IV MaintenanceThis section covers the proper way to assess a clients IV site. Correctly assessing and maintaining an IV site is crucial to providing the best care possible to every client. For your return demonstration you will be asked not only to inspect the solution being infused and the IV tubing, but also to assess for signs of complications related to IV therapy such as infection, infiltration, and phlebitis.
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Inspecting the IV Fluid
When inspecting a clients IV fluid, there are several things as a nurse that you need to do while assessing the client's IV fluids. Listed below are key guidelines that you should keep in mind when performing your assessment.
- Always check the physician's order for the IV solution that is being administered to the client.
- Documentation in today's hospitals is almost exclusively done with computers, so as the nurse identify that this is the correct patient and medication, check the time at which the solution was hung, and the nurse who began the infusion. The same process would be followed if checking a written MAR.
- Check the ordered infusion rate and volume to be infused in the MAR against what the current infusion. Most infusions are completed with IV pumps, which will give you the current rate and the volume left to be infused. However, there may be a case where a pump is not available and you as the nurse will need to verify the rate manually.
- Ensure that the solution is clear with no particles floating freely in the solution.
- The drip chamber should be half full with fluid and should be dripping.
Inspecting the IV tubing and Site
Ensuring the IV tubing is patent is key in successful IV therapy. Below are the guidelines for inspecting your client's IV tubing
- The IV tubing should have a label on it that tells you the date and time when the use of the IV tubing was started. In a majority of hospitals the guideline for changing IV tubing is every 72 hours. However, recently this timeframe has been increased to 96 hours. As a nurse, ensure that you know your hospital policy on the duration of IV tubing.
- If the tubing is expired, discard the old tubing and acquire new tubing. Get a IV tubing label and mark with the date and time at which you initiated the new line, and your initials.
- Ensure the roller clamp is fully open if you are using an IV pump. If not, this will control your client's IV infusion rate.
- Ensure that there are no kinks or leaks in the tubing and that the line is free from obstructions.
- Check to ensure that there is no air in the IV tubing. If so, remove the air from the line according to agency protocol and resume the infusion.
- Check the IV site. Make sure that there is a vaso-occlusive dressing that covers the IV site and that it is labeled with the date and time of IV start.
- IV sites are considered to be good for 72 hours before they are discontinued. Some agency policy may be different, so ensure that you know the guidelines you are to follow.
- If the IV is not attached to a current running infusion and you want to ensure the site is still useable, you can clean the port with an alcohol pad and inject 3-10 ml of 0.9% normal saline to ensure the site is still patent.
IV Site Complications
IV Infection
Although infection is not as common as other forms of IV complications, you are still breaking the patients skin, which automatically increases the chances of an infection. Bacteria exist on the skin that can easily enter through the insertion site around the catheter. IV site infection is usually a localized event but can progress to a condition such as septicemia, which is a systemic infection caused by a bacterial infection in the blood. Generally peripheral IV lines do not progress to these levels because of their short life span of only 72 hours. However, central lines such as PICC lines can cause these types of systemic infections.
Signs and Symptoms of IV Site Infection are:
Signs and Symptoms of IV Site Infection are:
- Reddened area around the site
- Swelling
- Site warm to touch
- Purulent drainage
- Pain
- Fever
IV Infiltration/Extravasation
Infiltration occurs when an IV fluid or medication accidentally enters the surrounding tissue rather than the vein. It is also known as extravasation (which refers to something escaping the vein). It may occur when the vein itself ruptures (the elderly are particularly prone to fragile veins due to a paucity of supporting tissues), where the vein is damaged during insertion of the intravascular access device or the device is not sited correctly or where the entry point of the device into the vein becomes the path of least resistance (e.g. if a catheter is in a vein for some time, the vein may scar and close and the only way for fluid to leave is along the outside of the cannula where it enters the vein). The IV must be removed from the client if infiltration occurs.
Signs and Symptoms of IV Infiltration/Extravasation are:
Signs and Symptoms of IV Infiltration/Extravasation are:
- Skin around IV site is cool to the touch
- Skin has a noticeable pallor
- Localized swelling or edema
- Localized tissue damage can be seen depending on the medication and its properties.
IV Phlebitis
Phlebitis is inflammation of a vein that may be caused by infection, the mere presence of a foreign body (the IV catheter) or the fluids or medication being given. Phlebitis can follow and infusion, but it is most common after continuous infusions, developing 2 to 3 days after the vein is exposed to the drug or solution. It develops more rapidly in distal veins than in veins closer to the heart. If phlebitis occurs, the IV device must be removed from the client, and if necessary, reinserted into another extremity.
Signs and Symptoms of Phlebitis are:
Signs and Symptoms of Phlebitis are:
- Reddened color of the vein
- Vein becomes hard
- Swelling of the vein
- Tenderness or pain over the vein