Intravenous Therapy: IV Bag and Tubing Preparation

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What is the purpose of the IV solution during intravenous therapy?

The IV solution corrects and prevents the client’s fluid and electrolyte imbalances.

Different IV solutions are prescribed to different clients who required intravenous therapy such as:

  • those with acute illness
  • those required to have nothing per orem
  • those with severe burns

What are the most common IV tubings?

These are IV tubings a nurse must be familiar with:

  • Primary Tubing – have no ports or multiple ports
  • Secondary Tubing – used when another solution is added to the primary tubing
  • Filtered Tubing – used in blood transfusion to filter the blood

Aside from the type, what must the nurse need to know about IV tubing?

The nurse must be familiar with the size of the tubing to be able to accurately count the IV flow rate.

Macrodrop IV tubing can vary from 10, 15, or 20 gtts per milliliter.

Microdrop IV tubing has a rate of 60 gtts per milliliter.

Materials needed:

  • Gloves
  • IV solution in a bag
  • IV tubing as order
  • Sterile 2 x 2 gauze

IV Bag and Tubing Preparation 

1. Check health care provider’s order for the IV solution. Ensures accurate administration of the solution.
2. Wash hands. Reduces transmission of microorganisms.
3. Check client’s identification bracelet. Ensures medication is given to the correct client.
4. Prepare new bag by removing protective cover. Check the expiration date on the bag and assess for cloudiness or leakage. Allows for quick, smooth preparation. Ensures that the solution is sterile.
5. Open new infusion set. Unroll tubing and close roller clamp. Prevents fluid from leaking after IV bag is spiked.
6. Spike bag with tip of new tubing and compress drip chamber to fill halfway. Promotes rapid flow of solution through new tubing without air bubbles.
7. Open roller clamp, remove protective cap from the end of the tubing, and slowly flush solution completely through tubing. Removes air from tubing. Prevents entry of air into the venous system, a cause of air embolus. If fluid enters tubing too rapidly air bubbles occur.
8. Close roller clamp and replace cap protector. Prevents fluid from leaking and maintains sterility of tubing.
9. Apply clean gloves. Reduces the transmission of microorganisms
10. Remove old tubing and replace with new tubing:

  • Place sterile 2 × 2 gauze under IV catheter or heparin lock.
  • Stabilize hub of catheter or needle and gently pull out
  • old tubing.
  • Quickly insert new tubing into hub of catheter or
  • needle.
  • Open roller clamp to establish flow of IV solution.
  • Reestablish drip rate.
  • Apply new dressing to IV site.
  • Absorbs fluids that may drip during the procedure, preventing contamination of surrounding areas.
  • Prevents accidental dislodging of catheter or needle.
  • Prevents backflow of blood or the entrance of air into the vein.
  • Prevents catheter occlusion and maintains IV flow at prescribed rate.
  • Maintains IV flow at prescribed rate.
  • Provides protection from infection and accidental dislodgement.
11. Discard old tubing and IV bag. Prevents accidental transmission of microorganisms.
12. Remove gloves and dispose with all used materials. Reduces transmission of microorganisms.
13. Apply a label with date and time of change to tubing. Calculate intravenous drip rates and begin infusion at prescribed rate. Allows for planning of next change.
14. Wash hands. Reduces transmission of microorganisms.

Note. Adapted from Fundamental and Advanced Nursing Skills. Third Edition, p. 1030-1032, by G. B. Altman, 2010,
Delmar: Cengage Learning.

What to document?

Document the following:

  • Date, time and name IV solution was started
  • Date and time IV tubing was changed

Key Considerations:

  • Before administering medications through IV, ensure its compatibility with the IV solution to prevent untoward reactions.
  • Always check the temperature of the IV solution so that it’s not too warm or too cold before administering it to the client.
  • Teach client to alert the nurse before the solution in the IV bag runs out so that the appropriate replacement will be given in due time.
  • If the IV tubing gets contaminated by needle piercing during the IV piggyback injection, stop the medication administration. Remove the needle and replace cap of the needle to maintain its sterility.  Stop IV flow, obtain a new tubing and change existing tubing using proper aseptic technique. Discard contaminated tubing and place a new IV tubing and solution and finally administer the IV piggyback medication.

Insulin

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What is Insulin?

Insulin is a natural hormone secreted by the cells of the pancreas whenever glucose levels in the blood are increased. Insulin attaches to cells that use glucose for energy and stimulates it to uptake glucose from the blood.

Whenever insulin secretion or insulin-cell receptor sensitivity is impaired, synthetic insulin is needed to continue the function of natural insulin and maintain life.

Unfortunately, synthetic insulin cannot reverse abnormal insulin conditions and is thus needed by patients throughout his or her lifetime.

Indication

Synthetic insulin is required in patients suffering from:

  • Type 1 Diabetes
  • Type 2 Diabetes if other measures such as lifestyle change and oral drug therapy can’t anymore adequately maintain the blood glucose levels

Types of Insulin

Type Insulin Onset Peak (h) Duration Color Nursing Considerations
Rapid-Acting Lispro, Aspart, Glulisine <15 min 1-2 3-5 Clear Clients must eat a meal within 10-15 minutes of injection
Short-Acting Regular 0.5-1 h 2-4 3-8 Clear

Only insulin that can be administered through IV

Should be given 30 – 45 minutes prior to meals

Intermediate Acting NPH 2-4 h 5-8 12-18 Cloudy Pre-filled syringes should be stored in the refrigerator with needle tips up
Long Acting Determir, Glargine 2-4 h Peakless 20-24 Clear Don’t mix with any other insulin or solution
Premixed 2-4 h Peakless 20-24 Cloudy

Rapid-acting Mixture: client must eat within 15 minutes of injection

Short-acting mixture: client should eat within 30 minutes of injection

Don’t mix with any other insulin

What does the peak hour mean?

The peak hour of each type of insulin is the time when hypoglycemia symptoms usually occur.

For instance, if you give a rapid acting insulin at 0800h, then you must look for hypoglycemia symptoms between 0900h-1000h since its peak hour is 1-2 hrs from the time of administration.

Hypoglycemia symptoms to note for include:

  • hunger
  • decreased levels of consciousness
  • hunger
  • diaphoresis
  • weakness
  • dizziness
  • tachycardia

Insulin Administration: Mixing Insulin

Let’s take this scenario as an example:

Doctor orders to give a mixture of 3 units of regular insulin (clear) and 2 units of NPH (cloudy).

Method 1

  1. Add a total of 5 units of air to the syringe
  2. Withdraw 3 units of clear insulin
  3. Change the needle
  4. Withdraw 2 units of cloudy insulin

Method 2

  • If the needle cannot be changed, add a total of 5 units of air to the syringe
  • Withdraw 3 units of clear insulin
  • Withdraw 2 units of cloudy insulin

These methods will prevent the clear solution being contaminated by the cloudy one. If the short-acting medication was contaminated by the intermediate-acting one, masking effect could occur which could be fatal for the client.

Mixing Insulin Clear Before Cloudy
Mixing Insulin Clear Before Cloudy

When mixing insulin just remember: a clear day is preferable to a cloudy day.

Key Points

  • Blood glucose must always be tested prior to administration.
  • Insulin is never to be administered to an already hypoglycemic client.
  • CLEAR insulin must be withdrawn first prior to CLOUDY insulin when mixing insulin.
  • The peak hour of each type of insulin is the time when hypoglycemia symptoms usually occur.
  • Regular insulin is the only insulin that can be given through IV.  All other insulin types are given through subcutaneous injection.

Intravenous Therapy: Assessment and Maintenance of an IV Insertion Site

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Why should the IV insertion site be regularly assessed and maintained?

Assessment and maintenance of an IV insertion site is done to ensure that the client does not suffer any untoward complications connected to IV therapy.

What indicates a normal IV insertion site?

  • Healthy Vein. A healthy vein is round, firm, elastic and engorged without hardened, bumpy or flattened areas.
  • Absence of signs and symptoms of complications. The IV insertion site must be free from redness, swelling, bleeding, warmth at the IV site, pallor, pain or discharge.

Assessment and Maintenance of an IV Insertion Site

Steps Rationale
1. Review the doctor’s order for IV therapy. Ensure accuracy of the administration of IV therapy.
2. Review for hypersensitivity to medications. Prevents risk of allergic reactions.
3. Review client’s IV site record and Intake and Output records. To check for previously noted IV site problems or fluid and electrolyte imbalances.
4. Wash hands and obtain vital signs. Decreases transmission of microorganisms and checks changes in client’s cardiovascular system.
5. Check IV fluid for the following:

  • right fluid
  • right additives
  • right rate
  • right volume at the beginning of shift
Ascertains client is receiving the appropriate IV therapy.
6. Check IV tubing connections. To avoid fluid leaks.
7. Check the gauze IV dressing and vein site for the following:

  • Dampness
  • Redness
  • Warmth
  • Swelling
  • Pain
  • Drainage
These are early signs and symptoms of IV insertion site complications: infection, infiltration or phlebitis.
8. Document according to institution policy:

  • Name of IV solution with additives
  • Rate of infusion
  • IV site condition
  • Time assessed
Provide record of significant IV site findings and proof of regular IV site observation.
9. Wash hands and do aftercare. Decreases transmission of microorganisms.

What must the nurse do with the abnormal IV site assessment findings?

IV Site Complication Nursing Intervention

Hypersensitivity

Note for:

  • fever
  • joint swelling
  • rash
  • hives
  • wheezing
  • Discontinue the infusion.
  • Notify doctor immediately.

Infiltration

Note for:

  • swelling
  • discomfort
  • burning sensation
  • cool skin
  • pallor of site
  • Stop infusion and discontinue IV.
  • Elevate affected extremity.
  • Restart new IV site above previous site or opposite extremity.
  • Document findings and intervention done.
  • Notify doctor for follow-up care.

Phlebitis

Note for:

  • redness
  • tenderness at tip of the IV catheter
  • edema over vein
  • warmth of IV site or general elevated temperature
  • Stop infusion.
  • Apply warm packs for client’s comfort.
  • If necessary, restart new IV site on the opposite arm with larger vein and smaller device.
  • Document findings and intervention done.
  • Notify doctor for follow-up care.

Extravasation

Note for:

  • burning or stinging discomfort
  • cool skin
  • redness
  • swelling 
  • Follow agency’s protocol for extravasation.
  • Stop IV flow or remove IV line.
  • Estimate amount of extravasated solution.
  • Instill appropriate antidote per agency protocol. The commonly used antidote is phentolamine [Regitine].
  • Elevate extremity.
  • Document findings and intervention done.
  • Notify doctor.

Key Considerations:

  • Elderly patients have fragile veins that are prone to infiltration. Extra careful assessment must be done.
  • Always teach client the signs and symptoms of IV insertion site complications so that they know what to report.