23.3 Intravenous Therapy Assessment
Open Resources for Nursing (Open RN)
To prepare for intravenous therapy administration, the nurse should collect important subjective and objective assessment information from the patient.
When performing the subjective assessment, the nurse should begin by focusing on data collection that may signify a potential complication if a patient receives IV infusion therapy. The nurse should begin by identifying if the patient has medication allergies or a latex allergy. The patient’s history should also be considered with special attention given to those with known congestive heart failure (CHF) or chronic kidney disease (CKD) because they are more susceptible to developing fluid overload. Additionally, the patient should be asked if they have any pain or discomfort in their IV access site now or during the infusion of medications or fluids.
Life Span Considerations
Safety measures for a child with an IV infusion include assessing the IV site every hour for patency. Infused volumes and signs of fluid overload should be carefully assessed and documented frequently per agency policy. The IV may be wrapped in gauze or an arm board may be used to deter the child from tampering with the IV site or tubing. Additionally, the tubing should be well-secured, and the dressing should remain free from moisture so the IV site is not compromised. Be aware that mobile children will require guidance to ensure that the tubing is not obstructed if they sit or lie on the tubing accidentally.
Older adults with an IV infusion should be frequently monitored for the development of fluid volume overload. Signs of fluid volume overload include elevated blood pressure and respiratory rate, decreased oxygen saturation, peripheral edema, fine crackles in the posterior lower lobes of the lungs, or signs of worsening heart failure. Additionally, older adults have delicate venous walls that may not withstand rapid infusion rates. It is important to monitor the IV site patency carefully when infusing large amounts of fluids at faster rates and appropriately modify the infusion rate.
The patient’s IV site should be checked for patency before initiating IV therapy and throughout the course of treatment. The IV site should be free of redness, swelling, coolness, or warmth to the touch. The IV infusion should flow freely. The nurse should also be aware of different types of intravenous access that may be used for an infusion. For example, a peripherally inserted central catheter (PICC) looks similar to intravenous access, but requires different assessment and monitoring as a central line. Please review Table 23.3 to consider the expected and unexpected assessment findings that may occur with IV therapy.
Table 23.3 Expected Versus Unexpected Findings With IV Therapy
|Assessment||Expected Findings||Unexpected Findings (document and notify provider if a new finding*)|
|Inspection||IV site free of redness, swelling, tenderness, coolness, or warmth to touch||IV site with redness, swelling, tenderness, coolness, or warmth to the touch|
|Patency||IV fluid flows freely||IV fluid does not flow; patient reports pain during flush|
|*CRITICAL CONDITIONS to report immediately||Notify the HCP if there is redness, warmth, or blisters at the site|