#17 Discuss assessment and interventions for IV therapy

# 17 Discuss the assessment and nursing interventions for the client
receiving IV therapy

Maintaining Infusions: (Kozier, skills bk.pg.549)

Once an intravenous infusion has been established, it is the nurse’s responsibility to maintain the prescribed flow rate and to prevent complications associated with IV therapy. (Fluid volume excess, electrolyte imbalance) Current research indicates that routine change of peripheral IV catherers/needles and IV tubing can be performed every 72 hours (or according to agency policy). Dressings should be changed on the IV site only when soiled, wet, or dislodged.

In maintaining the infusion, the nurse will examine the appearance of infusion site; patency of system; type of fluid being infused and rate of flow; and the response of the client. From physician’s order, determine the type and sequence of solutions to be infused. Determine the rate of flow and infusion schedule.

-Ensure that the correct solution is being infused.
-Observe the rate of flow every hour.
-Observe the position of the solution container. (should be 3 ft. above the IV site)
-If the rate is too fast, check agency policy, the physician may need to be notified.
-If the rate is too slow, adjust the IV to the prescribed rate. (check with facility policy)
-If prescribed rate of flow is 150mL/hr or more, check the rate of flow more frequently, for
example, every 30 min.
-Inspect the patency of the IV tubing and needle.(make appropriate changes/corrections when
nec.)
-Inspect the insertion site for fluid infiltration
-Inspect the insertion site for phelbitis
-Inspect the intravenous site for bleeding
-Teach the client ways to help maintain the infusion system(avoid twisting or turning the
arm/hand w/IV)


ATI book pg. 416-417 Says:

Monitor IV infusion at least every hour, count drip rate, check tubing for kinking/leaks, observe settings on pump, inspect site for swelling, pain, coolness, or pallor which may indicate infiltration.

-Inspect insertion site for redness, swelling, heat, and pain which may indicate phelbitis.
-Change tubing every 48-72 hours depending on policy
-Change tubing when hanging new solution container.
-Verify solution type and flow rate
-Peripheral IV dressings should be changed when damp or soiled or every 48-72 hours
depending on protocol.
-Label the dressing and secure the IV tubing