Administering Intravenous Fluid Therapy
Dressing the Infusion Site
Select a Skill:
- » Preparing an Infusion Site
- » Performing Venipuncture
- » Dressing the Infusion Site
- » Troubleshooting Intravenous Infusions
- » Discontinuing Intravenous Therapy
Take the Review Test:
Safety
- Note the date of the last IV administration set and dressing change.
- Maintain sterility of a patent IV system using Infusion Nursing Society (INS) standards:
- Palpate the insertion site for tenderness every shift (or according to agency policy) through the intact dressing.
- Directly inspect a catheter site if the patient develops tenderness at the site, fever without an obvious source, or symptoms of local or bloodstream infection.
- Perform hand hygiene before and after palpating, inserting, replacing, or dressing any intravascular device.
- Use a catheter stabilization device that allows inspection of the access site.
- Gauze dressings that cover a catheter site must be changed every 48 hours.
- Intravenous tubing administration sets can remain sterile for 96 hours.
- Replace the dressing over a peripheral venous catheter when replacing the catheter or when the dressing becomes damp, loose, or soiled.
- Replace short peripheral venous catheters, and rotate sites based on clinical assessment.
Equipment
(Roll cursor over items to see labels)
2x2 gauze pads
Clean gloves
Tape
Clear, occlusive dressing
Permanent Marker
Stabiliztion device (optional)
PrintableDelegation
The skill of caring for an intravenous site may not be delegated to nursing assistive personnel (NAP). Delegation to licensed practical nurses (LPNs) varies by state Nurse Practice Act. Be sure to inform NAP of the following:
- Instruct NAP to inform you if the patient complains of any IV-related complications, such as pain, redness, swelling, or bleeding.
- Instruct NAP to inform you if the patient’s IV dressing becomes wet.
- Ask NAP to report to you if the level of fluid in the IV bag is low or the electronic infusion device (EID) alarm sounds.
Preparation
- Review the health care provider’s orders, assess the patient, and select and prepare the IV insertion site. (For details, see the Video Skill “Preparing the Infusion Site.”)
- Perform the venipuncture, and begin to infuse the IV solution as ordered. (For details, see the Video Skill “Performing Venipuncture and Initiating an Infusion.”)
- Select dressing material appropriate to patient needs.
- Assess laboratory data.
- Assess the patient’s history of allergies, especially to iodine, adhesive, or latex.
Follow-up
- Routine site care and dressing changes of transparent dressings are not performed on short peripheral catheters unless the dressing is soiled or no longer intact.
- Palpate the insertion site for tenderness every shift (or according to agency policy) through the intact dressing.
- Change gauze dressings that cover a catheter site every 48 hours or as needed.
- Intravenous tubing administration sets can remain sterile for 96 hours.
- Replace the dressing over peripheral venous catheters when replacing the catheter or when the dressing becomes damp, loose, or soiled.
Documentation
Report to the health care provider any signs and symptoms of IV-related complications.
- Record time of dressing change, reason for change, type of dressing material used, patency of system and description of venipuncture site.
Review Questions
1. Why is it important to label the gauze dressing covering the site of an intravenous access device with the date, time, and nurse’s initials?
Reminds the nurse to document the insertion of the device - Proves that the access site was assessed
Informs the nurse and other staff when the next dressing change is due- Reminds the nurse when to change the infusion tubing
INCORRECT. The dressing is labeled in order to inform the nurse when the next dressing change is due.
INCORRECT. Labeling the dressing does not indicate that the access site was assessed.
CORRECT. The gauze dressing over an intravenous access site must be changed every 48 hours. This is the reason for labeling the dressing with the date, time, and nurse’s initials.
INCORRECT. Intravenous infusion tubing has its own labeling.
2. Which action will the nurse take to minimize a patient’s risk for injury when applying a dressing to an infusion site?
- Use aseptic technique throughout the process.
- Apply a skin protectant to the skin before the intervention.
- Apply a transparent dressing that allows for visualization of the site.
- Explain the process to the patient before implementation.
CORRECT. Following aseptic technique throughout the dressing application will minimize the patient’s risk for injury related to infection.
INCORRECT. Applying a skin protectant will not minimize the patient’s risk for injury.
INCORRECT. Being able to visualize the infusion site will not minimize the patient’s risk for injury.
INCORRECT. Patient teaching before the procedure will not minimize the patient’s risk for injury.
3. The nursing assistive personnel (NAP) reports to the nurse that a patient’s intravenous access device dressing is wet. What would the nurse do first?
- Assess the site.
- Instruct the NAP on how to change the dressing.
- Remove the device, and insert a new one.
- Reinforce the dressing with more gauze.
CORRECT. The nurse would first assess the site to check for infiltration and to see if the IV has become dislodged.
INCORRECT. The nurse may not delegate to NAP the changing of dressing on an intravenous device.
INCORRECT. The device may not need to be removed and reinserted.
INCORRECT. Reinforcing the dressing is not sufficient.
4. When applying a dressing to an infusion site on a patient’s left forearm, what will the nurse do to ensure proper maintenance of the tubing?
- Apply a transparent dressing to the insertion site.
- Use a catheter stabilizing device when applying the dressing.
- Apply the dressing proximal to the tubing and catheter hub connector.
- Secure the tubing to the patient’s dressing with 1-inch tape.
INCORRECT. Use of a transparent dressing does not address maintenance of the tubing.
INCORRECT. Use of a catheter stabilizing device does not address maintenance of the tubing.
CORRECT. Applying the dressing proximal to the tubing and catheter hub connector will allow the tubing to be disconnected and changed when indicated.
INCORRECT. Securing the tubing to the patient’s dressing with 1-inch tape is not recommended because it would hinder the view of the insertion site.
5. Which action will the nurse take to minimize a patient’s risk for injury when applying a gauze dressing to an infusion site?
- Avoid encircling the arm with tape
- Not secure the tubing and catheter hub with tape
- Secure the tubing in two different locations on the arm
- Label the dressing with the date and time of application
CORRECT. The nurse will avoid encircling the arm with tape, because doing so can impede circulation in the arm.
INCORRECT. Failing to secure the tubing and catheter could increase the patient’s risk for injury.
INCORRECT. Securing the tubing in two different locations on the arm will not minimize the patient’s risk for injury.
INCORRECT. Labeling the dressing with the date and time of application will not minimize the patient’s risk for injury.
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