Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

SKILL 15-1

Initiating a Peripheral Venous

Access IV Infusion (Continued)

Comments

30. Using an antimicrobial swab, cleanse the access cap on the
    extension tubing. Remove the end cap from the administra-
    tion set. Insert the end of the administration set into the
    end cap. Loop the administration set tubing near the site
    of entry, and anchor with tape (nonallergenic) close to the
    site. Remove gloves.


31. Open the clamp on the administration set. Set the flow rate
    and begin the fluid infusion. Alternately, start the flow of
    solution by releasing the clamp on the tubing and counting
    the drops. Adjust until the correct drop rate is achieved.
    Assess the flow of the solution and function of the infusion
    device. Inspect the insertion site for signs of infiltration.


32. Apply an IV securement/stabilization device if not already
    in place as part of dressing, as indicated, based on facility
    policy. Explain to patient the purpose of the device and
    the importance of safeguarding the site when using the
    extremity.


33. Remove equipment and return the patient to a position of
    comfort. Lower bed, if not in lowest position.


34. Remove additional PPE, if used. Perform hand hygiene.


35. Return to check flow rate and observe IV site for infiltration
    30 minutes after starting infusion, and at least hourly there-
    after. Ask the patient if he or she is experiencing any pain or
    discomfort related to the IV infusion.

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