Nursing Management of Intravenous Therapy PDF

11/27/23, 4:35 AM Realizeit for Student Nursing Management of the Patient Receiving Intravenous Therapy In many settings, the ability to perform venipuncture to gain access to the venous system for administering fluids and medication is an expected nursing skill. This responsibility includes selec...

11/27/23, 4:35 AM Realizeit for Student Nursing Management of the Patient Receiving Intravenous Therapy In many settings, the ability to perform venipuncture to gain access to the venous system for administering fluids and medication is an expected nursing skill. This responsibility includes selecting the appropriate venipuncture site and type of cannula and being proficient in the technique of vein entry. The nurse should demonstrate competency in and knowledge of IV catheter placement according to the Nurse Practice Act applicable in their state and should follow the rules and regulations, organizational policies and procedures, and practice guidelines of that state’s board of nursing (Gorski, Hadaway, Hagle, et al., 2016). Managing Systemic Complications Fluid Overload Overloading the circulatory system with excessive IV fluids causes increased blood pressure and central venous pressure. Signs and symptoms of fluid overload include moist crackles on auscultation of the lungs, cough, restlessness, distended neck veins, edema, weight gain, dyspnea, and rapid, shallow respirations. Possible causes include rapid infusion of an IV solution or hepatic, cardiac, or renal disease. The risk of fluid overload and subsequent pulmonary edema is especially increased in older patients with cardiac disease; this is referred to as circulatory overload. Its treatment includes decreasing the IV rate, monitoring vital signs frequently, assessing breath sounds, and placing the patient in a high Fowler position. The primary provider is contacted immediately. This complication can be avoided by using an infusion pump and by carefully monitoring all infusions. Complications of circulatory overload include heart failure and pulmonary edema (Connelly, 2018). Air Embolism The risk of air embolism is rare but ever-present. It is most often associated with cannulation of central veins and directly related to the size of the embolus and the rate of entry. Air entering into central veins gets to the right ventricle, where it lodges against the pulmonary valve and blocks the flow of blood from the ventricle into the pulmonary arteries. Manifestations of air embolism include palpitations, dyspnea, continued coughing, jugular venous distention, wheezing, and cyanosis; hypotension; weak, rapid pulse; altered mental status; and chest, shoulder, and low back pain. Treatment calls for immediately clamping the cannula and replacing a leaking or open infusion system, placing the patient on the left side in the Trendelenburg position, assessing vital signs and breath sounds, and administering oxygen. Air embolism can be prevented by using locking adapters on all lines, filling all tubing completely with solution, and using an air detection alarm on an IV infusion pump. Complications of air embolism include shock and death. The amount of air necessary https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZsc2gfB3djkaGXwQ9ctgb2A3gz%2bCKrCW4cKwIi8CIqb… 1/7 11/27/23, 4:35 AM Realizeit for Student to induce death in humans is not known; however, the rate of entry is probably as important as the actual volume of air (Malik, Claus, Illman, et al., 2017). Infection Pyogenic substances in either the infusion solution or the IV administration set can cause bloodstream infections. Signs and symptoms include an abrupt temperature elevation shortly after the infusion is started, backache, headache, increased pulse and respiratory rate, nausea and vomiting, diarrhea, chills and shaking, and general malaise. Additional symptoms include erythema, edema, and induration or drainage at the insertion site. In sepsis, vascular collapse and septic shock may occur (Connelly, 2018). Infection ranges in severity from local involvement of the insertion site to systemic dissemination of organisms through the bloodstream, as in sepsis. Measures to prevent infection are essential at the time the IV line is inserted and throughout the entire infusion (Hugill, 2017). Managing Local Complications Local complications of IV therapy include phlebitis, infiltration and extravasation, thrombophlebitis, hematoma, and clotting of the needle (Simin, Milutinović, Turkulov, et al., 2019). Chart 10-4 provides a Nursing Research Profile about complications of peripheral IVs. Phlebitis Phlebitis, or inflammation of a vein, can be categorized as chemical, mechanical, or bacterial; however, two or more of these types of irritation often occur simultaneously. Chemical phlebitis can be caused by an irritating medication or solution (increased pH or high osmolality of a solution), rapid infusion rates, and medication incompatibilities. Mechanical phlebitis results from long periods of cannulation, catheters in flexed areas, catheter gauges larger than the vein lumen, and poorly secured catheters. Bacterial phlebitis can develop from poor hand hygiene, lack of aseptic technique, failure to check all equipment before use, and failure to recognize early signs and symptoms of https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZsc2gfB3djkaGXwQ9ctgb2A3gz%2bCKrCW4cKwIi8CIqb… 2/7 11/27/23, 4:35 AM Realizeit for Student phlebitis. Other factors include poor venipuncture technique, catheter in place for a prolonged period, and failure to adequately secure the catheter (Hugill, 2017). Phlebitis is characterized by a reddened, warm area around the insertion site or along the path of the vein, pain or tenderness at the site or along the vein, and swelling. The incidence of phlebitis increases with the length of time the IV line is in place, the composition of the fluid or medication infused (especially its pH and tonicity), catheter material, emergency insertions, the size and site of the cannula inserted, ineffective filtration, inadequate anchoring of the line, and the introduction of microorganisms at the time of insertion (Mihala, Ray-Barruel, Chopra, et al., 2018). The Infusion Nurses Society (INS) has identified specific standards for assessing phlebitis (Gorski et al., 2016); these appear in Chart 10-5. Phlebitis is graded according to the most severe presenting indication. Treatment consists of discontinuing the IV line and restarting it in another site, and applying a warm, moist compress to the affected site (INS, 2016). Phlebitis can be prevented by using aseptic technique during insertion, using the appropriate-size cannula or needle for the vein, considering the composition of fluids and medications when selecting a site, observing the site hourly for any complications, anchoring the cannula or needle well, and changing the IV site according to agency policy and procedures (Mihala et al., 2018). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZsc2gfB3djkaGXwQ9ctgb2A3gz%2bCKrCW4cKwIi8CIqb… 3/7 11/27/23, 4:35 AM Realizeit for Student Infiltration and Extravasation Infiltration is the unintentional administration of a nonvesicant solution or medication into surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate. When the solution is particularly irritating, sloughing of tissue may result. Close monitoring of the insertion site is necessary to detect infiltration before it becomes severe (Nickel, 2019; Simin et al., 2019). Infiltration is usually easily recognized if the insertion area is larger than the same site of the opposite extremity but is not always so obvious. A common misconception is that a backflow of blood into the tubing proves that the catheter is properly placed within the vein. However, if the catheter tip has pierced the wall of the vessel, IV fluid will seep into tissues and flow into the vein. Although blood return occurs, infiltration may have occurred as well. A more reliable means of confirming infiltration is to apply a tourniquet above (or proximal to) the infusion site and tighten it enough to restrict venous flow. If the infusion continues to drip despite the venous obstruction, infiltration is present. As soon as the nurse detects infiltration, the infusion should be stopped, the IV catheter removed, and a sterile dressing applied to the site after careful inspection to determine the extent of infiltration. The infiltration of any amount of blood product, irritant, or vesicant is considered the most severe (Brooks, 2018; Odom, Lowe, & Yates, 2018). The IV infusion should be started in a new site or proximal to the infiltration site if the same extremity must be used again. A warm compress may be applied to the site if small volumes of noncaustic solutions have infiltrated over a long period, or if the solution was isotonic with a normal pH; the affected extremity should be elevated to promote the absorption of fluid. If the infiltration is recent and the solution was hypertonic or had an increased pH, a cold compress may be applied to the area (Gorski et al., 2016; Odom et al., 2018). Infiltration can be detected and treated early by inspecting the site every hour for redness, pain, edema, blood return, coolness at the site, and IV fluid leaking from the IV site. Using the appropriate size and type of cannula for the vein prevents this complication. The use of electronic infusion devices (EIDs) does not cause an infiltration or extravasation; however, these devices will exacerbate the problem until the infusion is turned off. The Infusion Nursing Standards of Practice state that a standardized infiltration scale should be used to document the infiltration (Brooks, 2018; Gorski et al., 2016) (Chart 10-6). Extravasation is similar to infiltration, with an inadvertent administration of vesicant or irritant solution or medication into the surrounding tissue. Medications such as vasopressors, potassium and calcium preparations, and chemotherapeutic agents can cause pain, burning, and redness at the site. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZsc2gfB3djkaGXwQ9ctgb2A3gz%2bCKrCW4cKwIi8CIqb… 4/7 11/27/23, 4:35 AM Realizeit for Student Blistering, inflammation, and necrosis of tissues can occur. Older patients, comatose or anesthetized patients, patients with diabetes, and patients with peripheral vascular or cardiovascular disease are at greater risk for extravasation; other risk factors include high pressure infusion pumps, palpable cording of vein, and fluid leakage from the insertion site. The extent of tissue damage is determined by the concentration of the medication, the quantity that extravasated, the location of the infusion site, the tissue response, and the duration of the process of extravasation (Gorski et al., 2016; Odom et al., 2018). When extravasation occurs, the infusion must be stopped and the provider notified promptly. The agency’s protocol to treat extravasation is initiated; the protocol may specify specific treatments, including antidotes specific to the medication that extravasated, and may indicate whether the IV line should remain in place or be removed before treatment. The protocol often specifies infiltration of the infusion site with an antidote prescribed after assessment by the provider, removal of the cannula, and application of warm compresses to sites of extravasation from alkaloids or cold compresses to sites of extravasation from alkylating and antibiotic vesicants. The affected extremity should not be used for further cannula placement. Thorough neurovascular assessments of the affected extremity must be performed frequently (Gorski et al., 2016). Reviewing the institution’s IV policy and procedures and incompatibility charts and checking with the pharmacist before administering any IV medication, whether peripherally or centrally, are recommended to determine incompatibilities and vesicant potential to prevent extravasation. Careful, frequent monitoring of the IV site, avoiding insertion of IV devices in areas of flexion, securing the IV line, and using the smallest catheter possible that accommodates the vein help minimize the incidence and severity of this complication. In addition, when vesicant medication is given by IV push, it should be given through a side port of an infusing IV solution to dilute the medication and decrease the severity of tissue damage if extravasation occurs. Extravasation is rated as grade 4 on the infiltration scale. Complications of an extravasation may include blister formation, skin sloughing and tissue necrosis, functional or sensory loss in the injured area, and disfigurement or loss of limb (Gorski et al., 2016; Nickel, 2019). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZsc2gfB3djkaGXwQ9ctgb2A3gz%2bCKrCW4cKwIi8CIqb… 5/7 11/27/23, 4:35 AM Realizeit for Student Thrombophlebitis Thrombophlebitis refers to the presence of a clot plus inflammation in the vein. It is evidenced by localized pain, redness, warmth, and swelling around the insertion site or along the path of the vein, immobility of the extremity because of discomfort and swelling, sluggish flow rate, fever, malaise, and leukocytosis (Brooks, 2018). Treatment includes discontinuing the IV infusion; applying a cold compress first to decrease the flow of blood, followed by a warm compress; elevating the extremity; and restarting the line in the opposite extremity. If the patient has signs and symptoms of thrombophlebitis, the IV line should not be flushed (although flushing may be indicated in the absence of phlebitis to ensure cannula patency and to prevent mixing of incompatible medications and solutions). The catheter should be cultured after the skin around the catheter is cleaned with alcohol. If purulent drainage exists, the site is cultured before the skin is cleaned (Brooks, 2018; Hugill, 2017). Thrombophlebitis can be prevented by avoiding trauma to the vein at the time the IV line is inserted, observing the site every hour, and checking medication additives for compatibility (Gorski et al., 2016). Hematoma Hematoma results when blood leaks into tissues surrounding the IV insertion site. Leakage can result if the vein wall is perforated during venipuncture, the needle slips out of the vein, a cannula is too large for the vessel, or insufficient pressure is applied to the site after removal of the needle or https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZsc2gfB3djkaGXwQ9ctgb2A3gz%2bCKrCW4cKwIi8CIqb… 6/7 11/27/23, 4:35 AM Realizeit for Student cannula. The signs of a hematoma include ecchymosis, immediate swelling at the site, and leakage of blood at the insertion site. Treatment includes removing the needle or cannula and applying light pressure with a sterile, dry dressing; applying ice for 24 hours to the site to avoid extension of the hematoma; elevating the extremity to maximize venous return, if tolerated; assessing the extremity for any circulatory, neurologic, or motor dysfunction; and restarting the line in the other extremity if indicated. A hematoma can be prevented by carefully inserting the needle and by frequently monitoring patients who have a bleeding disorder, are taking anticoagulant medication, or have advanced liver disease (Nickel, 2019). Clotting and Obstruction Blood clots may form in the IV line as a result of kinked IV tubing, a very slow infusion rate, an empty IV bag, or failure to flush the IV line after intermittent medication or solution administrations. The signs are decreased flow rate and blood backflow into the IV tubing (Brooks, 2018). If blood clots in the IV line, the infusion must be discontinued and restarted in another site with a new cannula and administration set. The tubing should not be irrigated or milked. Neither the infusion rate nor the solution container should be raised, and the clot should not be aspirated from the tubing. Clotting of the needle or cannula may be prevented by not allowing the IV solution bag to run dry, taping the tubing to prevent kinking and maintain patency, maintaining an adequate flow rate, and flushing the line after intermittent medication or other solution administration. In some cases, a specially trained nurse or primary provider may inject a thrombolytic agent into the catheter to clear an occlusion resulting from fibrin or clotted blood (Brooks, 2018; Gorski et al., 2016). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZsc2gfB3djkaGXwQ9ctgb2A3gz%2bCKrCW4cKwIi8CIqb… 7/7