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

325

Skill Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition

Name Date

Unit Position

Instructor/Evaluator: Position

SKILL 15-3

Monitoring an IV Site and Infusion

Goal:The patient remains free from complications and

demonstrates signs and symptoms of fluid balance. Comments

1. Verify IV solution order on the MAR/CMAR with the
   medical order. Clarify any inconsistencies. Check the
   patient’s chart for allergies. Check for color, leaking, and
   expiration date. Know purpose of the IV administration
   and medications, if ordered.
   2.Monitor IV infusion every hour or per agency policy.
   More frequent checks may be necessary if medication is
   being infused.


2. Perform hand hygiene and put on PPE, if indicated.


3. Identify the patient.


4. Close curtains around bed and close the door to the room,
   if possible. Explain what you are going to do to the patient.


5. If an electronic infusion device is being used, check settings,
   alarm, and indicator lights. Check set infusion rate. Note
   position of fluid in IV container in relation to time tape.
   Teach patient about the alarm features on the electronic
   infusion device.


6. If IV is infusing via gravity, check the drip chamber and
   time the drops. Refer to Box 15-1 to review calculation of
   IV flow rates for gravity infusion.


7. Check tubing for anything that might interfere with flow.
   Be sure clamps are in the open position.


8. Observe dressing for leakage of IV solution.
   10.Inspect the site for swelling, leakage at the site, coolness,
   or pallor, which may indicate infiltration. Ask if patient
   is experiencing any pain or discomfort. If any of these
   symptoms are present, the IV will need to be removed and
   restarted at another site. Check facility policy for treating
   infiltration.See Fundamentals Review 15-3 and Box 15-2.
   11.Inspect site for redness, swelling, and heat. Palpate for
   induration. Ask if patient is experiencing pain. These find-
   ings may indicate phlebitis. Notify primary care provider
   if phlebitis is suspected. IV will need to be discontinued
   and restarted at another site. Check facility policy for
   treatment of phlebitis.Refer to Fundamentals Review 15-3
   and Box 15-3.

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

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