1

Intravenous Therapy in Clinical Practice

Objectives
At the completion of this module, the student will be able to:
1. Calculate intravenous flow rates.
2. Discuss the two major complications associated with intravenous therapy.
3. Accurately calculate intake and output.
4. Identify the difference between the primary line and the intravenous piggyback (IVPB).

Case Study
Mrs. J., 61 years old, is admitted to the hospital from a board and care facility with the diagnosis
of dehydration and possible sepsis. Her medical history includes two episodes of urinary tract
infections (UTIs) during the past 9 months, Alzheimer’s disease for 5 years, a total abdominal
hysterectomy and bilateral salpingo-oopherectomy (TAH-BSO) 20 years ago, and a history of
hypothyroidism. The caregiver indicated that she noticed that Mrs. J. moaned upon urinating and
that the urine had an odor. Mrs. J. is widowed and has two grown married children. The son lives
out of state and the daughter visits her weekly.

On admission, the nurse’s assessment is significant for the following: T 99.8º F, P 82, R 18, BP
130/88. Skin dry and tenting; tongue pale, dry, and cracked; lips dry. The nurses assess Mrs. J.’s
mental status and find that Mrs. J. responds to simple questions inappropriately, is restless, and
disoriented.

The physician orders an indwelling urinary catheter, parenteral IV fluids of 0.9% normal saline
(NS) at 125 ml/hr, soft diet, push fluids, intake and output (I&O), complete blood count (CBC),
serum K+, Na+, Cl, CO2, urine for culture and sensitivity (C&S). Ciprofloxacin 400 mg q12h
IVPB, levothyroxine 0.1 mg qd, estradiol (Estrace) patch 2x/week, vital signs (VS) q4h, and vest
restraint. The nurse starts 1000 ml of 0.9% NS IV into the right forearm and catheterizes Mrs. J.
with a #16 urinary catheter obtaining 250 ml of dark yellow urine.

Problems/Nursing Diagnoses
Based on the data in the case study for Mrs. J., what problem/nursing diagnosis do you
wish to address first? Choose the three nursing diagnoses with the highest priority.

Deficient Fluid Volume

Deficient Fluid Volume is a priority problem. The client is manifesting signs and symptoms of
dehydration such as poor skin turgor (skin dry and tenting), dry mucous membranes (tongue
pale, dry, and cracked; lips dry), and concentrated urine. Confusion related to dehydration is
difficult to assess because the client has Alzheimer’s disease.

Risk for Injury

Risk for Injury is a priority problem. The client has Alzheimer’s disease and is agitated and
restless on admission. Her physical condition and her current diagnosis of dehydration could
contribute to increased confusion. Further, the application of the vest restraint predisposes the
client to increased agitation and possible tissue injury.

Chronic Confusion
Chronic Confusion is a priority problem. The client has had Alzheimer’s disease for the past 5
years. Mrs. J.’s admission to the hospital and her current diagnosis of dehydration could further
contribute to her confusion, agitation, and restlessness.

Clinical Decisions
Based on the data, what do you wish to accomplish? Choose three priority outcomes.

Outcome: Will demonstrate improved skin turgor and manifest moist mucous membranes.
Rationale: Tissue perfusion is increased as fluid balance approaches normal levels.

Outcome: Will be free from injury during hospitalization.

Rationale: Nursing interventions such as frequent monitoring, maintaining a calm,
nonstimulating environment, and restraints help to reduce the risk of physical
harm.

Outcome: Will manifest decreased agitation and restlessness.

Rationale: Nursing interventions that decrease agitation and promote safety will assist in
keeping confused clients free from harm.

Based on data for Mrs. J., the nursing diagnosis of Deficient Fluid Volume, and the
expected outcomes you have identified, which actions will you take?

Intervention: (1) Offer 100 ml of fluid every hour while awake.

Rationale: Offering small amounts of fluids throughout the day will assist in achieving and
maintaining the oral hydration needs of the client.

Intervention: (2) Maintain IV fluid therapy as ordered.

Rationale: Fluid replacement is more readily achieved through IV therapy. The body
normally loses between 2500 and 3000 ml of fluid per day through the urine,
feces, lungs and skin. Maintaining IV fluid therapy at the prescribed rate will
provide this client with 3000 ml of fluid per day.

Intervention: (3) Monitor I&O every shift.

Rationale: The I&O provides a guide to assessing fluid balance. Ideally fluid intake should
equal fluid output. Clients with dehydration should have a greater intake until
fluid balance is achieved.

Based on data for Mrs. J., the nursing diagnosis of Risk for Injury, and the expected
outcomes you have identified, which actions will you take?

Intervention: (1) Apply and maintain the vest restraint as ordered.

Rationale: The application of the vest restraint provides a means of limiting the client’s
physical activity during periods of confusion and agitation.

Intervention: (2) Remove vest restraint every 2 hours.

Rationale: A client who is restrained due to confusion and agitation should be monitored
frequently. Restraints should be removed every 2 hours, and the client’s skin
should be assessed for possible tissue injury.
 3

Intervention: (3) Reorient the client frequently and get the client out of bed 3 times per shift.
Rationale: Clients who are agitated and confused need to be reoriented routinely in an
effort to decrease confusion and agitation. Nursing interventions that assist in
decreasing restlessness include ambulating the client, speaking in a calm,
nonthreatening tone, and maintaining a nonstimulating environment.

Based on data for Mrs. J., the nursing diagnosis of Chronic Confusion, and the expected
outcomes you have identified, which actions will you take?

Intervention: (1) Give directions one at a time using clear, simple sentences.
Rationale: Simple, clear directions gives the client the opportunity to interpret the directions
and to follow through with the task, thus facilitating a sense of accomplishment.

Intervention: (2) Maintain a quiet, nonstimulating environment.

Rationale: A nonstimulating environment lessens the possibility of sensory overload.
Sensory overload can contribute to a client’s agitation and confusion.

Intervention: (3) Approach the client in a gentle, calm, nonthreatening manner.

Rationale: A gentle, calm, nonthreatening manners assists in decreasing a client’s agitation
and helps to maintain a client’s dignity and worth.

Content Mastery
1. Mrs. J. has a continuous IV of 0.9% NS infusing at 125 ml/hr. Ciprofloxacin 400 mg is
ordered IVPB. Which statement best describes the purpose of the IVPB system?
a. An intravenous infusion that is administered by attaching and running it through an
established primary line.
b. An intravenous tubing that provides direct access to the venous system while delivering
continuous fluid therapy.
c. An intravenous device that provides direct access to the venous system and may be used
intermittently; it is filled with heparin or saline between uses.
d. A medication-filled syringe that is administered directly into the venous system at a
prescribed rate using a port from the primary line.

Answers and Rationales

1a. Correct: The purpose of the IVPB system is to administer additional medications
periodically through an established intravenous line.
1b. Incorrect: Administering continuous fluid therapy describes the function of the primary
line.
1c. Incorrect: Although the heparin/saline lock may be used to administer continuous IV
fluid therapy and IVPBs, it does not describe the purpose of the IVPB system.
1d. Incorrect: A medication-filled syringe describes the administration of an IV bolus
medication. This does not describe the purpose of the IVPB system.

2. Mrs. J.’s first liter of 0.9% NS is completed and the nurse hangs the second liter into the
primary tubing and adjusts the rate of flow to deliver125 ml/hr. The nurse documents the
start of the second liter. Which of the following should be included in the documentation of
the second liter of IV fluid?
a. The date, start time, the volume and the type of the IV solution
 b. The date, start time, the volume and the type of the IV solution, and the rate of flow
c. The date, start time, the type of the IV solution, and the rate of flow
d. The date, the volume and the type of the IV solution, and the rate of flow

Answers and Rationales

2a. Incorrect: This information does not provide complete data.
2b. Correct: The date, start time, the volume and the type of the IV solution, and the rate of
flow provide complete information.
2c. Incorrect: This information does not provide complete data.
2d. Incorrect: This information does not provide complete data.

3. The nurse is preparing to administer the first dose of ciprofloxacin 400 mg IVPB to Mrs. J.
using a port from the primary line. It is most important for the nurse to ensure all of the
following prior to starting the IVPB except:
a. Observe the six rights of medication administration and triple-check all labels.
b. Know the therapeutic effects, usual dosage, recommended routes, and potential adverse
effects.
c. Patency of the intravenous line and incompatibility of the medication with the
intravenous solution.
d. The flow rate and drop factor of the primary line.

Answers and Rationales

3a. Incorrect: This is an important step in medication administration.
3b. Incorrect: This is an important step in medication administration.
3c. Incorrect: This is an important step in medication administration.
3d. Correct: The flow rate and drop factor of the primary line are important to know, but it is
more important for the nurse to take the necessary steps to prepare the administration of
medications safely prior to delivering the medication to the client.

4. The night nurse is preparing to calculate the 24-hour I&O for Mrs. J. She notes that Mrs. J.’s
primary line of 0.9% NS has infused continuously at 125 ml/hr all three shifts and she had
200 ml of IV fluid from the IVPBs. She took a total of 1000 ml of oral fluids the previous
two shifts and no oral intake on the night shift. She had 800 ml of output from the day and
evening shift and 200 ml from the night shift. Which entry reflects accurate documentation of
Mrs. J.’s total 24-hour I&O?
a. I = 1000 ml; O = 1000 ml
b. I = 3200 ml; O = 1000 ml
c. I = 4200 ml; O = 1000 ml
d. I = 1200 ml; O = 1000 ml

Answers and Rationales:

4a. Incorrect: This does not reflect the total 24-hour I&O.
4b. Incorrect: This does not reflect the total 24-hour I&O.
4c. Correct: The I&O includes all oral and parenteral intake and all output.
4d. Incorrect: This does not reflect the total 24-hour I&O.

5. The physician ordered an intravenous solution of 0.9% normal saline (sodium chloride) for
Mrs. J. to infuse at 125 ml/hr. The tonicity of this fluid is:
 5

a. isotonic fluid.
b. hypertonic fluid.
c. hypotonic fluid.
d. endotonic fluid.

Answers and Rationales

5a. Correct: Normal saline 0.9% (sodium chloride) is isotonic and is equal in tonicity to
intracellular fluid. It is used primarily as a plasma volume expander for Mrs. J. because
she is dehydrated.
5b. Incorrect: Hypertonic fluid has a greater tonicity than intracelluar fluid. Hypertonic fluid
such as 3% sodium chloride is used in severe sodium depletion.
5c. Incorrect: Hypotonic fluid has a lower tonicity than intracellular fluid. Hypotonic fluid
such as 0.45% sodium chloride is used when there is a need for sodium replacement.
5d. Incorrect: Endotonic fluid does not exist.

6. The physician prescribes 1 L of 0.9% normal saline to infuse at 125 ml/hr. Using tubing
labeled 15 gtt/ml, what should the nurse set the drops per minute to deliver the ordered
amount?
a. 25
b. 31
c. 38
d. 45

Answers and Rationales

6a. Incorrect: Recalculate the drops per minute.
6b. Correct: This calculation will deliver 125 ml/hr.
6c. Incorrect: Recalculate the drops per minute.
6d. Incorrect: Recalculate the drops per minute.

7. Mrs. J. has ciprofloxacin 400 mg IVPB q12h ordered. The pharmacy mixes ciprofloxacin 400
mg in 50 cc of 0.9% normal saline to infuse over 60 minutes. Using tubing labeled 60 gtt/ml,
what should the nurse set the drops per minute to deliver the ordered amount?
a. 25
b. 50
c. 60
d. 75

Answers and Rationales

7a. Incorrect: Recalculate the drops per minute.
7b. Correct: The IVPB rate is calculated the same as an IV rate utilizing the formula: total
volume to be infused x drip factor divided by infusion time in minutes.
7c. Incorrect: Recalculate the drops per minute.
7d. Incorrect: Recalculate the drops per minute.

8. When the nurse is assessing the IV site on Mrs. J., she finds the following: some redness,
tenderness, and complaints of pain at the site. The priority nursing intervention is for the
nurse to:
a. continue to monitor the IV site closely.
 b. notify the physician.
c. discontinue the infusion.
d. apply warm, moist compresses.

Answers and Rationales

8a. Incorrect: The IV has infiltrated and is causing signs and symptoms of phlebitis.
8b. Incorrect: The physician does not have to be notified.
8c. Correct: Discontinuing the IV is the priority intervention. If the IV is allowed to continue
the signs and symptoms of phlebitis will increase.
8d. Incorrect: Although applying warm, moist compresses is an intervention the nurse would
do, it would not be a priority intervention in this situation.

9. A urine for C&S has been ordered for Mrs. J. Which statement indicates the nurse’s
understanding of obtaining a urine specimen for C&S?
a. The nurse collects the specimen from the urinary collection bag at the beginning of the
shift.
b. The nurse collects the specimen into a clean urine container for the sample port of the
catheter.
c. The nurse disconnects the urinary catheter from the drainage tube and collects the urine
into a sterile urine container.
d. The nurse collects the specimen with a sterile needle and syringe from the sample port of
the catheter and puts it into a sterile container.

Answers and Rationales

9a. Incorrect: This is not the proper method of collecting a sterile urinary specimen from an
indwelling catheter.
9b. Incorrect: This is not the proper method of collecting a sterile urinary specimen from an
indwelling catheter.
9c. Incorrect: This is not the proper method of collecting a sterile urinary specimen from an
indwelling catheter.
9d. Correct: Introducing a sterile needle into the sample port of the catheter and putting the
specimen into a sterile container is the proper method of collecting a urine specimen for
C&S.

10. The nurse applies a vest restraint on Mrs. J. To promote a safe environment the nurse:
a. ties the restraint straps to the bed frame.
b. monitors the client every 4 hours.
c. ties the restraint straps to the side rails.
d. applies the cross straps to the back and ties them to the bed frame.

Answers and Rationales

10a. Correct: Straps from any restraint should be tied to the bed frame.
10b. Incorrect: Clients with restraints should be monitored at least every 2 hours.
10c. Incorrect: Restraint straps should not be tied to the side rails.
10d. Incorrect: The straps should be crossed in the front and secured to the bed.

Essay Questions
Identify the difference between the primary line and the IVPB. State the nursing
 7

implications associated with taking care of a client who has a primary line and receives
medications through the IVPB system.

The primary line refers to the intravenous tubing that provides direct access to the venous system
while delivering continuous fluid therapy. Clients who have a primary line will have continuous
intravenous fluid therapy administered by infusion pump or by gravity flow. The nursing
implications involve assessment of the IV insertion site for signs and symptoms of infiltration,
signs and symptoms of phlebitis, carefully monitoring the IV to ensure accurate delivery of the
intravenous fluid, and documentation of the IV fluid. You need to also ensure that the IV tubing
and the IV site are changed according to hospital policy.

The IVPB is used to administer medication intermittently into the venous system using an
established primary line. Nursing implications begin prior to hanging an IVPB. As the nurse, you
need to follow the recommended standards of practice associated with medication administration
(six rights of medication administration) and know the drug classification, usual dosage, routes
of administration, side effects, and adverse effects. You must be aware of any drug or food
allergies that the client may have and any drug incompatibilities associated with the IVPB
medication and the primary line. Being familiar with the IV tubing will assist you in selecting the
appropriate tubing for the hanging IVPB. It is important for you to assess the IV site prior to
starting the IVPB to determine line patency. Once the IVPB is attached to the primary line, you
need to calculate the flow rate to ensure delivery of the medication within the recommended rate
and time. After the IVPB is completed, ensure that the rate of flow for the primary line is
established and the administration of the IVPB is documented in the appropriate forms (i.e.,
medication record and I&O record).

Discuss the two major complications associated with intravenous therapy, identifying the
causes, signs and symptoms, and nursing interventions for each complication. The two
major complications associated with intravenous therapy are infiltration and phlebitis.

Infiltration is the leaking and accumulation of intravenous fluid into the surrounding tissue. This
occurs when the intravenous cannula breaks through the venous wall and leaks intravenous fluid
into the surrounding tissue. Clients who are at high risk for infiltration are the elderly because
they commonly have fragile veins, and clients who are unable to maintain an intravenous line in
a proper, stable position. The signs and symptoms of infiltration are swelling, pallor, coolness,
and discomfort in the area. IV sites should be monitored q2h to ensure patency. If signs and
symptoms of infiltration are assessed, the nursing interventions would be to discontinue the IV,
elevate the extremity, and apply warm, moist compresses. Document the findings and
interventions. If the client is on continuous IV therapy, the IV needs to be restarted above the
infiltrate site or in the other arm.

Phlebitis is the inflammation of the venous wall. This occurs when the venous wall becomes
irritated due to either the mechanical irritation of the intravenous cannula or by chemical
irritation due to the drug being infused. The client may complain of localized pain and
tenderness, especially when pressure is applied. As the phlebitis progresses, the area swells and
becomes red and warm. Phlebitis can progress to forming a cordlike mass under the skin, and
purulent drainage may develop. Intravenous sites should be monitored q2h to ensure patency. If
signs and symptoms of phlebitis are assessed, the nursing interventions would be the same as for
filtration: discontinue the IV, elevate the extremity, and apply warm, moist compresses. In
addition, the physician may order an antibiotic if there is purulent drainage. It is important for
you to document the findings and the interventions. If the client is on continuous IV therapy, you
need to restart the IV, preferably in the other arm.