Journal of Nursing Education

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Teaching principles of INTRAVENOUS therapy

Joan Haselman

No abstract available for this article.

Intravenous therapy is so common that it might well be a victim of the maxim "familiarity breeds contempt." Yet no procedure in the armamentarium of modern medicine requires more precise understanding by the nurse if it is to produce a maximum of benefit to the patient with a minimum of discomfort. The responsibility of the nurse in the administration of intravenous therapy is a culmination of that understanding. To discharge her function in this responsibility, she must be well informed of the principles involved and skilled in the techniques of administration.

Adequate understanding of the principles and techniques of intravenous therapy demands thorough knowledge of several major scientific areas. These areas include (1) the physical principles underlying intravenous therapy, (2) the physiologic principles involved, (3) the indications for intravenous therapy, (4) the attitudes and skills essential to such therapy, and (5) the possible adverse effects fluid therapy can produce and the corrective measures that must be instituted when untoward events occur.

Physical Principles Underlying Intravenous Therapy

The rate of flow of a fluid is influenced by pressure grathent, friction, the diameter and length of the tubing, the height of the column of fluid, the size of the orifice through which the fluid exits, and the viscosity of the fluid.

Gravity is defined as the force of attraction between two objects. This force of attraction causes fluids to flow from a higher to a lower level.

Liquids exert a continuous pressure on the container because the molecules are attracted to the earth in accordance with Newton's law of gravitation. This attraction produces what is called the weight of the liquid, and it is this weight that exerts the pressure. Pressure grathent is the difference between two points in a fluid. The greater the height of a column of fluid, the greater the pressure the fluid exerts on the bottom of the container. Thus, the pressure exerted at a level of the liquid is proportional to the depth. The rate of flow varies directly with the pressure difference.

The length of the tubing affects the flow inversely, i.e., the longer the tube, the slower the flow. In addition, the friction produced by the interaction between the molecules and the surfaces of the inner wall of the tubing decreases the rate of flow ; thus, the smoother the inner wall of the tube, the faster the flow. Pressure is gradually lost as the liquid flows through the tube. Viscosity of the fluid also influences the rate of flow, since there is an inverse relationship between the degree of viscosity and the rate of flow.

The diameter of the tubing (here including the infusion tube, the needle lumen, and the vein lumen) affects the volume of the fluid flowing through it. Poiseuille's law states that the volume varies as the fourth power of the diameter of the tube (V = D4), other things being equal. For example, by increasing the diameter of a tube from 2 mm to 4 mm, the volume, or flow rate, will be sixteen times as great. In addition to these physical factors the blood pressure, size, and condition of the blood vessels have an effect on the flow rate of a fluid.

Physiologic Principles Underlying Intravenous Therapy

The first consideration in this area is to answer why a system involving a circulating liquid medium is essential to life. We know that in the processes of anabolism and catabolism, source materials for energy and growth are required, and waste products of cellular metabolism must find an exit from the system if toxicity is to be prevented. The blood, then, provides a transport medium which carries the nutrients and oxygen to the cells, and from them, carries the waste products to their proper avenues of disposal from the body. In order to function efficiently this liquid medium, blood, must be present in the circulatory system in adequate volume to maintain proper pressures to facilitate its flow.

Generally speaking, then, in terms of physiologic principles, intravenous therapy is used to maintain or replace body stores of water, electrolytes, vitamins, calories, and proteins (the nutritional function); to restore acid-base balance (in effect, detoxification) ; and to restore blood volume. It may also provide a vehicle for medications not given by the usual routes.

Intravenous therapy is limited to a supplementary role, since it is inferior to, or inadequate, by comparison, to good oral nutrition. In addition, it is an expensive procedure.

Physical Characteristics of Intravenous Solutions

Cells are involved in all aspects of intravenous therapy, beginning with the erythrocytes present in the circulating blood. Since free hemoglobin is toxic, it is essential that there be no rupture of erythrocytes. This is a prime consideration in the selection of an intravenous solution. All cells are surrounded by a semipermeable membrane, the "barrier" between two fluid compartments which is permeable to water but not to some dissolved solutes. Osmotic pressure is the pressure set up by the solvent as it moves through the semipermeable membrane from the weaker to the stronger concentrated solution.

Descriptions of solutions in relation to their function in osmotic pressures include isotonic, hypotonic, and hypertonic. Isotonic solutions are those which exert upon the external aspect of the semipermeable membrane the same degree of osmotic pressure as that exerted by the fluids contained within the membrane. There is no effect upon the character of the semipermeable membrane in this case. Hypotonic solutions are those which exert less osmotic pressure on the external aspect of a semipermeable membrane, allowing a flow of fluid into the cell, since the direction of flow is from lower to higher concentrations. In this case sufficient swelling of the cell membrane occurs so that, eventually, the membrane ruptures. Hypertonic solutions are those in which the osmotic pressure on the external aspect of the semipermeable membrane is greater than that of the internal cell environment, causing a flow of fluid from the intracellular compartment to the external environment. This, of course, affects the cell by shrinking it.

Indications for Intravenous Therapy


To supply water in an isotonic solution, 5 per cent dextrose in saline is used. In addition, this solution spares protein by providing 200 calories, and it decreases ketone formation. The 200 calories in 1,000 ml is sufficient to spare protein from being burned for energy, and the patient is not subject to acidosis. However, minimum caloric needs will not be met.

Salt loss

A solution of 5 per cent dextrose in saline is also used to replace salt lost through vomiting, gastroinestinal suction, or diaphoresis. One must remember that if salt is used when salt replacement is not specifically indicated, the kidney has the extra burden of selecting and retaining what the body needs and of excreting the excess. This being the case, in order to prevent edema, saline should be used with discretion. It is most commonly used in the first 24 hours after surgery, in elderly patients, and in prolonged illness.

Potassium loss

Potassium chloride solution is given to replace potassium losses occurring with major surgery, vomiting, gastrointestinal suction, diarrhea, gastrointestinal fistulas, dehydration, diabetic acidosis, and ACTH and cortisone therapy. It must be given slowly, in dilute solution, in order to prevent symptoms that result from the presence of high levels of serum potassium. Clinically observed indications that are associated with hyperpotassemia include parasthesia of hands and feet, sudden weakness of the extremities, cardiac arrythmias and shock-like symptoms. It is essential to check urinary output as a source of information on kidney function, in order to prevent the accumulation of potassium in the blood stream. This therapy is safe if the kidney is able to excrete excess potassium.

Nutritional deficiency

Supplements used in the management of nutritional deficiencies include the vitamin B complex group and vitamin C. Vitamin B, particularly thiamine, aids in carbohydrate metabolism when glucose is being given. Vitamin C aids wound healing. Water-soluble vitamins are excreted in the urine unless they are given slowly, in dilute solution, and the body requires the vitamins. Because of rapid excretion and the expense, vitamins should be given only if the patient has been fasting at least 3 days.

Caloric need

A 5 to 10 per cent solution of dextrose, fructose, or invert sugar is commonly used, and since the aim is to provide calories, a 10 per cent solution is more efficient; twice the number of calories are supplied by this strength. Intravenous therapy is not so good as oral nutrition in this respect, since, for example, 3,000 ml of a 10 per cent solution of these sugars yields only about three-fourths of the body's basic needs while at rest.

Fructose and invert sugar are especially useful when more rapid utilization is desired, such as in diabetic acidosis.

It should be noted that 10 per cent solutions of sugars, when given rapidly, act as a diuretic. These are hypertonic solutions, and a characteristic of hypertonic solutions is that they are irritating to the veins, and thus, may induce sclerosis and/or thrombophebitis.

Caloric need and sedation

A solution of 0.5 per cent alcohol in 5 per cent dextrose supplies 480 to 620 calories per liter. It reduces the need for narcotics through its mild analgesic and sedative effect. It is particularly useful in patients who are sensitive to narcotics, and in the young. Choice of this solution depends, of course, on the patient's ability to tolerate alcohol. When this solution is given, it is essential that the patient be observed closely throughout the infusion for signs of restlessness, excitement, or inebriation. Should infiltration occur, tissue damage is quite likely to result. This solution must be given slowly, at a rate no more than 200 ml per hour.

Protein deficit

A 5 per cent solution of protolysate, which provides 37.5 Gm protein per liter, may be given when the gastrointestinal tract must be rested over a prolonged period ; as replacement for specific losses; as building material ; or to repair tissue. It must be given in conjunction with adequate calories, or the protein will be utilized for energy rather than for its primary purpose. It is an expensive solution. No more than 2 liters per day may be given. Certain precautions must be observed when this solution is being administered. Allergic and pyrogenic reactions may occur, requiring constant observation of the patient for symptoms of these reactions. The solution must be used immediately after being opened since it is an excellent medium for the growth of bacteria. When medications are added, precipitation may occur. Separate tubing must be used when the administration of this solution is preceded, or followed, by blood transfusion.

Another source of protein that may be given intravenously is a 25 per cent solution of albumin. This is available in 100-ml vials. It is used to replace specific losses of plasma albumin only, such as in surgical shock, hypoproteinemis, and burns. It helps to restore blood volume by maintaining osmotic pressure. Its caloric content is minimal; therefore, it cannot be used as a nutritional supplement. It is more expensive than protolysates. When it is to be used, the solution should be diluted in 500 ml dextrose in water, or be administered at a slow rate (45 minutes per vial of the concentrate). These precautions are necessary in order to avoid pulmonary edema.

Protein and caloric deficits

A solution containing 10 per cent dextrose, 5 per cent protolysate, and 7.5 per cent alcohol may be indicated for the patient when total replacement is necessary. This solution provides 970 calories and 37.5 Gm. protein per liter. Since adequate calories are included, the protein portion is used by the body for tissue replacement, and glycogen store is replenished. At least 6.5 hours are required for the administration of the solution because of the presence of the alcohol. It is an expensive solution. As in the case of other solutions that contain alcohol, constant supervision during the infusion is required. Because it is a hypertonic solution, it is likely to be irritating to the vein.

Acid-Base imbalance

The most common solution given in conditions involving electrolytes is 5 per cent dextrose in lactated Ringer's solution. Its purpose is replacement, supplying 130 mEq/1 chloride ion, and 28 mEq/1 lactate ion. Its caloric value is 179/1. This is a hypertonic solution, and the usual precautions for such solutions must be observed.

While the following solutions are usually unnecessary in the correction of acid-base imbalance, they may be indicated in specific instances. These solutions include ⅕ molar sodium lactate, which supplies sodium ions without chloride; ⅙ molar sodium bicarbonate, which may be indicated when the alkali reserve is depleted; 0.9 per cent or 2.2 per cent ammonium chloride, which provides an excess of chloride necessary to combat alkalosis.

Blood volume problems

Whole blood, albumin, 6 per cent Dextran in isotonic saline, or Macrodex may be used to restore blood volume lost through acute hemorrhage or shock. The artificial solutions are useful because they contain large molecules, similar to plasma, and thus remain in circulation longer than either glucose or saline alone. Dextran substitutes for whole blood, but it does not contain native protein or cellular elements. In heart and kidney disease, it is essential to observe for signs of pulmonary edema. Allergic reactions may occasionally occur.

Whole blood must be used with great discrimination since the risks involved may not be warranted. For example, it is unwise to give a unit of whole blood to the patient whose hemoglobin is only moderately below the normal just "to give him a boost"; yet this has been known to occur. Frequently whole blood is the treatment of choice for maintaining or increasing the volume of circulating blood. In addition, blood is given to improve or maintain the oxygen-carrying capacity of the circulating blood; to replace toxically affected blood, such as in icterus neonatorum or pediatric acute alcohol poisoning; and to enhance blood coagulation.

The oxygen-carrying capacity of the blood is dependent on the erythrocytes. When the patient is deficient in cell numbers or hemoglobin content, it is becoming more and more common to prescribe cell concentrates rather than whole blood.

Exchange transfusion is now a wellknown and frequently practiced treatment in the management of hemolytic disease of the newborn. It should be noted that the blood-brain barrier in infants is much less efficient than in adults, and this factor may contribute to brain damage as a result of kernicterus, which is secondary to, but extremely significant in, hemolytic disease of the newborn.

The use of blood fractions in the control of coagulation problems has developed along with knowledge of the factors involved in the coagulation process. Thus, we see the administration of platelet-rich blood in thrombocytopenias. Fresh plasma may be given to replace or supplement labile factors of coagulation, either as a prophylactic procedure before and during surgery or in the treatment of emergency situations.


Perhaps the most important attitude essential to successful intravenous therapy is that of confidence. The nurse must go about her work with self-assurance, secure in her knowledge of why the intravenous procedure is being done and in her grasp of the techniques involved. Confidence is contagious. This is important from the patient's point of view. When a patient is to be subjected to a procedure which involves a certain degree of discomfort (if nothing else, being immobilized can be a source of discomfort), that discomfort is lessened markedly when those who are serving him inspire confidence. Many, and oftentimes ungrounded, are the apprehensions the patient may have about intravenous therapy. Should the patient voice his apprehensions, the task of the nurse is simplified, for she can allay his fears with specific assurances. Should he not voice them, his best ally is a confident, matterof-fact manner. The patient readily discerns whether the nurse is alert, observant, and capable of good judgment.


Preparedness is the key to the skills involved in intravenous therapy. The first rule of preparedness contributes to smooth operation: basic items of equipment should be within reach before the procedure is begun. These items include antiseptic, sterile sponges (gauze or cotton ) , tourniquet, intravenous administration units, syringe, and needles. Adequate lighting is an absolute essential.

The patient should be as comfortable as possible during the induction of intravenous therapy and the infusion. The procedure itself, and the reasons for using it, should be explained to the patient when indicated, thus leading easily to reassuring him. For most infusions, activity is limited, at least in the extremity which is the site of infusion. With care, however, the patient receiving intravenous fluids can be turned and can perform many activities with help. Prevention of kinking of the tubing or obstruction or dislodgment of the needle is most important.

The technique of following a definite pattern during the venipuncture will facilitate the procedure. Obviously, the choice of vein to be used is of the utmost importance. It should be adequate in size to accommodate the needle used, and, preferably, one located in an area in which the surrounding tissue provides support. In general it may be said that if thé vein is larger than the needle, better results are obtained by inserting the needle with the bevel up. Positioning the bevel downward is indicated when the needle closely approximates the size of the vein. In either case, having the bevel downward prevents the blocking of the lumen of the needle by a valve or by the collapse of the venous wall upon the bevel. (For a detailed technique of venipuncture, see pages 40, 41 and 42. )

Once started, there must be careful observation throughout an infusion process. The rate of flow, the reaction and comfort of the patient, and possible infiltration must be watched. The nurse is responsible for the immediate reporting of certain observations and the recording of others. Recorded information should include the following:

1. Date and time infusion was started.

2. Site of venipuncture.

3. Kind and amount of solution started.

4. Name and amount of additives, if any.

5. Name of the person starting the infusion.

6. Symptoms of any untoward reactions.

7. Evidences of desired effects.

8. (If intake and output record is in use, record IV here also.) Time infusion was discontinued and the amount of solution taken.

Discontinuation of the infusion involves several well-prescribed steps in order to prevent extravasation of blood, which would render the site unusable for further venipunctures. After the prescribed amount of solution has been administered, the tubing is clamped off. The needle is withdrawn quickly, and pressure with a sterile pledget is applied until the bleeding stops. (Elevation of the extremity is a good means for hastening control of the bleeding.) A small pressure bandage is applied over the site.

Possible Untoward Reactions to Intravenous Therapy

Any procedure which involves entry into the blood stream gives rise to the possibility of undesirable or life-threatening reactions. Since it is the nurse who is in attendance during infusions, her accurate assessment of the patient's reactions, and her attention to the measures indicated are of utmost importance. Whether she understands anything else involved in intravenous therapy, this area is the most essential.

Reactions may be produced by a number of factors. The causes may be traced to bacterial contamination of the material being infused, immunologic or hypersensitive factors, mechanical factors, or psychic reactions. In any case, a wellstocked emergency tray should be available.

Bacterial contamination

This may be due to contamination of the fluid by living bacteria, pyrogens, or bacterial debris residual to sterilization. The symptoms include chills, fever, rapid pulse and respiration, nausea, and headache. Not all symptoms may be present at a given time, but the appearance of any of them requires attention. The first step toward correction is to discontinue the administration of the infusion by clamping off the tubing. The needle is left in the vein in case it is necessary to restart the infusion. The patient's vital signs are observed closely, and the patient's physician is notified. The patient is kept warm and as comfortable as possible while awaiting further attention from the physician and an accurate diagnosis of the cause of the reaction.

Immunologic or Hypersensitive reactions

An anaphylactic shock or an anaphylactoid reaction is always a possible reaction to the introduction of protein substances. An allergic reaction may also occur in hypersensitive persons. In anaphylaxis, typical symptoms of shock occur, with drop in blood pressure and its sequelae the most pronounced. In allergic reactions urticaria, dyspnea, wheezing, cyanosis, chills and, possibly, edema may be noticed. Unless the edema affects the glottis enough to impair breathing, the allergic reaction is not ordinarily serious beyond the discomfort the patient experiences. Discontinuation of the infusion is the first step to take in such cases, but the needle is left in the vein until a decision as to the severity and treatment of the reaction has been made.

Immunologic reactions are those related to the transfusion of blood. They may be the result of incompatibility of the major blood groups of the donor and recipient, or due to the presence of undetected antibodies of the Rh system or minor blood groups. The serious reaction of this type is the result of hemolysis. Early symptoms of this reaction are precordial distress and lumbar pain. These may increase in intensity, and in addition, the patient may experience abdominal cramps, nausea, vomiting, and chills. If untreated, the patient will experience severe shock. Proper diagnosis of the cause of incompatibility reactions demands that the blood being administered be returned to the laboratory at once for further checking. Nursing observations that follow the reaction include a notation of output, since oliguria is a common finding in such cases. Hemoglobinuria will produce a reddish tinge to the urine.

Mechanically produced reactions

These reactions are due to air or blood-clot embolism, too rapid infusion, and infiltration of the solution into the tissues around the vein. The least serious, infiltration, may be readily noticed and treated. Emboli produce a sudden pain in the affected part, circulatory disturbance, or neurologic disturbance. The infusion is discontinued, and further treatment is dependent upon the instructions of the physician. The patient should be kept warm and as comfortable as possible.

Symptoms of too rapid infusion are cardiac and pulmonary embarrassment. The immedate measures to be taken are to reduce the rate of flow of the infusion and to notify the physician, who will give further instructions. Oxygen therapy and rotating tourniquets may be indicated. Vital signs should be checked frequently.

Psychic reactions

These are due to marked anxiety or hysteria in the patient and are often influenced by suggestion and lack of preparation of the patient for the procedure. The measures to be taken depend upon the condition of the patient and his response to reassurances.

Techniques of Venipuncture

General information

The patient's arm is extended, and if the veins are not easily seen or felt, the arm is allowed to hang dependent for a short time to facilitate distension of the veins. In lieu of this, a warm towel may be wrapped around the part and left for at least 10 minutes. The size of the needle chosen for the process depends upon the solution to be used, but it should be the smallest possible consistent with the material to be given so that the patient will not be uncomfortable. When the needle has missed or gone through the vein and is lodged against sensitive structures such as tendons, ligaments, or nerves unusual pain will result. To avoid possible serious aftereffects, as well as patient discomfort, it is well to begin over again.

Closed technique

1. Apply antiseptic solution to the area involved in the venipuncture.

2. Clear the infusion tubing of air and fasten the pinch clamp.

3. Hold the limb with the left hand, using the thumb to place the skin on stretch and to anchor the vein.

4. Point the needle in the direction of the course of the vein at the proposed site of entry. The angle of the needle to the surface of the skin should be about 45°.

5. Place the tip of the needle slightly to one side of the vein and about one-half inch below the point where the needle will enter the vein proper.

6. Firmly pierce the skin to the depth of the vein.

7. Depress the needle (decrease its angle) so that the needle is almost flush with the skin. Move the tip of the needle directly above the vein.

8. Slowly enter the vein. A backflow of blood into the clear plastic tubing will indicate satisfactory entry, although in some cases, the bottle containing the fluid to be administered may have to be lowered to produce this effect.

9. When the blood appears, cautiously advance the needle until it lies well within the lumen of the vein. This should be done by lifting the vein on the needle with a slight upward pressure to prevent the needle from passing through the posterior wall of the vein.

10. Release the tourniquet and relax the tension of the skin.

11. Adjust the pinch clamp and start the infusion.

12. To protect the skin under the needle, place a sterile gauze under and over the needle.

13. Tape the needle firmly into place with adhesive tape. To minimize the movement of the needle in the vein, tape a looped portion of the tubing to the forearm.

14. Adjust the rate of flow to indicated number of drops per minute.

Separate syringe technique

1. Using a dry, empty syringe, attach needle loosely, and proceed with venipuncture as indicated above.

2. Exert slight pull on the plunger to make certain the vein has been entered.

3. When the blood flows freely into the syringe, advance the needle to secure placement.

Figure 1. Securing the intracath. (Courtesy C. R. Bard Inc., Murray Hill, N. J.)

Figure 1. Securing the intracath. (Courtesy C. R. Bard Inc., Murray Hill, N. J.)

4. Release the tourniquet.

5. Detach the syringe and attach tubing to the needle.

6. Anchor needle and tubing as given above.

Separate needle technique

1. Venipuncture is made as given above, except that the needle is not attached to tubing or syringe.

2. When the blood appears through the open hub, the tourniquet is released and the tubing is attached to the hub of the needle.

3. Advance the needle into the vein.

4. Anchor needle and tubing as directed above.

Intracath technique1

1. Remove guard from needle with a twisting motion and make venipuncture in the usual manner.

2. To push catheter into vein, grasp lightly with left hand, just back of the collar. With right hand, grasp catheter y% inch away. Repeat procedure until catheter is pushed desired distance into aie vein.

note: If venipuncture is not successful, remove needle and catheter together . . . do not pull catheter out through the needle, as the sharp bevel edge may cut the catheter.

3. Place adequate protection such as alcohol, iodine derivative, or antibiotic ointment pledget over puncture site. Cover with sterile, dry pledget and secure with tape, encircling the arm.

4. Slowly withdraw the needle from the vein while applying digital pressure over vein forward of the needle's piercing point to hold the catheter within the vein.

5. Release digital pressure on catheter. Grasp catheter with thumb and forefinger in front of needle, holding it in the vein. With other hand, carefully draw needle back until flared end of the catheter is securely seated with the needle hub, to prevent leakage.

6. With a breaking motion, remove the catheter guard from the needle hub and discard it. In this position the needle becomes the adapter for the intravenous therapy set.

7. Attach infusion set adapter to the needle hub to begin infusion.

8. Tape the Intracath set carefully to the adjacent skin surfaces as shown in Figure 1.

9. Secure the catheteT by taking a strip of adhesive tape 1 by 4", tearing it down the middle 3 to 3W'. Place halfwidth strip around tape of pressure bandage; wrap the other half-width around the catheter several times and tape to side of pressure bandage.

Rochester plastic needle technique1

Rochester plastic needles cannot be taken apart and reassembled. They are intended for one time use only, and like IV sets, are considered disposable.

Insertion: The plastic needle should be used in the larger and more accessible veins. (The introduction of a larger needle into a vein is appreciably facilitated by initially infiltrating the puncture site with a small amount of local anesthetic.)

The plastic needle, with the bevel up and the point directly over the vein, punctures the site easily, if the operator rotates the syringe with quarter turns while exerting a forward pressure.

The stylet needle is partly withdrawn while the hub of the plastic portion is held firmly in place (Figure 2b.) Once the stylet needle bevel is within the plastic tube, the hubbed section of the plastic tube may be safely advanced within the vein, up to the plastic cuff. Remove the stylet needle completely; the instrument now is ready for use( Figure 2.)

Figure 2. Insertion of the Rochester Plastic Needle (Courtesy of Rochester Products Company, Rochester, Minn.)

Figure 2. Insertion of the Rochester Plastic Needle (Courtesy of Rochester Products Company, Rochester, Minn.)


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