DEFINITION

It is an administrations of fluids,
electrolytes, nutrients or medications directly
into the vein.
DESCRIPTION OF PROCEDURE
• The provider prescribes the type of IV fluid,
volume, and the rate at which to infuse the IV.
• fluid , amount of time to infuse the fluid.
• The nurse regulates the IV infusion, either with
• an IV pump or manually.
• Nurses administer large‐volume IV infusions on a
continuous basis,
• A fluid bolus is a large amount of IV fluid to give in
a short time.
 ASSESSMENT
1. Determine physician’s order for IV therapy

LR
PNSS D5LR
2. Assess the patient’s need for psychological
support.

3. Assess the need for patient explanation

about IV therapy

4. Assess type and size of needle needed, IV

solution, site.

5. Assess the vein condition, ease of accsess

and the use of non dominant extremity.
 OBJECTIVES
1. To establish or maintain a fluid and electrolytes
balance.
2. Administer continuous or intermittent, and bolus
medications.
3. Administer fluid to keep vein open (KVO).
4. Administer blood or blood components
5. Administer intravenous IV anesthetic,
6. Maintain or correct patient’s nutritional status.
7. Administer diagnostic reagents.
8. Monitor hemodynamic functions.
INTRAVENOUS NURSING STANDARD OF PRACTICE

1. PRC- BON Resolution No. 8, 1994 issued the first Edition of

IV Standards on IV therapy.
2. RA 9173 ( Philippine Nursing Act of 2002) “ States that the
administration of oarenteral injection is included in scope of
nursing practice”.
3. Association of Nursing Service Administrations of the
Philippines, Inc (ANSAP) in collaboration with PRC BON.
4. Ensures a safe quality nursing practice in IV therapy in 2002.
IV PLACEMENT CHART
 TYPES OF IV SOLUTION
• ISOTONIC SOLUTION- a solution which has the same dissolved
particles with the plasma.

• HYPERTONIC SOLUTION – contains higher concentration of

solutes, causing the fluid out of the cell and cell shrink.

• HYPOTONIC SOLUTION- a solution with lower concentration of

solutes, causing a fluid to shift from intravascular to intracellular,
making the cell swell.
• ISOTONIC SOLUTION- For example: 0.9% NaCl,
• Uses: Extracellular fluids deficits with low serum levels of Na or chloride and metabolic
acid base imbalances.
• use before or after the infusion of blood products.
• PLR,
• Extracellular fluid deficits, such as fluid loss from burns, bleeding, and dehydrations from
loss of bile or diarhea.
• D5W.
• 5% dextrose in water : isotonic at the time of administration, w/in a short time after
administration dextrose is metabolized and the tonicity decreases in proportions to the
osmolarity or tonicity of the nondextrose components(electrolytes) within the water (may
become hypertonic)
• HYPERTONIC SOLUTION –For example: D5 0.9% NaCl,
• Uses= extracellular fluid deficits in clients with low serum levels of Na or chloride and
metabolic alkalosis
• D5 LR
• Use for extracellular fluid deficits , such as fluid loss from burns, bleeding
and dehydration from loss of bile or diarrhea.

• D5 0.225 % NS = isotonic at the time of administration, w/in a short time

after administration dextrose is metabolized and the tonicity decreases in
proportions to the osmolarity or tonicity of the nondextrose
components(electrolytes) within the water (may become hypertonic)

• HYPOTONIC SOLUTION-For example: 0.45% NaCl,

• Uses: use as initial fluid for hydartions because it probide more water than
the Na . Commonly used as maintenance fluid.

• 0.225% NaCl
Types of IV Solutions
1. Isotonic: 0.9% NaCl
PLR
D5W

2. Hypotonic: 0.45% NaCl

0.225% NaCl
types of IV solutions..
3. Hypertonic: D5 0.9% NaCl
D10W
D5LR
IV Cannula size

26G
IV Cannula size
 Complications of IV Therapy

1. Circulatory Overload
2. Air Embolism
3. Infection
4. Infiltration
5. Extravasation
6. Phlebitis/ Thrombophlebitis
7. Hematoma
Air embolism
Phlebitis
Infiltration
Extravasation
Hematoma
EQUIPMENT • IV TRAY:
• Alcohol swab
• Tourniquet
• Micropore
• IV solution
• Tubings
• Cannula
• Bandage scissors/ or electric shaver for
hair removal
• Clean gloves
• Infusion pump
Starter Kit
• IV Card
• Pentel Pen for calibration
• Splint or padded arm board
• Flashlight as needed
IV SET
gtts/min= amount of solutionx drop factor/ # of hrs x 60mins

cc/hr =Amount of solution/number of hours to infused

# of hours= amount of solution/cc/hour

NURSING ACTIONS
● Check the prescription (solution, rate).
● Assess for allergies to latex, tape, or iodine.
● Follow the rights of medication administration (including compatibilities of all IV
solutions).
● Perform hand hygiene.
● Examine the IV solution for clarity, leaks, and expiration date.
● Prime the tubing.
● Don clean gloves before insertion.
● Assess extremities and veins.
● Clip hair at and around the insertion site with scissors or shave it with an electric
shaver.
CLIENT EDUCATION
● Identify the client and explain the procedure.
● Place the client in a comfortable position.
INTRAPROCEDURE
NURSING ACTIONS
● Select the vein by choosing
◯ Distal veins first on the nondominant hand
◯ A site that is not painful or bruised and will not interfere with activity
◯ A vein that is resilient and has a soft, bouncy feeling
● Document in client’s medical record
◯ Date and time of insertion
◯ Insertion site and appearance
◯ Catheter size
◯ Type of dressing
◯ IV fluid and rate
◯ Number, locations, and conditions of previously attempted catheterizations
◯ The client’s response
Sample documentation: 1/16/2016, 1423, Inserted 22‐gauge IV catheter into right wrist cephalic vein
(one attempt); applied sterile occlusive dressing.
IV lactated Ringer’s infusing at 100 mL/hr per infusion pump without redness or edema at the site.
Tolerated without complications. L. Turner, RN
● Be sure to document thoroughly and accurately throughout the client’s course of IV therapy.
POSTPROCEDURE
NURSING ACTIONS: Maintain the patency of IV access.
● Do not stop a continuous infusion or allow blood to back up into the
catheter for any length of time. Clots can form at the tip of the needle or
catheter and can lodge against the vein’s wall, blocking the flow of fluid.
● Instruct clients not to manipulate flow rate device,
change settings on IV pump, or lie on the tubing.
● Make sure the IV insertion site’s dressing is not
too tight.
● Flush intermittent IV catheters with the solution the
facility specifies after every medication administration
or every 8 to 12 hr when not in use.
● Monitor the site and infusion rate at least every hour.
 STEPS RATIONALE
1. State the definition,
objective and
enumerate general
considerations .

2. Enumerate needed To safe, time, effort

equipment. and energy.

3. Identify patient and To gain patient’s

inform him/her of cooperation.
the procedure and its
purpose.
 STEPS RATIONALE
4. Re-check doctor’s To avoid error.
order from the chart
and kardex.

5. Examine intravenous
solutions to be
infused, as to the
name of solution,
expiry date.
 STEPS RATIONALE
6. Wash hands and To reduce the risk of
assemble all cross contamination.
equipment, bring
to IV room or at
patient’s bedside.

7. Prepare IV solutions
for infusion.

A. Aseptically To maintain sterility

remove the
covering of IV
container.
 STEPS RATIONALE
B. Close the control To eliminate air
clamp or regulator of bubbles that may cause
IV tubing and air emboli in the
connect it to the circulatory system.
ordered solution.
C. Invert the IV This action maintains
container and hang sterility before
it to the IV stand. infusion is establish.
Fill 1/3 of drip
chamber by slightly
squeezing it.
 STEPS RATIONALE
Remove covering of To keep the tip sterile.
tubing tip and open the
regulator control and
flush or prime tubing of
air, then re-clamp and
cover again the tubing
tip.

8. Place patient in To prevent discomfort

comfortable position and to have a good view
and expose the site to of site to be punctured.
be punctured. Adjust
lighting as necessary.
 STEPS RATIONALE
9. Offer tourniquet to the Application of tourniquet
physician. is highly recommended to
be done as soon the
provider has select the
best vein for IV insertion.
It is used to raise the vein
so it doesn’t collapse.
However, the longer the
tourniquet is applied the
higher the risk for tissue
damage due to insufficient
blood flow which may lead
to blood clot formations.
 STEPS RATIONALE
10. Physician determines
or select which vein
to be punctured as
she/he tightens the
tourniquet.

11. Request patient to By contracting the

open & close fist to muscle, blood is forced
palpate and distends into the veins.
vein for injection.
 STEPS RATIONALE
12. Open and give the To decrease endogenous
alcohol swab to the and exogenous
physician to disinfect organism at the
site to be punctured. venipuncture site.

13. Remove cover of

infusion needle and
give to the physician.
(ensure sterility of the
needle at all times)
 STEPS RATIONALE
14. When needle is
inserted and backflow
of blood is seen,
release tourniquet,
connect IV tubing to
the needle hub.
Open regulator
to allow the
solution to flow.
plaster.
15. Dry skin around
Drying the skin will
area of puncture
make the adhesive
and anchor needle
tape
by applying stripe
adhere more to the
of adhesive tapes/
skin.
plaster.
16. Apply padded arm Putting splint will allow
splint and anchor to some movement for
immobilize and patient altering the
maintain position of solution’s flow and
the needle. prevent needle from
being dislodged.

17. Regulate and calibrate Regulating and

flow rate of solution. monitoring solution’s
Indicating name of flow will prevent
drug incorporated, overloading and ensure
the time the that the patient received
solution is stated the specified amount of
and expected to IV fluids as ordered.
consume
 STEPS RATIONALE
and the number of
drops or cc ordered to
flow.
Although it is the
18.Give instruction to the responsibility of the nurse
patient or watcher to monitor patient
when to call the receiving IV fluids, giving
attention of nurse a clear to patient is also
immediately. necessary.
A. Change inflow rate
B. When site of
needle is bulging
 consumed
19. Make patient
comfortable and
return equipment to
proper places.
20. Evaluate and
document patient’s
reaction to IV insertion
and the type

Regulating and
monitoring solution’s
flow will prevent
overloading and ensure
that the patient received
the specified amount of
IV fluids as orderedand
Regulating and
monitoring solution’s
flow will prevent
overloading and ensure
that the patient received
the specified amount of
IV fluids
EVALUATION :
1. IV site is prepared appropriately.
2. IV therapy is initiated without difficulty.
fluids, additives and medications as
administered without adverse effects on
the patient.
3. IV site remains free from redness, edema
and purulent drainage.
4. IV infusion rate is accurately calculated ad
reassessed throughout the therapy.
5. IV therapy is discontinued without
complications.