IV Fluids

1. IV Infusion: Types, Calculation
and Nursing Consideration
Presented by
Bishuka Adhikari

2. Objectives
At the end of seminar, participants will be able to:
- define intravenous (IV) infusion.
- enlist purposes of IV infusion.
- describe solutions used for IV infusion.
- describe the equipments used in IV infusion.
- calculate the flow rate for a infusion.
- describe the factors affecting flow rate.
- enlist nursing considerations in IV therapy.
- describe complications that may occur following infusion.

3. Definition
• The administration of medication or solution into the patient’s vein.
(typically using only the pressure supplied by gravity)
• Commonly referred to as drips.

4. Purposes
• To supply fluid and electrolytes.
• To provide fluid and electrolyte replacement.
• To provide food in the form of glucose, amino acids and vitamins.
• To inject drugs into the body through the vein in emergency
conditions for quick action.

6. Types of solutions for iv infusion
A. Colloid solutions
 Contain large molecules that don’t pass the cell membranes.
 When infused, they remain in the intravascular compartment and
expand the intravascular volume and they draw fluid from
extravascular spaces via their higher osmotic pressure.
 always hypertonic.
Eg- Albumin, Haemacele, Dextran

7. Types of solutions for iv infusion
B. Crystalloid solutions
Contain small molecules that flow easily across the cell membranes
allowing for transfer from the blood stream into the cells and body
tissues.
Increases fluid volume in both interstitial and intravascular spaces.
May be isotonic, hypotonic or hypertonic.
Eg- NS, RL, 5% Dextrose

8. Replacement of blood loss
• Crystalloid/colloid solutions improves perfusion but not O2 carrying
capacity of blood.
• 3 ml of crystalloid infusion replaces 1 ml of blood lost for volume
replacement.
• Colloid infusion= Blood loss (1:1 ratio) only in terms of replacing
volume.

9. Tonicity
The measurement of osmotic pressure of the solution.
On the basis of tonicity:
1. Isotonic fluids
2. Hypotonic solutions
3. Hypertonic solutions

11. 1. Isotonic fluids
It has same concentration of solutes as plasma, therefore remains in
the vascular compartment, expanding vascular volume.
Examples:
-0.9% sodium chloride ( Normal saline)
-Ringer’s lactate solution (RL)
-5% dextrose in water (D5W)

12. 0.9% sodium chloride ( Normal saline)
• Composition: Na+ = 154mEq/L, Cl¯=154mEq/L
• Osmolarity: 308 mOsm /L
• Indication:
- Intravascular volume expander.
- only solution that may be administered with blood products.
- Hypercalcemia.

13. 0.9% sodium chloride ( Normal saline)
• 1 liter of normal saline 0.9% meets the usual daily requirement of
these electrolytes in an adult.
• Nursing consideration
- Administer cautiously, because it may cause intravascular volume
overload and pulmonary edema in clients with heart failure and renal
failure.

14. Ringer’s lactate solution (RL)
• contains multiple electrolytes in roughly the same concentration as found in plasma
(solution is lacking in Mg++).
• Also called Hartmann’s solution or physiological solution.
• provides 9 calories/L.
• Composition per liters:
- Na+ = 130 mEq/L
- K+ = 4 mEq/L
- Ca++ = 3mEq/L
- Cl¯=109 mEq/L
- Lactate = 28 mEq/L

15. Ringer’s lactate solution (RL)
• Osmolarity: 274 mOsm/L
• Indications:
- Burns
- Gastrointestinal fluid losses, especially below the pylorus (diarrhea,
bile juice)
- Dehydration
- Blood loss
- Hypovolemia secondary to third space loss

16. Ringer’s lactate solution (RL)
• Nursing considerations
- similar to serum expect it does not contain magnesium.
- contraindicated in renal failure and liver disease.
- contains potassium and can cause hyperkalemia in renal failure.
- should not be given with pH> 7.5, as bicarbonate is formed causing
alkalosis.

17. 5% dextrose in water (D5W)
• An isotonic solution that supplies 170 calories/L (1 gm dextrose
gives 3.4 kilocalories) and free water to aid in renal excretion of
solutes.
• Composition per liter: 50 gm of dextrose (no electrolytes)
• Osmolarity : 278 mOsm/L
• Indications
- Replacement of water losses in dehydration
- Hypernatremia
- Diluents for medication administration

18. 5% dextrose in water (D5W)
• Nursing consideration
- Converts to hypotonic solution as dextrose is metabolized by body.
It can cause water intoxication.
- Contraindicated in head injury because it may cause increased
intracranial pressure.
- Should not be used for fluid resuscitation as it can cause
hyperglycemia.

19. 5% dextrose in water (D5W)
• Nursing consideration
- Should not be used in excessive volumes in the early postoperative
period.
- Should be used with caution in patients with renal or cardiac disease
because of risk of fluid overload.

20. 2. Hypotonic solutions
• Hypotonic fluids have tonicity less than that of body fluids and they
are drawn from the intravascular space into intracellular and
interstitial spaces.
• A solution with lower osmolality than blood serum.
• Examples:
- 0.45% sodium chloride ( Half strength saline).
• Composition per liter: Na+ = 77 mEq/L, Cl¯=77 mEq/L
• Osmolarity: 154mOsm /L

21. 2. Hypotonic solutions
• Indications
- Hypertonic dehydration
- Replacement of gastric fluid loss due to NG suctioning or vomiting.
- Diabetic ketoacidosis after NS infusion if blood glucose is still
>250mg/dl.

22. 2. Hypotonic solutions
• Nursing considerations:
- May cause increase in intracranial pressure if administered too
quickly.
- Do not administer to client at risk for third space fluid shift.

23. 3. Hypertonic solutions
• Hypertonic solutions have a tonicity greater than that of body fluids
and draw fluid into the intravascular space.
• It has higher concentration of solutes than plasma, therefore causing
fluid shift from the cells into the vascular compartment, expanding
vascular volume.

24. 3. Hypertonic solutions
• Examples:
- 3% NaCl (hypertonic saline)
- 10% dextrose
- DNS (D5 0.9% NaCl)
- Haemacele
- Dextran 40 in NS or 5% D5W

25. 3% NaCl (hypertonic saline)
• Composition per liter: Na+ = 513mEq/L, Cl¯=513mEq/L
• Osmolarity: 1026 mOsm /L
• Indications:
- Used only in critical situations to treat hyponatremia
- Assists in removing intracellular fluid excess.

26. 3% NaCl (hypertonic saline)
• Nursing considerations:
- Must be administered slowly and cautiously, as it can cause
intravascular volume overload and pulmonary edema.
- Does not supply calories.

27. 10% Dextrose
• Composition per liter: 100 gm dextrose
• Indications:
- Free water replacement
- To provide calories
- Stand by solution for clients receiving TPN

28. 10% Dextrose
• Nursing considerations:
- Monitor for hyperglycemia
- May dilute plasma electrolytes and lead to imbalances
- Monitor for water excess
- May stimulate overproduction of insulin

29. DNS (D5 0.9% NaCl)
• Composition per liter: Na+ = 154mEq/L, Cl¯=154mEq/L
• Dextrose: 50 gm/L
• Indications:
- Hypotonic dehydration
- SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion)
- Addisonian crisis
• Nursing considerations
- Administer cautiously in clients with heart failure and renal failure.

30. Haemacele
• Composition per 100 ml:
- Gelatin = 3.5 gm
- Na+= 14.5mmol
- K+= 0.51mmol
- Ca++= 0.62mmol
- Cl¯=14.5mmol
- Water for injection= 100 ml
- Traces of PO4¯ and SO4¯.

31. Haemacele
• Indications
- Plasma expander
- Shock (Renal)
- Large loss of blood
- Volume losses during and after surgery

32. Haemacele
• Nursing considerations
- Infusion of haemacele leads to hemodilution and thus lowers viscosity of
the blood.
- Excretion completes in 48 hours after the end of infusion. No retention
occurs, since the haemacele molecule can be degraded by endogenous
proteases.
- Infuse only clear solutions.
- Citrated blood (preserved) should not be mixed with haemacele.
- If side effects occur, the infusion must be discontinued at once.
- The rate of infusion is controlled by monitoring the blood pressure.

33. Equipments used in IV infusion

34. Equipments used in IV infusion

35. Equipments used in IV infusion
2. Drip chamber
 a device used to allow gas (such as air) to rise out from a
fluid so that it is not passed downstream.
 commonly employed in delivery systems of IV therapy and
act to prevent air embolism.
 can be classified into macro-drip(about 10 to 20 gtts/ml) and
micro-drip (about 60 gtts/ml) based on their drop factors.

36. Equipments used in IV infusion
a. Macrodrip
 allows large volumes of fluid to flow from a bag into a collecting cha
mber and then into a patient, who requires rapid fluid resuscitation.
delivers 10, 15, or 20 drops per milliliter of a solution. Drop
factor of tubing is 20 gtts = 1 mL (usually)
 not usually used to deliver a small amount
of IV solution because the interval between drips is so long that
a clot may form at the tip of the IVcatheter.

37. Equipments used in IV infusion
Microdrip
 delivers relatively small measured amounts of IV solutions at
specific flow rates
 used for children and infants, or
 to infuse sensitive medications where precision in the flow
rate is essential.
 Microdrip tubing (sometimes called minidrip) comes in only
one size: 60 gtt/mL.

38. Equipments used in IV infusion
MICRODRIP (60 GTTS/ML) MACRODRIP (20 GTTS/ML)

39. Equipments used in IV infusion
3. Infusion pump
 infuses fluids, medication or
nutrients into a patient's circulatory
system.
 can administer fluids in ways that
would be impractically expensive or
unreliable if performed manually by
nursing staff.

40. Equipments used in IV infusion
4.Syringe pump
A syringe driver or syringe pump
is a small infusion pump (some
include infuse and withdraw
capability), used to gradually
administer small amounts of fluid
(with or without medication) to a
patient.

41. Equipments used in IV infusion
INFUSION PUMP
•draws fluid from a standard bag of
intravenous fluid and controls the rate
of flow
•provides accurate and continuous
therapy.
•can use any size bag of intravenous
fluid.
• Some pumps are able to control a
single intravenous line, whereas, other
infusion pumps have 3 pumps built
into one device..
SYRINGE PUMP
• Instead of drawing fluid from an
infusion bag, intravenous medications
are drawn into a syringe and installed
into the device.
• contain a maximum volume of 50 ml
•used to administer medications that
have very small hourly volumes (for
example, usually less than 5 ml/hr).

42. Equipments used in IV infusion
5. Pressure bags
This is an inflatable cuff placed
around the fluid bag to force the
fluid into the patient.
can be used if the patient requires
a high flow rate and the IV access
device is of a large enough
diameter to accommodate it.

43. Calculation of IV Infusion rate
• Drops/Minute = Total infusion volume x drop factor
Total time of infusion in minutes
• Drop factor varies with equipment and is usually printed on
administration set packaging.
• In macro-sets it varies from 10-20 (16 drops/ml).
• Micro-drip sets are always 60 drops/ml.

44. Factors affecting flow
• Flow is directly proportional to the height of the liquid column.
Raising the height of the infusion container may improve a sluggish
flow.
• Flow is directly proportional to the diameter of the tubing. The
clamp on IV tubing regulates the flow by changing the tubing
diameter. In addition, the flow is faster through large gauge rather
than small gauge cannulas.

45. Factors affecting flow
• Flow is inversely proportional to the length of tubing. Adding
extension tubing to an IV line decreases the flow.
• Flow is inversely proportional to the viscosity of fluid. Viscous IV
fluids, such as blood, require a large cannula than do saline solutions

46. Factors affecting flow
• Because so many factors influence an IV set to gravity flow, a
solution does not necessarily continue to run at the speed originally
set.
• The flow rate is calculated when the solution is originally started and
then monitored at least hourly

47. Nursing considerations in IV therapy
• Explain to the patient about the purpose of starting the IV infusion
therapy.
• Maintain hand hygiene.
• Collect the equipments required in the bedside.
• Perform IV cannulation following the standard protocol.
• Always use DEHP free tubings.
• Maintain aseptic technique throughout the circuit connection.
• Connect the prepared IV tubing and do not let air entrance by
flushing the tube first.

48. Nursing considerations in IV therapy
• Assess for prescribed rate, calculate the flow rate, use appropriate
IV infusion equipments as per requirement.
• Label the administration set with any added medication, date and
time. Iv stand height to be maintained within 18-24 inches.
• Instruct client to notify of any of the following conditions:
- Flow rate changes or solution stops dripping.
- Solution container is nearly empty.
- There is blood in IV tubing or at insertion site.
- There is discomfort or swelling at insertion site.

49. Nursing considerations in IV therapy
• Site inspection
• Monitor the flow rate timely.
• Inspect the IV cannulation site for infection.
• Flush the cannula with 0.9% NS every 8 hours.

50. Nursing considerations in IV therapy
• Cannula access and replacement
• Use aseptic/non-touch technique.
• Firmly wipe port or hub using friction with 2% CHX/ 70%
isopropylalcohol for 30 secs and allow drying prior to access.

51. Nursing considerations in IV therapy
• Site care and maintainance
Set change :
 IV: every 72 hours. Prior if clots formed.
Parenteral nutrition : every 24 hours.
Blood and blood product : discarded after use.
Piercing of the bottle to escape air from collapsed infusion bottle is a
wrong practice.

52. Nursing considerations in IV therapy
• At least every 8 hours, document solution, amount, infusion device,
rate, site, location and condition of site and dressing.
• Certain IV additives should be avoided in specific disease state.

53. Nursing considerations in IV therapy
• Clients with diabetes mellitus should not receive dextrose.
• Clients with heart failure or otherwise at risk for excess fluid volume
should not receive sodium in IV fluids; if sodium containing
solutions are necessary, they should be infused cautiously and with
use of an IV pump.
• Clients with liver disease should not receive RL because of possible
lack of ability to convert lactate to bicarbonate.
• Clients with renal failure should not receive potassium additives in
IV solutions because they cannot excrete it.

54. Complications of IV therapy
1. Infections
• Characterized by fever, chills, erythema, elevated WBC and possibly
septic shock
• Nursing actions:
- Use strict septic technique.
- Change IV tubing and dressing.
- Monitor site for 48 hours, the catheter tip may be sent to lab for
cultures if sepsis is suspected.

55. Complications of IV therapy
2. Air embolism
• Characterized by respiratory distress, chest pain, dyspnea,
hypotension, weak and rapid pulse.
• Nursing actions:
- Clamp the catheter.
- Position the client in left Trendelenburg’s position.
- Administer Oxygen and call physician.

56. Complications of IV therapy
3. Hypersensitivity reactions
• Characterized by flushing, itching and urticaria.
• Nursing actions:
- Check client for allergies prior to administering medications.
- Stop the infusion.
- Notify the physician.
- Monitor vital signs.

57. Complications of IV therapy
4. Circulatory overload
• Characterized by cough, dyspnea, crackles, distended neck veins,
tachycardia, hypertension, S3 heart sounds.
• Nursing actions:
- Monitor the client’s IV infusion rates at least hourly.
- Monitor the client’s vital signs, intake, output, breath and heart
sounds.

58. Complications of IV therapy
4. Circulatory overload
- For fluid volume overload:
Slow or stop the infusion rate per order.
Place the client in high fowler’s position.
Administer oxygen and diuretics per order.
Notify the physician.

59. Complications of IV therapy
5. Infiltration
• Characterized by localized swelling, coolness, pallor and discomfort
at the IV site.
• Nursing actions
- Discontinue infusion and remove needle.
- Apply warm compress to encourage absorption.
- Restart IV at another site.

60. Complications of IV therapy
6. Phlebitis
• Characterized by warmth, swelling, red streak at vein site, pain
along the course of vein.
• Nursing actions:
- Discontinue infusion and remove the venous access device.
- Apply warm compress.
- Restart IV at another site.
- Dilute irritating medications and apply over prescribed amount of
time.

61. References
Nursing procedure manual, Hospital Nursing service, College of Nursing, BPKIHS, Dharan, 1st edition, June 2011,
Page no. 49-52.
Carroll, Conn’s current therapy, Physical and chemical injuries, W.B Saunders Company, 1st edition, 1986, Page
no 929.
Sandra, Clinical Nursing skills, Intravenous therapy, 4th edition, 1996, page no 815, 822, 823.
Roshan, J. Rijuta, J and J Health Science, Body fluid, 4th edition, 2016, page no 9-15
https://en.wikipedia.org/wiki/Intravenous_therapy cited on 5th dec 2018
https://medical-dictionary.thefreedictionary.com/microdrip cited on 5th dec 2018
https://www.lhsc.on.ca/critical-care-trauma-centre/critical-care-trauma-centre-283 cited on 5th dec 2018
https://www.rcn.org.uk/clinical-topics/infection-prevention-and-control/standards-for-infusion-therapy cited on
5th dec 2018

62. Thank you
Rub the hub
before use.