COMPLICATIONS OF

INTRAVENOUS THERAPY

HEMATOMA formations resulting from the infiltration of

blood into the tissues at the venipuncture site

Causes: nicking the vein during an unsuccessful venipuncture attempt, discontinuing the I.V. cannula or needle without pressure, applying a tourniquet too tightly above a previously attempted venipuncture site

Signs/symptoms: black-and-blue skin discoloration, site swelling and discomfort, inability to advance the cannula all the way into the vein during insertion, inability to flush the IV line

* NURSING ASSESSMENT

Although hematoma formation cannot always be avoided, the incidence can be reduced with thorough assessment of the client’s skin and vein integrity.

Identification of a hematoma is fairly easy because the area around the venipuncture site is usually ecchymotic.

*NURSING MANAGEMENT

The method of vein cannulation may need to be altered, especially for clients with fragile veins, paper-thin skin, or veins that roll—those that move laterally when manipulated. For fragile veins, it may be necessary to enter the vein bevel-down rather than bevel-up and not use a tourniquet. For veins that roll, it may be preferable to enter the vein indirectly from the side, rather than over the vein.

Once a hematoma is identified, discontinue the IV and apply a small pressure dressing.

The extremity may be elevated and warm moist compresses applied, depending on the severity of the hematoma and agency protocols.

PHLEBITIS

An inflammation of the vein in which the endothelial cells of the venous wall become irritated and cells roughen, allowing platelets to adhere and predispose the vein to inflammation-induced phlebitis

TypesMechanicalChemical BacterialPost-infusion

Bacterial phlebitis: inflammation caused by pathogenic organisms

Mechanical phlebitis: caused by irritation of the venous

endothelium  Chemical phlebitis:

inflammation due to irritating or vesicant infusates—usually those with high or low osmolarities or those with high or low pH

Mechanical phlebitis: inflammation resulting from physical trauma to the intima of the vein

Signs/symptoms: redness at site, site warm to touch, local swelling, palpable cord along the vein, sluggish infusion rate, increase in basal temperature of 1 degree C or more

*NURSING ASSESSMENT

Know what infusates will be administered – expected outcomes, side effects, pH, and osmolalities.

Assess containers, tubings, and insertion devices to be sure there are no breaks in their integrity.

Assess infusates for clarity, the presence of particulate matter, and discoloration.

Assess proposed IV site, and determine whether the intended vein is appropriate for the infusate that will be delivered.

*NURSING MANAGEMENT

Discontinue IV, and remove cannula. Notify physician if there is fever or purulent

drainage at the IV site. Culture the catheter and IV site, per agency

policy. Apply warm compresses, per agency

protocols. Restart the IV at another site, using new

infusate and tubing.

THROMBOSIS Catheter-related obstructions can be

categorized as mechanical or non-thrombotic ( 42% of all obstructions) or thrombotic (58% of all obstructions),

Signs/symptoms: fever and malaise, slowed or stopped infusion rate, inability to flush licking device

THROMBOPHLEBITIS

Thrombosis and inflammation. Signs/symptoms: sluggish flow rate, edema

in the limbs, tender and cordlike vein, site warm to touch, visible red line above venipunture site, diminished arterial pulses, and mottling and cyanosis of the extremities

*NURSING ASSESSMENT (FOR THROMBOSIS & THROMBOPHLEBITIS)

Assess proposed IV site, and determine whether the intended vein is appropriate for the infusate that will be delivered.

Assess extremities for warmth and tenderness.

Assess for Homans’ sign—pain in the calf upon flexion of the foot.

*NURSING MANAGEMENT FOR THROMBOSIS AND THROMBOPHLEBITIS Prevention is the best intervention for thrombosis and

thrombophlebitis. Discontinue IV, and remove cannula. Notify physician if there is fever or purulent drainage at the

IV site. Culture the catheter and IV site, per agency policy. Apply warm compresses, per physician’s order and agency

protocols. Restart the IV at another site, using new infusate and

tubing. Apply antiembolic stockings or use sequential compression

devices (SCDs) per physician’s order. Administer anticoagulants and anti-inflammatory agents as

ordered. Initiate a balanced routine of active and passive activity

and rest.

INFILTRATION

Inadvertent administration of a nonvesicant solution into surrounding tissue

Signs/symptoms: coolness of skin around site, taut skin, dependent edema, absence of blood backflow, a pinkish blood return, infusion rate slows but the fluid continues to infuse

EXTRAVASATION The inadvertent administration of a vesicant

solution into surrounding tissue Signs/symptoms: complaints of pain or

burning; swelling proximal to or distal to the IV site; puffiness of the dependent part of the limb; skin tightness at the venipuncture site; blanching and coolness of the skin; slow or stopped infusion; damp or wet dressing

*NURSING ASSESSMENT (INFILTRATION & EXTRAVASATION)

Pain at or near the IV site may or may not be present, depending on the chemical nature of the infusate, the amount of infiltration, the client’s pain threshold, or the client’s level of consciousness. The nurse must assess for circulatory competence by checking for capillary refill and pulses proximal and distal to the area.

*NURSING MANAGEMENT FOR INFILTRATION & EXTRAVASATION

Stop the infusion. Remove the catheter or needle. Arrest any bleeding at the site with firm

pressure. Warm or cool compresses, depending on the

type and amount of infiltration, and the physician’s order.

For extravasation, the proper antidote must be immediately initiated.

Restart the IV at another site.

VENOUS SPASMS A sudden involuntary contraction of a vein or

an artery resulting in temporary cessation of blood flow through a vessel.

Signs/symptoms: sharp pain at the IV site that travels up the arm, which is caused by a piercing stream of fluid that irritates or shocks the vein wall; slowing of the infusion

*NURSING ASSESSMENT

The nurse should assess for a large vein so that blood flow is unrestricted and the infusate can be well diluted.

Assess the client’s anxiety level. Assess pain threshold.

*NURSING MANAGEMENT

Use measures to help the client relax. Use the smallest gauge cannula that will

accommodate the prescribed infusate. Administer infusates at room temperature. Dilute irritating infusates. Once spasm is identified, slow the infusion

rate. Apply warm compresses to the site of spasm. Consult with the pharmacist or physician

regarding buffering irritating infusates. Discontinue the IV if spasm continues in spite

of measures used to stop it.

SEPTICEMIA Septicemia: a febrile disease process that

results from the presence of microorganisms or their toxic products in the circulatory system

S/S: fluctuating fever, tremors, chattering teeth, profuse cold sweat, nausea and vomiting, diarrhea, abdominal pain, tachycardia, increased respirations or hyperventilation, altered mental status, hypotension

*NURSING ASSESSMENT

Assess VS and LOC. Assess for internal bleeding. Assess for DIC. Assess for pressure sore areas. Do regular head-to-toe, system-by-system

assessment for septic shock.

*NURSING MANAGEMENTCARE IS DIRECTED TOWARD SUPPORTING THE CLIENT AS SYMPTOMS DEVELOP. THESE INCLUDE BUT ARE NOT LIMITED TO THE FOLLOWING:

Aggressive measures to prevent septic shock and death Antibiotics, analgesics, and antipyretics administration as

ordered Oral hydration IV hydration and antibiotic administration using strict

aseptic technique. Prevent chilling Pressure and cool compresses to sites of bleeding Blood or blood product replacement Protection from injury Promotion of self-care, within limitations Encourage therapeutic communication Support for client to conserve strength and allow for rest Emotional and psychological support for client and family

INFECTION Microbial contamination of the cannula or

infusate Signs/symptoms: redness and swelling at the

site; possible exudate of purulent material; increased quantity of white blood cells; elevated temperature

*Nursing Assessment Assess for signs and symptoms of systemic

infection and sepsis.

*NURSING MANAGEMENT

Discontinue the infusion. Start the IV elsewhere with new infusate and

tubing. The infection control department must be

notified. The cannula, connection sites, tubing, and

infusate should be cultured. Administer antibiotics and analgesics as

ordered.

CELLULITIS diffuse inflammation of connective tissue with

severe inflammation of dermal and subcutaneous layers of the skin

Signs/Symptoms Etiology/Contributing Factors : Diffuse inflammation and infection of cellular

and subcutaneous connective tissue Fever Chills Malaise

Pain Induration Site feels warm Edema: localized with poorly defined borders

that spreads to surrounding areas by way of watery seepage that extends along tissue spaces

If severe, abscess formation and ulceration of body’s deeper tissues

Evidence of lymphatic system involvement identified by red streaks on the skin over the vessels

Vesicles may form and there is often purulent exudate

*NURSING ASSESSMENT

The nurse must assess for circulatory competence by checking for capillary refill and pulses proximal and distal to the area.

Assess for signs and symptoms of systemic infection and sepsis.

*NURSING MANAGEMENT

Discontinue the infusion. Start the IV elsewhere. Elevate extremity to reduce edema. Alternate cool compresses with warm, moist

compresses to promote circulation, depending on medical directives and agency protocols.

Apply meticulous hand hygiene. Wear gloves when tending to cellulites. Apply sterile dressings. Assist physician with incision and drainage of

abscess, if necessary. Administer antibiotics and analgesics as ordered.

FLUID OVERLOAD & PULMONARY EDEMA

Caused by infusing excessive amounts of isotonic or hypertonic crystalloid solutions tot rapidly, failure to monitor the IV infusion or too-rapid infusion of any fluid in a patient compromised by cardiopulmonary or renal disease

S/S: restlessness, headache, increased in pulse rate, weight gain over a short period of time, cough, presence of edema, hypertension, wide variance between intake and output, distended neck veins, SOB

*NURSING MANAGEMENT

Prevention: monitor I&O, be aware of client history. Carefully monitor infusion flow rates, may need to use pump or volutrol or hang smaller bags.

Treatment: slow IV down, do assessment, elevate HOB, call MD. MD may order Lasix.

AIR EMBOLISM Air entering the central vein, which is quickly

trapped in the blood as it flows forward. Prevention is the key.

S/S: complaints of palpitations, lightheadedness and weakness, pulmonary findings: dyspnea, cyanosis, tachypnea, expiratory, wheezes, cough, and pulmonary edema. Cardiovascular: “mill wheel” murmur; weak, thready pulse; tachycardia; substernal chest pain; hypotension; and jugular venous distention. Neurologic findings: change in mental status, confusion, coma, anxiousness, and seizures

*NURSING MANAGEMENT

Prevention: be sure connections are tight, lure locks should be tight.

Treatment: clamp central line and get new tubing.

SPEED SHOCK Occurs when a foreign substance usually a

medication is rapidly introduced into the circulation

S/S: dizziness, facial flushing, headache, tightness in the chest, hypotension, irregular pulse, progression of shock.

Prevention: use a pump. Treatment: show IV down and call MD.

NERVE, TENDON, AND LIGAMENT DAMAGE

Signs/Symptoms Etiology: Tingling , numbness, loss of sensation, loss of

movements, cyanosis, pallor, deformity, paralysis

Contributing factors: Incorrect insertion and placement of the IV

cannula Improper securing and stabilization of the

cannula and infusion line

*NURSING ASSESSMENT

The nurse must assess for circulatory competence by checking for capillary refill and pulses in the extremity where the IV is in place.

Assess for movement and sensation in the extremity.

*NURSING MANAGEMENT

Access the appropriate vein for infusion therapy.

Avoid moving the cannula back and forth in the subcutaneous tissue in an attempt to find a vein.

CATHETER AND NEEDLE DISPLACEMENT

Catheter or needle displacement usually occurs because:

The cannula was inadequately secured after its insertion into the vein.

The tape around the site becomes loose or detaches from the skin.

When infiltration occurs, the cannula can be physically pushed out of its position in the vein from the pressure of the fluid in the tissues surrounding the needle or catheter.

Cannulas that are placed in the radial or metacarpal veins can easily become dislodged or pulled out during routine movements.

*NURSING ASSESSMENT

Prior to inserting an IV cannula, the nurse must make a detailed assessment of the client’s level of consciousness, activity, movement, and comprehension of the need for infusion therapy. By using the most appropriate site and the correct type of tape and dressing, the IV device should remain intact. The dressing should allow for frequent inspection of the site so that any change in cannula position can be expediently recognized.

*NURSING MANAGEMENT

Remove the IV device. Apply appropriate treatment to the site of

displacement. Restart the IV at another site.

OCCLUSION AND LOSS OF PATENCY

Infusion stops running. Infusion site pain, in spite of normal appearance Backflow of venous blood into the cannula tubing (when

the infusate runs out and is not immediately replaced)—if left unchecked, the backed-up blood will clot and the IV line may be lost.

Tubing that is kinked or bent because the client has rolled over onto it

Insertion of IV device near a joint, such as the antecubital space

Client, visitors, or untrained personnel manipulating the line

Line is changed from an electronic infusion device to gravity flow (such as during showering or ambulation)

Line is kept open at too slow a rate, causing the fluid flow to cease (especially if the client is hypertensive)

Loss of gravitational flow that is overtaken by venous pressure

Damage to the intima of the vein during cannulation, precipitating platelet attachment to the injured area and obstructing flow

Use of too large a cannula to access the vein (so the tip of the catheter presses against the wall of the vein)

Improper routine flushing for veins kept open with intermittent infusion devices

Loss of patency can easily be prevented. The nurse can usually maintain the integrity of the IV thorough assessment of the client’s position, the IV site, and the flow of infusate through the IV tubing.

*Nursing Management If an obstruction occurs, despite all measures

to prevent the loss of patency, the nurse must intervene appropriately. If there are no problems with the position of the cannula, the taping, the tubing, or the height of the infusate (which should be maintained at 36 inches above the IV site) but the flow is impeded, the nurse should try the following:

Using the fingertips, pinch the IV tubing open and closed or gently milk it in an attempt to free a cannula tip that is positioned against the vein wall and obstructing flow.

If the fluid still doesn’t infuse properly, attempt to irrigate the line with normal saline in a 3 or 5 ml syringe (2 ml of normal saline (NS) in a 3 ml syringe; 3–4 ml in a 5 ml syringe ). Should there be any resistance when light pressure is applied to the plunger, stop.

Discontinue the IV, and restart the infusion in another location.