Basic Equipment and Supplies for Intravenous Therapy

Upon successful completion of this chapter, the student will be able to:

• Identify and define the equipment needed for initiation of intravenous therapy.

• Identify the types of containers holding intravenous infusion fluids.

• Identify the types of intravenous administration sets and the uses of each type as primary and secondary lines.

• Describe the differences in peripheral or central infusion devices.

• Describe the advantages and disadvantages of needles, over-the-needle catheters, and scalp vein or winged needles and the selection for infusion therapy based on patient needs.

• Discuss the basic types of intravenous solutions and the primary uses for each.

• Describe the types of devices used to regulate flow rates of intravenous infusions.

• Decide the adjunct supplies, such as those for dressings, that are needed for safe infusions for patients.

• Describe the safe handling of the equipment and supplies.

Key Terms

back-check valve

device in the primary tubing that prevents the backflow of secondary infusates into the primary line.

bolus

amount of medication given rapidly intravenously that is used to provide a rapid response to the medication or to give a dose to raise the level of the drug in blood.

cannula

sheath used to infuse fluids into the vein.

catheter

hollow flexible tube that is inserted into a vessel or cavity to instill fluids.

collodial

suspension in which small particles are dispersed through the liquid.

crystalloid

solution in which the substances are dissolved in the fluid; a fluid that has the ability to diffuse through a semipermeable membrane.

drip chamber

elongated, enlarged rigid section located at the top of the tubing; holds fluids for administration between the supply container and the tubing.

drop factor

number of drops needed to deliver 1 mL of fluid.

drop orifice

opening in the top of the drip chamber that determines the size and shape of the drop.

flow rate

speed at which IV fluids are regulated for administration.

hypertonic solution

solution that causes a flow of water out of the cell across its semipermeable membrane into the vascular system.

hypotonic solution

solution that causes the flow of water into the cell across its semipermeable membrane from the vascular system.

infusate

parenteral fluid that is slowly introduced intravenously over a specific period.

infusion pump

apparatus designed to deliver a predetermined amount of IV solution or drug through an IV injection over a certain period of time.

injection port

accesses located along primary administration tubing that are used for the administration of secondary infusates.

isotonic solution

solution in which the body tissues can be bathed without the transfer of fluids across the semipermeable membrane of a cell; IV solution with the same tonicity of body fluids.

IV piggyback (IVPB)

set of short tubing that has a standard drop factor of 10 to 20 drops/mL that is added to the injection port of the primary administration set; secondary line for administering infusates over a short time.

macrodrip

tubing that supplies large drops of fluids, such as 8 to 20 drops/mL.

microdrip

tubing that supplies small drops of fluids, such as 50-60 drops/mL.

needleless systems

blunt-tipped plastic insertion device that is inserted into an injection port for the secondary administration of infusates without the use of a needle; the system opens the port and reseals the port on removal.

over-the-needle catheter

infusion set that uses a needle as a stylet and leaves the catheter found over the needle in place for the infusion.

peripherally inserted central catheter (PICC)

long IV access device made of a soft, flexible material that is inserted peripherally and threaded into the superior vena cava.

scalp vein or butterfly needle

infusion needle that has plastic holders on each side of the needle hub to help hold the needle in place during infusion.

spike

sharply tipped plastic end of the drip chamber that is inserted into the infusate container to allow the flow of the infusate from the storage container into the tubing.

stylet

needle or guide that is found within a catheter to allow penetration of the vein and is then removed, leaving the catheter in place.

through-the-needle catheter

catheter that is 8 to 36 inches long and lies within a plastic or metal encasement for the insertion into a vein for IV therapy; the encasement is removed after insertion and the catheter is left in place.

INTRODUCTION TO BASIC IV EQUIPMENT

Types of equipment needed for the infusion of solutions and medications intravenously is based on the needs of the patient, and the proper selection of the equipment to meet the physician’s order and patient safety is essential. Through the appropriate choice of the equipment and supplies prior to initiation of the infusion, complications are reduced and problems are minimized during the actual intravenous (IV) infusion. The selection is limited to the choice of IV fluids as ordered, and it is also dependent on the correct decision for flow times based on patient conditions. The patient has little to no input into these decisions, although the safety of the patient is paramount in the correct selection. The person performing the infusion must be sure that patient safety is promoted and that the infusion is effectively delivered.

TYPES OF CONTAINERS

Containers for IV infusions are in open systems, in which the air entering the container displaces the fluids for the infusion, or in closed systems, in which atmospheric pressure is the factor for fluid displacement. In either case, the appropriate infusion sets must be used for the containers to function correctly and to minimize the problems that may occur. When the infusion administration equipment does not match the type of fluid container, the infusion will not be as safe and effective and could even be harmful to the patient.

Rigid or Semirigid Open Containers

Open containers are rigid and usually made of glass, but they are seldom used today except when the fluids to be infused are incompatible with the more commonly used plastic bags. Examples of the incompatibilities include nitroglycerin, insulin, and parenteral lipid additives that cling to the plastic bag.

Glass containers are sealed with a thick rubber disk with an area in the disk for perforation using the tubing spike found on the administration set. In this system, air is vented through a filter to allow entrance into the rigid container. This allows fluid to flow by the displacement of the fluids by air. The administration sets may use nonvented sets that have a straw within the bottle. This straw runs the length of the bottle, keeping it above the fluid level to allow air to be pulled in as the fluid is infused. The other type of infusion set for the open containers is a vented set that has a vent at the site of the spike, thus preventing the formation of a vacuum that prevents flow of the fluid.

Glass rigid or plastic semirigid containers provide easy visualization of the fluids in the container, thus allowing the person responsible for the fluids to observe for particles of undissolved medications or other materials that might be floating in the infusate. The disadvantages include the possibility of glass breakage during storage or transport, fragments of rubber from the spiking of the container being introduced into the fluids, and the possible contamination from the venting of the fluids. The rigid/semirigid containers also require more storage space and more space for disposal than plastic bags or closed containers. Finally, if the fluids have the rubber disk covering the rubber stopper for spiking removed such as for adding mixtures, the fluids must be used immediately or the opening recovered with a sterile cover immediately following the addition to prevent possible contamination of the sterile fluids or fluid bag.

Plastic or Closed Containers

Most IV fluids today are in closed containers made of flexible plastic. Closed containers are those that do not require venting; instead, the fluids are dispensed by atmospheric pressure. With this system, the bag collapses as the fluids infiltrate and the chance of contamination is reduced because no air enters through the closed system. But, the collapse of the bag on infusion makes the determination of the amount of fluid left in the container difficult to evaluate. The system is closed to air so the chance of contamination is reduced and the safety for the patient is increased. In these containers, the fluids are easily transported and the chance for breakage is reduced (Figure 4-1). The storage requirements are reduced because the containers are more flexible and weigh less, but the need to inspect the container for possible contamination from tears or leaks is increased. Because of the chance of leaks and puncturing the container, writing directly on the container should not occur.

Figure 4-1 Flexible plastic fluid container in closed system. (From Perry AG, Potter PA: *Clinical nursing skills & techniques*, ed 6, St Louis, 2006, Mosby.)

One of the major disadvantages of the plastic container is the interaction with medications that are added to the fluids. When this interaction with medications has the potential to occur, the use of bags that do not contain DEHP (di-2-ethylhexyl-phthalate, a plasticizer used to make plastic pliable) is indicated. These containers are called semirigid containers–plastic containers that appear to be a bottle. The same needs for venting tubing as found with glass containers are necessary with the plastic semirigid bottles.

With all types of fluid containers, quality control would expect that the person responsible for the infusion should check for clarity of the solution, ensuring that no precipitates are present and that the fluid has not changed color. As with all medications, the expiration date should be checked and any solution out of date should be discarded. If the fluid appears to be contaminated, the container should be so labeled and returned to the proper source.

If the plastic container has been refrigerated, bubbles may be present. In this case, the fluids should be agitated to move the bubbles to the bottom of the bag so these will escape when the bag is spiked and the fluids are primed. Remember that quality control with IV fluids is an important step in patient safety.

TYPES OF IV ADMINISTRATION SETS

Administration sets include the tubing, drip chamber, and other accessories to the tubing that are needed to move the fluid from the container to the patient’s vein. These sets are supplied in different forms based on the use for the particular patient. The sets vary in the length of the tubing, the size of the drip chamber, and the size of the drops that will be administered per milliliter to the patient. The packaged sets usually contain the cannula and needle needed for injection as well as the tubing, whereas other sets allow for the selection of the needle/cannula as separate equipment. In either case, the needle/cannula should be carefully chosen by the responsible person using the needs of the patient, the patient’s condition, and the intended use for determining of selection. The infusion sets are labeled individually with the information showing the name; drops per milliliter; the use, such as primary set, secondary set, metered volume set, or other specialty sets; and the gauge/length of the needle/cannula as appropriate. The most frequently used are single line sets that include the primary line and the ability to add secondary lines such as IV piggyback (IVPB). In some cases Y-sets are used, as are some specialized sets that will not be included in this basic IV therapy text.

Basic Components Found in Administration Sets

The basic components of administration sets include a spike or piercing pin that is sharply tipped to allow for insertion into the solution container (Figure 4-2). This may be a vented spike as needed for open fluid containers or nonvented sets as needed for closed containers, as described earlier. The spike must remain sterile, so it is manufactured with a removable cover to protect its sterility. The spike has a flange so the fingers do not contaminate the actual spike during the piercing.

Figure 4-2 Primary administration set. (From Hankins et al: *Infusion therapy in clinical practice*, ed 2, Philadelphia, 2001, Saunders.)

The spike is an extension of the drop orifice and drip chamber. The drop orifice is found at the top of the drip chamber and determines the size and shape of the drop. These drops are calibrated for the infusion rate in drops per milliliter. This is called the drop factor used for calculations of flow rate. Primary infusion sets are available in macrodrip form, which allows 8 to 20 drops/mL to enter the drip chamber, and microdrip, also called the pediatric chamber, which allows 50 to 60 drops/mL to enter. The microdrip or minidrip is used when only small amounts of fluid are to be infused (Figure 4-3).

Figure 4-3 A, macrodrip chamber. B, microdrip chamber. (From Clayton BD, Stock YN: *Basic pharmacology for nurses*, ed 13, St Louis, 2004, Mosby.)

Tubing connects to the drip chamber and may vary in length depending on whether the set is for primary lines or secondary lines. Primary line tubing ranges from 60 to 110 inches in length, whereas secondary administration sets are between 18 to 70 inches long, with the most frequently used being 30 to 36 inches. The tube varies with flexibility and with internal diameter or lumen. Standard tubing is relatively flexible and is the most frequently used. Macro tubing, used for rapid flow rates, has a larger lumen and is usually less flexible than standard tubing. Microtubing or microbore tubing is smaller channeled for use with low flow rates, as found with ambulatory infusions of analgesics.

Clamps, injection ports, and back-check valves may be found on the tubing, depending on the manufacturer (Figure 4-4). Clamps are used to compress the walls of the tubing to adjust flow rates by changing the size of the lumen of the tubing. The clamp may be on a roller, screw, or slide device, with the slide clamp being the least reliable method of compression. Roller and screw clamps may be adjusted in small increments to regulate the amount of fluid being infused. Injection ports are an access into the tubing and are used to add piggyback fluids to the primary set. These ports are usually located along the tubing at various sites, and small-lumened needles or needleless systems should be used for the secondary infusion to ensure the port will reseal following the secondary infusion. The backcheck valve is used to allow the primary infusion to continue when the secondary or piggyback infusion has completed. It also prevents the secondary infusion from entering the primary solution.

Figure 4-4 Control clamps. A, Roller clamp. B, Slide clamp. (A from Perry AG, Potter PA: *Clinical nursing skills & techniques*, ed 6, St Louis, 2006, Mosby; B from Otto SE: *Pocket guide to infusion therapy*, ed 5, St Louis, 2005, Mosby.)

The hub for the needle is the final basic component on the tubing. In most cases, the hub or adapter for the needle will be either a Luer-Lock connector or a slip connection. The slip connection slides onto an IV catheter using some force to ensure tightness of the connection and prevent leaks. The Luer-Lock connection requires less force and screws onto the needle or catheter to form a reliable connection against leaks. Luer-Lock connectors are the safest to prevent the accidental disconnection of the needle or catheter from the tubing.

Finally filters may be manufactured in the tubing or may be added to the tubing as needed (Figure 4-5). These filters are used to remove foreign particles such as bacteria, air, particulates, and the like from the infusion prior to the fluid entering the body.

Figure 4-5 Posidyne ELD IV Filter Set. (From Otto SE: *Pocket guide to infusion therapy,* ed 5, St Louis, 2005, Mosby.)

Primary Infusion Sets

Primary infusion sets (Figure 4-2, p. 49) are also referred to as standard sets. These are selected by the correct infusion flow rate and the intended use. The most often used primary infusion set is the nonvented or universal set that is used for plastic bags of fluids. The primary line may also contain Y-connectors that allow secondary lines to be attached to the primary set. The drop size should be correctly selected for the time of infusion and the condition of the patient. The length of the tubing for the primary set should also be chosen by the size, condition, and ambulatory needs of the patient. The tubing should be long enough to allow the patient some activity while providing for the proper placement and securing of the needed equipment. Therefore, most tubing for primary administration sets is between 60 and 110 inches, usually about 80 inches. Again, remember that the manufacturer’s packaging label shows the drop size and the tubing length, and it states whether the tubing is vented and other possible additions to the tubing. In the case where needles or catheters are provided with the tubing, the gauge and length of the needle or catheter will also be shown on the label.