Skill 16-3

Changing an Intravenous Solution Container and Administration Set

Intravenous (IV) fluid administration frequently involves multiple containers of fluid for infusion. Verify the amount and type of solution to be administered as well as the prescribed volume and/or infusion rate. Critically evaluate all prescribed infusions prior to administration. Any concerns regarding the type or amount of therapy prescribed should be immediately and clearly communicated to the prescribing practitioner. Evaluate the patient's need for IV therapy, the type of solution being used, its desired effect, and potential adverse reactions and effects. Follow the facility's policies and guidelines to determine if the infusion should be administered by electronic infusion device or by gravity/free flow. Refer to Box 16-1 in Skill 16-1 for guidelines to calculate the flow rate for gravity/free-flow infusion. Monitor these fluid infusions and replace the fluid containers, as needed. Focus on the following points:

If more than one IV solution or medication is ordered, check facility policy and the appropriate literature to make sure that the additional IV solution can be attached to the existing tubing.
As one bag is infusing, prepare the next bag so it is ready for a change when less than 50 mL of fluid remains in the original container.
Ongoing assessments related to the desired outcomes of the IV therapy, as well as assessing for both local and systemic IV infusion complications, are required. Refer to Fundamentals Review 16-3.
Before switching the IV solution containers, check the date and time of the infusion administration set to ensure it does not also need to be replaced. Check facility policy for guidelines for changing IV administration sets. Refer to Box 16-3 for recommended administration set change guidelines based on the type of infusion and device, as suggested by Infusion Nurses Society Standards (Gorski et al., 2021).
Infusion administration sets should be changed immediately upon suspected contamination, or when the integrity of the administration product or system has been compromised (Gorski et al., 2021, p. S123). Infusion administration sets should also be changed when a new VAD is placed (Gorski et al., 2021, p. S124).

Delegation Considerations

The changing of an IV solution container and administration set 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

For solution container change:

IV solution, as prescribed
eMAR/MAR
Time tape and/or label (for IV container)
PPE, as indicated

For tubing change:

IV administration set
Label for administration set (for next change date)
Transparent semipermeable membrane (TSM) dressing
Nonallergenic tape
IV securement/stabilization device, as appropriate
Passive disinfection caps (based on facility policy)
Gloves
Additional PPE, as indicated
Antimicrobial wipes

Assessment

Review the patient's record for baseline data, such as vital signs and intake and output balance, and pertinent laboratory values, such as serum electrolytes. Assess the 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.

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. 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. Skill 16-4 provides additional detail related to monitoring an IV site.

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 achieve when changing an IV solution container and tubing are that the prescribed IV infusion continues without interruption, and no infusion complications are identified.

Implementation

Action	Rationale
1. Verify the prescribed IV solution order on the eMAR/MAR. Consider the appropriateness of the prescribed therapy in relation to the patient. Clarify any inconsistencies. Check the patient's health record for allergies. Check the solution for color and the container for leaking and expiration date. Know the purpose of the IV solution administration. Gather the necessary supplies.	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 prior to administration. 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. Preparation promotes efficient time management and an organized approach to the task.
2. 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.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Assemble equipment on the bedside stand or overbed table or other surface within reach.	Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
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. Ask the patient about allergies to medications or tape, as appropriate.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement. Possible allergies may exist related to the IV solution additive or tape.
6. Compare the IV container label with the eMAR/MAR. Remove the IV bag from the outer wrapper, if indicated. Check expiration dates. Scan the bar code on the container, if necessary (Figure 1). Compare the patient identification band with the eMAR/MAR. Alternatively, label the solution container with the patient's name, solution type, additives, date, and time. Complete a time strip for the infusion and apply it to the IV container.	Checking the label with the eMAR/MAR ensures the correct IV solution will be administered. Identifying the patient ensures the right patient receives the medications and helps prevent errors. Time strip allows for quick visual reference by the nurse to monitor infusion accuracy.
7. Maintain aseptic technique when opening sterile packages and the IV solution. Remove the administration set from the package. Apply the label to the tubing reflecting the day/date for the next set change, per facility guidelines.	Asepsis is essential for preventing the spread of microorganisms. Labeling the tubing ensures adherence to facility policy regarding administration set changes and reduces the risk of the spread of microorganisms. Refer to Box 16-3 for recommended administration set change guidelines.
To Change IV Solution Container
8. If using an electronic infusion device, pause the device or put on “hold.” Close the slide clamp on the administration set closest to the drip chamber. If using a gravity/free-flow infusion, close the roller clamp on the administration set.	The action of the infusion device needs to be paused while the solution container is changed. Closing the clamp prevents the fluid in the drip chamber from emptying and air from entering the tubing during the procedure.
9. Carefully remove the cap on the entry site of the new IV solution container and expose the entry site, taking care not to touch the exposed entry site.	Touching the opened entry site on the IV container results in contamination, resulting in the need to discard the container.
10. Lift the completed container off the IV pole and invert it. Quickly remove the spike from the old IV container, taking care to not contaminate the spike. Discard the old IV container.	Touching the spike on the administration set results in contamination, resulting in the need to discard the tubing.
11. Using a twisting and pushing motion, insert the administration set spike into the entry site of the IV container. Alternatively, follow the manufacturer's directions for insertion. Hang the container on the IV pole.	Inserting the spike punctures the seal in the IV container and allows access to the contents.
12. Alternatively, hang the new IV fluid container on an open hook on the IV pole. Carefully remove the cap on the entry site of the new IV solution container and expose the entry site, taking care not to touch the exposed entry site. Lift the completed container off the IV pole and invert it. Quickly remove the spike from the old IV container, taking care to not contaminate the spike (Figure 2). Discard the old IV container. Using a twisting and pushing motion, insert the administration set spike into the entry port of the new IV container as it hangs on the IV pole (Figure 3).	Touching the opened entry site on the IV container or the administration set spike results in contamination, resulting in the need to discard both. Inserting the spike punctures the seal in the IV container and allows access to the contents.
13. If using an electronic infusion device, open the slide clamp, check the drip chamber of the administration set, verify the flow rate programmed in the infusion device, and turn the device to “run” or “infuse.”	Verifying the rate and device settings ensures the patient receives the correct volume of the solution.
14. If using a gravity/free-flow infusion, slowly open the roller clamp on the administration set and count the drops. Adjust until the correct drop rate is achieved (Figure 4).	Opening the clamp regulates the flow rate into the drip chamber. Verifying the rate ensures that the patient receives the correct volume of solution.
To Change IV Solution Container and Administration Set
15. Prepare the IV solution and administration set. Refer to Skill 16-1, Steps 7-11.
16. Hang the new IV container on an open hook on the IV pole. Close the clamp on the existing IV administration set. Also, close the clamp on the short extension tubing connected to the IV catheter in the patient's arm.	Clamping the existing IV tubing prevents leakage of fluid from the administration set after it is disconnected. Clamping the tubing on the extension set prevents introduction of air into the extension tubing.
17. If using an electronic infusion device, remove the current administration set from the device. Following the manufacturer's directions, insert a new administration set into the infusion device.	The administration set must be removed in order to insert a new tubing into the device.
18. Put on gloves. Remove the current infusion tubing from the needleless connector or end cap on the short extension IV tubing. Using an antimicrobial swab, vigorously disinfect the connection surface and sides of the needleless connector or end cap on the extension tubing and allow them to dry. Remove the end cap from the new administration set. Insert the end of the administration set into the needleless connector or end cap (Figure 5). Loop the administration set tubing near the entry site, and anchor it with tape (nonallergenic) close to the site (Figure 6). Remove your gloves. Perform hand hygiene.	VAD entry points, end caps, and needleless connectors must be vigorously scrubbed and disinfected prior to each access to reduce the risk for introduction of microorganisms and prevent VAD-related infection (Frimpong et al., 2015; Gorski et al., 2021; Harper, 2014; Loveday et al., 2014). Friction is needed to physically remove microorganisms from the top, sides, and threads of the needleless connector or end cap. Allow the antiseptic to dry completely, following the manufacturer's directions for use (Gorski et al., 2021). Inserting the administration set allows initiation of the fluid infusion. The weight of the tubing is sufficient to pull it out of the vein if it is not well anchored. Nonallergenic tape is less likely to tear fragile skin. Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.
19. Open the clamp on the extension tubing. Open the clamp on the administration set.	Opening clamps allows the solution to flow to the patient.
20. If using an electronic infusion device, check the drip chamber of the administration set, verify the flow rate programmed in the infusion device, and turn the device to “run” or “infuse.”	Verifying the rate and device settings ensures the patient receives the correct volume of solution.
21. If using a gravity/free-flow infusion, slowly open the roller clamp on the administration set and count the drops. Adjust until the correct drop rate is achieved.	Opening the clamp regulates the flow rate into the drip chamber. Verifying the rate ensures the patient receives the correct volume of solution.
22. Apply a passive disinfection cap to each access site on the administration set; use an antimicrobial swab to vigorously disinfect the connection surface and sides of each access site and allow them to dry. Attach a passive disinfection cap to each site.	Passive disinfection caps contain an antiseptic-impregnated sponge that dispenses the antiseptic over the connector's top and threads and protects the hub from contamination by touch or airborne sources (Gorski et al., 2021; Stango et al., 2014). VAD administration set entry points, end caps, and needleless connectors must be vigorously scrubbed and disinfected prior to each access to reduce the risk for introduction of microorganisms and prevent VAD-related infection (Frimpong et al., 2015; Gorski et al., 2021; Harper, 2014; Loveday et al., 2014). Friction is needed to physically remove microorganisms from the top, sides, and threads of the needleless connector or end cap. Allow the antiseptic to dry completely to ensure complete effectiveness.
23. Remove equipment. Ensure the patient's comfort. Lower the bed, if it is not in the lowest position.	This promotes patient comfort and safety.
24. Remove additional 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.
25. Return to check the flow rate and observe the IV site for infiltration and/or other complications 30 minutes after starting the infusion and at least hourly thereafter. Ask the patient if they are experiencing any pain or discomfort related to the IV infusion.	Continued monitoring is important to maintain the correct flow rate. Early detection of problems ensures prompt intervention.

Evaluation

The expected outcomes have been met when the IV solution container and administration set have been changed, the IV infusion has continued without interruption, and no infusion complications have been identified.

Documentation

Guidelines

Document the type of IV solution and the rate of infusion (often done in the eMAR/MAR) and the assessment of the access site. Record the patient's reaction to the procedure and pertinent patient teaching, such as alerting the nurse if the patient experiences any pain from the IV or notices any swelling at the site. Document the IV fluid solution on the intake and output record.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Infusion does not flow or flow rate changes after bag and tubing are changed (gravity/free flow): Make sure that the flow clamp is open, and the drip chamber is approximately half full. Check the electronic device for proper functioning. Check the IV site for possible problems with the catheter, such as bending of the catheter or the position of the patient's extremity and inspect the IV site for signs and symptoms of complications. Readjust the flow rate as necessary (gravity/free flow).
After attaching new IV tubing, you note air bubbles in the tubing: If the bubbles are above the roller clamp, you can easily remove them by closing the roller clamp, stretching the tubing downward, and tapping the tubing with your finger so the bubbles rise to the drip chamber. If there is a larger amount of air in the tubing, swab the medication port on the tubing below the air with an antimicrobial solution and attach a syringe to the port below the air. Clamp the tubing below the access port. Aspirate the air from the tubing via the syringe. Remember that air bubbles in the tubing can be reduced if the tubing is primed slowly with fluid instead of allowing a wide-open flow of the solution.

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Skill 16-3

EVIDENCE FOR PRACTICE