Which action can the nurse take to minimize the patients risk for infection when applying new tubing to a primary IV infusion?

Chapter 8. Intravenous Therapy

Inhaltsverzeichnis Show

Checklist 66: Priming IV Tubing
Checklist 67: Changing an IV Bag
Checklist 68: Changing IV Tubing
Critical Thinking Exercises
What will the nurse do to prevent possible complications after removing an IV access device?
Which action would the nurse take if an intravenous insertion site appeared red warm and swollen?
How would the infusion of intravenous IV fluids be affected if the tubing were unintentionally dislodged from the chamber of the control mechanism of the IV pump?
How do you keep an IV line sterile?

Primary and secondary IV tubing and add-on devices (extension tubing) must be primed with IV solution to remove air from the tubing. Priming refers to placing IV fluid in IV tubing to remove all air prior to attaching the IV tube to the patient. IV tubing is primed to prevent air from entering the circulatory system. An air embolism is a potential complication of IV therapy and can enter a patient’s blood system through cut tubing, unprimed IV tubing, access ports, and drip chambers with too little fluid (Perry et al., 2018). It is unknown how much air will cause death, but deaths have been reported with as little as 10 ml of air. The best way to avoid air bubbles in IV tubing is to prevent them in the first place (Perry et al., 2018). New IV tubing may also be required if leaking occurs around the tube connecting to the IV solution, if the tubing becomes damaged, or if it becomes contaminated. Checklist 66 outlines the process of priming IV tubing.

Checklist 66: Priming IV Tubing Disclaimer: Always review and follow your agency policy regarding this specific skill.
Safety considerations: Primary IV tubing can be macro-drip or micro-drip tubing. The drop factor of the IV tubing is required to complete the IV drip rate calculation for a gravity infusion. Remember to invert all access ports and backcheck valve whilst fluid is running past that location.
Steps	Additional Information
1. Perform hand hygiene.	This step prevents the transmission of microorganisms.
2. Check order to verify solution, rate, and frequency.	This ensures IV solution is correct and helps prevent medication error.
3. Gather supplies.	You will need IV solution, primary IV tubing, the labels for tubing and the bag, alcohol swab, and basin or sink.
4. Remove IV solution from outer packaging and gently squeeze. Check expiry date. Assess for precipitates or cloudiness. Hang IV bag on hook or IV pole in a way that will allow gravity to help you to prime the line.	You need to verify integrity of the solution. Note the expiry date on IV bags are reported by month and year. The product is valid for the entire month.
5. Remove primary IV tubing from outer packaging. Remover paper.
6. Move the roller clamp to about 3 cm below the drip chamber and close the clamp.
7. Remove the protective cover on the IV solution port and keep sterile. Remove the protective cover on the IV tubing spike. Follow principles of asepsis.	Do not contaminate the spike.
8. Remove the protective cover from the IV solution port. Without contaminating the solution port or spike, carefully insert the IV tubing spike into the port, gently pushing and twisting.
9. Fill the drip chamber one-third to one-half full by gently squeezing the chamber. Only if absolutely necessary, remove protective cover on the distal end of the tubing and keep sterile.	Filling the drip chamber prevents air from entering the IV tubing. Fill drip chamber Not removing the protective cover on the distal end of the tubing helps to maintain asepsis.
10. With distal end of tubing over a basin / sink / garbage, slowly open roller clamp to prime the IV tubing. Invert back check valve and ports as the fluid passes through the tubing. Tap gently to remove air and to fill with fluid.	Inverting and tapping the back check valve and access ports helps displace and remove air when priming the IV tubing.
11. Once IV tubing is primed, check the entire length of tubing to ensure no air bubbles are present.	This step confirms that air is out of the IV tubing.
12. Close roller clamp. If removed earlier, cover distal end with sterile dead-ender or sterile protective cover. Hang tubing on IV pole to prevent from touching the ground.	Keep the distal end sterile prior to connecting IV to patient.
13. Label tubing and IV bag with date, time, and initials.	Label IV solution bag as per agency policy. Do not write directly on the IV bag.
14. Perform hand hygiene.	This reduces the transmission of microorganisms.
Data sources: Fulcher & Frazier, 2007; Perry et al., 2018.

Watch the video Priming IV Lines developed by Renée Anderson and Wendy McKenzie TRU School of Nursing (2018).

IV solutions are considered sterile for 24 hours. An IV solution may be changed if the physician’s order changes, if an IV solution has been running slowly and has been hanging for 24 hours, or if the IV solution becomes contaminated. To change an IV solution bag, follow Checklist 67.

Checklist 67: Changing an IV Bag Disclaimer: Always review and follow your agency policy regarding this specific skill.
Steps	Additional Information
1. Verify and select correct IV solution bag, and compare to the medication administration record (MAR) or prescriber’s orders.	IV solutions are considered a medication and must be checked using the SEVEN rights and THREE checks, as per agency policy. Sterile IV solution
2. Introduce yourself, identify patient, and explain procedure.	Proper identification of a patient prevents medication errors. Explaining the procedure provides an opportunity for the patient to ask questions.
3. Perform hand hygiene.	Hand hygiene prevents the transmission of microorganisms.
4. Remove IV solution from outer packaging and gently squeeze. Check expiration date. Assess for precipitates or cloudiness. Hang new IV solution on IV pole.	Expiry dates on IV bags are reported by month and year. The product is valid for the entire month.
5. If infusing the IV by EID, pause the device. If infusing the IV via gravity, close the roller clamp on the infusion set.	Stops the infusion to prevent air bubbles from forming in IV tubing.
6. Remove the protective cover from the IV solution (new bag) port.	Keep all ports sterile.
7. Remove the old IV solution bag from the IV pole. Turn old IV bag upside down, grasping the bag with the non-dominant hand and the spike with the dominant hand. With a twisting motion, carefully remove IV tubing spike from old IV solution bag.	Removing old solution from IV pole and inverting it prevents spilling of solution. Ensure IV tubing spike remains sterile during removal to avoid contaminating IV tubing.
8. Using a gentle back and forth twisting motion, firmly insert the spike into the new IV bag.	This ensures that principles of asepsis are followed.
9. If necessary, fill the drip chamber by compressing it between your thumb and forefinger. Ensure the drip chamber is one-third to one-half full. Check IV tubing for air bubbles.	Fluid in the drip chamber helps prevent air from being introduced into IV tubing.
10. If using gravity: Open clamp and regulate IV infusion rate with the roller clamp. If using EID: Confirm rate and volume to be infused, press start to resume the infusion.	If using gravity, count the drops per minute in the drip chamber If using an EID follow the prompts on the screen to ensure the IV is running at the correct rate.
11. Label new IV solution bag as per agency policy.	Labelling IV solutions provides easy viewing of infusing solutions, additives and when the bag was hung.
12. Dispose of used supplies, perform hand hygiene, and document IV solution bag change according to agency policy.	Document time, date, type of solution, rate, and total volume.
Data sources: Fulcher & Frazier, 2007; Perry et al., 2018.

Watch the video Changing IV bags developed by Renée Anderson and Wendy McKenzie TRU School of Nursing (2018)

Checklist 68 describes how to change the IV administration set and IV solution at the same time.

Checklist 68: Changing IV Tubing Disclaimer: Always review and follow your agency policy regarding this specific skill.
Steps	Additional Information
1. Verify prescriber’s orders for the type of solution, rate, and duration. Collect necessary supplies.	This step verifies the patient’s need for IV fluids or medications. It also confirms the correct rate and solution for patient safety.
2. Perform hand hygiene.	Hand hygiene prevents the transmission of microorganisms.
3. Identify yourself, identify the patient using two identifiers, and explain the procedure to the patient.	Proper identification of patient prevents errors.
4. Prime new administration set using a new IV solution bag and new IV tubing. Label IV solution and IV tubing as per agency policy. If necessary, add an extension set including a needleless cap.	IV solutions are considered a medication. Prime as per Checklist 66. If possible, keep distal protective cap attached to IV tubing to ensure sterility of distal end. Labelling ensures communication between staff. Extension sets help to reduce micromovements at the cannula insertion site and protect from BBF exposure during IV tubing changes. Note: Some CVADs have extension tubing as a permanent part of their structure.
5. Hang new administration set (primed primary line and IV solution) on IV pole.	This prepares the equipment and adheres to the principles of aseptic technique.
6. Stop the infusion. If using an EID, remove IV tubing from the device.	Stop the flow of infusion during tubing and solution change.
7. Perform point of care risk assessment; donne non-sterile gloves. Clean the connection between the distal end of old IV tubing and the needleless cap. Scrub the area for 15 to 30 seconds using friction, and let it dry.	Proper disinfection of equipment decreases bacterial load and prevents infections. Clean the connection between the IV tubing and needleless cap using friction
8. Remove the protective cap on the distal end of the new IV administration set.	Remove sterile cap
9. If the extension is present and you are NOT changing it, leave extension and needleless cap in place. If the extension isn’t present and/or you are changing the extension set, loosen the IV tubing from the IV cannula. PVAD-short: Occlude the vein. CVAD – open ended: Use clamps. CVAD – closed ended: Lumens have valves to prevent reflux.	Understanding the structure and function of different IV access devices helps to determine risk of air emboli / exposure to BBF and subsequent safety considerations and need for clamping. PVAD-short: Occluding vein reduces risk of BBF exposure. CVAD – open ended: Clamps reduce risk of air emboli and/or BBF exposure.
10. Carefully disconnect the old tubing and Luer lock the new IV tubing into the cap.	Disconnect old IV tubing from the needleless cap, and Luer lock new tubing Luer locks reduce risk of air emboli and provide security for keeping IV lines and connections intact. Maintain principles of asepsis.
11. If using gravity: Open clamp and regulate IV infusion rate. If using EID: Confirm rate and volume to be infused, press start to resume the infusion.	This step ensures the IV solution is infusing at the correct rate. Regulate IV tubing using a roller clamp Ensure IED is programmed with correct rate and volume to be infused
12. Check IV site for patency and evidence of complications.	IV site should be free from redness, swelling, pain and leaking. Transparent semipermeable dressing on IV site should be dry and intact.
13. Discard old supplies and perform hand hygiene.	This step prevents the spread of microorganisms.
14. Document procedure as per agency policy.	Document the date and time of IV tubing and solution change.
Data sources: BCIT, 2015b; Fulcher & Frazier, 2007; Perry et al., 2018

Critical Thinking Exercises

What is the purpose of removing air from IV tubing?
You come on shift and notice the patient’s IV tubing is not labeled. Describe your next actions.

What will the nurse do to prevent possible complications after removing an IV access device?

Instruct the patient to report immediately any sign of bleeding on the site dressing..

Perform hand hygiene and wear clean gloves while removing the device..

Which action would the nurse take if an intravenous insertion site appeared red warm and swollen?

An IV site that is red, warm and swollen suggests phlebitis or infection and the IV catheter must be removed to prevent further damage to the patient's arm.

How would the infusion of intravenous IV fluids be affected if the tubing were unintentionally dislodged from the chamber of the control mechanism of the IV pump?

How would the infusion of intravenous (IV) fluids be affected if the tubing were unintentionally dislodged from the chamber of the control mechanism of the electronic infusion device (EID)? The infusion would slow to a “keep vein open” rate.

How do you keep an IV line sterile?

These conditions should include: 1) covering the exposed end of IV tubing used for intermittent infusions with a sterile cap between uses, and 2) disinfecting the port before connecting tubing or a syringe to the port.