Monitoring an IV Site and Infusion

Goal: The patient remains free from complications and demonstrates signs and symptoms of fluid balance.

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.

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

4. Identify the patient.

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

6. 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.

7. 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.

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

9. 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 findings 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.

12. Check for local manifestations (redness, pus, warmth, induration, and pain) that may indicate an infection is present at the site, or systemic manifestations (chills, fever, tachycardia, hypotension) that may accompany local infection at the site. If signs of infection are present, discontinue the IV and notify the primary care provider. Be careful not to disconnect IV tubing when putting on patient’s hospital gown or assisting the patient with movement.

13. Be alert for additional complications of IV therapy.
a. Fluid overload can result in signs of cardiac and/or respiratory failure. Monitor intake and output and vital signs. Assess for edema and auscultate lung sounds. Ask if patient is experiencing any shortness of breath.
b. Check for bleeding at the site.

14. If possible, instruct patient to call for assistance if any discomfort is noted at site, solution container is nearly empty, flow has changed in any way, or if the electronic pump alarm sounds.