blood will clot inside the
result in damage or slicing of the catheter. lumen.
A catheter removed from the skin is - Stabilize the catheter and apply a
considered contaminated and cannot be dressing by securing the catheter
reused according to the manufacturer’s
- hematoma, the insertion has not been instructions and agency policy. If
successful. Immediately release the tape is used, it must be sterile tape or
tourniquet, remove the catheter, surgical strips and they should be
applying pressure over the insertion applied only to the catheter adapter
site with dry gauze. Attempt the and not placed directly on the
venipuncture in another site, in the catheter–skin junction site. Use of a
opposite arm if possible manufactured stabilization device is
Rationale: Placing the tourniquet back preferred
above the unsuccessful site may cause it to - Apply a TSM dressing over the
bleed. Placing the IV below the insertion site. Additional tape may be
unsuccessful site could result in infusing used to secure the IV catheter below
fluid into the already punctured vein, the TSM, if necessary. Do not place
causing it to leak. tape on the TSM dressing
- Release the tourniquet and put - Label the dressing with the date and
pressure on the vein proximal to the time of insertion, gauge, and your
catheter to eliminate or reduce blood initials
oozing out of the catheter. Stabilize
 RETURN DEMONSTRATION (NCMA 113)

- Apply an IV site protection device, if appropriate; type, length, and gauge

available. help prevent dislodgement of the needle or catheter;
of the catheter and still provide easy venipuncture site, how many
assessment of the IV site attempts were made, amount and
- Loop the tubing and secure it with type of solution used, including any
tape additives (e.g., kind and amount of
Rationale: prevent the weight of the medications); flow rate; the type of
tubing or any movement from pulling on dressing applied; the client’s general
the needle or catheter. response; and client education.
18. Discard the tourniquet, remove and
discard gloves, perform hand IVT DISCONTINUING
hygiene PURPOSE
19. Ensure appropriate infusion flow, - discontinue an IV infusion when the
apply a padded arm board to splint therapy is complete or when the IV
the joint if needed, adjust the site needs to be changed
infusion rate of flow according to the ASSESSMENT
order - Appearance of the venipuncture site
20. Label the IV tubing with the date and - Any bleeding from the infusion site
time of attachment and your initials - Amount of fluid infused
Rationale: The tubing is labeled to ensure - Appearance of short peripheral
that it is changed at regular intervals catheter
21. complete the following client PLANNING
teaching: - Review the client record regarding
- Any limitations as to movement or the primary care provider’s orders.
mobility and protection of the site Note if there were any previous
- Signs and symptoms to report to the infusions and if there were any
nurse complications and how they were
- Alarms if an electronic infusion managed.
device is being used EQUIPMENT
- Infection prevention precautions, - Clean gloves
including hand hygiene by all - Linen-saver pad
healthcare providers who provide - Small sterile dressing and tape
care IMPLEMENTATION
1. Introduce self, verify client’s
22. Document all assessments and identity, explain procedure, why it is
interventions necessary and how client will
- Record the venipuncture on the participate. If possible, explain how
client’s chart.Include the date and long the IV will remain & how it will
time of the venipuncture; use of be used
visualization technology as
 RETURN DEMONSTRATION (NCMA 113)

2. Hand hygiene & other infection …Teach client to inform the nurse if the site
prevention procedures begins to bleed at any time or any other
3. Place client in a comfortable position abnormalities in the area
sitting or lying. Expose IV site, 6. Examine the catheter removed from
provide for client privacy. Place a the client make sure it is intact…
linen saver pad under the extremity Rationale: If a piece of tubing remains in
that has the IV. the client’s vein it could move centrally
4. Prepare the equipment by clamping (toward the heart or lungs)
the infusion tubing… …Report a broken catheter to the nurse in
Rationale: prevents the fluid from flowing charge or the primary care provider
out of the needle onto the client or bed immediately. If a broken piece can be
…Apply clean gloves, remove the dressing, palpated, apply a tourniquet above the
stabilization device, and tape at the site insertion site.
while holding the needle firmly and Rationale: Application of a tourniquet
applying countertraction to the skin… decreases the possibility of the piece
Rationale: Countertraction prevents moving until a primary care provider is
pulling the skin and causing discomfort. notified
… Assess the vascular access site… 7. Cover the venipuncture site by
Rationale: signs of infection or phlebitis applying new sterile dressing to the
…Apply the sterile gauze above access site site with tape…
with the nondominant hand. Only touch the Rationale: The dressing continues the
upper portion of the gauze pad pressure and covers the open area in the
5. Withdraw the catheter from the vein skin, preventing infection.
with the dominant hand by pulling it … Discard used supplies appropriately,
out along the line of the vein using remove and discard gloves, perform hand
gentle, even pressure hygiene
Rationale: avoids injury to the vein. Do 8. Read the amount remaining in the IV
not press down on the sterile gauze pad solution container.
while removing the catheter 9. Apply a black-out label over the
… immediately apply firm pressure to the existing IV solution label prior to
site, using sterile gauze, for a minimum of discarding the IV solution into a
30 seconds or until hemostasis is achieved… biohazard container
Rationale: Pressure helps stop the Rationale: The existing IV label contains
bleeding and prevents hematoma client information. The black-out label
formation conceals client information and ensures
…Hold client’s arm above heart level if any client confidentiality. These labels are
bleeding persists… called IV HIPAA-compliant labels.
Rationale: decreases blood flow to the 10. Document all relevant information.
area Record:
 RETURN DEMONSTRATION (NCMA 113)

- amount of fluid infused on - In some agencies, written consent for

the intake and output record transfusion is required. Check policy
and in the record and obtain as indicated.
- container number, type of - Know the purpose of the transfusion.
solution used, time of - Plan to begin the transfusion as soon
discontinuing the infusion, as the component is ready. Typing
and the client’s response. and crossmatching can take several
hours.
BLOOD TRANSFUSION USING Y-SET - Note any premedication ordered by
PURPOSE the primary care provider
- restore blood volume after severe
hemorrhage EQUIPMENT
- restore the oxygen-carrying capacity - Unit of whole blood, PRBCs, or
of the blood other component
- provide plasma factors, such as - Blood administration set
antihemophilic factor (AHF) or - IV pump, if needed (use EIDs that
factor VIII, or platelet concentrates, have a labeled indication for blood
which prevent or treat bleeding transfusion)
ASSESSMENT - 250 mL normal saline for infusion •
- Vital signs; oxygen saturation is IV pole
often included - Venipuncture set containing a #20- to
- Physical examination: fluid balance #24-gauge catheter (if one is not
and heart and lung sounds as already in place)
manifestations of hypo- or - Alcohol swabs
hypervolemia - Tape
- Status of infusion site and patency of - Clean gloves
vascular access device
- Blood test results such as IMPLEMENTATION
hemoglobin value or platelet count ● If the client has an IV solution
- Any unusual symptoms infusing, check whether the IV
catheter and solution are appropriate
PLANNING to administer blood
- Review the client record previous ● If the client does not have an IV
transfusions. Note any complications solution infusing,infusion must be
and how they were managed running before the blood is obtained
- Confirm the primary care provider’s from the blood bank. you will need
order (number and type of units and to perform a venipuncture on a
the desired speed of infusion) suitable vein and start an IV infusion
of normal saline
 RETURN DEMONSTRATION (NCMA 113)

● Obtain assistance of another RN to tubing with saline, Close both

perform client and blood clamps
identification process 6. Start the saline solution
1. Introduce self, verify the client’s - If an IV solution
identity, explain what you are going incompatible with blood is
to do, why it is necessary, and how to infusing, stop the infusion
participate. Instruct the client to and discard the solution and
report any sudden chills, nausea, tubing
itching, rash, dyspnea, back pain, or - Attach the blood tubing
other unusual symptoms primed with normal saline to
2. Prepare the client by assisting to a the IV catheter
comfortable position, either sitting or - Open the saline and main
lying. Expose the IV site but provide flow rate clamps and adjust
for client privacy. the flow rate. Use only the
3. hand hygiene and other appropriate main flow rate clamp to
infection prevention procedures adjust the rate
4. Prepare the infusion equipment by - Allow a small amount of
ensuring that the blood filter inside solution to infuse to make
the drip chamber is suitable for the sure there are no problems
blood components to be transfused. with the flow or with the
Attach the blood tubing to the blood venipuncture site.
filter, if necessary… Rationale: Infusing normal saline before
Rationale: allow the blood components initiating the transfusion also clears the
through easily but are designed to trap IV catheter of incompatible solutions or
clots. medications
… Apply gloves, close all the clamps on the 7. Obtain the correct blood component
Y-set: the main flow rate clamp and both for the client
Y-line clamps, insert the piercing pin (spike) - Check the primary care provider’s
into the saline solution, hang the container order with the requisition.
on the IV pole about 1 m (39 in.) above the - Check the requisition form and the
venipuncture site. blood bag label with a laboratory
5. Prime the tubing by opening the technician or according to agency
upper clamp on the normal saline policy. Specifically, check the
tubing ,squeeze the drip chamber client’s name, identification number,
until it covers the filter and one-third blood type and Rh group, the blood
of the drip chamber above the filter, donor number, and the expiration
Tap the filter chamber to expel any date of the blood. Observe the blood
residual air in the filter, Open the for abnormal color, RBC clumping,
main flow rate clamp, and prime the gas bubbles, and extraneous material.
 RETURN DEMONSTRATION (NCMA 113)

Return outdated or abnormal blood bubbles, cloudiness, clots or

to the blood bank. clumps, or loss of integrity of
- With another nurse and in the the container.
presence of the client, verify the - If any of the information does not
following before initiating the match exactly, notify the charge
transfusion: nurse and the blood bank. Do not
● Order: blood or component administer blood until discrepancies
against the primary care are corrected or clarified.
provider’s written order - Sign the appropriate form with the
● Transfusion consent form: other nurse according to agency
Ensure the form is completed policy.
per facility policy. - Make sure that the blood is left at
● Client identification: The room temperature for no more than
name and identification 30 minutes before starting the
number on the client’s transfusion.
identification band must be Rationale: As blood components warm,
identical to the name and the risk of bacterial growth also increases.
number attached to the unit If the start of the transfusion is
of blood. unexpectedly delayed, return the blood to
● Unit identification:unit the blood bank after 30 minutes. Do not
identification number on the store blood in the unit refrigerator.
blood container, the Rationale: temperature of unit
transfusion form, and the tag refrigerators is not precisely regulated
attached to the unit must and the blood may be damaged.
agree. 8. Prepare the blood bag by inverting
● Blood type: The ABO group the blood bag gently several times to
and Rh type on the primary mix the cells with the plasma…
label of the donor unit must Rationale: Rough handling can damage
agree with those recorded on the cells.
the transfusion form. …Expose the port on the blood bag
● Expiration: expiration date by pulling back the tabs, insert the
and time of the donor unit remaining Y-set spike into the blood bag.
should be verified as 9. Establish the blood transfusion by
acceptable. closing the upper clamp below the
● Compatibility: compatibility IV saline solution container, open the
testing must be recorded on upper clamp below the blood bag.
the transfusion form and on The blood will run into the
the tag attached to the unit. saline-filled drip chamber. If
● Appearance: no necessary, squeeze the drip chamber
discoloration, foaming, to reestablish the liquid level with
 RETURN DEMONSTRATION (NCMA 113)

the drip chamber one-third full. (Tap no signs of a reaction, establish the
the filter to expel any residual air required flow rate. Most adults can
within the filter.), Readjust the flow tolerate receiving 1 unit of blood in
rate with the main clamp, 1.5 to 2 hours. Do not transfuse a
- Remove and discard gloves unit of blood for longer than 4
- Perform hand hygiene hours. If the client has a reaction and
10. Observe the client closely for the the blood is discontinued, send the
first 15 minutes. blood bag and tubing to the
- start the transfusion slowly at laboratory for investigation of the
approximately 2 mL per minute for blood
the first 15 minutes, and remain 13. Terminate the transfusion
near the patient; increase the - Apply clean gloves.
transfusion rate if there are no signs - no infusion is to follow, clamp the
of a reaction blood tubing. If another transfusion
Rationale: small amount is enough to is to follow, clamp the blood tubing
produce a severe reaction, could be and open the saline infusion arm.
treated successfully - If the primary IV is to be continued,
- Note adverse reactions, such as flush maintenance line with saline
chills, nausea, vomiting, skin rash, solution. Disconnect the blood
dyspnea, back pain, or tachycardia. tubing system and reestablish the IV
Rationale: The earlier a transfusion infusion using new tubing. Adjust
reaction occurs, the more severe it tends the drip to the desired rate.
to be. Promptly identifying such reactions - Measure vital signs.
helps to minimize the consequences. 14. Follow agency protocol for
- Remind the client to call a nurse appropriate disposition of the used
immediately if any unusual supplies.
symptoms are felt during the - Discard the administration set
transfusion according to agency practice:
- If any reactions occur, report them to ❖ Dispose of blood bags and
the nurse in charge, and take administration sets. fill in the
appropriate nursing action time the transfusion was
11. Document relevant data. completed and the amount
- starting the blood, including vital transfused.
signs, type of blood, blood unit ❖ Attach one copy of the requisition to
number, sequence number, site of the client’s record and another to the
venipuncture, size of the catheter, empty blood bag
and drip rate. ❖ Agency policy generally involves
12. Monitor the client returning the bag to the blood bank
- 15 minutes after initiating the for reference in case of subsequent or
transfusion check the vital signs. If delayed adverse reaction.
 RETURN DEMONSTRATION (NCMA 113)

- Remove and discard gloves

- Perform hand hygiene.
15. Record completion of the
transfusion, amount of blood
absorbed, the blood unit number, and
the vital signs. If the primary IV
infusion was continued, record
connecting it. Also record the
transfusion on the IV flow sheet and
intake and output record.