8.4. Procedures of intravenous therapy

8.4 .1 Assembling the IV Equipment

• Select the equipment you require for the patient
• Open the package containing the tubing. Be sure to maintain the sterility of the connectors. If the connectors are covered with plastic caps, leave the plastic caps in place until you are ready to connect the tubing. Check the drop factor of the tubing.
• Open the entry area of the fluid container according to the manufacturer‘s direction. There should be evidence that the container was sealed, which certified sterility. Be careful that you do not contaminate the entry port.
• Follow the manufacturer‘s directions about cleaning the entry port with an alcohol swab. Most fluid containers are sealed so that the entry area is sterile and does not need to be cleaned.
• Close the regulator on the tubing.
• Insert the tubing into the fluid container through the correct entry port.
• Invert the bottle with the tubing hanging down. It is convenient to be able to hang the bottle on a hook or stand at this time.
• For a flexible plastic drip chamber, squeeze the chamber to fill it half full with fluid. A rigid drip chamber usually fills when the container is inverted.
• Hold the end of the tubing over a basin or waste container. Open the regulator gradually and allow the tubing to fill. If the end of the tubing is tightly capped, that cap must be loosened to allow the tugging to fill. Replace the cap when the tubing is full. Be sure that all large bubbles are eliminated.

8.4.1 Preparing a patient for intravenous therapy:

A few minutes before the infusion is to be started, the anesthetist or other practitioner should psychologically and physically prepare the patient. To some patients, the knowledge that they are about to receive intravenous fluids is threatening. Certain patients feel the procedure implies serious illness; others are frightened by the threat of pain, discomfort, and immobility. Previous experience can help make the patient less apprehensive, assuming the experience was a good one. For other patients, however, the memories of problems related to the IV make the impending experience truly frightening.

Explain the procedure to the patient and tell him or her why it has been ordered. Tell the patient that a venipuncture can cause discomfort for a few seconds, but there should be no discomfort while the solution is flowing. Check the patient‘s gown to make sure that it can be removed over the IV apparatus if necessary.

8.4.2 Venipuncture site selection: 

Before performing venipuncture, you have to accomplish hand hygiene and apply gloves. Next select the most appropriate insertion site and type of cannula for a particular patient. Factors influencing these choices include the type of solution to be administered, the expected duration of IV therapy, the patient‘s general condition, and the availability of veins. The skill of the person initiating the infusion is also an important consideration.

Infants: Because infants do not have large veins in the antecubital fossa, veins in the temporal region of the scalp or sometimes the back of the hand or the dorsum of the foot are used.

Adults: For prolonged therapy, veins on the back of the hand and on the forearm are preferred. The metacarpal, basilic, and cephalic veins are commonly used. These forearm sites are equipped with the natural splits of the ulna and radius, and allow the patient more arm movement for activities.

Select the vein by looking, palpating, and attempting to distend any veins in the area. You want a clearly visible vein that can be palpated and that has a straight section for entry. If one is not visible, look for the faint outline of a blue vein under the skin to determine where to begin. When even an outline is not visible, you must begin to distend the veins to make them visible or palpable. To distend the veins, place a tourniquet a few inches above the area where you want to start the IV, and ask the patient to "pump" (opening and closing the fist). Generally, these maneuvers distend the vein, making it easier to locate and enter.

8.4.3 Performing the venipuncture

Perform the venipuncture after you have selected the needed IV equipment, assembled the equipment, prepared your patient psychologically and physically, and selected an appropriate site for inserting the IV with the following sequence of procedure.

• Wash your hands and put on clean glove. Starting an IV is a sterile procedure for which your hands must be clean.
• Position yourself to be comfortable. In order to start an IV, you will find that it is equally important for you to be comfortable as it is for the patient.
• Locate a vein in which to start the IV. Examine both forearms and select a site to begin. Place a tourniquet a few inches above the area where you want to start, and ask the patient to open and close his or her fist. If the vein does not distend, you may have to place the limb in a dependent position or apply warm moist packs to the area.
• Clean the area thoroughly. Start from the point at which you want to enter and move with a circular motion away from it, cleaning the skin thoroughly at and around the vein you have selected. If the area is especially hairy, shave or clip the hairs. Try not to touch the area after it has been cleaned.
• Insert the needle. Using the thumb of the non dominant hand, gently retract the skin away from the site. Holding the needle at about a 45° angle, with the bevel up, pierce the skin immediately beside the vein you have selected. When the needle is through the skin, decreases the angle until it is almost parallel with the skin, and enter the vein. When blood comes back into the tubing or syringe (depending on the device you use), insert the needle or catheter almost the full length of the needle.
• Release the tourniquet. Holding the needle or other device steadily with your dominant hand, release the tourniquet with your other hand. Apply gentle pressure with index finger of nondominant hand 1 ¼ inches above site.
• Connect the tubing to the IV tube and initiate the flow. Remove the protective cap from the IV tubing (maintaining sterile technique), connect it securely to the needle, and open the regulator to initiate the flow. This should be done quickly to prevent the patient‘s blood from clotting and clogging the needle.
• Tape the needle securely: Tape the needle and tubing in place, using paper tape (if available – it is usually less traumatic to the patient‘ skin).
• Adjust the flow rate:
• Dispose of the equipment.
• Remove gloves.
• Wash your hands.
• Teach the patient how to protect the IV: avoid sudden twisting or turning movements of the arm with the infusion, avoids stretching or placing tension on the tubing and try to keep the tubing from dangling below the bevel of the needle.

8.4.4 Maintaining an IV infusion:

After the IV has been started, maintain the infusion by regulating the flow rate.

Regulating flow rate

Milliliters per hour: This calculation is made by dividing the total infusion volume by the total time in hours. Milliliters per hour = Total infusion volume / Time of infusion in hours

Example: If the requirement is 1000 ml in 8 hours, the calculation is: 1000/ 8 = 125 ml per hour

Hourly checks are required to ensure that the correct number of ml has infused. We have to put a strip of adhesive tape on the IV container with the exact times for the infusion or the amount to be infused hourly.

Drops per minute: The number of drops per minute (gtts/min) is calculated as follows: Multiply the milliliters per hour by the drip factor (read on the package) and divide by the number of minutes.

Example: IV to infuse at 125 cc/hr per IV set with drip factor of 15.

(125 x 15/60) = 1875/60 = 31 gtts/min. The infusion rate can then be established by adjusting the clamp on the tubing and counting the drops in the drip chamber. .

8.4.5 Steps in discontinuing IV

• Wash your hands and wear clean gloves
• Gather the necessary equipment: a 2 x 2 sterile gauze square and plaster and bandage.
• Explain the procedure to the patient. Tell him/her that this should not cause discomfort.
• Shut off the IV flow and carefully remove the tape.
• Hold the 2 x 2 gauze above the entry site. Be ready to exert pressure as soon as the needle is out, but do not exert pressure on the site while pulling the needle out. This compresses the vein wall between the needle and the swab and can damage the vein.
• Remove the needle by pulling straight out in line with the vein. Check needle or catheter to be sure it is intact.
• Immediately put pressure on the site.
• Raise the patient‘s arm above his or her head for about one minute. Hold it there until the bleeding is controlled.
• Put a bandage or plaster over the site.
• Remove all the equipment.
• Remove gloves and wash your hands.
• Chart, including intake, and note if needle or catheter is intact. It is important to chart carefully after IV care and monitoring are done. The charting must include the exact time started and stopped, and the exact content in detail.