Here’s a simple way to monitor I.V. infusion rate: Attach a piece of tape or a preprinted strip to the I.V. container; then write hourly times on the tape or strip beginning with the time you hung the solution.

By comparing the actual time with the label time, you can quickly see if the rate needs to be adjusted. Remember that you should never increase I.V. infusion rates by more than 30% unless you first check with the doctor.

Other factors that affect infusion rate include the type of I.V. fluid and its viscosity, the height of the infusion container, the type of administration set, and the size and position of the venous access device.

Infusion rates can be fickle; you must check and adjust them regularly. The frequency with which you should check infusion rates depends on the patient’s condition and age and the solution or medication being administered.

Many nurses check the I.V. infusion rate every time they’re in a patient’s room and after each position change. Assess the infusion rate more frequently for some patients, such as:

• Critically ill patients

• Patients with conditions that might be exacerbated by fluid overload

• Pediatric patients

• Elderly patients

• Patients receiving a drug that can cause tissue damage if infiltration occurs.

When checking the infusion rate, inspect and palpate the I.V. insertion site, and ask the patient how it feels.

If the infusion rate slows significantly, you can usually get it back on schedule by adjusting the rate slightly. Don’t make a major adjustment, though. If the rate must be increased by more than 30%, check with the doctor.

You should also time an infusion control device or rate minder for 1 to 2 hours per shift. (These devices have an error rate ranging from 2% to 10%.) Before using any infusion control device, become thoroughly familiar with its features. Attend instruction sessions and perform return demonstrations until you learn the system.

Professional and Legal Standards

Administering drugs and solutions to patients is one of the most legally significant tasks nurses perform. Unfortunately, the number of lawsuits directed against nurses who are involved in I.V. therapy is increasing. For example, a 1995 Missouri study reported a high incidence of errors involving I.V. solution administration in which wrong solutions were used or solutions were administered by an incorrect route. Many lawsuits centered on errors in infusion pump use.

Lawsuits may also result from administration of the wrong medication dosage, inappropriate placement of an I.V. line, and failure to monitor for adverse reactions, infiltration, dislodgment of I.V. equipment, or other mishaps.

Here are some examples of lawsuits involving I.V. therapy.

In Los Angeles, a nurse administered midazolam (Versed) through a port in an I.V. line to an infant, leading to the infant’s death. This nurse had never administered I.V. Versed to an infant or child before. A facility protocol prohibited the use of Versed on the pediatric floor. The manufacturer recommended a dosage of 0.1 mg/kg, and the infant weighed 9 kg. The hospital record indicated 5 mg had been administered. A settlement awarded the plaintiff $225,000.

In another Los Angeles case, continuous infusion of 145 mg of morphine over 18 hours led to a patient’s death. The doctor failed to limit the amount to be infused. Nevertheless, the charge nurse and staff nurse were held accountable for failing to recognize a “gross overdose.” The patient’s widow and children were awarded more than $2 million for lost wages and general damages.

In Illinois, a nurse administered the wrong dose of lidocaine (Xylocaine). The order was for 100 mg; the nurse injected 2 g. The packaging caused confusion: the Xylocaine was provided in a 2-g syringe for mixing into an I.V. solution and in a 100-mg syringe for direct injection. The nurse accidentally used the 2-g syringe. However, information about previous overdose incidents from the Food and Drug Administration and medical literature had been available to the hospital.

In Ohio, a nurse failed to clamp a pump regulating the flow of an antibiotic through a central line to a child. This resulted in delivery of nearly seven times the prescribed dosage of gentamicin, causing the child to become totally deaf.

In Pennsylvania, an emergency department nurse misplaced an I.V. line, which infiltrated the patient’s hand, resulting in reflex sympathetic dystrophy. The patient couldn’t return to work and won a $702,000 award.

Several recent lawsuits have involved allegations that a nurse struck a patient’s radial nerve during insertion of an I.V. line. Such injuries can cause compartment syndrome and may require emergency fasciotomy, skin grafts, and other surgery. Uncorrected compartment syndrome can progress to gangrene and amputation of fingers. One New York case involving finger amputation resulted in a $40 million jury verdict, which was later reduced to $5 million.

When monitoring an I.V. line, listening to the patient is as important as monitoring the site, pump, and tubing. In the Tampa, Florida, case of Frank v. Hillsborough County Hospital, a patient’s frequent complaints of pain were ignored. The patient suffered permanent nerve damage and later obtained an award of almost $60,000.

As a nurse, you have a legal and ethical responsibility to your patients. The good news is that if you honor these duties and meet the appropriate standards of care, you’ll be able to hold your own in court.

By becoming aware of professional standards and laws related to administering I.V. therapy, you can provide the best care for your patients and protect yourself legally. Professional and legal standards are defined by state nurse practice acts, federal regulations, and facility policies.

Each state has a nurse practice act that broadly defines the legal scope of nursing practice. Your state’s nurse practice act is the most important law affecting your nursing practice.

Every nurse is expected to care for patients within defined limits. If a nurse gives care beyond those limits, she becomes vulnerable to charges of violating her state nurse practice act. For a copy of your state nurse practice act, contact your state nurse’s association or your state board of nursing or its Web site.

Many states’ nurse practice acts don’t specifically address scope of practice regarding I.V. therapy by registered nurses (RNs). However, many nurse practice acts do address whether licensed practical nurses (LPNs) or licensed vocational nurses (LVNs) can administer I.V. therapy. It’s important for LPNs and LVNs as well as for the RNs who are supervising or training them to be familiar with this information.

The federal government issues regulations and establishes policies related to I.V. therapy administration. For example, it mandates adherence to standards of I.V. therapy practice for health care facilities so that they can be eligible to receive reimbursement under Medicare, Medicaid, and other programs.

Medicare and Medicaid, the two major federal health care programs, serve about 75 million Americans. They’re run by the Health Care Financing Administration (HCFA), which is part of the U.S. Department of Health and Human Services. HCFA formulates national Medicare policy, including policies related to I.V. therapy, but contracts with private insurance companies to oversee claims and make payment for services and supplies provided under Medicare. These agencies, in turn, enforce HCFA policy by accepting or denying claims for reimbursement. When reviewing claims, agencies may evaluate practices and quality of care—an important factor underlying the emphasis on proper documentation in health care.

Medicaid, which serves certain low-income people, is a state-federal partnership administered by a state agency. There are broad federal requirements for Medicaid, but states have a wide degree of flexibility to design their own programs.

To be eligible for reimbursement, health care agencies must comply with the standards of a complex network of regulators. Consider, for example, a patient receiving I.V. medications at home with a reusable pump. This patient is primarily covered by Medicare with secondary Medicaid coverage. A variety of carriers, fiscal intermediaries, and agencies share responsibility for reimbursement and regulatory oversight of the patient’s care:

• An insurance carrier contracts with Medicare to cover services such as refilling the pump.

• A separate insurance carrier (a durable medical equipment carrier designated by HCFA) covers administered drugs, the pump, and pump supplies.

• Another insurance carrier (called a fiscal intermediary) contracts with Medicare to cover preliminary in-hospital training of the patient in I.V. therapy techniques.

• A Medicaid agency also covers a portion of the patient’s care.

Nursing documentation must be complete to meet the requirements of all these different agencies. The underlying (though unstated) philosophy of these agencies is that “if it isn’t documented, it isn’t done.” The regulatory network is becoming more complicated as many Medicare and Medicaid patients are being covered by managed care organizations that have their own rules and procedures.

Every health care facility has I.V. therapy policies for nurses. Such policies are required to obtain accreditation from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and other accrediting bodies. These policies can’t go beyond what a state’s nurse practice act permits, but they more specifically define your duties and responsibilities.

Awareness of facility policy is particularly important in rapidly developing areas of practice such as home care, where the intensity of service and patient needs is increasing dramatically. For example, home health nurses must be acutely aware of patient and family education policies because infusion systems are being used in the home 24 hours per day without the presence of full-time nursing staff.

The Infusion Nurses Society (INS) has developed a set of standards, the Infusion Nursing Standards of Practice, that are commonly used by committees developing facility policy. According to the INS, the goals of these standards are to “protect and preserve the patient’s right to safe, quality care and protect the nurse who administers infusion therapy.” These standards address all aspects of I.V. nursing. For more information, contact the INS at (781) 440-9408 or at http://www.ins1.org.

Documentation

You must document I.V. therapy for several reasons. Proper documentation provides:

• Accurate description of care that can serve as legal protection (e.g., as evidence that a prescribed treatment was administered)

• Mechanism for recording and retrieving information

• Record for health care insurers of equipment and supplies used.

When you initiate I.V. therapy, it’s important to include specific information about where the I.V. was started, what kind of equipment was used, and what solution was infused.

Take Note!

Documenting I.V. therapy

Follow these tips to document your care when you perform I.V. site care or catheter removal or when you document I.V. infusion using a sequential system or on a flow sheet or an intake and output sheet.

I.V. therapy may be documented on progress notes, a sequential system, a special I.V. therapy sheet or flow sheet, a nursing care plan on the patient’s chart, or an intake and output sheet.

In addition to documentation in the patient’s chart, you need to label the dressing on the catheter insertion site. Whenever you change the dressing, label the new one.

You should also label the fluid container and place a time tape on it. With a child, you may need to label the volume-control set as well. In labeling the container and the set, follow your facility’s policy and procedures.

It’s equally important to document how the I.V site is maintained, including the conditions of the site; care that was provided; dressing, solution, tubing, or equipment changes you made; and teaching you provided.

Teacher’S Lounge

Teaching about I.V. therapy

Although you may be accustomed to I.V. therapy, many patients aren’t. Your patient may be apprehensive about the procedure and concerned that his condition has worsened.

Teaching the patient and, when appropriate, members of his family will help him relax and take the mystery out of I.V. therapy.

References

Berman, A., & Snyder, S. J. (2012). Skills in clinical nursing (7th ed.). Upper Saddle River, NJ: Pearson Education.

Berman, A., Snyder, S. J., & McKinney, D. S. (2011). Nursing basics for clinical practice. Upper Saddle River, NJ: Pearson Education.

Treas, L. S., & Wilkinson, J. M. (2014). Basic nursing concepts, skills & reasoning. Philadelphia, PA: F. A. Davis.

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