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Initiating Maintenance IV Fluids

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Hospitalized patients frequently require the administration of intravenous fluids to maintain hydration and electrolyte balance. This may be due to medical conditions which preclude oral intake, the need to increase intravascular volume following blood loss, or because patients are required to be NPO-meaning to take nothing by mouth-prior to anesthesia or other procedures. IV fluids can be administered by infusion pump, which uses a pump mechanism that delivers the fluid by generating positive pressure, or by gravity flow, which relies on gravitational forces to push the fluid into the bloodstream.

This video will describe how to initiate gravity flow infusions, as well as how to calculate and set the infusion rate.

Upon entering the patient's room, wash your hands with soap and water using vigorous friction for 20 seconds, or cleanse your hands with sanitizer and vigorous friction, if they are not visibly soiled.

At the bedside computer, log into the patient's electronic health record, or EHR, and assess their need for continuous IV fluid administration. This is done by reviewing their medical history, input and output balance, vital signs, and serum laboratory results. Also assess the patient's skin turgor and mucous membranes to evaluate their hydration status. Next, review the patient's Medication Administration Record, or MAR, for the IV fluid order, including the type of fluid and rate of infusion. Confirm that the orders are appropriate for the patient's condition, diagnosis, and fluid and electrolyte balance.

Exit the patient's room and perform hand hygiene again. In the medication preparation area, acquire the appropriate IV fluid bag according to the orders and compete the first safety check, as reviewed in the JoVE video, "5 Rights of Medication Administration." Subsequently, remove IV tubing from the packaging. Before you connect the tubing to the IV fluid bag, hold the IV tubing in your non-dominant hand and slide the roller clamp towards the narrow end with your dominant hand to occlude the tubing so fluid will not leak out when the bag is connected. Then place the tubing on the counter.

Now, hold the IV fluid bag in your non-dominant hand and use your non-dominant index finger and thumb to grasp the part of the IV port that connects to the IV bag. Then, with your dominant hand, remove the pigtail that covers the IV bag port and drop it on the counter. Avoid touching the IV bag port opening, as this would contaminate the fluid. If it is accidentally touched, discard the bag of fluid and obtain a new bag.

Next, pick up the IV tubing with your dominant hand. Hold the spike between the middle finger and the base of the thumb, remove the protective cover with your thumb and index finger, and drop the cover on the counter. Continue to hold the IV bag with your non-dominant hand and use your dominant index finger and thumb to insert the spike of the IV tubing into the IV bag port using a gentle twisting motion. Then invert the IV bag and hold it near eye-level while holding the IV drip chamber between your dominant index finger and thumb. Squeeze the drip chamber until it is one-third to half full of liquid.

The next step is priming the IV tubing. To do this, roll the clamp to the larger end with your dominant thumb and index finger; this will allow the fluid to flow freely into the tubing. Once the fluid has reached the end of the tubing, stop the flow by rolling the clamp to the narrow end. Then complete the second safety check using the 5 "rights" of medication administration and collect all of the supplies to bring to the patient's room.

Upon returning to the patient's room, set the supplies on the counter; perform hand hygiene again; and complete the third and final medication safety check, adhering to the 5 "rights" of medication administration.

After this, hang the IV fluid bag onto one of the hooks at the top of the IV pole. Inspect the tubing for air and prime the tubing again if necessary. Next, assess and flush the peripheral IV and assess insertion site. This technique is described in the JoVE video, "Assessing and Flushing a Peripheral Intravenous Line." Next, remove the paper ties from the IV tubing and wash your hands again.

Now, open an alcohol wipe and, while holding the needleless injection site with your non-dominant hand, use your dominant hand to cleanse the needleless injection site with the wipe using friction and intent-as if you were juicing an orange-for 15 seconds. Continue to hold the injection site while it dries, taking care to avoid contamination.

Now, using your dominant thumb and middle finger, grasp the IV tubing near the connection port and gently toggle the cap back and forth to remove the plastic cap. Take care not to contaminate the end of the tubing. Push gently to insert the tip of the connection port into the center of the needleless injection site and then turn the outer portion of the connection port clockwise. This will attach the connection port to the needleless injection site.

To calculate the IV drip rate, you must know the drop factor for the IV tubing. The drop factor is the number of drops per milliliter of solution delivered by a drip chamber. This factor varies amongst different types of tubing and can be found on the IV tubing package. Using this information, multiply the milliliters per hour by the drop factor for the IV tubing and divide by 60 minutes. Then divide by 4 to get the number of drops per 15 seconds.

To set the drip rate, hold a watch next to the drip chamber of the tubing and gently slide the clamp roller towards the larger end of the clamp. Count the number of drops in the drip chamber for 15 seconds and increase or decrease the flow until the drip rate corresponds to the calculated amount.

Once the drip rate is appropriate, re-assess the PIV site for leaking or swelling and ask the patient if they are experiencing any pain. The patient may report a cool feeling, which is an expected sensation. If there are no problems with the infusion, return to the patient's EHR and document the date, time, and location where the IV fluid was connected and the PIV site assessment. Finally, discard waste in the appropriate receptacles, exit the patient's room, and perform hand hygiene as previously described.

"Delivering maintenance IV fluids is a standard part of patient care and there are several important points to keep in mind. Remember that IV fluids are a medication and the 5 "rights" and 3 checks must be followed to prevent a medication error."

"Also, the IV site and fluid status must be assessed to prevent site complications and fluid overload. In addition, you must not overlook any change in the provider's orders affecting the type of fluid or rate of administration."

You've just watched a JoVE educational video describing how to initiate maintenance IV fluids using gravity tubing. You should understand the steps involved in setting up the apparatus and also how to calculate the drip rate for the desired infusion rate. As always, thanks for watching!

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