Nursing Practical Guideline Procedure : Intravenous fluid

Intravenous fluid :

The introduction of large amount of fluid into body via veins is termed as I.V. infusions.

It has the following purpose :

1.     To restore the fluid volume that is lost from the body due to hemorrhage, vomiting, diarrhoea, drainage etc.

2.     To meet the patient's basic requirements for calories, water, minerals and vitamins.

3.     To prevent and treat shock and collapse.

4.     To supply the body with adequate amounts of fluids, electrolytes, and other nutrients when the patient is unable to take in adequate amounts by mouth or oral intake is contraindicated or impracticable.

5.     To administer medicines.

Indications of intravenous infusions:

Intravenous  infusions are indicated in the following situations :

1.     To save the patients in life threatening situations e.g., patients having hemorrhage, shock, extensive burns etc.

2.     To supply fluids and nutrients to the patients who may have nothing by mouth or who are unable to ingest oral liquids to prolonged nausea, vomiting, diarrhoea, peritonitis, paralytic ileus, fistulas etc.

3.     Supply fluids and nutrients to the patients who are unable to digest or absorb a diet administered by mouth or through the nasal tube; e.g., patients who do not have an anatomically intact intestinal tract or the patients with septicaemia etc

4.     To dilute toxins in case of toxaemia or septcaemia.

5.     To administer medications that are destroyed by the gastric juices or that will not be absorbed by the gastro-intestinal tract, if administered orally.

Solutions used:

1.     Nutrient solutions e.g.. dextrose 5%, 10%. 20%, 25%. 50%. etc.

2.     Electrolyte solutions available in isotonic, hypotonic and hypertonic concentration, e.g., normal saline, dextrose saline, lactated ringer's solution. 1/6 molar sodium lactate solutions etc.

3.     Alkalinizing and acidifying solutions, e.g.. sodium lactate solution, sodium bicarbonate, potassium chloride etc.

4.     Blood volume expanders. These are plasma substitutes and contain large molecular substances which will not escape through the vessel walls and tend to prevent the circulating fluid from leaking into the tissues, e.g.. dextran, lomodex. haemocoele etc.

Venipuncture sites:

a.     When selecting a site for administration of I.V. fluids, it is essential to consider the following factors :

2.     The condition of veins (collapsed or too small).

3.     The characteristics of tissues over the vein (oedematous, injured, diseased, inflammed etc.)

4.     Purpose and the duration of infusions.

5.     The type and the amount of I.V fluid ordered.

6.     The diagnosis and the general conditions of the patient.

7.     The most convenient veins for venipuncture in the adult are the basilic and the median cubital vein in the antecubital fossa because these veins are large and superficial. However, for prolonged infusions, these veins cannot be used without limiting the movements at the elbow joints by the use of splints.

8.     If the person is right handed, use of the left arm allows more independence and vice versa.

9.     The most commonly used veins in the order of their frequency of use are as follows:

a.     Veins of the forearm (basilic and cephalic veins).

b.     Veins in the antecubital fossa (median cubital, cephalic and basilic vein).

c.      Veins in the radial area (radial vein).

d.     Veins in the hand (dorsal metacarpel veins).

e.      Veins in the foot.

f.       Veins in the thigh (femoral and saphenous veins)

g.     Veins in the scalp (for infants).

Nurse's responsibility in the administration

a)     Check the patients' name, bed number and other identifications

b)    Check the diagnosis and the age of the patient.

c)     Check the purpose of infusion.

d)    Check the physician's orders for the type of infusion fluid, the strength, the amount and the duration of infusion.

e)     Check the consciousness of the patient and his ability to follow the instructions.

f)      Check the general condition of the patient, whether overhydrated or dehydrated.

g)     Check the site of infusion - note the condition of the veins and tissue at the infusion site.

h)    Check the abilities and limitations of the patient.

i)       Check the need for additional restraints.

j)       Check the patient's previous experience with infusions.

k)    Check the articles available in the patient's unit.

l)       Check the articles for their working order, the sterility of drip sets and the fluid. Check the expiry date of the fluid. Check the fluid fix discolouration, suspended particles etc.

Preparation of articles

Articles

1.     I.V. solutions (sterile and clear) in required number of bottles for a day.

2.     Sterile I.V. tubing with attached drip chamber and damp.

3.     Sterile [Butterfly (or) real] needle with a protective on its needle.

4.     Sterile syringes (2 or c Needles no. 20) and

5.     Sterile transfer forceps in jar

6.     Sterile cotton swabs and, pieces in sterile containers

7.     Methylated spirit container

8.     Kidney tray and paper

9.     I Bowl with water

10.                        Tourniquet

11.                        Adhesive plaster with scissors Covered arm splint with the bandages.

12.                        Specimen bottles

13.                        Mackintosh and towel

14.                        Intravenous pole

15.                        Purpose:

16.                        To administer fluid without interruption.

17.                        To apply the fluid into the patient.

18.                        It can be used for unstable vein and also allows maximum freedom of movement.

19.                        To take blood specimens, if necessary , to add medications to0 the intravenous drip or to initiate the procedure.

20.                        To handle sterile supplies.

21.                        To clean the skin at the site of infusion and to cover the needle after the venipuncture.

22.                        To clear the skin.

23.                        To receive the wastes.

24.                        To receive the used syringes and needles

25.                        To occlude venous return and to make the veins visible.

26.                        To secure the needle and the tubling.

27.                        To immobilize the part in order to prevent the needle dislodging from the site.

28.                        To collect blood specimen if ordered.

29.                        To protect the bed and the garments.

30.                        To hang the bottle at the required height.

Preparation of the patient

1.     Explain the procedure to the patient to win confidence and co-operation. Explain the sequence of the procedure and tell how he can co-operate in the procedure.

2.     Tactfully send the visitors out of the patient' s room.

3.     1f the general conditions allows ask the patient to wash hands with soap and water.

4.     Provide privacy with curtain and drapes.

5.     Restraint the site, in case of children.

6.     Offer the bed pan or urinal as needed.

7.     See that the patient has taken food or drink, if allowed.

8.     Check the vital signs and record it in the nurses record for the future reference.

9.     Divert the attention of the patient away from the infusion procedures by friendly conversations and by curious articles.

10.                        If any sedation is ordered, it may be given to quiet the patient.

11.                        Adjust the height of the bed for comfortable working of the nurse.

12.                        Clear the bedside table or overbed table and arrange the articles conveniently.

13.                        Place the patient in a comfortable and relaxed position suitable for the infusion site.

14.                        Select a site on the non-dominant arm to give maximum freedom for the patient.

15.                        Keep the I.V. stand in position.

16.                        Place the mackintosh and towel under area where the infusion is to be given.

17.                        Provide a good source of light if the lighting in the room is inadequate.

18.                        Call for assistance if necessary.

Procedure:

1.     Wash hands

2.     Prepare the I.V. solution

3.     Carefully remove the bottle seal from the top of the bottle. Clean the top with a spirit swab; holding the bottle upright, insert the drip set and the air vent into the bottle openings.

4.     Every step requires aseptic technique to prevent contamination of the whole apparatus.

5.     Close the screw clamp to prevent the drip chamber completely filled with the fluid loss from the drip set.

6.     Hang the bottle on the I.V. pole about 18 to 24 inches high.

7.     Connect the butterfly needle to the I.V. tubing and remove the protective covering.

8.     Open the damp and flow the iv fluid through tubing and needle into kidney tray until all air is removed. Clamp the tubing and reapply the protective cap over the needle.

9.     Prepare few strips of adhesive tapes and keep ready for use.

10.                        Prepare the venipuncture site.

11.                        Place the extremity independent position (1ower than the patient's heart).

12.                        Apply a tourniquet firmly 6 to 8 inches proximal to the venipuncture site.

13.                        Massage or stroke the vein distal to the knot and in the direction of the venous flow (towards the heart).

14.                        Encourage the patient to clench and unclench the fist rapidly.

15.                        Lightly tap the vein your finger tips.

16.                        If the veins are not visible by the above stops, remove the tourniquet and apply heat to the entire extremity for 10 to 15 minutes. Then apply the tourniquet.

17.                        Clean the area with a spirit swab.

18.                        Dry the area with a sterile dry swab.

19.                        Insert the needle into the vein by grasping the arm distally to the point of the entry of the needle.

20.                        Place the left thumb one inch below the expected point of entry. Pull the skin taut.

21.                        Holding the needle

Reasons:

1.     To prevent cross infection.

2.     Sufficient height needed for gravity to overcame venous pressure and to facilitate the flow of solution into the vein.

3.     After care of the patient and the articles:

4.     Maintain the. specified rate of flow throughout the procedure.

5.     Remove the mackintosh and towel.

6.     Make the patient comfortable in bed. Tidy up the bed.

7.     If the patient is conscious, instruct the patient not to move the hand.

8.     Collect all articles used for infusion and take them to the utility room; clean them first with cold water and then with warm soapy water and rinse them thoroughly with clean water. Dry them and replace them in their proper places.

9.     Send the blood specimens, if any, to the lab.

10.                        Record the following informations on the nurses record with date and time :

Type of fluid administered.

The concentration of the solution.

The amount of fluid.

The rate of flow of fluid.

Any medicines added to the bottle. (If medicines are added to the I.V. bottle, it should be clearly written on the I.V.bottle also).

Any reaction noticed in the patient.

11.                        Return to the bedside to assess the comfort of the patient and observe any complications developing in the patient. Stay with the patient and observe the patient constantly in order to prevent accidents and complications. Watch for any un-favourable signs such as headache, chills, nausea, restlessness, dyspnoea etc. Watch the infusion site for swelling, pain etc.

12.                        If appropriate, teach the family members to observe and report the following conditions and request for nursing assistance.)

a.     The fluid chamber is not dripping.

b.     Bottle or bag of fluid nearly empty.

c.      Backflow of blood into the tubing.

d.     Needle or connections in the tubing is disconnected.

13.                        Increasing pain and. discomfort at the needle site or along the vein.

14.                        Swelling of tissues around the needle insertion site.

15.                        Any unusual symptoms such as chills, restlessness etc.

16.                        When leaving the ward, the nurse should report the following to the relieving nurse.

17.                        The name and bed number of the patient getting I.V. drip.

18.                        The time at which the drip has started.

19.                        The type of fluid that is given.

20.                        The amount of fluid that is administered and how much more to be administered.

21.                        Any specific precautions to be followed.

22.                        The specified rate of flow.

23.                        The general condition of the patient.

24.                        To change the intravenous bottles :

25.                        Prepare the new bottle prior to the old one running out completely. Remove the bottle seal and clean the top with a spirit swab.

26.                        Clamp the intravenous tubing. Remove the air inlet from the old bottle and insert the new one, followed by the I.V. tubing. Hang up the new bottle, release the clamp and re-establish the infusion in the specified rate of flow.

27.                        Chart the amount and type of fluid infused or added each time.

28.                        When the prescribed volume of fluid has been infused, it is discontinued. To discontinue it :

a.     Clamp the infusion tubing. Loosen all the adhesive tapes that have been used to fix the needle and the

29.                        Withdraw the needle by pulling on the needle hub in line with the vein. At the same time hold a dry sterile swab over the needle site.

30.      When the needle is out, apply firm pressure to the site for 2 or 3 minutes, to prevent bleeding

31.      Apply a small sterile dressing over the needle site, which can be removed on the following day.

32.      Discard the bottle and tubing as desired.

33.      Record the total amount of fluid infused, the amount of fluid discarded if any, and the time at which the infusion is stopped.

34.      Watch for the general condition of the patient after the fluids have been discontinued. If the condition deteriorates, inform the doctor and restart the infusion.

Subcutaneous infusions (hypodermoclysis)

In medical practice, the term subcutaneous infusion or hypodermoclysis is used to designate an injection of a large amount of fluid into the subcutaneous tissues, by means of a needle for the purpose of supplying the body with fluids.

In this method, the fluid is absorbed principally by the lymphatics. It is given in a part where the tissue is loose. The purpose of subcutaneous infusions are same as that of intravenous infusions. This route is seldom used now-a-days due to increased facilities available for the intravenous infusions.

However, this route may be useful under emergency conditions. The Sites used for subcutaneous infusions are:

1.     Anterior and outer aspect of the thigh, midway between the knee and the hip.

2.     Under and outer margins of the breast.

3.     Abdominal wall halfway between the umbilicus and the flank.

4.     Back, just below the scapula.

5.     The equipment used for the subcutaneous infusion is same which is used for intravenous infusions.

6.     The subcutaneous infusions may be given in two places, using a T- connection to help in the maximum absorption of the fluid.

7.     To start the subcutaneous infusions, pick up a fold of subcutaneous tissue with the left hand and with the right hand insert the needle at an angle into the subcutaneous tissue in the direction of venous blood flow.

8.     The rate of flow is determined by the individual's rate of absorption.

9.     In all cases, the rate at which the fluid is given, should be such that the tissue around the needle stay nearly normal in tension and appearance.

10.                        Hyaluronidase injected into the tissues at the site of infusion or added to the infusion fluid, will increase absorption.

11.                        When swelling occurs, the infusion should be stopped completely.

12.                        The solutions used for the subcutaneous infusion should be isotonic.

13.                        Sugar solutions that are electrolyte free are contraindicated, as it may produce oedema at the injection site.

14.                        Hypertonic solutions are not absorbed. On the contrary, they may attract body fluids into the injection site.