Nursing Field Notes / Renal + Fluid · Fundamentals of Nursing
IV Therapy 💉
Changes & Cautions — intervals, site assessment, and the four complications you must tell apart
NG-007Renal + FluidADHD-friendly visual edition
IV insertion through peripheral veins is the fastest route to get medication into the body — which is exactly why it is the most dangerous one. This page is about keeping the line safe: when you change what, what a site should look like every time you walk past it, and how to tell infiltration from extravasation from phlebitis from infection.
💊 IV infusions ARE medicationsThe HCP must prescribe type · volume · rate.
🚨 NEVER push potassiumK⁺ / KCl is always diluted, always on a pump. IV push = death.
⏱️ 24 / 72 / 1×Bags 24 h · tubing & site 72 h · blood tubing single use.
🧊 Cool & pale vs 🔥 red & hotInfiltration is cool, pale, swollen. Phlebitis is red, warm, streaky.
💉
THE LINE
STEP 1 · WHAT YOU ARE PUTTING IN
Know what a good site looks like on the inside, and you will recognize a bad one from the doorway.
🔬 What is actually happening under that dressing
The catheter tip sits inside the vein lumen and the fluid joins the bloodstream immediately. Every complication on this page is a version of “the tip is no longer where it should be,” or “the vein does not like what is going through it.”
🧠 Picture the tip. Tip in the vein = fluid goes with the blood. Tip out of the vein = fluid goes into the tissue. That one image separates infiltration from everything else.
✅ Advantages of the IV route
Absorbs quickly — the fastest route there is.
Keeps a constant therapeutic level with a continuous infusion.
Less tissue damage than the other routes (SQ, IM, PR, PO) for irritating drugs.
Usable when the client is NPO, vomiting, or unable to swallow.
🧠 Fast in = fast wrong. There is no taking it back once it is in the vein — which is why the checks happen before you connect.
🧠 “Nasty drugs need a big river.” Anything that would burn a small vein — chemo, TPN, concentrated potassium, vasopressors — belongs in a central line.
🗺️ Site selection — go here, never there
✅ Start distal and work proximal — if a distal site fails you can still move up the arm; if you start at the AC you have burned everything below it. Use the client's non-dominant arm when you can.
🧠 “No Fistula, No Flap, No Feeble arm.” Never the dialysis fistula/graft arm, never the mastectomy (lymph node) side, never a paralyzed limb.
⏱️
CHANGE IT · WATCH IT
STEP 2 · THE ROUTINE
Two habits keep clients safe: change things on schedule, and look at the site every single time you touch the line.
⏱️ When to change IVs — the intervals
⚠️ Practice varies and it has changed over time. Your source teaches 72 hours for tubing and site; national guidance allows peripheral catheters and continuous tubing to run to 96 hours, and many hospitals now replace peripheral IVs only when clinically indicated. Answer with your facility's policy — and say “72 hours” if the question comes from this study guide.
Other intervals worth knowing (verify locally): lipid / TPN tubing every 24 hours, intermittent (“secondary”) tubing every 24 hours, and a transparent dressing changed when it is damp, loosened, or visibly soiled — or with the catheter.
🧠 “Bag one day, tubing & site three, blood is one-and-done.”24 · 72 · 1×. Label everything with date, time and your initials — an unlabeled bag is an unknown bag.
👁️ Site assessment — what you do EVERY time
Assess the site at least hourly for a continuous infusion (and per policy), before and after every IV medication, and any time the pump alarms or the client complains.
↔️COMPAREto the other arm — size, color, temperature
🗣️ASK“any pain, burning or tightness?”
🩸CHECKblood return & easy flushing
📉WATCHthe rate — slowing or alarming = investigate
EXAM TIP A client who says the IV “feels tight” or “burns” is telling you the answer before any sign appears. Stop and look.
🧠 “Look · Feel · Compare · Ask.” Four seconds at the bedside. Most infiltrations are caught by the compare step — one arm is simply fatter than the other.
🚨 The BIG NO-NOs
1
Potassium (K⁺, KCl) — NEVER IV push. Instant death. Always diluted, always on an IV pump, never faster than the ordered rate. Check urine output before you give it, and watch the site — potassium burns.
2
NO adding medications to blood transfusion bags or TPN bags. Ever. Blood runs with 0.9% normal saline only.
3
Compatible medications only in the same tubing — check compatibility and check hospital policy. When in doubt, flush between, or run a separate line.
Add two more that examiners love: never let air into the line (prime it, and keep the drip chamber ⅓–½ full), and never re-insert a stylet/needle into a catheter you have already advanced — that is how a catheter embolises.
🧠 “Push potassium and the heart stops.” Say it in that many words. It is the single most-repeated IV safety fact in nursing school, and it is true.
👵 Nursing considerations — older adults
NO tourniquets — fragile veins and paper-thin skin. Use a blood pressure cuff instead, inflated just below the systolic pressure.
Don't slap the extremity. Tap gently, or use warmth and gravity to fill the vein.
Anchor the vein — older veins roll.
Watch for fluid volume overload: smaller cardiac and renal reserve, so a rate that is fine for a 30-year-old can put an 85-year-old into pulmonary edema.
Use the smallest gauge that will do the job, and secure with minimal tape/paper tape to protect skin.
🧠 “BP cuff, not tourniquet. Tap, don't slap.” Two lines, two easy exam points.
🧼 Infection prevention
Universal / standard precautions (PPE) and hand hygiene before and after every contact.
Firmly use the alcohol swab, applying pressure over the vein, and let it dry — friction and dry time are what kill the organisms.
Scrub the hub before every access, per policy.
Change the catheter if aseptic technique was broken at insertion (e.g. an emergency line) — do not wait for the interval.
Remove the IV as soon as it is no longer needed. The most effective infection-prevention measure there is.
Keep the dressing clean, dry and intact; date it.
🧠 The best line is the one that isn't there. Every day a catheter stays in is another day of risk — ask daily whether it is still needed.
🚨
WHEN IT GOES WRONG
STEP 3 · TELL THEM APART
Four complications, four different first actions. Getting the name right is how you get the action right.
🔍 The same site, three pathologies — drawn side by side
🧠 “COOL and pale = fluid OUT of the vein. HOT and red = the vein itself is angry.” Temperature is the fastest discriminator at the bedside — and it is free.
📊 The comparison table — infiltration vs extravasation vs phlebitis vs infection
💧 Infiltration
🔥 Extravasation
🌡️ Phlebitis
🦠 Infection
What it is
Non-vesicant fluid leaks into the tissue around the vein
The same leak, but the drug is a VESICANT — it destroys tissue
Inflammation of the vein wall — mechanical, chemical or bacterial
Micro-organisms at the site or in the bloodstream
Skin color
Pale / blanched
Dusky, then blistered & necrotic
Red, often a streak along the vein
Red, may have purulent drainage
Temperature
COOL
Cool → then hot as tissue dies
WARM
Warm; client may be febrile
Swelling
Marked, taut, shiny
Marked
Usually mild; a palpable cord
Localized induration
Pain
Tight, aching
BURNING, severe
Tenderness along the vein
Tenderness at the site
Flow / blood return
Slows or stops; no blood return
Slows or stops
May still flow
May still flow
FIRST action
STOP the infusion, remove the catheter, elevate the limb, compress (warm or cool per the solution), restart in the other extremity
STOP the infusion — but do NOT remove the catheter yet. Aspirate residual drug through it, follow the antidote protocol, notify the HCP, mark and photograph the area, elevate
Discontinue the IV, warm moist compress, restart in a different vein, document the phlebitis score
Discontinue, culture the site (and blood cultures if febrile), notify the HCP, restart elsewhere with fresh equipment
Never restart the new IV distal to (below) an infiltrated or phlebitic site — the fluid will simply leak out of the damaged vein again. Go to the other arm, or above the injury.
🧠 The one difference that gets tested: in infiltration you pull the catheter straight away; in extravasation you leave it in long enough to aspirate the drug and give the antidote through it.
🚨 Fluid volume overload — the systemic complication
Signs: crackles, dyspnea, cough with frothy sputum, JVD, bounding pulse, raised BP, rapid weight gain, edema, restlessness.
Action: slow the infusion to KVO (keep vein open) rate, sit the client up, oxygen, notify the HCP, expect a diuretic order, monitor breath sounds, I&O and weight.
🧠 Crackles + a new 2 kg overnight = you gave too much, too fast. Slow it, sit them up, call.
🫁 Air embolism & speed shock
Air embolism — sudden dyspnea, chest pain, hypotension, tachycardia, anxiety, altered LOC. Action:clamp the line, place the client on the LEFT side in Trendelenburg, give oxygen, call for help, stay with them.
Speed shock — a bolus given too fast: flushing, headache, chest tightness, irregular pulse, hypotension, loss of consciousness. Action: stop the infusion immediately, keep the line open with saline, call for help.
🧠 Air → LEFT side, head DOWN. Trapping the air in the right ventricle keeps it out of the pulmonary circulation.
📎 Where to go next
📎 NG-085 IV Therapy Problems — the complication deep dive, with the full presentation of each problem.
📎 NG-120 IV Solutions — what is in the bag: normal saline, lactated Ringer's, dextrose solutions and when each is used.
📎 NG-213 Isotonic · Hypotonic · Hypertonic — which way the water moves across the cell membrane, and who must never receive which.
📎 NG-169 Fluid Overload and NG-191 Fluid Volume Deficit — the assessment picture behind the rate you choose.
📎 NG-088 Potassium — the “never push” drug, in full.
🧠 This page is the safety page. NG-120 and NG-213 tell you what to hang; NG-007 tells you how not to hurt anyone with it.
⚡
QUICK RECALL
SAY IT OUT LOUD
🚨 Never push K⁺Diluted · on a pump · never a bolus.
⏱️ 24 · 72 · 1×Bag 24 h · tubing & site 72 h · blood tubing single use.
🔥 Extravasation: leave the catheterAspirate, antidote, notify — then remove.
🎯 Cover & check — 7 rapid-fire questions
Q1: Three things the HCP must prescribe for an IV infusion?
Type of solution, volume (amount), and rate. IV infusions are medications.
Q2: The site is swollen, cool and pale with no blood return. Name it and give the first action.
Infiltration. Stop the infusion, remove the catheter, elevate the limb, apply a warm or cool compress per the solution, and restart in the other extremity.
Q3: A vasopressor has leaked into the tissue and the client has burning pain and blistering. Do you pull the catheter?
No — this is extravasation. Stop the infusion but leave the catheter in to aspirate residual drug and give the antidote per protocol, notify the HCP, mark/photograph the area, then remove it as directed.
Q4: Red streak along the vein, warm, tender, palpable cord. Name it and give the action.
Phlebitis. Discontinue the IV, apply a warm moist compress, restart in a different vein (not distal to the injured one), and document the phlebitis score.
Q5: Your client is 88 with fragile skin. How do you distend the vein?
No tourniquet — use a blood pressure cuff inflated below the systolic pressure instead. Do not slap the extremity; tap gently, use warmth and gravity.
Q6: Name the three BIG NO-NOs from the source.
① Never IV push potassium — always diluted and on a pump. ② Never add medications to blood transfusion bags or TPN bags. ③ Only compatible medications in the same tubing — check hospital policy.
Q7: Which locations do you avoid for a peripheral IV?
Antecubital area (too many nerves, and it bends), over valves, a paralyzed arm, the mastectomy side, a fistula or graft arm, varicose veins, and scar tissue. Lower extremities are avoided in adults.