Skill 16-2

Monitoring an Intravenous Site and Infusion

The nurse is responsible for maintaining the proper intravenous infusion flow rate and monitoring the intravenous (IV) site. This is routinely done as part of the initial patient assessment and at regular intervals, based on patient condition and facility policy. In addition, IV sites are checked at specific intervals and each time an IV medication is given, as dictated by the facility's policies. It is common to check the IV infusion and site every hour, but it is important to be familiar with the requirements of your facility. Monitoring the infusion rate is a very important part of the patient's overall management. If the patient does not receive the prescribed rate, they may experience a fluid volume deficit. In contrast, if the patient is administered too much fluid over a period of time, they may experience fluid volume overload. Other responsibilities involve checking the IV site for possible complications and assessing for both the desired effects of an IV infusion as well as potential adverse reactions to the IV therapy.

Delegation Considerations

The monitoring of an IV site and infusion is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, these procedures may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

PPE, as indicated
Standardized scale for assessing and documenting phlebitis (Box 16-2 provides an example of one scale)

Assessment

Assess the continued appropriateness of the solution for the patient. Inspect the IV infusion solution for any particulates and check the IV label. Confirm it is the solution prescribed. Review assessment and laboratory data that may influence solution administration. Assess the current rate of flow by verifying the settings on the electronic infusion device or timing the drops if it is a gravity/free-flow infusion. Check the tubing for kinks or anything that might clamp or interfere with the flow of the solution. Inspect the IV site. The dressing should be intact, adhering to the skin on all edges. Check for any leaks or fluid under or around the dressing. Inspect the tissue around the IV entry site for swelling, coolness, or pallor. These are signs of fluid infiltration into the tissue around the IV catheter. Also inspect the site for redness, swelling, and warmth. These signs might indicate the development of phlebitis or an inflammation of the blood vessel at the site. Grade phlebitis, if present. Refer to Box 16-2. Ask the patient if they are experiencing any pain or discomfort related to the IV line. Pain or discomfort can be a sign of infiltration, extravasation, phlebitis, thrombophlebitis, and infection related to IV therapy; refer to Fundamentals Review 16-3. Assess the patient's fluid intake and output. Assess the patient's knowledge of IV therapy.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Fluid imbalance
Infection risk
Altered skin integrity risk

Outcome Identification and Planning

The expected outcomes to be achieved when monitoring the IV infusion and site are that the patient remains free of complications related to IV therapy and exhibits a patent IV site, and the IV solution infuses at the prescribed flow rate.

Implementation

Action	Rationale
1. Verify the IV prescribed solution on the eMAR/MAR with the health record. Consider the appropriateness of the prescribed therapy in relation to the patient. Clarify any inconsistencies. Check the patient's health record for allergies. Check solution for color and the container for leaking and expiration date. Know the purpose of the IV administration.	This ensures that the correct IV solution and rate of infusion and/or medication will be administered. The nurse is responsible for critically evaluating all patient orders. Any concerns regarding the type or amount of therapy prescribed should be immediately and clearly communicated to the prescribing health care provider. This knowledge and skill are essential for safe and accurate IV and medication administration.
2. Monitor the IV infusion every hour or per facility policy. More frequent checks may be necessary if medication is being infused.	This promotes safe administration of IV fluids and medication.
3. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
4. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
5. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement.
6. If an electronic infusion device is being used, check settings, alarm, and indicator lights. Check the set infusion rate (Figure 1). Note the position of fluid in the IV container in relation to the time tape. Teach the patient about the alarm features on the electronic infusion device.	Observation ensures that the infusion control device and the alarm are functioning. Lack of knowledge about “alarms” may create anxiety for the patient.
7. If the IV is infusing via gravity/free flow, check the drip chamber and time the drops (Figure 2). Refer to Box 16-1 in Skill 16-1 to review calculation of IV flow rates for gravity/free-flow infusion.	This ensures that the flow rate is correct. Use a watch with a second hand for counting the drops in regulating a gravity/free-flow drip IV infusion.
8. Check the tubing for anything that might interfere with the flow (Figure 3). Be sure the clamps are in the open position.	Any kink or pressure on the tubing may interfere with the flow.
9. Observe the dressing for leakage of the IV solution.	Leakage may occur at the connection of the tubing with the hub of the catheter and allow for loss of the IV solution.
10. Inspect the site for swelling, leakage at the site, coolness, or pallor, which may indicate infiltration (Figure 4). Ask if the patient is experiencing any pain or discomfort. If any of these symptoms are present, the IV will need to be removed and restarted at another site. Check facility policy for treating infiltration. See Fundamentals Review 16-3.	The catheter may become dislodged from the vein, and IV solution may flow into the subcutaneous tissue.
11. Inspect the site for redness, swelling, and heat. Palpate for induration. Ask if the patient is experiencing pain. These findings may indicate phlebitis, making it necessary to discontinue and restart the IV at another site. Grade phlebitis (refer to Box 16-2 and Fundamentals Review 16-3). Check facility policy for treatment of phlebitis.	Chemical irritation, mechanical trauma, and microorganisms may cause injury to the vein and can lead to phlebitis.
12. Check for local manifestations (redness, pus, warmth, induration, and pain) that may indicate an infection is present at the site. Also check for systemic manifestations (chills, fever, tachycardia, hypotension) that may accompany local infection at the site. If signs of infection are present, discontinue the IV and notify the health care team. Be careful not to disconnect the IV tubing when putting on the patient's hospital gown or assisting the patient with movement to avoid contamination.	Poor aseptic technique may allow bacteria to enter the catheter insertion site or the tubing connection and may occur with manipulation of equipment.
13. Be alert for additional complications of IV therapy, such as fluid overload or bleeding. Refer to Fundamentals Review 16-3.	Infusing too much IV solution results in an increase of circulating fluid volume.
a. Fluid overload can result in signs of cardiac and/or respiratory failure. Monitor intake and output and vital signs. Assess for edema and auscultate lung sounds. Ask if the patient is experiencing any shortness of breath.	Older adults are most at risk for this complication due to possible decrease in cardiac and/or renal functions.
b. Check for bleeding at the site.	Bleeding may be caused by anticoagulant medication. Bleeding at the site is most likely to occur when the IV is discontinued.
14. If appropriate, instruct the patient to call for assistance if any discomfort is noted at the site, the solution container is nearly empty, the flow has changed in any way, or if the electronic pump alarm sounds.	This facilitates patient engagement and safe administration of IV solution.
15. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.

Evaluation

The expected outcomes have been met when the patient has remained free of complications related to IV therapy and has exhibited a patent IV site, and the IV solution has infused at the prescribed flow rate.

Documentation

Guidelines

Document the type of IV solution as well as the infusion rate. Note the insertion site location and site assessment. Document the patient's reaction to the IV therapy as well as the absence of subjective reports that they are not experiencing any pain or other discomfort, such as coolness or heat associated with the infusion. In addition, record that the patient is not demonstrating any other IV complications, such as signs or symptoms of fluid overload. Document pertinent patient teaching. Document the IV fluid solution on the intake and output record.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient's lung sounds were previously clear, but now some crackles in the bases are auscultated, and the patient reports some shortness of breath: Notify the health care team immediately. The patient may be exhibiting signs of fluid overload. Be prepared to tell the health care provider what the past intake and output totals were as well as the patient's vital signs and pulse oximetry assessment findings.
IV is not flowing as easily as it previously had been: Check all clamps on the tubing, and check the tubing for any kinking. Check that the patient is not lying on the tubing. If the IV is over a joint, reposition the extremity and see if this helps the flow. Attempt to flush the PIVC with normal saline. If the IV is painful, you meet resistance when attempting to flush, or fluid still does not flow easily, discontinue the IV and restart it in another place.

EVIDENCE FOR PRACTICE

Short Peripheral Intravenous Catheters and Phlebitis

Phlebitis (inflammation of the wall of a vein) is one venous access device-related infection that causes pain, interrupts infusion therapy, necessitates insertion of a new intravenous catheter, may compromise subsequent vascular access, and is a potentially serious complication related to IV therapy (Gorski et al., 2021; Gunasegaran et al., 2018). What can nurses do to decrease the risk of this potential complication of IV therapy?

Related Research

Gunasegaran, N., See, M. T. A., Leong, S. T., Yuan, L. X., & Ang, S. Y. (2018). A randomized controlled study to evaluate the effectiveness of two treatment methods in reducing incidence of short peripheral catheter-related phlebitis. Journal of Infusion Nursing, 41(2), 131-137. https://doi.org/10.1097/NAN.0000000000000271

The purpose of this randomized-controlled trial was to evaluate the effectiveness of two treatment methods in reducing the incidence of short-peripheral catheter (SPC)-related phlebitis. Patients from a medical ward of an acute tertiary hospital in Singapore (n = 969) who had an SPC in an upper limb and were between ages 21 and 99 years participated in the study. Patients were excluded who were critically ill, allergic to alcohol and/or chlorhexidine, admitted for upper limb phlebitis and/or cellulitis, or known to have dermatologic issues. Participants were randomly assigned a treatment method by week of admission; all patients admitted to the unit in any one particular week received the same preinsertion SPC skin antisepsis treatment method and post removal dressing material. Treatment method 1 consisted of preinsertion skin antisepsis with 70% isopropyl alcohol applied in a circular motion that was allowed to dry, and post removal dressing of sterile gauze and application of an adhesive bandage after hemostasis was achieved. Treatment method 2 consisted of preinsertion skin antisepsis with 2% chlorhexidine in 70% isopropyl alcohol applied in a circular motion that was allowed to dry, and post removal dressing of sterile gauze and application of film dressing (spray-on) after hemostasis was achieved. Participants in both treatment groups received the same care while the catheter was in place: use of aseptic technique when manipulating the SPC; flushing before and after drug administration; and routine removal after 72 to 96 hours. The primary outcome was signs of phlebitis during the course of infusion therapy or within 48 hours after removal. Participants were evaluated for signs of phlebitis daily, once every shift, using the visual infusion phlebitis (VIP) score tool to determine the presence and severity of phlebitis. Participants who were discharged before the 48 hours following the removal of the catheter were educated on the signs and symptoms of phlebitis before discharge and were contacted by phone to inquire about the presence of signs and symptoms of phlebitis. There was no significant difference in the incidence of phlebitis between participants in the two treatment methods. The researchers concluded that the type of cleansing solution and post removal dressing material used may not be the most important factor in reducing the incidence of phlebitis. The researchers suggested strict adherence to aseptic techniques and prompt removal of the SPC remain the cornerstone in the prevention of phlebitis.

Relevance for Nursing Practice

Nurses are responsible for identifying clinical practice concerns and possible solutions, working to improve patient care. Nurses should consider interventions to provide the best care for patients. Safe clinical practice including strict adherence to aseptic technique and compliance with best practice related to skin antisepsis and management of intravenous access sites are important to improve patient outcomes.

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Skill 16-2

EVIDENCE FOR PRACTICE

EVIDENCE FOR PRACTICE