Chapter 8. Intravenous Therapy

8.5 IV Administration Equipment

Intravenous fluids are administered through thin, flexible plastic tubing called an infusion set or primary infusion tubing/administration set (Perry et al., 2018). The infusion tubing/administration set connects to the bag of IV solution. IVs are then run either by gravity or by an intravenous infusion pump, sometimes referred to as electronic infusion device (EID).

Primary IV tubing is used to infuse continuous or intermittent fluids or medication. It consists of the following parts (see Figure 8.15):

Figure 8.15 IV tubing (primary & secondary)
  • Sterile spike: Connects the tubing into the IV bag.
  • Drip chamber: Used to observe flow of IV fluids and / or to calculate drops per minute.
  • Backcheck valve: Prevents fluid or medication from travelling up the IV.
  • Access ports: Used to infuse secondary medications and give IV push medications.
  • Roller clamp: Used to regulate the speed of, or to stop or start, a gravity infusion.
  • Extension set: 10 to 20 cm IV tubing attached to IV cannula. Helps to reduce micro-movements at IV insertion sites and protects from BBF exposure during IV tubing changes.
  • Slide clamps: Used to stop the infusion. Are needed to open and close IV infusion pump (a.k.a. EID).

The following table is intended to familiarize you with common IV equipment.

Table 8.7 Common IV Equipment
Primary IV tubing IV tubing/administration set that connects to the bag of IV solution. May or may not contain injection ports. See Table 8.9 Frequency of IV Tubing Changes.

Primary IV tubing is either a macro-drip solution administration set that delivers 10, 15, or 20 gtts/ml, or a micro-drip set that delivers 60 drops/ml. Macro-drip sets are used for routine primary infusions. Micro-drip IV tubing is used mostly in pediatric or neonatal care, when small amounts of fluids are to be administered over a long period of time (Perry et al., 2014). The drop factor can be located on the packaging of the IV tubing.

Figure 8.16 Drop factor located on IV tubing package

Note: Suppliers provide different kinds of tubing for different purposes. Read the packaging and choose tubing that is appropriate.
Secondary tubing It is shorter in length than primary tubing, with no access ports or backcheck valve. It is connected to a primary line via an access port near the top of the set. It is used to infuse intermittent medications or fluids. Secondary tubing should be changed every 24 hours.
IV bags IV solutions come in a variety of solutions, concentrations, and volumes. They are considered medication, and as such the 7 Rights apply. The prescriber will order the IV solution and rate. The nurse monitors for signs of complications related to the solution and IV equipment. IV bags and tubing should have a sticker or label with the date, time, and initials of the healthcare provider marked on them to be valid. IV bags and/or 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)
Figure 8.17 Different volumes of IV bags
Extension sets A.k.a. “add on device,” 10 to 20 cm of IV tubing attached to IV cannula. Helps to reduce micro-movements at IV insertion sites, and protects from BBF exposure during IV tubing changes. Should be added to all PVAD-short and CVADs that do not have permanent extension tubing as part of their structure if tubing changes are expected.

If added at the time of insertion—does not require routine changing—it is considered part of the IV cannula.

If added after the insertion, change when integrity is compromised and at each tubing change.

PVAD-short – Saline lock with extension and needleless cap
Needleless cap Added to the distal end of all extension sets of all lumens of VADs to prevent backflow of blood and BBF exposure to healthcare provider. Also added to indwelling subcutaneous devices (butterflies) to allow needleless access when administering medications.

Can be bonded to the extension set or can be separate (add on) to the extension set.

Must be sanitized according to agency policy prior to accessing.

Can be neutral, negative displacement, and positive pressure. Negative caps are not recommended.

Changed q 7 days; each time a site is changed; following blood draws; following blood product administration; when all residual blood cannot be cleared for the device; when contamination is suspected or confirmed. Check agency protocols for correct flushing technique.

Figure 8.18 Different types of needleless caps
IV tubing with filter Used to filter bacterial particulate and candida. Available with different filter capabilities. Used when administering packed red blood cells, PN, and some medications. Refer to your agency’s parenteral practices guidelines. When administering packed red blood cells, always use a special blood administration set with a filter.
Vented set IV administration set used for solutions that are supplied in glass containers.
Volume control set A type of reservoir that holds a controlled volume of fluid from the IV bag. Limits volume of IV fluids or medications able to infuse into the patient. Often used in pediatrics. IV fluids are attached above the buretrol and refilled manually as the volume decreases.

Figure 8.19 volume control set
Data sources: Interior Health, 2012; Perry et al., 2018; Vancouver Coastal Health, 2008

Frequency of IV Tubing Changes

Primary and secondary administration sets should be changed regularly to minimize risk and prevent infection (CDC, 2017; Fraser Health Authority, 2014). Change IV tubing according to agency policy. Table 8.8 lists the frequency of IV tubing change.

Table 8.8 Frequency of IV Tubing Changes
Safety considerations:
  • All IV tubing must be changed using principles of asepsis.
  • 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.
  • Tubing that contains a large amount of blood and is suspected of being clotted requires immediate changing to prevent risk of introducing a thrombus into circulation.

Frequency of IV Tubing Change

Type of IV Tubing and Solution
Every 72 to 96 hours For continuous primary infusion sets with hypotonic, isotonic, or hypertonic solution, when insertion site is changed, or when indicated by the type of solution or medication being administered.
Every 24 hours As of 2017, the CDC is saying no recommendation can be made regarding the frequency for replacing intermittently used administration sets. Historical thinking was that 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. Follow agency protocol.

Note: Agency policy sometimes recommends secondary tubing be changed every 24 hours.
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: Parenteral nutrition (PN).
4 hours or 4 units, whichever comes first, or between products Blood and blood products
Data sources: CDC, 2017; Interior Health, 2012

Assessing an IV System

All patients with IV therapy (PVAD-short, midline catheters, and CVADs) are at risk for developing IV-related complications. The assessment of an IV system (including the IV site, tubing, rate, and solution) should take into account the IV administration system AND the patient. Checklist 65 provides general guidelines for assessing an IV system.

    Checklist 65: Assessing an IV System

Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: 
  • IV systems must be assessed according to agency protocols. This might mean every 5 minutes when administering specific medications, to hourly, to every 1 to 2 hours, or to once per shift.
  • An IV system should be assessed whenever 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 PVAD-short catheter is usually replaced every 72 to 96 hours, depending on agency policy.
  • If a venous access device is not in use (i.e., it is locked) care and maintenance are still required to keep the site patent. Refer to agency policy for flushing guidelines.
  • IV therapy is considered medication. Document according to agency guidelines.
  • Patients with cardiac or renal disease, as well as the elderly and young, 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 name band
Compare MAR with patient wristband
4. 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.

Assess IV site prior to use

Ensure patient is informed to alert the healthcare 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.
5. 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.
6. 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 the tubing was initiated.
7. Check the rate of infusion for the primary and secondary IV solutions. 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.
8. Assess the type of solution and label on bag indicating when it was hung.

Check volume of solution in bag.

Assess labels on IV tubing for information about when tubing needs to be changed.

 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 according to agency guidelines.

If an IV pump is used, ensure it is plugged into an outlet. This ensures good battery charge.

If IV tubing is due to be changed, consider priming a new bag and hanging it on the IV pole until the current bag is infused.
9. Assist patient into comfortable position, place call bell in reach, and ensure necessary side rails are used. These precautions prevent injury to the patient.
10. Perform hand hygiene. This step prevents the spread of microorganisms.
11. Document procedure and findings as per agency policy. Timely and accurate documentation promotes patient safety.
Data sources: Fulcher & Frazier, 2007; Perry et al., 2018

Critical Thinking Exercises

  1. What is the purpose of the back-check valve on primary IV tubing?
  2. When is it important for the nurse to know the drop factor of IV tubing?
  3. What is the purpose of extension tubing?
  4. The nurse has found the patient to have an IV administration set hung 96 hours prior. Explain the necessary next steps.

Attribution

Figure 8.15 IV Primary and Secondary Tubing Setup by BCIT is used under a CC BY-SA 4.0 international license.

Figure 8.16. drop factor by author is used under a CC BY-SA 4.0 international license.

Figure 8.17 Different volumes of IV bags by author is used under a CC BY-SA 4.0 international license.

Figure 8.18 Needleless caps by author is used under a CC BY-SA 4.0 international license.

Figure 8.19 Volume Control Set by author  is used under a CC BY-SA 4.0 international license.

License

Icon for the Creative Commons Attribution 4.0 International License

Clinical Procedures for Safer Patient Care Copyright © 2018 by Thompson Rivers University is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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