Learning Objectives

• Inspect established IV site for deviations from normal
• Prepare and safely administer primary and secondary IV fluids and medication
• Calculate and ensure designated flow rate
• Change IV tubing
• Change IV site dressing
• Discontinue short-term peripheral IV
• Modify the procedure to reflect variations across the life span
• Document actions and observation
• Report significant deviations from norms

The purpose of intravenous (IV) therapy is to replace fluid and electrolytes, provide medications, and replenish blood volume.

The nurse’s responsibilities in managing IV therapy include the following:

• assessing an IV site
• priming and hanging a primary IV bag
• preparing and hanging a secondary IV bag
• calculating IV rates
• monitoring the effectiveness of IV therapy
• discontinuing a peripheral IV

IV medications and fluids enter the patient’s bloodstream directly through the vein. They act rapidly within the body to restore fluid volume and deliver medications. Once a medication enters the vein, there is no way to terminate this action. Therefore, it is important to properly prepare the IV medication or fluid, correctly calculate the dosage, and administer it safely to the patient. Additionally, IV fluid administration is considered a medical intervention and requires a medication order prior to the initiation of fluid therapy.

Primary IV Fluid Infusion

Primary IV fluid infusions are prescribed by health care providers to restore or maintain hydration and electrolyte status within the body. When administering IV fluids to a patient, the nurse must continually monitor the patient’s fluid and electrolyte status to evaluate the effectiveness of the infusion and to avoid potential complications of fluid overload and electrolyte imbalance.

The most commonly used primary IV fluid bag contains 1,000 mL. There are also 500 mL, 250 mL, 100 mL, and 50 mL bags. The size of the primary fluid bag is based on infusion need, patient condition, and age. Most adult patients receive continuous IV fluids with 1,000 mL bags due to the higher drip (gtt) rate. Many other fluid volume bags are used for intermittent infusions or short-term therapy.

For example, for renal dialysis patients, IV bags smaller than 1,000 mL are used because large amounts of continuous fluids are contraindicated due to their renal impairment. Many institutions will hang smaller volume normal saline continuous infusion bags just to serve as an additional reminder that these patients should not receive large amounts of primary fluids. Another example of patients requiring smaller IV bags are pediatric patients who, due to their smaller anatomical size, do not require large primary fluid infusion volumes.

Primary fluids are typically administered using an IV pump. An IV pump is the safest method of administration to ensure specific amounts of fluid are administered. However, there may be situations when IV pumps are not available and nurses administer primary fluids by gravity using drip tubing. Read more about calculating infusion rates in the “Math Calculation” chapter.

Primary fluids are run at consistent infusion rates for a prescribed period of time. For example, a continuous fluid infusion may be ordered at a rate of 125 mL/hour for 24 hours. Continuous fluids may also be ordered to run until the provider gives a follow-up order to discontinue or decrease the fluid rate.

IV primary fluid bags consist of various types of fluid such as 0.9% normal saline, 0.45% (½) normal saline, lactated ringers solution, and dextrose (5%) preparations. They may also contain replacement electrolytes like potassium chloride. The provider will order primary fluids based on the patient’s fluid and electrolyte statuses.

There are three types of intravenous fluid concentrations: isotonic, hypertonic, and hypotonic fluids.

• Isotonic fluids are typically administered for fluid and electrolyte replacement. Isotonic fluids have a similar concentration to the solutes contained in blood, so they do not cause the osmotic movement of fluid into or out of the patient’s individual cells. An example of isotonic fluid is 0.9% normal saline.
• Hypertonic fluids have a higher concentration of solutes than blood. They are typically used in critical care situations to treat hyponatremia and avoid pulmonary edema by relying on osmosis to help remove excess fluid. An example of a hypertonic fluid is dextrose 5% in 0.9% normal saline (D5NS).
• Hypotonic fluids have a lower concentration of solutes than blood. The goal of hypotonic fluid administration is to move fluids into a patient’s cells due to osmosis. Hypotonic solutions are commonly used when a patient has severe intracellular dehydration such as during diabetic ketoacidosis. An example of hypotonic fluid is 0.45% normal saline (1/2NS). See Figure 23.1^[1] for an example of the effects of the administration of hypertonic, isotonic, and hypotonic IV fluids on a patient’s red blood cells.

Figure 23.1

Osmotic Effects of Hypertonic, Isotonic, and Hypotonic IV Fluids on Red Blood Cells

Because a patient’s fluid and electrolyte statuses are constantly changing when receiving IV fluids, it is important for the nurse to monitor for signs of fluid or electrolyte imbalances and appropriately notify the health care provider of any concerns. For example, primary fluids may be started at a higher rate of infusion when a patient is receiving nothing by mouth (NPO), but should be tapered as they resume normal diet and fluid intake. It is important for the nurse to continually monitor a patient’s skin turgor, urinary output, lung sounds, and oxygen requirements and to assess for any new edema to offer important insight into their fluid volume status. A nurse must also evaluate the effects of replacement fluids and discuss their ongoing need with the prescribing provider.

Secondary Fluid Infusion

Secondary IV fluid administration is usually an intermittent infusion that infuses at regular intervals (e.g., every 8 hours). This form of IV therapy usually contains medications that are supplied in a smaller infusion bag and mixed with a diluent fluid like saline (e.g., IV antibiotics). Many common preparations come in 25 to 100 mL bags.

Secondary IV therapy is often referred to as “IV piggyback” (IVPB) medication because it is attached to the primary bag of intravenous fluids. In this case, the primary line maintains venous access between drug doses.

It is important to remember that not all IV solutions are compatible with all IV medications. It is vital for the nurse to triple check that the secondary medications/fluids are compatible with primary fluids. If medication and fluids are not compatible, a precipitate may form when the fluids mix within the line, posing a significant health danger for the patient.

IV Administration Equipment

Intravenous (IV) fluids and medications are administered through flexible plastic tubing called an IV administration set. The IV administration set connects the bag of solution to the patient’s IV access site. There are two major types of IV administration sets: primary tubing and secondary tubing. Additionally, IV fluids can be administered by gravity or by infusion pump, and each method requires its own administration set.

Primary and Secondary Administration Sets

PRIMARY IV ADMINISTRATION SETS

Primary IV administration sets are used to infuse continuous or intermittent fluids or medications. Primary IV tubing can be a macro-drip or micro-drip solution set. A macro-drip infusion set delivers 10, 15, or 20 drops per milliliter, whereas a micro-drip infusion set delivers 60 drops per milliliter. The drop factor is located on the packaging of the IV tubing and is important to verify when calculating medication administration rates. Macro-drip sets are used for routine primary infusions for adults. Micro-drip IV tubing is used in pediatric or neonatal care where small amounts of fluids are administered over a long period of time.

Primary IV administration sets consist of the following parts:

Sterile spike: This part of the tubing must be kept sterile as you spike the IV fluid bag.

Drip chamber: The drip chamber allows air to rise out from a fluid so that it is not passed onto the patient. It is also used to calculate the rate at which fluid is administered by gravity (drops per minute). It should be kept ¼ to ½ full of solution.

Backcheck valve: A backcheck valve prevents fluid or medication from travelling up into the primary IV bag.

Access ports: Access ports are used to infuse secondary medications and to administer IV push medications. These may also be referred to as “Y ports.”

Roller clamp: A roller clamp is used to regulate the speed, or stop, an infusion by gravity.

SECONDARY IV ADMINISTRATION SETS

Secondary IV administration sets are used to intermittently administer a secondary medication, such as an antibiotic, while the primary IV is also running. Secondary IV tubing is shorter in length than primary tubing and is connected to a primary line via an access port or an IV pump. The secondary infusion is hung above the primary infusion and connected at an access port.

Secondary fluids should always be “piggybacked” into primary infusion lines to ensure that the correct amount of medication is infused. By piggybacking a medication, the solution from the primary fluid line is used to prime the secondary tubing. However, if a secondary infusion is run as a primary fluid, there is a risk of losing some of the secondary medication when priming the line, which results in less medication being administered. Loss of medication is considered a medication error because the patient received less active medication than prescribed.

See Figure 23.2^[2] for an illustration of the set up of a primary and secondary tubing for administration of fluids and a secondary medication by gravity. See Figure 23.3^[3] for an example of an IV infusion pump.

Figure 23.2

Primary and Secondary Tubing Administration Set

Figure 23.3

Example of an IV Infusion Pump

IV Administration

When initiating or changing an IV bag of fluids or medications, it is important to remember these items:

• IV fluids are a medication. Verify physician orders and check that the patient does not have an allergy to this medication. Perform the six rights of medication administration three times as you would when giving any other medication. Check the type of fluid and the expiration date, and verify the fluid is free of discoloration and sediment. Check the expiration date when obtaining a new tubing administration set.
• Examine the bag to ensure that the bag itself is intact and not leaking. There may be moisture on the inside of the plastic IV bag storage container; this is normal.
• Verify the infusion rate of IV fluids is appropriate based on the patient’s age, size, preexisting medical conditions, and prescribed indication. If a manual calculation is needed to set the IV flow rate, calculate the rate and double-check the calculated rate with another registered nurse.
• IV tubing administration sets require routine replacement to prevent infection. Follow agency policy regarding initiating tubing change before initiating a new bag of fluid or medications.
• If administration set tubing is present, trace the tubing from the patient to its point of origin to make sure that you’re accessing the correct port.
• Assess the IV site. Inspect for redness, swelling, or tenderness that can be a sign of irritation, inflammation, or infection.
• Ensure the IV site is patent when initiating new fluid or medication. Aspirate for blood return and flush the IV catheter according to agency policy.

Complications of IV Therapy

While monitoring a patient receiving IV fluids, it is important to assess for potential complications such as infiltration, extravasation, phlebitis, or infection. If these conditions occur, promptly notify the provider for treatment; the IV catheter will need to be removed and replaced at an alternative site, and additional medication may be prescribed.

Infiltration occurs when the tip of the catheter slips out of the vein. The catheter passes through the wall of the vein, or the blood vessel wall allows part of the fluid to infuse into the surrounding tissue, resulting in the leakage of IV fluids into the surrounding tissue. Infiltration may cause pain, swelling, and skin that is cool to the touch. If you are concerned an IV is infiltrated, follow your facility policy and, as a general guideline, discontinue the site and relocate the IV. If the infiltration is severe, you may consider the application of a compress in addition to elevating the affected limb. Check your institution’s policy regarding which type of compress (warm or cold) should be applied.^[4],^[5] Additionally, clinical pharmacists can also be helpful resources for determining the appropriate type of infiltration treatment.

Extravasation refers to infiltration of damaging intravenous medications, such as chemotherapy, into the extravascular tissue around the site of infusion. Extravasation causes tissue injury, and depending on the medication, site, and length of exposure, it can cause tissue death, which is also referred to as necrosis. If detected early, extravasation may be treated with medications that help avoid the complication of necrosis.

Phlebitis is inflammation of a vein. Phlebitis of superficial veins can occur due to trauma to the vein during insertion of the IV catheter. It can cause redness and tenderness along the vein and can lead to infection if not treated appropriately. Treatment may include warm compresses and nonsteroidal anti-inflammatory medications.

Infection can occur whenever the skin barrier is broken by the insertion of an IV catheter. Signs of infection include redness, warmth, tenderness, and possible fever. Vascular catheter–associated infection is considered a hospital-acquired condition because it can be prevented using best practices. Be sure to follow evidence-based infection prevention practices, such as performing hand hygiene, performing a vigorous mechanical scrub of needleless connectors, limiting catheter access, and following sterile no-touch technique during intravenous infusion to reduce the risk of vascular catheter–associated infection.

References

1.

“Osmotic pressure on blood cells diagram.svg“ by LadyofHats is in the Public Domain ↵.

2.

“intravenous_equipment_labels-2.png” by British Columbia Institute of Technology is licensed under CC BY 4.0. Access for free at https://opentextbc​.ca​/clinicalskills/chapter​/8-2-types-of-iv-therapy/ ↵.

3.

“DSC_0738-e1443533768679-678x1024.jpg” by British Columbia Institute of Technology is licensed under CC BY 4.0. Access for free at https://opentextbc​.ca​/clinicalskills/chapter​/8-2-types-of-iv-therapy/ ↵.

4.

Drugs.com [Internet]. IV Infiltration. © 2000-2020 [updated 3 February, 2020; cited 7 August, 2020]. https://www​.drugs.com​/cg/iv-infiltration-aftercare-instructions.html ↵.

5.

AMN Healthcare Education Services. (2015). Know the difference: Infiltration versus extravasation. https://www​.rn.com/nursing-news​/know-the-difference-infiltration-vs-extravasation/ ↵.

Subjective Assessment

When performing the subjective assessment, the nurse should begin by focusing on data collection that may signify a potential complication if a patient receives IV infusion therapy. The nurse should begin by identifying if the patient has medication allergies or a latex allergy. The patient’s history should also be considered with special attention given to those with known congestive heart failure (CHF) or chronic kidney disease (CKD) because they are more susceptible to developing fluid overload. Additionally, the patient should be asked if they have any pain or discomfort in their IV access site now or during the infusion of medications or fluids.

Objective Assessment

The patient’s IV site should be checked for patency before initiating IV therapy and throughout the course of treatment. The IV site should be free of redness, swelling, coolness, or warmth to the touch. The IV infusion should flow freely. The nurse should also be aware of different types of intravenous access that may be used for an infusion. For example, a peripherally inserted central catheter (PICC) looks similar to intravenous access, but requires different assessment and monitoring as a central line. Please review Table 23.3 to consider the expected and unexpected assessment findings that may occur with IV therapy.

Sample Documentation of Expected Findings

Initiated IV infusion of normal saline at 125 mL/hr using existing 22 gauge IV catheter located in the right hand. The IV site is free from pain, coolness, redness, or swelling.

Sample Documentation of Unexpected Findings

Attempted to initiate IV infusion in right hand using existing 22 gauge IV catheter. The IV site was free from pain, redness, or signs of infiltration. It infused freely with the normal saline flush. IV fluids were connected to run the normal saline infusion at 200 mL/hr. The infusion was started, but immediate leaking around the infusion site was noted. Swelling was noted superior to the infusion site and the fluids were immediately stopped.

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1.

Gather supplies: IV fluid, primary tubing, tubing change label, and alcohol pads/scrub hubs.

2.

Verify the provider order with the medication administration record (eMAR/MAR).

3.

Perform the first check of the six rights of medication administration while withdrawing the IV fluids from the medication dispensing unit. Check expiration date and verify patient allergies.

4.

Remove the IV solution from the packaging and gently apply pressure to the bag while inspecting for tears or leaks.

5.

Check the color and clarity of the solution.

6.

Perform the second check of the six rights of medication administration.

7.

Enter the patient room and greet the patient.

8.

Perform safety steps:

• Perform hand hygiene.
• Check the room for transmission-based precautions.
• Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
• Confirm patient ID using two patient identifiers (e.g., name and date of birth).
• Explain the process to the patient and ask if they have any questions.
• Be organized and systematic.
• Use appropriate listening and questioning skills.
• Listen and attend to patient cues.
• Ensure the patient’s privacy and dignity.
• Assess ABCs.

9.

Perform the third medication check of the six rights of medication administration at the patient’s bedside.

10.

Remove the primary IV tubing from the packaging. If administering IV fluid by gravity, note the drip factor on the package and calculate drops/min. Perform the necessary calculations for the infusion rate.

11.

Move the roller clamp so that it is halfway up the tubing and clamp it.

12.

Remove the cover from the tubing port on the bag of IV fluid.

13.

Remove the cap from the insertion spike on the tubing. While maintaining sterility, insert the spike into the tubing port of the bag of IV fluid.

14.

Squeeze the drip chamber two or three times to fill the chamber halfway.

15.

Loosen the cap from the end of the IV tubing and open the clamp to prime the tubing over the sink:

• If using multiple port tubing, invert the ports to prime them and to prevent air accumulation in line.
• If the solution is an antibiotic, take care to not waste solution while priming the tubing to ensure the patient receives the correct dosage.

16.

Once primed, clamp the IV tubing and check the entire length of the tubing for air bubbles. Tap the tubing gently to remove any air.

17.

Replace or tighten the cap on the end of the tubing.

18.

Label the primary IV fluid bag with the date and time. Place the tubing label on the tubing near the drip chamber.

19.

Assess the patient’s venipuncture site for signs and symptoms of vein irritation or infiltration. Do not proceed with administering fluids at this site if there are any concerns.

20.

Vigorously cleanse the catheter cap on the patient’s IV port with an alcohol pad/scrub hub (or the agency required cleansing agent) for at least five seconds and allow it to dry.

21.

Assess IV site patency according to agency policy. Purge a prefilled normal saline syringe of air. Attach the syringe onto the the saline lock cap. Undo the clamp on the extension tubing. Inject 3 to 5 mL of normal saline using a turbulent stop-start technique. If resistance is felt, do not force the flush and do not proceed with IV solution administration; follow up according to agency policy.

22.

Remove the syringe from the IV cap and then clamp the extension tubing.

23.

Vigorously cleanse the catheter cap on the patient’s IV port with an alcohol pad/scrub hub (or the agency required cleansing agent) for at least five seconds and allow it to dry.

24.

Remove the protective cap from the end of the primary tubing and attach it to the IV port while maintaining sterility.

25.

Move the slide clamp on the saline lock to open the tubing.

26.

Set the infusion rate based on the provider order:

• For infusion pump: Set volume to be infused and rate (mL/hr) to be administered.
• For gravity: Calculate drop per minute.

27.

Assess the patient’s IV site for signs and symptoms of vein irritation or infiltration after infusion begins.

28.

Secure the tubing to the patient’s arm.

29.

Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.

30.

Ensure safety measures when leaving the room:

• CALL LIGHT: Within reach
• BED: Low and locked (in lowest position and brakes on)
• SIDE RAILS: Secured
• TABLE: Within reach
• ROOM: Risk-free for falls (scan room and clear any obstacles)

31.

Perform hand hygiene.

32.

Document the procedure and related assessment findings. Report any concerns according to agency policy. Include IV fluids on patient’s input/output documentation.

References

1.

Open RN Project. (2021, November 11). Primary IV Solution Administration. [Video]. YouTube. Video licensed under CC-BY-4.0. https://youtu​.be/0uK2m0Mk0bA ↵.

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1.

Gather supplies: secondary IV fluid/medication, secondary IV tubing, alcohol wipe/scrub hubs, and tubing labels.

2.

Verify the provider order with the medication administration record (eMAR/MAR).

3.

Perform the first check of the six rights of medication administration while withdrawing the IV solution and tubing from the medication dispensing unit. Check expiration dates on the fluid and the tubing and verify allergies.

4.

Verify compatibility of the secondary IV solution with the other IV fluids the patient is concurrently receiving.

5.

Remove the IV solution from the packaging and gently apply pressure to the bag while inspecting for tears or leaks. Check the color and clarity of the solution.

6.

Perform the second check of the six rights of medication administration.

7.

Enter the patient room and greet the patient.

8.

Perform safety steps:

• Perform hand hygiene.
• Check the room for transmission-based precautions.
• Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
• Confirm patient ID using two patient identifiers (e.g., name and date of birth).
• Explain the process to the patient.
• Be organized and systematic.
• Use appropriate listening and questioning skills.
• Listen and attend to patient cues.
• Ensure the patient’s privacy and dignity.
• Assess ABCs.

9.

Perform the third check of the six rights of medication administration at the patient’s bedside.

10.

If the patient is receiving the medication for the first time, teach the patient and family (if appropriate) about the potential adverse reactions and other concerns related to the medication.

11.

Remove the secondary IV tubing from the packaging.

12.

Place the roller clamp to the “off” position.

13.

Remove the protective sheath from the IV spike and the cover from the tubing port of the IV solution.

14.

Insert the spike into the IV bag while maintaining sterility.

15.

Compress and release the drip chamber, filling halfway.

16.

Prime the secondary IV tubing. Back priming is considered best practice and is performed using an infusion pump with primary fluids attached:

• Vigorously cleanse the catheter tip on the patient’s IV port with an alcohol pad/scrub hub (or the agency required cleansing agent) for at least five seconds and allow it to dry.
• Connect the secondary tubing to the port closest to the drip chamber. Lower the secondary bag below the primary bag, and allow the fluid from the primary bag to fill secondary tubing. Fill the secondary tubing until it reaches the drip chamber, and then raise the secondary bag above the primary line.

17.

Hang the secondary IV solution on the IV pole with the primary bag lower than the secondary bag.

18.

Label the secondary tubing near the drip chamber.

19.

Set the infusion rate:

• For infusion pump: Set the volume to be infused and the rate (mL/hr) to be administered based on the provider order.
• For gravity: Set the roller clamp to achieve the appropriate number of drops per minute based on the provider order.

20. Assess the patient’s IV site for signs and symptoms of vein irritation or infiltration after infusion begins. Do not proceed with administering secondary fluids if there are any concerns about the site.

21. Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.

22. Ensure safety measures when leaving the room:

• CALL LIGHT: Within reach
• BED: Low and locked (in lowest position and brakes on)
• SIDE RAILS: Secured
• TABLE: Within reach
• ROOM: Risk-free for falls (scan room and clear any obstacles)

  23.

  Perform hand hygiene.

  24.

  Document the procedure and assessment findings. Report any concerns according to agency policy.

References

1.

Open RN Project. (2021, November 11). Secondary IV Solution Administration. [Video]. YouTube. Video licensed under CC-BY-4.0. https://youtu​.be/8xW5LJb-xLQ ↵.

Sample Documentation of Expected Findings

IV catheter on the right hand was discontinued. IV catheter tip was intact. Site is free from redness, warmth, tenderness, or swelling. Gauze applied with pressure for one minute with no bleeding noted. Dressing applied to the site.

Sample Documentation of Unexpected Findings

IV catheter on the right hand was discontinued. IV catheter tip was intact. Site free from redness, warmth, tenderness, or swelling. Gauze applied with pressure for one minute but bleeding was noted to continue around the gauze dressing. Ongoing pressure was held for five minutes until hemostasis was achieved.

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1.

Gather supplies: gauze, tape, or a Band-Aid.

2.

Perform safety steps:

• Perform hand hygiene.
• Check the room for transmission-based precautions.
• Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
• Confirm patient ID using two patient identifiers (e.g., name and date of birth).
• Explain the process to the patient.
• Be organized and systematic.
• Use appropriate listening and questioning skills.
• Listen and attend to patient cues.
• Ensure the patient’s privacy and dignity.
• Assess ABCs.

3.

Prepare the gauze and tape.

4.

Place the IV clamp to the “off” position (clamped).

5.

Loosen the edges of the transparent dressing and tape in the direction of the IV site.

6.

Place a gauze pad over the IV site and gently pull the IV out parallel to the skin in a slow and steady motion.

7.

Hold pressure on the IV site for 2-3 minutes. If the patient is on anticoagulant medication, you may need to hold for 5-10 minutes.

8.

Inspect the catheter to ensure it is intact and dispose of it in an appropriate container.

9.

Remove the gauze pad once bleeding has stopped and assess for any signs of infection at the site, such as redness, swelling, warmth, tenderness, or purulent drainage.

10.

Tape the gauze or apply a Band-Aid over the IV site.

11.

Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.

12.

Ensure safety measures when leaving the room:

• CALL LIGHT: Within reach
• BED: Low and locked (in lowest position and brakes on)
• SIDE RAILS: Secured
• TABLE: Within reach
• ROOM: Risk-free for falls (scan room and clear any obstacles)

13.

Perform hand hygiene.

14.

Document the procedure and related assessment findings. Report any concerns according to agency policy.

References

1.

Open RN Project. (2021, November 11). IV Removal. [Video]. YouTube. Video licensed under CC-BY-4.0. https://youtu​.be/z_AQ81whZ98 ↵.

References

1.

RegisteredNurseRN. (2017, March 10). How to prime IV tubing line | How to spike a IV bag for nursing. [Video]. YouTube. All rights reserved. Video used with permission. https://youtu​.be/4ntqS_R1r70 ↵.

Learning Activities

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

The patient’s IV site is cool to the touch and swollen. The patient states “it hurts a little.” List in order the steps the nurse should take.

a.

Discontinue the IV

b.

Stop the IV infusion

c.

Elevate the affected site

d.

Document the findings