Administering Intravenous Fluid Therapy
Discontinuing Intravenous Therapy
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- » Preparing an Infusion Site
- » Performing Venipuncture
- » Dressing the Infusion Site
- » Troubleshooting Intravenous Infusions
- » Discontinuing Intravenous Therapy
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Safety
- Follow infection prevention guidelines to minimize the chance of the patient’s acquiring an infection.
- Use caution to avoid breaking off the catheter during removal, since a damaged catheter increases the risk for embolus formation.
- Never use scissors to remove the tape or dressing because you may accidentally cut the catheter.
- To avoid trauma and possible hematoma formation, do not raise or lift the catheter before it has been completely removed from the vein.
Equipment
(Roll cursor over items to see labels)
Antiseptic swabs
2x2 inch gauze pads
Tape
Clean gloves
PrintableDelegation
The skill of discontinuing a short peripheral intravenous line 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 report to you any bleeding at the site after the catheter has been removed.
- Instruct NAP to report to you any complaints of pain by the patient or observations of redness at the site.
Preparation
- Observe the existing IV site for signs and symptoms of IV-related complications, such as pain, infiltration, phlebitis, and exudate.
- Assess if the patient is receiving an anticoagulant or has a history of a coagulopathy.
- Review the accuracy and completeness of the health care provider’s orders to discontinue IV therapy.
- Assess the patient’s understanding of the need to discontinue the IV.
Follow-up
- Observe the site for evidence of any complications, such as bleeding, pain, exudate, and swelling.
Documentation
Document the procedure in the patient’s medical record.
Review Questions
1. What would the nurse do to assess a patient’s risk for embolus when removing a venous access device?
Inspect the site for redness.
Visualize the tip of the IV device.- Palpate the site for possible edema.
- Ask the patient to rate any pain at the site.
INCORRECT. Inspecting the site for redness would identify phlebitis or infection, but doing so would not help assess the patient’s risk for embolus.
CORRECT. Damage to the tip of the device, resulting in a portion of the device remaining in the vessel, may cause an embolus to form.
INCORRECT. Palpating the site for possible edema would identify infiltration, but doing so would not help assess the patient’s risk for embolus.
INCORRECT. Asking the patient to rate his or her pain would not help assess the patient’s risk for embolus.
2. Which instruction might the nurse give to nursing assistive personnel (NAP) when caring for a patient whose IV access device is to be removed?
- “Remember to wear gloves to minimize the risk for infection.”
- “Be sure to keep pressure on the site for at least 2 to 3 minutes.”
- “Let me know if you notice any bleeding on the site dressing.”
- “Make sure the patient knows to notify me if the IV site becomes painful.”
INCORRECT. The removal of an IV access device cannot be delegated to NAP.
INCORRECT. The removal of an IV access device cannot be delegated to NAP.
CORRECT. The nurse might offer this instruction because the task of reporting signs of bleeding may be delegated to NAP.
INCORRECT. Patient education may not be delegated to NAP.
3. What might the nurse do to improve a patient’s cooperation during the removal of an IV access device?
- Describe the entire procedure to the patient.
- Assure the patient that you will remove the IV catheter quickly.
- Assure the patient that the procedure will take only about 5 minutes.
- Tell the patient that the procedure will cause only a slight burning sensation.
CORRECT. Describing the entire procedure in advance will minimize fear and thus encourage the patient’s cooperation.
INCORRECT. The patient is more likely to be cooperative if he or she understands the entire procedure. The IV device will be removed slowly and steadily.
INCORRECT. The patient is more likely to be cooperative if he or she understands the entire procedure. Discussing how long it will take is only one aspect of a complete description of the procedure.
INCORRECT. The patient is more likely to be cooperative if he or she understands the entire procedure. Telling the patient that the procedure will cause only a slight burning sensation is only one aspect of a complete description of the procedure.
4. Which action will best minimize the patient’s risk for vein injury when removing an IV access device from a patient’s arm?
- Keep the hub parallel to the skin.
- Cleanse the site with an antibacterial swab.
- Cut the dressing to facilitate its removal.
- Turn the IV tubing roller clamp to the “off” position.
CORRECT. Keeping the hub parallel to the skin minimizes vein trauma during removal of the device.
INCORRECT. Cleansing the site with an antibacterial swab is not part of the procedure for removing an IV access device.
INCORRECT. Cutting the dressing may damage the device.
INCORRECT. Turning the infusion off prevents fluid from flowing through the catheter as it is removed. It does not, however, protect the patient from vein injury.
5. What will the nurse do to prevent possible complications after removing an IV access device in a patient on anticoagulant therapy?
- Instruct the patient to report immediately any sign of bleeding on the site dressing.
- Perform hand hygiene and wear clean gloves while removing the device.
- Encourage the patient to keep a cold compress on the site for 15 minutes.
- Apply firm pressure to the site with sterile gauze for 10 minutes.
INCORRECT. Instructing the patient to report immediately any sign of bleeding will not prevent complications after the device is removed.
INCORRECT. Performing hand hygiene and wearing clean gloves will not ensure the patient’s safety after the device is removed.
INCORRECT. Applying a cold compress is not appropriate technique.
CORRECT. Applying firm pressure will facilitate clotting. Maintaining pressure at the site for 5 to 10 minutes is recommended because the patient is receiving medication that prolongs the amount of time it takes for blood to clot.
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