When should the nurse change the IV site?

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Figure 8.4 IV Primary and secondary tubing set up

IV solution bags should have the date, time, and initials of the health care provider marked on them to be valid. Add-on devices (e.g., extension tubing or dead-enders) should be changed every 96 hours, if contaminated when administration set is replaced, or as per agency policy. Intravenous solution and IV tubing should be changed if:

• IV tubing is disconnected or becomes contaminated by touching a non-sterile surface
• Less than 100 ml is left in the IV solution bag
• Cloudiness or precipitate is found in the IV solution
• Equipment (date and time) is outdated
• IV solution is outdated (24 hours since opened)

Primary and secondary administration sets (see Figure 8.4) should be changed regularly to minimize risk and prevent infection (CDC, 2011; Fraser Health Authority, 2014). Change IV tubing according to agency policy. Table 8.5 lists the frequency of IV tubing change.

Table 8.5 Frequency of IV Tubing Changes

Safety considerations: All IV tubing must be changed using sterile technique. IV tubing is changed based on the type of tubing, time used, and the type of solution. If possible, coordinate IV tubing changes with IV solution changes.
Frequency of IV Tubing Change	Type of IV Tubing and Solution
Every 72 -96 hours	Primary tubing with hypotonic, isotonic, or hypertonic continuous solution, when insertion site is changed, or when indicated by the type of solution or medication being administered.
Every 24 hours	Secondary or intermittent IV solution or medication. Rationale: When an intermittent infusion is repeatedly disconnected and reconnected for infusion, there is increased risk of contamination at the catheter hub, needleless connector, and the male Luer end of the administration set, potentially increasing risk for CR-BSI.
Every 24 hours	Infusions containing fat emulsions (IV solutions combined with glucose and amino acids infused separately or in a 3 in 1 admixture). Example: Total parenteral nutrition (TPN).
4 hours or 4 units, whichever comes first, or between products	Blood and blood products
Data source: CDC, 2011

Infusing IV Fluids by Gravity or an Electronic Infusion Pump (EID)

To ensure therapeutic effectiveness of IV fluids, a constant, even flow is necessary to prevent complications from too much or too little fluid. A physician must order a rate of infusion for IV fluids or for medications. The rate of infusion for medications (given via a secondary or primary infusion) can be found in the Parenteral Drug Therapy Manual (PDTM). If an order for IV fluids is “to keep vein open” (TKVO), the minimum flow rate is 20 to 50 ml per hour, or according to physician’s orders (Fraser Heath Authority, 2014).

A health care provider is responsible for regulating and monitoring the amount of IV fluids being infused. IV fluid rates are regulated in one of two ways:

1. Gravity. The health care provider regulates the infusion rate by using a clamp on the IV tubing, which can either speed up or slow down the flow of IV fluids. An IV flow rate for gravity is calculated in gtts/min.
2. Electronic infusion device (EID) (see Figure 8.5). The infusion rate is regulated by an electronic pump to deliver the fluids at the correct rate and volume. All IV pumps regulate the rate of fluids in ml/hr. An IV pump (EID) is used for many types of patients, solutions, and medications (Vancouver Coastal Health, 2008).

An IV pump must be used for:

• All CVC devices
• All opioid infusions (use a patient-controlled analgesia)
• All pediatric patients
• All medication as described in the PDTM
• Infusion rates below 60 ml/hr
  
  Figure 8.5 Electronic infusion device (EID)

To calculate the drops per minute for an infusion by gravity, follow the steps in Table 8.6.

Table 8.6 Calculating the Drops per Minute (gtts/min) for an Infusion by Gravity

Steps	Additional Information
1. Verify the physician order.	An order may read: Example 1. Give NS IV 125 ml/hr Example 2. Give 1000 ml of NS IV over 8 hours.
2. Determine the drop factor on the IV administration set.	The drop factor is the amount of drops (gtts) per minute. IV tubing is either macro tubing (10, 15, or 20 gtts/min) or micro tubing (60 gtts/min). The drop factor (or calibration of the tubing) is always on the packaging of the IV tubing.
3. Complete the calculation using the formula.	Use the formula: Infusion rate (ml/hr) × IV  drop factor (gtts/min) = drops per minute 60 (Administration time is always in minutes) To calculate ml/hr, divide 1000 ÷ 8 = 125 ml/hr. Example: Infuse IV NS at 125 ml/hr. IV tubing drop factor is 20 gtts/min 125 × 20 = 41.6 gtts/min, round up to 42 gtts/min (Round down or up to the nearest whole number) 60
4. Regulate IV infusion using the roller clamp.	Observe and count the drips in the drip chamber and regulate for 42 gtts/min (one full minute). Alternatively, divide 42 by 4 (rounded down from 10.4 to 10 gtts/min) to count for 15 seconds. The gtts/min should be assessed regularly to ensure the IV is infusing at the correct rate (e.g., every 1 to 2 hours, if the patient accidentally bumps the IV tubing, or if a patient returns from another department). Regulate IV tubing by using a roller clamp
Data source: Fulcher & Frazier, 2007; Perry et al., 2014

Take the IV calculations quiz for more practice with IV fluid dose calculation.

When an infusion is by gravity, there are several factors that may alter the flow/infusion rate (Fulcher & Frazier, 2007). In addition to regulating the flow rate, assess the IV system to ensure these factors are not increasing or decreasing the flow of the IV solution. These factors are listed in Table 8.7.

Table 8.7 Factors Influencing the Flow Rate of Infusions

Factors	Additional Information
Tube occlusion	May occur if the tubing is kinked or bent. Tubing may become kinked if caught under the patient or on equipment, such as beds and bed rails.
Vein spasms	Irritating or chilled fluids (fluids stored in the fridge) may cause a reflex action that causes the vein to go into spasm at or near the intravenous infusion site. If fluids or medications are chilled, bring to room temperature prior to infusion.
Height of the fluid container	The IV tubing drip chamber should be approximately 3 feet above IV insertion site.
Location/position of IV cannula	If the cannula is located in an area of flexion (bend of an arm), the IV flow may be interrupted when the patient moves around. To avoid this issue, replace IV cannula.
Infiltration or extravasation	If the cannula punctures the vein, the fluid will leak into the surrounding tissue and slow or stop the flow, and swelling will develop.
Accidental touching/bumping of the control clamp or raising arm above heart level	Instruct the patient not to touch the roller clamp and to take care not to bump the clamp, as this may accidentally change the flow rate. Instruct patient to keep hand/arm below heart level; an elevated hand/arm will slow or stop an infusion running by gravity.
Needle or cannula gauge/diameter	The smaller the needle or cannula, the slower the fluid will flow.
Data source: Fulcher & Frazier, 2007; Perry et al., 2014

Assessing an IV System

All patients with IV fluid therapy (PIV and CVC) are at risk for developing IV-related complications. The assessment of an IV system (including the IV site, tubing, rate, and solution) (see Figure 8.6) often depends on what is being infused, the patient’s age and medical condition, type of IV therapy (PIV or CVC), and agency policy. Generally, an IV system should be assessed as described in Checklist 65.

Figure 8.6 Assess IV site prior to use     Checklist 65: Assessing an IV System

Disclaimer: Always review and follow your hospital policy regarding this specific skill.
Safety considerations:  IV systems must be assessed every 1 to 2 hours or more frequently if required. An IV system should be assessed at the beginning of a shift, at the end of a shift, if the electronic infusion device alarms or sounds, or if a patient complains of pain, tenderness, or discomfort at the IV insertion site. Review the patient’s chart to determine insertion date and type of solution ordered. A peripherally inserted catheter is usually replaced every 72 to 96 hours, depending on agency policy. If the peripheral catheter or central venous catheter is not in use, or is being used intermittently, flushing is required to keep the site patent. Refer to agency policy for flushing guidelines. A not-in-use peripheral IV site is generally flushed every 12 hours with 3 to 5 ml of normal saline. Review the in-and-out sheet to determine expected amount in the IV solution bag. Patients with cardiac or renal disease, as well as pediatric patients, are at a higher risk for IV-related complications. Elderly patients often have fragile veins and may require closer monitoring.
Steps	Additional Information
1. Perform hand hygiene.	This step reduces the transmission of microorganisms.
2. Introduce yourself and explain the purpose of the assessment.	This builds trust with patient and allows time for the patient to ask questions.
3. Confirm patient ID using two patient identifiers (e.g., name and date of birth), and compare the MAR printout with the patient’s wristband.	This step ensures you have the correct patient and complies with agency standard for patient identification. Compare MAR with patient wristband
4. Apply non-sterile gloves (optional).	This reduces the transmission of microorganisms.
5. Assess the IV insertion site and transparent dressing on IV site.	Check IV insertion site for signs and symptoms of phlebitis or infection. Check for fluid leaking, redness, pain, tenderness, and swelling. IV site should be free from pain, tenderness, redness, or swelling. Ensure patient is informed to alert the health care provider if they experience pain or notice swelling or redness at the IV site. If patient is unable to report pain at IV site, more frequent checks are required.
6. Inspect the patient’s arm for streaking or venous cords; assess skin temperature.	Assess complications on hand and arm for signs and symptoms of phlebitis and infiltration/extravasation.
7. Assess IV tubing for kinks or bends.	Kinks or bends in tubing may decrease or stop the flow of IV fluids. Ensure tubing is not caught on equipment or side rails on bed. Tubing should be properly labelled with date and time.
8. Check the rate of infusion on the primary and secondary IV tubing. Verify infusion rate in physician orders or medication administration record (MAR).	If IV solution is on gravity, calculate and count the drip rate for one minute. If solution is on an IV pump, ensure the rate is correct and all clamps are open as per agency protocol. If secondary IV medication is infusing, ensure clamp on secondary IV tubing is open. The EID is unable to distinguish if the primary bag or secondary bag is infusing.
9. Assess the type of solution and label it on bag. Check volume of solution in bag.	IV solutions become outdated every 24 hours. Ensure the correct solution is given. If 100 ml of solution or less is left in the bag, change the IV solution and document on in-and-out sheet. If an IV pump is used, ensure it is plugged into an outlet. Ideally, the IV solution should be 90 cm above patient heart level.
10. Assist patient into comfortable position, place call bell in reach, and put up side rails on bed as per agency policy.	These precautions prevent injury to the patient.
11. Perform hand hygiene.	This step prevents the spread of microorganisms.
12. Document procedure and findings as per agency policy.	Timely and accurate documentation promotes patient safety.
Data source: Fulcher & Frazier, 2007; Perry et al., 2014

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