Intravenous therapy
Introduction
Intravenous (IV) therapy is a vital route for administering fluids, medications, blood products, and nutrition, especially when rapid absorption is required. For nurses, proficiency in IV care goes beyond just inserting a line: it includes fluid selection, complication prevention, monitoring for infection, and recognizing when central access is needed.
The NCLEX frequently tests on IV site assessments, complication management, and types of access devices. Blood product administration follows its own verification protocol, covered in the blood and blood product administration chapter.
Learning objectives
By the end of this section, you should be able to:
- Identify types of IV fluids and their clinical indications
- Differentiate between peripheral and central lines, including PICCs and ports
- Recognize and manage IV-related complications
- Follow sterile and aseptic protocols when handling IV access
- Document and monitor IV fluid administration accurately
Types of IV fluids
IV fluids are classified by tonicity, which describes their concentration compared to plasma:
| Type | Examples | Use |
| Isotonic | 0.9% NS, LR, D5W (initially isotonic in the bag) | Hydration, hypotension, post-op fluids |
| Hypotonic | 0.45% NS, 0.33% NS | Hypernatremia and cellular dehydration (use with caution) |
| Hypertonic | 3% NS, D5NS, D5 0.45% NS, D10W | Selected indications (e.g., severe hyponatremia, cerebral edema) |
Peripheral IVs
Peripheral IV lines are placed in the arm or hand for short-term access.
Nursing interventions:
- Inspect for signs of infiltration (swelling, cool skin), phlebitis (redness, warmth), or infection.
- Replace peripheral IV catheters based on clinical indication and institutional policy.
- Secure tubing and label lines.
- Flush per protocol to prevent occlusion.
- Avoid using the same arm as an arteriovenous fistula, significant injury, or affected arm after breast surgery (per institutional policy).
Central venous access devices (CVADs)
Used for long-term therapy, vesicant drugs, TPN, or poor peripheral access. TPN in particular carries added risks of hyperglycemia and catheter-related infection, so monitor the client’s blood glucose and the insertion site closely.
| Type | Examples | Nursing notes |
| PICC (Peripherally inserted central catheter) | Inserted in arm, tip ends in SVC | Use sterile technique for dressing changes. Monitor the external catheter length for migration. |
| Central line (CVC) | Subclavian, internal jugular, femoral | High infection risk. Verify tip placement before use per institutional policy. |
| Implanted port | Under skin (e.g., for chemo) | Accessed with a Huber needle. Flush when not in use (typically every 4 to 12 weeks per institutional policy). |
Preventing air embolism during central line removal: When a central line is removed, air can be pulled into the vein through the open catheter. To prevent this, place the client supine or in Trendelenburg and have them perform a Valsalva maneuver (bear down) or exhale during withdrawal, then apply an occlusive dressing immediately. These steps raise central venous pressure so air can’t be drawn in.
IV complications and nursing interventions
| Complication | Signs | Nursing action |
| Infiltration | Cool, swollen, pale skin | Stop infusion, elevate the limb, and apply warm or cold compresses as indicated |
| Phlebitis | Red, warm, tender vein | Discontinue IV, apply warm compress, document |
| Infection | Redness, pus, fever | Notify the primary health care provider, obtain cultures, and administer antibiotics as ordered |
| Air embolism | Chest pain, dyspnea, cyanosis, ↓BP | Clamp the line, administer oxygen, place the client in left lateral Trendelenburg (Durant maneuver) to trap air in the right atrium, and activate the rapid response team |
| Fluid overload | Crackles, edema, ↑BP, JVD | Reduce or stop the infusion as indicated, elevate the head of the bed, notify the primary health care provider, and administer diuretics as ordered |
| Extravasation | Burning, stinging, blistering | Stop infusion, aspirate the drug if appropriate, and follow the institution’s extravasation protocol. |
Nursing documentation and safety
- Verify orders: correct fluid, rate, additives, duration.
- Label bags, tubing, and sites.
- Use electronic pumps for accuracy.
- Document start time, site, fluid type, rate, and client tolerance.
- Change tubing and dressings per institutional protocol.
Example: Calculating an IV flow rate
A client is ordered 1,000 mL of 0.9% NS to infuse over 8 hours via an electronic pump. What rate, in mL/hr, should the nurse program?
Answer: 125 mL/hr
Clinical vignette
A nurse is caring for a client receiving D5 0.45% NS at 125 mL/hr via a PICC. During a flush, the client reports burning. The nurse stops the flush, checks for blood return (none), and notes swelling at the site. Suspecting catheter migration with possible extravasation, she halts the infusion, elevates the arm, applies a warm compress, and notifies the primary health care provider. The PICC is removed and replaced after confirmation of tip migration.
Key actions: Recognized a complication, stopped the infusion, initiated appropriate care, and documented thoroughly.