Nursing Implications for IV Infusion and IV Medication Administration
Complications of IV
Occurs when IV fluid enters the SQ space, can range from mild to severe,
is usually due to catheter dislodgement, and manifestations include swelling,
pain, cool skin, pallor, and decreased flow in gravity
implications include discontinuing the IV, elevate the extremity, warm
compresses (depending on the medication infiltrated) to the affected site,
notify the MD, and restart the IV in the opposite extremity or above the
- Phlebitis: Inflammation of the vein caused by a
chemical irritant or a mechanical irritant (catheter). The wrist is the most common site for
phlebitis. Manifestations include
pain, redness/hardness along the vein path, warmth at the IV site, and can
progress to thrombophlebitis. The
IV site will need to be discontinued and restarted in the opposite
- Infection/Septicemia: Direct entrance into circulatory system
of microorganisms due to poor skin prep, poor asepsis, and prolonged
catheter dwell time. Manifestations
include fever/chills, drainage at the IV site, warmth to touch. Nursing implications include notifying
the MD, discontinuing the IV site (catheter tip may need to be cultured),
and patient may be placed on antibiotic therapy.
reactions: Usually related to latex
or medications and is manifested by itching, teary eyes, wheezing, edema,
rash, and shortness of breath.
Nurses should STOP the infusion, maintain airway, notify MD, and
stay with the patient monitoring VS.
IV Flow Rates: It is critical to monitor IV flow rates. Too fast can cause fluid volume excess and
too slow can cause cardiac/circulatory collapse. Always use a pump if possible, especially in
patients with congestive heart failure, renal failure, and pediatrics
(buretrols) to prevent overload. Table
5-1 highlights the common signs and symptoms associated with fluid volume
excess as well as the nursing implications:
Table 5-1 Fluid Volume Excess
Signs and Symptoms
Shortness of breath (SOB)
Elevate head of bed (HOB)
Intake greater than output
Infusion: IV infusions are closed
systems and are sterile, therefore nurses should remember when handling IV
tubing and solutions to wash hands, use gloves and alcohol wipes. General time frames for tubing changes are
noted on page 1004 of skills book.
Nurses should check institutional policy as well. Additional nursing care will include:
the patient in self care (changing the gown; procedure on page 1017 of
skills book) to prevent disruption of the closed system.
the patient the signs and symptoms of infiltration: pain, swelling,
redness, and warmth at the site.
administering IV fluids via a pump, the rate in ml/hr must be entered.
an in-service on the pump at the facility to ensure safety
to follow the 5 + 1 rights with +1 referring to documentation, write it!
the correct dilution
familiar with adverse affects/side effects
antidote nearby if applicable
current IV drug guide should always be consulted prior to giving an IV
there is not a current IV drug guide available, consult the pharmacist. Note incompatibilities.
of IV medication is within the scope of practice of LVNs in most states
(know the institutional policy as well).
and administering IV medications are sterile procedures and introduction
of bacteria into the bloodstream can lead to FATAL consequences.
filter needles when drawing up medications with sharps or from ampules.
of IV site is a pre-requisite to all IV medication administration.
incompatible solutions or medications must never come in contact with one
another in an IV line.
- KCl is
incompatible with many medications.
in doubt about compatibility flush, flush, flush with NS.
use ccs/hr not gtts/min.
- Do not
clear the pump before the change of shift.
The number of cc's infused is used to calculate intake and output.
Piggybacks: An intermittent volume-controlled infusion
(small volume 25-100 ml) connected to a secondary (shorter) tubing that is
inserted into the upper Y-port of the primary infusion tubing. The primary infusion does not infuse at the
same time as the piggyback but will resume infusion after the piggyback
infusion is completed. The piggyback
must always be higher than the primary to infuse and the piggyback tubing
should be primed by back flushing if the medication is compatible with the IV
solution that is infusing. Most nurses
set IV pump piggyback volumes 5 cc's greater than the amount indicated on the
bag so that all the solution in the piggyback tubing will infuse, leaving the
tubing empty. Some nurses use a
different set of piggyback tubing for each IV.
This is not necessary if the medications are compatible. If the medications are incompatible back
flushing make this unnecessary. If
different sets of piggyback tubing are used the access device on the end of the
piggyback tubing must be changed each time.
IV Push/Bolus: Administration of a concentrated dose of
medication directly into the systemic circulation and is the most dangerous
method of medication delivery. Nursing
- May be
given via saline/heparin lock.
Remember, flush with saline first, follow with medication, flush
with saline after, and if using heparin to maintain patency, flush with
- May be
given via injection port closest to the IV site in the primary infusion
tubing. Know compatibility with
primary infusion and remember to continually flush with primary infusion.
the drug whenever possible according to the drug book (check with the
patient for reactions to the IV bolus (pain, swelling, complaints of not
feeling well) while administering the medication.