Intravenous

Therapy

By: mplestor,rn,man
Intravenous Therapy
Definition:
-The insertion of a needle or
catheter/cannula into a vein,
based on the physician’s written
prescription.
- The needle or catheter/cannula
is attached to a sterile tubing
and a fluid container to provide
medication and fluids
 Intravenous Therapy
Objectives:
-Serves
-
as a guide for nurses in providing safe and
quality nursing care to patients, relative to IV
therapy
-Promote the application of principles underlying the
administration of IV Therapy
-Recognize the ethico-legal implications
of IV Therapy
 Intravenous Therapy
Scope of Practice

1. Role Definition:
- The IV nurses are
registered nurses committed
to ensure the safety of all
patients receiving IV therapy
 Intravenous Therapy
2. Basis of Practice:
-
- Legal therapeutic prescription of
a licensed MD
- Thorough knowledge of the
vascular system
- Recognition of holistic
approach to patient care
 Intravenous Therapy
2. Basis of Practice:
- Individual
- profession
accountability

- Networking and linkages with

external environment
- Collaboration with members
of health team
 Intravenous Therapy
2. Basis of Practice:
- Utilization
- of Nursing Process, through:
Assessment
Planning
Implementation
Evaluation
 Intravenous Therapy

3. Clinical skills:
- An IV therapy nurse shall be
proficient and competent in all
clinical aspects of the IV
Therapy
 Intravenous Therapy
4. Procedures:
- an IV therapy nurse shall perform procedures
that include but not limited to the ff:
Carry out MD’s prescription for IV
therapy
Perform peripheral venipuncture
(except insertion of subclavian and
cut-down catheter)
Prepare, initiate, monitor and terminate
IV therapy
Administer Blood and blood
components as prescribed by MD
 Intravenous Therapy
4. Procedures:
Determine solution and medication
incompatibilities
Change IV site, tubings and dressings,
according to IV therapy standards
Establish flow rates of solutions, medications,
blood and blood components as
prescribed by the MD
Nursing management of patients receiving IV
therapy and peripheral/central and
parenteral nutrition in various set-ups
(hospitals/home/others)
 Intravenous Therapy
4. Procedures:
Adherence to established infection control
practices
Observation and assessment of all adverse
reaction related to IV therapy and initiation
of appropriate nursing interventions
Appropriate documentation relevant to the
preparation, administration and termination
of all forms of IV Therapy
 Intravenous Therapy
5. Indications of IV
Therapy: To maintain hydration and/or correct
dehydration in patients unable to
tolerate sufficient volumes of oral
fluids/medications

Parenteral Nutrition

Administration of Drugs

Transfusion of Blood and blood

components
 Intravenous Therapy
6. Contraindications of
IV Therapy:
Administration of irritant
fluids or drugs through
peripheral access (i.e.
highly concentrated, high
osmolarity solutions)
 Intravenous Therapy
7. Communication
skills:
An Iv therapy nurse shall posses verbal and
written communication skills in
translating ideas and facts to patients,
health care members and others
 Intravenous Therapy
8. Client Education
An IV therapy nurse have the responsibility of educating
patients and significant others on pertinent aspects of IV
therapy
 Intravenous Therapy
9. Continuing
Education
Continuing education and staff
development are vital to professional
advancement. In this regard, the IV therapy
nurse actively participate and share
knowledge with other disciplines
 Intravenous Therapy
Standards of Nursing Practice
1.Standard policies & procedures:
A. Physician’s prescribed treatment
- Patient’s name
-Type and amount of solution
- Flow rate
-Type, dose and frequency of drugs
- Others affecting the procedures
- MD’s signature
 Intravenous Therapy
Standards of Nursing Practice
1.Standard policies & procedures:
B. Patient Assessments
- Clinical status of patient - Type of solution
- Patient’s diagnosis - Duration of therapy
- Patient’s age
- Dominant arm
- Condition of vein and skin
- Cannula size
 Intravenous Therapy
Standards of Nursing Practice
1.Standard policies & procedures:
C. IV set and equipment preparation
- Check for expiration date
- Check for clarity, sediments, packaging
- Check label against doctor’s written prescription
- Label for any medication that are added: (date, time,
dose and amount; compatibility of drug with the
solution)
- Functionality of infusion pump, Pt. CA
 Intravenous Therapy
Standards of Nursing Practice
2. Medications
10 GOLDEN RULES FOR DRUG ADMINSTRATION

1. Administer the right drug

2. Administer to the right patient
3. Administer the right dose
4. Administer at the right route
5. Administer at the right time
 Intravenous Therapy
Standards of Nursing Practice
2. Medications
10 GOLDEN RULES FOR DRUG ADMINSTRATION
6. Right documentation
7. Teach patient about the drugs he’s
receiving
8. Take complete drug history
9. Assess for drug allergies
10. Be aware of potential drug-drug or
drug-food interactions
 Intravenous Therapy
Standards of Nursing Practice

3. Initiation of IV therapy
- Initiation of IV therapy
shall be to provide
peripheral intravascular
access for therapeutic
indications
- This requires physician’s
prescription
 Intravenous Therapy
Standards of Nursing Practice
4. Choices of Cannula
For peripheral infusion:
- Purpose of infusion
- Type of infusion
- Size and condition of the patient’s vein
- Duration of treatment
- Condition of patient
 Intravenous Therapy
Standards of Nursing Practice
4. Choices of Cannula
Needle gauge and color:
16 - grey
18 – green
20 – pink
22 – blue
24 – yellow
26 – violet
 Intravenous Therapy
Standards of Nursing Practice
4. Choices of Cannula
Parts of a Cannula
 Intravenous Therapy
Standards of Nursing Practice
5. Selection of venipuncture site
Take note for:
- Patient’s condition
- Patient’s age
- The size and vein condition
- Type and duration of therapy
- Functional utilization of the hand
 Intravenous Therapy
Standards of Nursing Practice
6. Anchoring Cannula & Tubing
Good anchoring…
- Allows normal blood flow
- Prevents movement of cannula
- Prevents irritation of the vein
- Puncture site should not be covered with tape
 Intravenous Therapy
Standards of Nursing Practice

7. IV Cannula Removal

- Peripheral IV cannulas and the site are routinely

changed aseptically or re-sited every 48-72 hrs
or when necessary
 Intravenous Therapy
Standards of Nursing Practice
8. Quality Control of IV Solution
All IV fluids shall be inspected prior to use:
- Visible sediments
- Turbidity
- Leaks/cracks
- Expiration date
- Damaged caps
 Intravenous Therapy
Standards of Nursing Practice
9. Documentation of IV Therapy
Proper documentation provides:
- An accurate description of care that can serve
as legal protection
- A mechanism for recording and retrieving info
- A record for health insurers and retrieving info
documenting the insertion or beginning of
therapy.
 Intravenous Therapy
Standards of Nursing Practice
9. Documentation of IV Therapy
The ff. info. of care can serve as legal protection
- Size, type and length of cannula/needle
- Name of person who inserted the IV catheter
- Date and time of insertion
 Intravenous Therapy
Standards of Nursing Practice
9. Documentation of IV Therapy
The ff. info. Is documented in the patient’s chart:
- Location and condition of insertion site
- Complications, pt. response & nsg.
Interventions
- Pt. teaching and evidence of patient’s
understanding
- Nurse’s signature
 Intravenous Therapy
Standards of Nursing Practice
9. Documentation of IV Therapy
Policies on Documentation:
- Never chart ahead of time
- Chart properly
- Clearly identify who did the procedure
- Don’t leave space on charting
- Identify late entries
- Don’t criticize personnel on the chart
 Intravenous Therapy
Standards of Nursing Practice
9. Documentation of IV Therapy
Policies on Documentation:
- Avoid error
- Don’t tamper records
- Document all reports to the doctor
- Chart abbreviations properly
- Refusal of meds should be charted
- Don’t invent!!!
 Intravenous Therapy
Standards of Nursing Practice
10. Infection Control
 Intravenous Therapy
Standards of Nursing Practice
10. Infection Control
The ff. measures reduces patient’s risk:
- Wash hands before and after a
procedure
- Use an approved antiseptic to clean
the client’s skin
- Cut/clip the hair of the
venipuincture site. Don’t shave
- Do not re-use catheter or needle
 Intravenous Therapy
Standards of Nursing Practice
10. Infection Control
Center for Disease Control:
- IV should be change 48-72 hrs
- Site prep: tincture of iodine 1-2% (30 sec before
venipuncture
- Piggyback tubing should be change after 48 hrs
- Tubing should be changed after admin. of blood
products
- Between changes of components, the IV system should
be maintained as a closed system as much as
possible
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
LOCAL COMPLICATIONS

HEMATOMA – a collection of extravasated blood

trapped in the tissues of skin or in an organ.
S/S:
- Tenderness - Bluish
- Bruising around site - Inability to advance catheter
- Resistance during flushing
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
HEMATOMA
Nsg. Intervention:
- Remove IV
- Check for bleeding
Prevention:
- Choose a good vein
- Release torniquet as soon as
insertion is achieved
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
THROMBOSIS – an abnormal condition in which a
clot (thrombus) develops within a blood vessel
S/S: Nsg. Intervention:
- Tenderness - D/C IV
- Swollen vein - Restart new site
- Reddened Prevention: - Warm compress
- Sluggish - Proper venipuncture
technique to reduce injury
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
PHLEBITIS – inflamed vein
S/S: Nsg. Intervention:
- Redness - Removed IV
- Puffy area - Warm compress
- Hard vein on palpation - Notify MD
- Increase body temp. Prevention:
- Restart at large vein or use
small gauge cannula
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
INFILTRATION – a process whereby fluid passes
into the tissues
S/S:
- Swelling - Discomfort
- Tightness at IV site - Blanching at site
- Decrease temp at site - Absence of backflow
- Continues fluid infusion even when vein is occluded
although rate may decrease
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
INFILTRATION
Nsg. Intervention:
- Removed IV & restart new site
- Warm compress & elevate limbs
- Check for pulse & numbness
Prevention:
- Notify MD
- Restart at large vein or
use small gauge cannula
- Monitor IV site
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
LOCAL INFECTION – an infection within a
specific area
S/S: Nsg. Intervention:
- Redness and swelling - D/C
- Presence of exudates - Request for C/S
- Inc. WBC count - Apply sterile dressing
Prevention:
- Apply antibiotics
- Good aseptic technique
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
SYSTEMIC COMPLICATIONS
VENOUS SPASM – a spasmodic constriction of vein
S/S: Nsg. Intervention:
- Sharp pain at IV site - Warm compress flow rate
- Decrease the flow rate
Prevention:
- Restart is spasm is gone
- Check for allergies
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
SPEED SHOCK – a sudden adverse physiologic
reaction to IV medications or drugs
S/S: that are administered too quickly
- Dizziness - Headache
- Facial flush - Shock
- Hypotension - Irregular pulse
- Tight feeling in the chest - Loss of consciousness
- Cardiac arrest
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
SPEED SHOCK
Nsg. Intervention:
- Warm compress flow rate
- Decrease the flow rate
Prevention:
- Restart is spasm is gone
- Check for allergies
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
SEPTICEMIA – systemic infection in which
pathogens are present in the
circulating blood, having spread from
an infection in any part of the body
S/S:
- Fever & Chills - Hypotension
- Body malaise - Pain
- Contaminated IV site - Nausea
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
SEPTICEMIA
Nsg. Intervention:
- Notify MD
- Do C/S & Initiate Antibiotic
- Monitor V/S
Prevention:
- Hand hygiene - cover infusion site - follow SOP
- Secure all connections - inspect fluids
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
CIRCULATORY OVERLOAD – an elevation in blood
pressure caused by an increased blood
volume, as by transfusion. It may lead to
heart failure or pulmonary edema
S/S:
- Discomfort - Intake increase
- Neck vein engorgement - Decrease output
- Resp. distress
- Increse BP
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
CIRCULATORY OVERLOAD
Nsg. Intervention: Prevention:
- High fowler’s position - Use volume control set
- Slow flow rate - Calculate rate
- Admin. Oxygen as needed - Monitor infusion
- Admin. Furosemide as - Do not “catch-up” infusion
ordered
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
CATHETER EMBOLISM
S/S:
- Sharp sudden pain @ IV site
- Rough and uneven catheter noted
- Chest pain
- Tachycardia
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
CATHETER EMBOLISM
Nsg. Intervention: Prevention:
- Tourniquet above elbow - Don’t apply pressure
- Start new site - Use radio opaque
- Inform MD - Avoid joint flexion
- Never re-insert stylet
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
ALLERGIC REACTION – an unfavorable
physiologic response to an allergen to
which a person has previously been
exposed and to which a person has
S/S: developed antibodies
- Itching - Wheezing
- Bronchospasm - Anaphylactic rxn
- Urticarial rash - Edema
- Bronchospasm
 Intravenous Therapy
Standards of Nursing Practice
11. Complications in IV therapy
ALLERGIC REACTION
Nsg. Intervention: Prevention:

- STOP!!! – Flush w/ PNSS - Obtain allergic history

- Notify MD - Monitor client

- Admin. Antihistamine as - Test dosing (slow rate)

ordered
 Intravenous Therapy
Standards of Nursing Practice
12. Procedural Problems Associated
with IV Therapy
Fluctuating flow rate
Runaway IV
Sluggish IV
tubing/ loose connection / disconnection
IV line obstruction/kinking of IV tubing
Clogged filter
Break in aseptic technique
leaks due to inappropriate device
 Intravenous Therapy
Standards of Nursing Practice

13. Risk associated w/ IV therapy

Infectious organism exposure
Needle stick injury
Chemical exposure
 Intravenous Therapy
Standards of Nursing Practice
14. Outcome Criteria
The desired outcome criteria of these
IV Nursing standard shall be to:
- To deliver safe and quality IV Therapy care
- Protect the patient and the IV nurse
therapist
- Protect the IV therapy nurse’s practice
 Intravenous Therapy
Standards of Nursing Practice
14. Outcome Criteria
All nurses are responsible for quality, utilizing
IV nursing process of:
- Assessment
- Planning
- Implementation
- Evaluation
Deviation from optimal care in the IV therapy
nursing practice requires corrective care
 Intravenous Therapy
Standards of Nursing Practice
PROCEDURES
 Intravenous Therapy
Standards of Nursing Practice
PROCEDURE I.
A. SETTING-UP an IV
1. Verify doctor’s order & make I.V.
label.
- An order requiring the initiation
of IV must be made by the
physician prior to the
implementation of this procedure.
 Intravenous Therapy
Standards of Nursing Practice
A. SETTING-UP an IV
2. Observe 10 Rules in Drug Admin.
- For legal purposes
 Intravenous Therapy
Standards of Nursing Practice
A. SETTING-UP an IV
3. Explain Procedure to Client and secure
consent if necessary
- To decrease anxiety and foster
cooperation
 Intravenous Therapy
Standards of Nursing Practice
A. SETTING-UP an IV
4. Assess client’s vein;
choose appropriate vein:
location, size, condition.
- Good condition of the vein will
facilitate easier insertion of
the needles.
 Intravenous Therapy
Standards of Nursing Practice
A. SETTING-UP an IV
5. Hand hygiene before and after the
procedure
- To reduce transmission of
microorganisms and to prevent
infection.
 Intravenous Therapy
Standards of Nursing Practice
A. SETTING-UP an IV
6. Prepare the necessary materials for
procedure
- Organization saves nursing time.
- IV tray w/ IV solution - Cotton balls w/ alcohol
- Administration set - Plaster and gloves
- IV cannula with IV solution - Tourniquet and splints
- Forceps soaked in antiseptic solution - Sterile gauze or dressing
 Intravenous Therapy
Standards of Nursing Practice
A. SETTING-UP an IV
 Intravenous Therapy
Standards of Nursing Practice
A. SETTING-UP an IV
7. Check the sterility &
integrity of the IV
solution, IV set &
other devices.
- Break in the integrity of the
materials can lead to infection.
 Intravenous Therapy
Standards of Nursing Practice
A. SETTING-UP an IV
8. Place IV label on the IV fluid bottle
(client’s name, room number,
solution, drug incorporation, bottle
sequence and duration)
- To ensure that the correct client
will receive the IVF, and for
documentation purposes.
 Intravenous Therapy
Standards of Nursing Practice
A. SETTING-UP an IV
9. Open the seal of the IV solution and
disinfect port with cotton balls with
alcohol.
- To reduce number or microorganisms
residing in the port.
 Intravenous Therapy
Standards of Nursing Practice
A. SETTING-UP an IV
10. Open the administration set (IV set)
aseptically and close the IV clamp.

- Closing the IV clamp prevents the solution

from spilling unintentionally after insertion
to the solution bottle.
 Intravenous Therapy
Standards of Nursing Practice
A. SETTING-UP an IV

11. Spike container

aseptically
 Intravenous Therapy
Standards of Nursing Practice
A. SETTING-UP an IV
12. Fill drip chamber to
at least half and
prime the tubing
aseptically.
 Intravenous Therapy
Standards of Nursing Practice
A. SETTING-UP an IV
13. Remove air bubbles if any and
put back the cover to the distal end
of the IV tubing (get ready for IV
insertion).
- To remove air along the tubing and to
prevent air embolism.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
1. Verify doctor’s written prescription
for IV therapy, check prepared IVF and
other things needed.
- An order requiring the initiation
of IV must be made by the
physician prior to the
implementation of this procedure.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
2. Observe 10 Rules in Drug Admin.
- For legal purposes
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
3. Explain Procedure to Client and secure
consent if necessary
- To decrease anxiety and foster
cooperation
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM

4. Assess client’s vein;

choose appropriate vein:
location, size, condition.
- Good condition of the vein will
facilitate easier insertion of
the needles.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
5. Hand hygiene before and after the
procedure

- To reduce transmission of
microorganisms and to prevent
infection.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
6. Apply tourniquet 5-12cm (2-6in)
above injection site depending on
condition of client
- To distend the veins
and facilitates easier
insertion.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
7. Check for radial pulse below
tourniquet.
- To distend the veins
and facilitates easier
insertion.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
8. Prepare site with effective topical
antiseptic according to hospital policy or
cotton balls with alcohol in circular
motion and allow 30 seconds to dry. (No
touch technique).
- To reduce number of microorganisms in the area
and to prevent infection.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
9. Using the appropriate I.V. cannula,
pierce skin with needle positioned on a
15-30 degree angle; upon flashback
visualization decrease the angle,
advance the catheter and stylet (1/4 inch)
into the vein.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
10. Position the I.V.
catheter parallel to the
skin. Hold stylet
stationary the slowly
advance the catheter,
until the hub is 1mm
to the puncture site.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
11. Slip a sterile gauze under the hub.
Release the tourniquet, remove the stylet
while applying digital pressure over
the catheter with one finger about 1-2in.
from the tip of the inserted catheter
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
12. Connect the infusion tubing of the
prepared IVF aseptically to the
catheter.
- To initiate flow of solution
into the vein.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
When steel-winged needle (butterfly) is used:
A. Connect the I.V. tubing to the steel-winged needle
connector & prime the needle with I.V. fluid.
B. Using the steel-winged needle, pierce skin with the needle
bevel up, positioned on a 5-10 degree angle.

C. With steel-winged needle, parallel on the skin, enter the

vein directly and advance needle ¼ inch after
successful venipuncture. Check for backflow.
Remove tourniquet.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
13. Open the clamp, regulate the flow
rate and reassure the client.
- To initiate flow of solution into the vein.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
14. Anchor needle firmly w/ the use of:
a. transparent tape/dressing directly
on the puncture site.
b. tape (approp. anchoring style).

- To secure the needle in

place.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
15. Tape a small loop of I.V. tubing for
additional anchoring; apply splint (if
needed).
- To secure the needle in
place.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
17. Label on I.V.
tape near the
I.V. site to
indicate the
date of
insertion.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
16. Calibrate the IVF bottle & regulate
flow of infusion according to
duration.

- Improper calibration can

lead to under dosage or over
dosage.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM

18. Label with plaster on the I.V.

tubing to indicate the date when to
change the I.V. tubing.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
19. Observe patient
and report any
untoward effect.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
20. Document in
the patient’s
chart and
endorse to
incoming shift.
 Intravenous Therapy
Standards of Nursing Practice
B. INSERTING IV w/ DUMMY ARM
21. Discard
sharps and
waste according
to Health Care
Waste Mgt.
 Intravenous Therapy
Standards of Nursing Practice
C. CHANGING an IV SOLUTION
1. Verify doctor’s prescription
in doctor’s order sheet,
countercheck IV label, IV
card, infusate sequence, type,
amopunt additives (if any)
and duration of infusion.
 Intravenous Therapy
Standards of Nursing Practice
C. CHANGING an IV SOLUTION

2. Observe 10 Rules in Drug Admin.

- For legal purposes
 Intravenous Therapy
Standards of Nursing Practice
C. CHANGING an IV SOLUTION

3. Explain Procedure to Client and assess

IV site for redness, swelling and pain…
- To decrease anxiety and foster
cooperation
 Intravenous Therapy
Standards of Nursing Practice
C. CHANGING an IV SOLUTION

4. Change Iv tubings & cannula if

48- 72hrs. Has lapsed after IV
insertion
- Prolonged used of needle is the
primary source of infection in IVF.
 Intravenous Therapy
Standards of Nursing Practice
C. CHANGING an IV SOLUTION

5. Hand hygiene before and after the

procedure

- To reduce transmission of
microorganisms and to prevent
infection.
 Intravenous Therapy
Standards of Nursing Practice
C. CHANGING an IV SOLUTION

6. Prepare necessary materials.

- To save time and effort

- IV tray - Cotton balls w/ alcohol

- New IV bottle w/ IV label - Forceps soaked in antiseptic solution
 Intravenous Therapy
Standards of Nursing Practice
C. CHANGING an IV SOLUTION

7. Check sterility and integrity of IV

solution.
- Break in the integrity of the materials can
lead to infection.
 Intravenous Therapy
Standards of Nursing Practice
C. CHANGING an IV SOLUTION

8. Place IV label on the IV bottle

 Intravenous Therapy
Standards of Nursing Practice
C. CHANGING an IV SOLUTION
9. Calibrate the new IV bottle according
to duration of infusion. Place IV label
on the IV bottle.
- Improper calibration can lead to underdosage
or overdosage.
 Intravenous Therapy
Standards of Nursing Practice

C. CHANGING an IV SOLUTION
10. Open and disinfect rubber port of IV
solution to follow
 Intravenous Therapy
Standards of Nursing Practice
C. CHANGING an IV SOLUTION
11. Close the IV clamp or kink tubing
and spike the container aseptically.
- Closing the IV clamp prevents the solution
from spilling unintentionally after insertion to the
solution bottle.
 Intravenous Therapy
Standards of Nursing Practice
C. CHANGING an IV SOLUTION
12. Regulate the flow rate based on
duration of infusion. Remove air
bubbles (if any).
- Improper calibration can lead to underdosage
or overdosage. Air in the tubings can lead
to air embolism.
 Intravenous Therapy
Standards of Nursing Practice
C. CHANGING an IV SOLUTION
13. Reassure client
and significant
others
 Intravenous Therapy
Standards of Nursing Practice
C. CHANGING an IV SOLUTION

14. Discard
sharps and
waste according
to Health Care
Waste Mgt.
 Intravenous Therapy
Standards of Nursing Practice
C. CHANGING an IV SOLUTION
15. Document in
the patient’s
chart and
endorse to
incoming shift.
 Intravenous Therapy
Standards of Nursing Practice
D. DISCONTINUING IV INFUSION

1. Verify doctor’s order to discontinue

IV including IV medications
 Intravenous Therapy
Standards of Nursing Practice
D. DISCONTINUING IV INFUSION

2. Observe 10 Rules in Drug Admin.

- For legal purposes
 Intravenous Therapy
Standards of Nursing Practice
D. DISCONTINUING IV INFUSION

3. Assess & inform the client of the

discontinuation of IV infusion and of any
medication.
- Decreases anxiety and foster cooperation.
 Intravenous Therapy
Standards of Nursing Practice
D. DISCONTINUING IV INFUSION
4. Prepare the necessary materials.
- Saves time and effort

- IV tray - Cotton balls w/ alcohol

- Plaster - Forceps soaked in antiseptic solution
-Sterile gauze or dressing - kidney basin
 Intravenous Therapy
Standards of Nursing Practice
D. DISCONTINUING IV INFUSION

5. Hand hygiene before and after the

procedure

- To reduce transmission of
microorganisms and to prevent
infection.
 Intravenous Therapy
Standards of Nursing Practice
D. DISCONTINUING IV INFUSION

6. Close the clamp of the IV

administration set.
- To prevent spilling of solution.
 Intravenous Therapy
Standards of Nursing Practice
D. DISCONTINUING IV INFUSION

7. Moisten adhesive tape around the I.V.

catheter with cotton ball with
alcohol; remove plaster gently.
- It facilitates easier removal of the plaster.
 Intravenous Therapy
Standards of Nursing Practice
D. DISCONTINUING IV INFUSION
8. Use pick-up forceps to get cotton ball
with alcohol and without applying
pressure, remove needle or IV
catheter then immediately apply
pressure over the venipuncture site.
 Intravenous Therapy
Standards of Nursing Practice
D. DISCONTINUING IV INFUSION
9. Inspect IV catheter for completeness.
- Make sure that the entire length of the
catheter is complete. If not, inform the
physician immediately.
 Intravenous Therapy
Standards of Nursing Practice
D. DISCONTINUING IV INFUSION
10. Place dressing over the venipuncture
site
- Make sure that the entire length of the
catheter is complete. If not, inform the
physician immediately.
 Intravenous Therapy
Standards of Nursing Practice
D. DISCONTINUING IV INFUSION

11. Discard sharps

and waste
according to
Health Care
Waste Mgt.
 Intravenous Therapy
Standards of Nursing Practice
D. DISCONTINUING IV INFUSION
12. Document time
of
discontinuance,
status of insertion
and integrity of
IV catheter and
endorse
 Intravenous Therapy
Standards of Nursing Practice
PROCEDURE II
A. INCORPORATION INTO IV BOTTLE
1. Verify written
medication card against
MD prescription;
observe hospital policy
on drug administration
- To make sure that correct
medication will be administered.
 Intravenous Therapy
Standards of Nursing Practice

A. INCORPORATION INTO IV BOTTLE

2. Observe 10 Rules in Drug Admin.

- For legal purposes

 Intravenous Therapy
Standards of Nursing Practice

A. INCORPORATION INTO IV BOTTLE

3. Explain Procedure (medication &
action) and check patency and IV site
- To decrease anxiety and foster
cooperation
 Intravenous Therapy
Standards of Nursing Practice

A. INCORPORATION INTO IV BOTTLE

4. Verify for skin test of drug for IV

incorporation (if skin testing is
necessary)
 Intravenous Therapy
Standards of Nursing Practice
A. INCORPORATION INTO IV BOTTLE

5. Hand hygiene before and after the

procedure

- To reduce transmission of
microorganisms and to prevent
infection.
 Intravenous Therapy
Standards of Nursing Practice
A. INCORPORATION INTO IV BOTTLE

6. Prepare necessary materials needed

for the procedure such as:
- IV tray - Cotton balls w/ alcohol
- syringes needed - Forceps soaked in antiseptic solution
-Sterile gauze or dressing - kidney basin
 Intravenous Therapy
Standards of Nursing Practice
A. INCORPORATION INTO IV BOTTLE

7. Disinfect the injection port of the vial

and the ampule before breaking then
aspirate the right drug to be
incorporated either in vial or ampule.
 Intravenous Therapy
Standards of Nursing Practice
A. INCORPORATION INTO IV BOTTLE

8. Remove the cover of the airway of the

administration set, maintain the
sterility and incorporate prepared
drug into the airway. Recap airway
after.
 Intravenous Therapy
Standards of Nursing Practice
A. INCORPORATION INTO IV BOTTLE
 Intravenous Therapy
Standards of Nursing Practice
A. INCORPORATION INTO IV BOTTLE
*** If the administration set has no airway,
put down the bottle, kink the IV tubing,
remove the administration set from the
bottle aseptically; disinfect the bottle’s
rubber stopper; incorporate the right drug to
the IVF bottle; return the administration set
to IVF bottle aseptically;
 Intravenous Therapy
Standards of Nursing Practice
A. INCORPORATION INTO IV BOTTLE
 Intravenous Therapy
Standards of Nursing Practice
A. INCORPORATION INTO IV BOTTLE

9. Swirl the IV bottle to mix the drug,

with IVF and regulate the flow rate
accordingly.
 Intravenous Therapy
Standards of Nursing Practice
A. INCORPORATION INTO IV BOTTLE
 Intravenous Therapy
Standards of Nursing Practice
A. INCORPORATION INTO IV BOTTLE
 Intravenous Therapy
Standards of Nursing Practice
A. INCORPORATION INTO IV BOTTLE

10. Observe for 5-10mins for any drug

interaction while reassuring the
patient; monitor V/S.
 Intravenous Therapy
Standards of Nursing Practice
A. INCORPORATION INTO IV BOTTLE
11. Document in the patient’s chart
 Intravenous Therapy
Standards of Nursing Practice
A. INCORPORATION INTO IV BOTTLE

12. Discard sharps

and waste
according to
Health Care
Waste Mgt.
 Intravenous Therapy
Standards of Nursing Practice
B. IV PUSH THROUGH THE IV PORT
1. Verify written
medication card against
MD prescription;
observe hospital policy
on drug administration
- To make sure that correct
medication will be administered.
 Intravenous Therapy
Standards of Nursing Practice

B. IV PUSH THROUGH THE IV PORT

2. Observe 10 Rules in Drug Admin.

- For legal purposes

 Intravenous Therapy
Standards of Nursing Practice
B. IV PUSH THROUGH THE IV PORT
3. Explain Procedure (medication &
action) and check patency and IV site

- To decrease anxiety and foster

cooperation
 Intravenous Therapy
Standards of Nursing Practice
B. IV PUSH THROUGH THE IV PORT
4. Hand hygiene before and after the
procedure

- To reduce transmission of
microorganisms and to prevent
infection.
 Intravenous Therapy
Standards of Nursing Practice
B. IV PUSH THROUGH THE IV PORT

5. Check patency and other reactions

signs of swelling, redness, phlebitis,
etc.. Do not give the drug.
 Intravenous Therapy
Standards of Nursing Practice
B. IV PUSH THROUGH THE IV PORT

6. Check for skin test result of drug for

IV push, drug-drug, drug IV fluid
incompatibility, dosage computation.
 Intravenous Therapy
Standards of Nursing Practice
B. IV PUSH THROUGH THE IV PORT
7. Prepare necessary materials needed
for the procedure such as:
- Right drug - IV tray
- Right diluent - syringes needed
- Cotton balls w/ alcohol - etc…..
 Intravenous Therapy
Standards of Nursing Practice
B. IV PUSH THROUGH THE IV PORT

8. Disinfect the injection port of the

diluent vial or ampule as appropriate.
 Intravenous Therapy
Standards of Nursing Practice
B. IV PUSH THROUGH THE IV PORT

9. Aspirate right amount of

diluent for the drug (if drug
needs to be diluted.)
 Intravenous Therapy
Standards of Nursing Practice
B. IV PUSH THROUGH THE IV PORT

10. Aspirate the right drug

dose; disinfect the Y-
injection port of the IV
administration set
 Intravenous Therapy
Standards of Nursing Practice
B. IV PUSH THROUGH THE IV PORT
 Intravenous Therapy
Standards of Nursing Practice
B. IV PUSH THROUGH THE IV PORT

11. Close the roller clamp of the IV

tubing from the bottle and push IV
drug aseptically and slowly or
according to the manufacturer’s
recommendation
 Intravenous Therapy
Standards of Nursing Practice
B. IV PUSH THROUGH THE IV PORT
 Intravenous Therapy
Standards of Nursing Practice
B. IV PUSH THROUGH THE IV PORT

12. Using the same syringe aspirate

1-2cc of IVF to flush the medicine
given.
 Intravenous Therapy
Standards of Nursing Practice
B. IV PUSH THROUGH THE IV PORT

13. Regulate the rate of IV fluid

infusion as prescribed.
 Intravenous Therapy
Standards of Nursing Practice
B. IV PUSH THROUGH THE IV PORT
14. Reassure the patient and observe
for signs and symptoms of adverse
drug reaction.
 Intravenous Therapy
Standards of Nursing Practice
B. IV PUSH THROUGH THE IV PORT

15. Discard sharps

and waste
according to
Health Care
Waste Mgt.
 Intravenous Therapy
Standards of Nursing Practice
C. DRUG INCORPORATION INTO
VOLUMETRIC CHAMBER
1. Verify written
medication card against
MD prescription;
observe hospital policy
on drug administration
- To make sure that correct
medication will be administered.
 Intravenous Therapy
Standards of Nursing Practice
C. DRUG INCORPORATION INTO
VOLUMETRIC CHAMBER

2. Observe 10 Rules in Drug Admin.

- For legal purposes

 Intravenous Therapy
Standards of Nursing Practice
C. DRUG INCORPORATION INTO
VOLUMETRIC CHAMBER
3. Explain Procedure (medication &
action) and check patency and IV site.

- To decrease anxiety and foster

cooperation
 Intravenous Therapy
Standards of Nursing Practice
C. DRUG INCORPORATION INTO
VOLUMETRIC CHAMBER
4. Hand hygiene before and after the
procedure

- To reduce transmission of
microorganisms and to prevent
infection.
 Intravenous Therapy
Standards of Nursing Practice
C. DRUG INCORPORATION INTO
VOLUMETRIC CHAMBER
5. Prepare necessary materials needed
for the procedure such as:
- Right drug and dose - Right diluent needed
- IV injection tray - Syringes and needle
 Intravenous Therapy
Standards of Nursing Practice
C. DRUG INCORPORATION INTO
VOLUMETRIC CHAMBER
6. Check present IV fluid label, level and the
incorporated medicine in the Volumetric
chamber or IV bottle if w/ incorporated
medicine, check for drug-drug
incompatibility and if the on-going IV fluid in
the volumetric chamber is to be consumed in
6-8 hrs. Request a prescription for IVF to be
used solely for drug administration and keep
 Intravenous Therapy
Standards of Nursing Practice
C. DRUG INCORPORATION INTO
VOLUMETRIC CHAMBER

7. Aspirate prepared right

drug and with correct
dose.
 Intravenous Therapy
Standards of Nursing Practice
C. DRUG INCORPORATION INTO
VOLUMETRIC CHAMBER

8. Add desired IVF diluent into

volumetric chamber by opening the
sliding clamp from the bottle then
close the clamp.
 Intravenous Therapy
Standards of Nursing Practice
C. DRUG INCORPORATION INTO
VOLUMETRIC CHAMBER

9. Disinfect rubber injection port

of the volumetric chamber and
incorporate the drug. Mix
gently
 Intravenous Therapy
Standards of Nursing Practice
C. DRUG INCORPORATION INTO
VOLUMETRIC CHAMBER
 Intravenous Therapy
Standards of Nursing Practice
C. DRUG INCORPORATION INTO
VOLUMETRIC CHAMBER

10. Open the clamp of the airway at

the volumetric chamber
 Intravenous Therapy
Standards of Nursing Practice
C. DRUG INCORPORATION INTO
VOLUMETRIC CHAMBER

11. Regulate the flow rate of IVF

infusion accordingly
 Intravenous Therapy
Standards of Nursing Practice
C. DRUG INCORPORATION INTO
VOLUMETRIC CHAMBER

12. Place IV label on

volumetric chamber
indicating the drug
incorporated and
flow rate
 Intravenous Therapy
Standards of Nursing Practice
C. DRUG INCORPORATION INTO
VOLUMETRIC CHAMBER

13. Reassure/monitor client when

incorporated medicine is
consumed, close airway of VC
and IVF and regulate flow rate of
main IVF as prescribed
 Intravenous Therapy
Standards of Nursing Practice
C. DRUG INCORPORATION INTO
VOLUMETRIC CHAMBER

14. Discard sharps

and waste
according to
Health Care
Waste Mgt.
 Intravenous Therapy
Standards of Nursing Practice
C. DRUG INCORPORATION INTO
VOLUMETRIC CHAMBER
15. Document in the patient’s chart,
IVF sheet and Kardex
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH - HEPARIN LOCK
1. Verify written
medication card against
MD prescription;
observe hospital policy
on drug administration
- To make sure that correct
medication will be administered.
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

2. Observe 10 Rules in Drug Admin.

- For legal purposes

 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

3. Explain Procedure (medication &

action) and check patency and IV site.

- To decrease anxiety and foster

cooperation
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

4. Hand hygiene before and after the

procedure

- To reduce transmission of
microorganisms and to prevent
infection.
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

5. Prepare necessary materials needed

for the procedure such as:
- heparin solution - Normal saline
- 2.5cc syringe (3pcs) - tuberculin syringe 1pc)
- IV tray - cotton balls with alcohol
- etc….
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

6. Prepare medication to be administered

e.g. antibiotic and draw it up into a
syringe.
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

7. Fill the tuberculin syringe with

Heparin solution. (heparin solution is
usually prepared with 0.1cc heparin
plus 0.9cc Normal saline solution.
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

8. Fill the 2.5cc syringe with Isotonic

solution or Normal saline 1cc each
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

9. If using Hep lock device with 3-way

stop cock with luer-lock, rotate the
stop cock so that the line going to the
patient is closed (this will prevent
backflow of blood)
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

10. Remove the cover of the injection

port aseptically and keep the sterility
of the cover.
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

11. Check the patency, open the IV line,

inject NSS to flush Heparin solution
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

12. Close the IV line and remove saline

syringe and insert medication
syringe into the port.
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

13. Open the IV line & inject medication

into the vein, timing the flow rate
according to doctor’s order of drug
manufacturer’s instructions.
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

14. Observe client for any adverse

reactions and do nursing intervention
accordingly
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

15. Close the IV line & remove

medication syringe.
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

16. Insert the saline syringe, open the line

& flush catheter tubing/IV cannula
to flush the line.
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

17. Close & remove saline syringe.

 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

18. Close the IV saline, remove syringe

and return the cover of the injection
port aseptically.
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK
19. Document in the patient’s chart,
IVF sheet and Kardex
 Intravenous Therapy
Standards of Nursing Practice
D. IV PUSH – HEPARIN LOCK

20. Discard sharps

and waste
according to
Health Care
Waste Mgt.
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION
Type (ABO/Rh) Can receive blood from:
O+ O (+/-)
O- O (-)
A+ A (+/-) or O (+/-)
A- A (-) or O (-)
B+ B (+/-) or O (+/-)
B- B (-) or O (-)
AB+ AB, A, B or O (all+/-)
AB- AB, A, B or O (all -)
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION
Product Description Indications
Whole Blood 1 unit = 450ml Acute massive
Contains RBC, bleeding, open
WBC, Platelets heart surgery,
and Plasma neonatal total
exchange
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION
Product Description Indications
Packed Red Most Plasma Replacement in
Blood Cells removed chronic and acute
1 unit = 250- blood loss, GI
300ml bleeding and
trauma
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION
Product Description Indications
Platelets 1 “pack” should Active bleeding,
raise count by 5- contiguous
8,000. petechiae
1 pack = about
50ml
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION
Product Description Indications
Leukocyte-poor Most WBC Potential renal
red cells removed to make transplant,
it less antigenic previous febrile
1 unit = 200- transfusion
250ml reaction,
leukemia.
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION
Product Description Indications
Washed RBC WBC almost As for leukocyte-
completely poor red cells but
removed very expensive
1 unit = 300ml and much more
purified
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION
Product Description Indications
Fresh Frozen Contains Factors Emergency
Plasma II, VII, IX, X, XI, reversal of
XII, XIII & heat warfarin
labile V and VII. (coumadin),
About 1 hr. to suspected
thaw. coagulopathy,
1 unit = 150- clotting factor
250ml replacement
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION
Product Description Indications
5% Albumin or Precipitate from Plasma volume
5% Plasma plasma expanders in
Protein Fraction acute blood loss
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION
Product Description Indications
25 % Albumin Precipitate from Volume
plasma expanders, burns,
hypoalbuminemia.
Draws
extravascular fluid
into circulation.
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION
TRANSFUSION REACTIONS
- Sudden fever - Tachycardia - Backache
-Diaphoresis - Hypotension - Shock
- Chills - Headache
- Hypersensitivity Reactions ( hives, wheezing, pruritus)
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION
TREATMENT FOR TRANSFUSION
REACTIONS
- STOP!!!! The blood product transfusion ASAP!
- Keep IV line (PNSS) open and monitor V/S and urine output
carefully
- Save the blood bag, have the lab verify the type and crossmatch.
- In mild febrile transfusion reactions antipyretics can be used
- With urticarial reactions dipenhydramine(Benadryl) should be
given.
- In more sever reaction, prevent acute renal failure.
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

1. Verify doctor’s order and make

treatment card according to hospital
policy
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

2. Observe 10 Rules when preparing and

administering any Blood or blood
components
- For legal purposes
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

2. Observe 10 Rules in giving blood

transfusion
- For legal purposes
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

3. Explain the procedure/rationale for

giving blood transfusion to reassure
client and significant others and
secure consent. Get client’s history
regarding previous transfusion.
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

4. Explain the importance of the benefits

on Voluntary Blood donation
(RA 7719 – National Blood
Service Act of 1994)
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION
5. Request prescribed
blood/blood components
from blood bank to
include blood typing and
X-matching and blood
result of transmissible
dse.
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

6. Using a clean lined tray,

get compatible blood
from hospital blood
bank
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

7. Wrap blood bag with

clean towel and keep it at
room temp.
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION
8. Have a doctor and a nurse assess
client’s condition. Countercheck the
compatible blood to be transfused
against the X-matching sheet noting
ABO grouping and RH, serial #, expiry
date w/ the blood bag label and other lab.
Blood exam as required before
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

9. Get baseline vital signs

and refer to MD
accordingly
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

10. Give pre-med 30 mins.

before transfusion as
prescribed
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

11. Hand hygiene before and after the

procedure

- To reduce transmission of
microorganisms and to prevent
infection.
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

12. Prepare equip. needed for BT:

- IV tray - Compatible blood set
-IV catheter (gauge 18-19) - Plaster
- tourniquet - Blood component
- Plain NSS - IV set and IV hook
- gloves - Sterile gauze or dressing
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

13. If main IVF is with dextrose 5%

initiate an IV line with appropriate IV
catheter with PNSS on another site,
anchor catheter properly and
regulate drops
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

14. Open compatible blood set aseptically

and close roller clamp. Spike blood
carefully; fill the drip chamber at
lest half full; prime tubing and remove
air bubbles (if any). Use gauge 18-19 for
adults and 22 for pedia
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

15. Disinfect the Y-injection port of

tubing (Plain NSS) and insert the needle
from BT administration set and secure
w/ adhesive tape.
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

16. Open roller clamp of IV fluid of

PNSS and regulate to KVO while
transfusion is going on.
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

17. Transfuse the blood via injection port

and regulate @ 10-15gtts
initially for 15 mins. And then at
prescribed rate.
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

18. Observe client for 10-15 mins for

any immediate reaction.
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

19. Observe client on an on-going basis

for any untoward s/s such as:
- flushed skin - chills - inc. temp.
- itchiness - urticaria - dyspnea

*** if any of these s/s occurs STOP !!! the transfusion,

open the roller clamp of the IV line w/ PNSS, and report it
to the MD.
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

20. Swirl the bag hourly to mix the solid

with the plasma
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

21. When blood is consumed, close the

roller clamp of BT, and disconnect
from IV line then regulate the IVF of
PNSS as prescribed
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

22. Continue to observe and monitor

patient post transfusion, for delayed
reaction could still occur.
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

23. Re-check Hgb & Hct, bleeding time,

serial platelet count within specified
hours as prescribed &/or per
institution’s policy.
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION

24. Discard blood bag

and BT set and
sharps accdg. to
Health and Waste
Mgt.
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION
25. Document the
procedure, pertinent
observations and
Nsg. Intervention
and endorse
accordingly
 Intravenous Therapy
Standards of Nursing Practice
BLOOD TRANSFUSION
26. Remind the doctor
about the
administration of
Calcium Gluconate
if client had several
units of Blood
transfusion (3-6 units)
The End