Assessing a Patient's Tubes

Intravenous Infusions:

Assessing an IV Infusion from bag to patient:

  • Check IV solution - right solution? on time?
  • Check the IV rate - right rate?
  • "Run" the IV tubing - intact? clamps okay? connections tight?
  • Check IV site
    • redness, swelling, pain, drainage?
    • intact?

 

Calculating IV drip rates:

 

 

Making a timing strip:

Not all IV bags start with "0" as the first marking, but may start with a "1", meaning that when the IV fluid is on the "1", 100 ml of fluid has been infused.

This timing strip is for an infusion ordered at 150 ml/hr

Include the Date and time the IV bag was hung and the gtts/min.

Write in the hours using large print so that the strip is easily read [even at night].

Be sure to include the time at the bottom of the strip when the IV bag is expected to be empty.

 

Changing a patient gown while IV is infusing:

  • Use an IV gown with shoulder snaps or ties whenever possible
  • Never lower the IV bag below the level of the patient's IV site
  • Do not pull on the patient's IV site

Discontinuing an IV infusion:

  • Check the physician's order to see if the IV site is to be discontinued or if the site needs to be changed to an intermittent device.
  • Clamp the IV tubing
  • Undo the tape (if a bio-occlusive dressing is used, stretching the dressing will help release it from the patient's skin) by peeling the tape toward the IV site
  • Loosely hold a sterile cotton ball or dressing on the IV site
  • Withdraw the IV cannula, immediately put pressure on the site, and if possible raise the arm so that IV site is above the level of the heart
  • Hold pressure until the bleeding has stopped (this may be several minutes if the patient is receiving anticoagulant therapy)

 

Measuring Intake and Output:

Determine how much IV fluid has infused over the shift



Document how much IV fluid is LTC (Left to Count) - How much fluid is currently in the IV bag that the next shift will account for? 

Checking Tubes:

Oxygen

  • Correct oxygen delivery system?
  • Flow rate is correct?
  • Humidification present? (notice that this setup does not include a humidifier!)
  • No presence of skin irritation from tubing?
  • Applied to patient correctly?



 

Nasogastric tubes

 

  • No presence of skin irritation from tubing?
  • No kinks or problems with tubing? No dependent loops? Connections tight?
  • If to suction:
    • Correct amount of suction?
    • Expected amount and type of drainage?
  • If tube feeding:
    • Correct formula and rate?
    • Correct tube placement?



 

Drainage tubes

  • Jackson-Pratt
    • JP #1 is draining an area without suction being applied.
    • JP#2 has suction applied by compressing the bulb.
    JP Drain
    • Evaluate drainage - expected amount and type?
    • Empty bulb with 1/2 - 2/3 full
    • Compress bulb to maintain suction unless contraindicated
  • Hemovac
    Hemovac To empty, carefully remove the plug and pour drainage into a measuring container
    Restoring pressure in hemovac After empying, compress the hemovac by pushing down on the top and insert the plug