IV Complications PDF

LAKELAND COMMUNITY COLLEGE NURS 1090 COMPLICATIONS OF IV THERAPY Local Complications INFILTRATION  IV fluids leak into the tissue surrounding the vein instead of infusing in to the v...

LAKELAND COMMUNITY COLLEGE NURS 1090 COMPLICATIONS OF IV THERAPY Local Complications INFILTRATION  IV fluids leak into the tissue surrounding the vein instead of infusing in to the vein. o You will see one or more of the following around the insertion site:  Swelling  Pallor  Cool  Pain  Taut (tight) tissue/skin  Damp dressing o In addition, you may see IV flow rate:  Slow  Stop EXTRAVASATION  When a vesicant drug leaks out of the vein and into the surrounding tissue, causing tissue damage.  Nursing Interventions for Infiltration and Extravasation o Discontinue the fluid infusion o Discontinue the IV catheter o Raise the extremity (to promote venous return and decrease edema) o Apply compress  Warm, moist compress (to promote vasodilation and absorption of the fluid from the tissue; reduce pain and edema) OR  Cold compress (to promote vasoconstriction and to prevent medication from entering system)  Choose heat or cold based on medication in IV fluid that has infiltrated or facility policy PHLEBITIS/THROMBOPHLEBITIS  Inflammation of the inner lining of the vein. May be caused by mechanical or chemical irritation o Mechanical: movement of the catheter o Chemical: from IV electrolytes or medications o You will see one or more of the following: over the vein; above the insertion site (in some cases travels along the path of the vein)  Redness (erythema), warmth, swelling (edema) at the IV site  Pain, burning or throbbing along the course of the vein  Warmth along course of vein o In addition, you may see IV flow rate:  Slow  Stop   Nursing Interventions o Discontinue IV fluids o Discontinue IV catheter o Elevate the extremity o Apply warm or cold compresses to the site Systemic Complications CATHETER THAT IS DISCONTINUED IS NOT INTACT (Catheter Embolism)  This could occur if catheter was “sheared” (incorrect procedure during insertion)  Nursing Interventions o Quickly apply tourniquet above the level of the insertion site o Call the physician o Save the catheter after removal to determine the cause CIRCULATORY (Fluid) OVERLOAD  IV solution infused too rapidly or in too great an amount  S&S based on patient, age, disease process and/or type of fluid o Distended neck veins o Increased BP o Tachycardia o Shortness of breath/dyspnea o Cough o Crackles in lungs  Nursing Interventions o Reduce or stop IV flow rate and notify health care provider (follow orders) o Elevate head of bed o Assess vital signs and oxygen saturation o Adjust the rate as ordered o Administer diuretics IF ordered INFECTION (Cellulitis)  Infection at catheter insertion site o Erythema (redness) o Heat o Swelling o Possible purulent drainage  Systemic symptoms o Fever o Chills o Malaise  Nursing Interventions – Notify health care provider o Discontinue infusion & IV catheter o Culture drainage and catheter tip if ordered o Elevate extremity o Apply warm compresses   May need to administer: o Antibiotics o Analgesics o Antipyretics BLEEDING AT VENIPUNCTURE SITE  Oozing or slow continuous seepage of blood o Your will see bright red blood at insertion site  Assess IV system (are connections loose??)  Discontinue IV o If patient is on anticoagulants, be especially cautious when removing an IV. Apply pressure for several seconds to minutes to assure bleeding has stopped HEMATOMA (Ecchymosis at site)  May occur during insertion or after discontinuation  During insertion o Do not keep tourniquet on too long o Remove tourniquet prior to starting infusion  After discontinuation of IV catheter o Hold pressure over the insertion site (sterile gauze pad) until bleeding/oozing stops  May need to hold longer if patient is on anticoagulants Discontinuing IV: The procedure itself is sterile. Use a sterile gauze pad (only touch the outside of the dressing; apply the sterile side to the IV insertion site). You DO NOT need to wear sterile gloves. You wear non-sterile gloves to protect YOU from potential exposure to blood/body fluids. Hold pressure over the insertion site until you are sure the bleeding has stopped (generally 1 – 2 minutes; longer if they are on anticoagulants). F 24