1. Chapter 27 (Perry & Potter)
IV Priming
Chapter 27 (Perry & Potter)

2. IV Priming Why do clients need an IV? Replacing fluids
Correct or prevent nutritional imbalances
Provide IV medication therapy

3. Nursing Responsibilities
Know the correct solution & equipment needed & how to initiate the infusion
Regulate the infusion (with or without a pump)
Care for an maintain the system
Indentify and correct problems
Discontinue the infusion

4. Categories of IV solutions
Isotonic
Hypotonic
Hypertonic
Determined by serum electrolyte values and
fluid volume balance
RN must understand the rationale for IV fluid administration and the type of solution ordered

5. Establish IV Access
IV catheter can remain in place for 96 hrs (check hospital policy, most are 72 hours), IV solution replaced every 24 hours
Palpate insertion site daily and prior to initiating infusion
Inspect site if client c/o pain at site or developed S&S of infection
Change transparent dressing if becomes damp, soiled, loose
Clean injection port with antiseptic before accessing system

6. Supplies Administration set (IV lines) Correct IV solution
Antiseptic swabs
Tape
IV pole, rolling or ceiling mounted
Hospital gown with snaps
1-3 ml normal saline, 3 ml syringe (or larger)…pre-filled n/s syringes may be available, to flush IV catheter prior to initiating infusion

7. Nursing Diagnosis Risk for imbalanced fluid volume
Deficient fluid volume
Excess fluid volume
Risk for infection

8. Assessment Review physician’s order (type, amount and/or rate)
6 medication rights (medication, dose, client, route, time, documentation)
Physical assessment pertaining to IV fluid administration
Understand rationale and purpose of IV fluid, potential incompatibilities, and potential side effects

9. Implementation Change gown Prepare tubing and solution
Check solution (6 rights)
Color
Clarity
Expiration date
Leaks

10. Open infusion set (maintaining sterility of each end)
Place roller clamp 2-5 cm below drip chamber and move to OFF position
Remove sheath over port on IV solution bag
Remove tubing spike (DO NOT TOUCH)
Insert spike into IV bag

11. Priming: Compress drip chamber, fill 1/3 to ½
Remove cap on end of tubing, KEEP and maintain sterility
Slowing open roller clamp and prime tubing with fluid, return roller clamp to OFF position
Inspect for air bubbles, tap tubing where bubbles are visible, and invert ports and tap to fill and remove air
Replace cap from end of tubing
Label tubing and bag with date and time

12. Saline lock is attached to end of IV catheter which is then
Prepare n/s (1-3 ml) to flush intermittent infusion device (saline lock, PIID, clave) (p. 749 – establish IV access, pictureA)
Saline lock is attached to end of IV catheter which is then
attached to the primary line
Has a port or stopper (needleless)
Must be irrigated q8-12 h, and before & after each drug infusion (hospital policy)
Saline or heparinized saline (hospital policy)
Sterile technique

13. Regulating IV Flow Rate (Gravity)
Flow rate established using pump (ml/hr) or gravity (gtt/min)
If line patent and IV infusion initiated, flow rate must be established
Educate client regarding positioning
Inspect site often

14. What is the drop factor: number of drops per ml (gtt/ml) IV tubing provides:
Microdrip: 60 gtt/ml
Macrodrip: Abbott: 15 gtt/ml
Travenol: 10 gtt/ml
McGaw: 15 gtt/ml

15. Calculating drip rate:
ml/hr x gtt/ml = drops/min
60 min

16. If ml/hr unknown:
ml/hr = total infusion (ml)
hours of infusion

17. Remember: if infusion is not exactly 1 hour (15 min, 30 min, 120 min, etc…) you must calculate hourly rate. 50 ml x ? = 200 ml 15 min 60 min hr

18. Calculate drip rate: ? gtt/min
Example:
Order: 75 ml/hr
Drop factor: 15 gtt/ml
Calculate drip rate: ? gtt/min
Answer: 75 ml/hr x 15 gtt/ml = gtt/min
60 minutes (18-19 gtt/min)

19. Order: Give 1 L Ringer’s Lactate over 4 hours Drop factor: 15 gtt/ml
Example:
Order: Give 1 L Ringer’s Lactate over 4 hours
Drop factor: 15 gtt/ml
Calculate drip rate: ? gtt/min
Answer: ml x ? = ml
240 min min hr
250 ml/hr x 15 gtt/ml = 62.5 gtt/min
60 minutes ( gtt/min)

20. Establishing Drip Rate
Count drops in drip chamber for 1 minute (with second hand), adjust roller clamp as needed (2-5 cm below drip chamber)
If very fast or very slow, count for 30 sec (x 2) and adjust roller clamp. Count for 1 full minute once clamp is adjusted .

21. Evaluation Monitor infusion at least q1h (note volume, rate)
Assess for S&S of overhydration or dehydration, response, lab values
Assess S&S of infiltration, inflammation, clot in catheter, kink or knot in tubing etc…

22. Recording and Reporting
Rate of infusion, gtt/min, and ml/hr in nursing notes or IV fluid form
Document any ordered changes in IV fluid rates
Report rate, solution, volume remaining to the nurse assuming care of client at break or change of shift

23. Practice Priming

24. IV Medication Secondary Lines
Chapter 21 (Perry & Potter)

25. Piggyback (p. 737)
A small IV bag connected to short tubing that is connected to the upper Y port of a primary infusion line. The small bag is set higher than the primary infusion bag. Upon completion of the secondary solution when the solution in the tubing falls below the primary drip chamber the primary solution begins again.

26. IV Medication Secondary line (piggyback)
Prepare medications: 6 rights and 3 checks
Medical history & allergies
Review medication indication

27. Drugs prescribed 1 to 6 times per day, dissolved in small volumes of IV fluid
Usual infusion time : 30 to 60 minutes
Check compatibility of drug to solution

28. When mixing powders for injections, remember:
Check the type of fluid recommended to dissolve the powder
The amount of fluid to add
The strength of the solution made (mg/ml)
Further dilution for infusion
Infusion time

29. Where to find information regarding reconstitution of the powder
The label of the vial
Package insert inside the vial package
Nursing Drug book
Compendium of Pharmaceuticals and Specialties ( CPS)
Parenteral drug manual

30. Medication Calculation
Example:
Order: Drug 0.65 g QID IV
Label directions : Add 2.5 ml water for injection. Provides approx volume of 3 ml (325mg/ml)
Note : the manufacturer gives the strength of the solution
Desire 0.65g
Have: 325 mg/ml
Stock : in every ml

31. 1g = 1000 mg ( therefore answer should be bigger) 1000mg = Three zeros
Desire: 0.65 g
Have: 325 mg/ml
Stock : in every ml
Convert: g to mg
1g = mg ( therefore answer should be bigger)
1000mg = Three zeros
Therefore move decimal point three spaces to the right
0.65 g = 650 mg
Desire X Stock = Amount
Have
650 mg X 1ml = mL
325 mg

32. Calculation of Drip Rate
Example: Order: Flagyl 500mg/100 ml normal saline IV BID (administered over 1 hour) Drop factor: 15 gtt/ml Calculate drip rate: ? gtt/min Answer: 100 ml x ? = 100 ml 60 min 60 min hr 100 ml/hr x 15 gtt/ml = 25 gtt/min 60 minutes

33. When calculating IV rates, if the medication volume exceeds 5 – 10 ml, add this into calculations
Example:
Amount: 100 ml NS plus 8 ml penicillin=108 ml
Duration: Give over 30 minutes
Calculate rate: ? ml/hr
Answer: ml x ? = 216 ml
30 min min hr

34. Let’s Practice (vial containing a powder) p.706
Reconstitution of medication
Adding to secondary bag
Attaching secondary line to primary line
Regulating rate

35. Follow 6 rights and 3 checks Wash hands Gather supplies
Medication, secondary line,10 ml syringe, gauge needle (filtered if indicated), alcohol swabs, dilutant (saline or sterile water), mini bag (medication bag), medication label, MAR

36. Order Ampicillin 500 mg IV, q6h
See vial for directions: to have 500 mg/ml add 5.6 ml dilutant
IV drug manual indicates: add to ml normal saline and infuse over 60 minutes
How many ml of medication will you add to your minibag?
What is the rate (ml/hr)?
What is the drip rate with drop factor of 15 gtt/min?
Answers: 50 ml X ? = 50 ml gtt/min = 50 ml/hr X 15 gtt/min = 12.5 gtt/min
60 min min hr min (12-13)
100 ml X ? = 100 ml gtt/min = 100 ml/hr X 15 gtt/min = 25 gtt/min
60 min min hr min

37. Preparation
Remove cap covering medication and dilutant (6 rights, 3 checks), swab both rubber seals with alcohol swab and allow to dry
Attach needle (or needleless device) to syringe, pull back on plunger drawing the equivalent amount of air (i.e. 5.6 ml) as solution and inject into solution (hold plunger firmly, vial on flat surface)
Invert vial and allow pressure from the vial to fill syringe with solution (5.6 ml), pull back gently if required. Keep tip of needle in fluid. Place vial on flat surface to remove needle
Inject dilutant into medication vial, remove needle and recap (scoop technique)

38. Roll in palms (DO NOT SHAKE)
Wait until medication is clear, swab medication bottle again, and withdrawal desired amount (follow same steps as withdrawing dilutant (inject equal volume of air (i.e.1 ml) as medication to be removed)
Add medication to secondary bag, wipe port with alcohol swab, lay medication bag on flat surface, insert needle and inject. Discard needle (no need to recap)
Mix medication turning gently end to end
Complete medication label (apply to back of medication bag)
Spike bag with secondary IV tubing, ensure clamp is CLOSED

39. Clean port of main line and connect secondary tubing to medication bag, squeeze and fill drip chamber.
Back prime: drop medication bag below level of primary drip chamber, open secondary line roller clamp, prime line, hang medication bag above primary fluid bag (use hook to lower main bag)
Regulate flow by adjusting regulator clamp or using IV pump
Observe for S&S of reaction
Assess IV site frequently

40. Order Ampicillin 500 mg IV, q6h
See vial for directions: 500 mg/ml add 5.6 ml solution
IV drug manual indicates: add to ml normal saline and infuse over 60 minutes
Answers: 50 ml X ? = 50 ml gtt/min = 50 ml/hr X 15 gtt/min = 12.5 gtt/min
60 min min hr min (12-13)
100 ml X ? = 100 ml gtt/min = 100 ml/hr X 15 gtt/min = 25 gtt/min
60 min min hr min

41. Subcutaneous Injection & Insulin
Next Lab
Subcutaneous Injection & Insulin
Chapter 21