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surrounding tissues. Clinical Manifestations Swelling, blanching, and coolness of surrounding skin and tissue. Discomfort, depending on nature of solution. Fluid flowing more slowly or ceasing. Absence of blood backflow in intravenous catheter and tubing. Nursing Interventions: 1.) Stop the infusion immediately and remove the intravenous needle or catheter. 2.) Restart the intravenous in the other arm. 3.) If infiltration is moderate to severe, apply warm, moist compresses and elevate the limb. 4.) If a vasoconstrictor agent (eg, norepinephrine bitartrate, dopamine) or vesicant has infiltrated, initiate emergency local treatment as directed. Serious tissue injury, necrosis, and sloughing may result if actions are not taken. 5.) Document interventions and assessments. Preventive Measures Make sure that the intravenous and the distal tubing are secured sufficiently with tape to prevent movement. Splint the patient’s arm or hand as necessary. Check the intravenous site frequently for complications.
THROMBOPHLEBITIS Causes Injury to vein during venipuncture, largebore needle or catheter use, or prolonged needle or catheter use. Clinical Manifestations Preventive Measures
Tenderness at first, Anchor the needle or catheter securely at then pain along the the insertion site. vein. Change the insertion site every 72hours Swelling, warmth, in adult patients (it may not be feasible to and redness at remove short-term catheters in neonates infusion sites; the and pediatric patients every 72 hours; Irritation to vein due vein may appear as however, they should be removed to rapid infusions or a red streak above immediately if contamination or
Use strict sterile technique when inserting the intravenous or changing the intravenous dressing. BACTEREMIA Causes Underlying phlebitis. which rapidly dilutes the irritant.) Follow the moist. smaller veins are more susceptible. vomiting equipment or Elevated white infused solutions blood cell (WBC) Prolonged count placement of an intravenous device Malaise. strong acids or alkalis. Use large veins for irritating fluid because of higher blood flow.) Apply cold compresses immediately to relieve pain and inflammation. 3. container) headache . potassium. Clinical Manifestations Elevated temperature. Change the insertion site every 72 hours in an adult patient and within 48 hours if catheter was placed in an emergent situation. (eg.) Document interventions and assessment.irritating solutions the insertion site. 2. Peripheral (short-term) catheters placed during an emergency where aseptic techniques could have been compromised should be removed no later than 48 hours. Nursing Interventions: complications are suspected). hypertonic glucose solutions. chills Preventive Measures Follow the same measures as outlines for thrombophlebitis. solution Backache. increased (catheter or needle. Clot formation at the end of the needle or catheter due to slow infusion rate. warm compresses to stimulate circulation and promote absorption. pulse tubing. 1. Contaminated Nausea. Sufficiently dilute irritating agents before infusion. Solutions should never hang longer than 24 hours. More commonly seen with synthetic catheters than steel needles. cytotoxic agents. and others).
5. May progress to Change continuous intravenous septic shock with administration sets no more frequently than profound every 72 hours and intermittent intravenous hypotension administration sets every 24 hours.) Gauze dressing that prevents redness. b. Possible signs of Change intravenous dressing on a routine local infection at basis and immediately if it becomes intravenous compromised.) Transparent semipermeable dressing on central line sites should be changed at least every 7 days. . Maintain skin integrity of the infusion set. A critically ill or immunosuppressed patient is at greatest risk of bacteremia. foul visualization of the site should be drainage) changed every 48 hours. CVP. and immediately sent to the laboratory for analysis.) Transparent semipermeable dressing on peripheral short-term site should be changed at site change or if the dressing loses its integrity.) Start appropriate antibiotic therapy immediately after receiving orders. insertion site (eg. wound). sputum. Be particularly vigilant in the high-risk patient. 2. Nursing Interventions: 1. 3. Crosscontamination by the patient with other infected areas if the body. pain. and assess for the other sites of infection (urine.) Obtain WBC count. CIRCULATORY OVERLOAD Clinical Causes Manifestations Delivery excessive amounts of Increased pulse of Increased BP Preventive Measures and Know whether patient has existing heart or kidney condition. placed in a dry sterile container. as directed. 6. reassure the patient. 4.) Intravenous device should be removed and the tip cut off with sterile scissors. a.) Document interventions and assessments.) Check vital signs.) Discontinue infusion and intravenous cannula.Nonsterile intravenous insertion or dressing change. c.
Clear all air from tubing before infusion to elevated heart rate patient. when air enters catheter during tubing changes (air sucked in during inspiration due to negative intrathoracic pressure) Clinical Manifestations Preventive Measures Drop in BP. Cyanosis. or patients with cardiac or renal insufficiency) venous distension (engorged jugular Closely monitor the infusion flow rate. coughing Pulmonary crackles Chest pain (if history of coronary artery disease) Splint the arm or hand if the intravenous flow rate fluctuates too widely with movement. status. in this . tachypnea. 3. infused by infusion pump.) Immediately turn the patient on his left side and lower the head of the bed. tachypnea Rise in CVP Change solution containers before they run dry. loss of consciousness Use precipitate and air-eliminating filters unless contraindicated.) Monitor closely for worsening condition. AIR EMBOLISM Causes A greater risk exists in central venous lines. 2. Nursing Interventions: 1. Ensure that all connections are secure. veins) Headache. Air in tubing delivered by Change intravenous tubing during intravenous push or expiration. anxiety Shortness of breath. Always use luerlock connections on Changes in mental central lines. Nursing Interventions: 1.) Slow infusion to a “keep-open” rate and notify the health care provider. infants.) Raise the patient’s head to facilitate breathing. Keep accurate intake and output records.intravenous fluid (greater risk exists for elderly patients.
catheter or needle regulator sounding Infiltration of May be signs of local intravenous cannula irritation—swelling. 7.) position.) 4.) 3.) Elevate or lower needle to prevent occlusion of bevel. Sluggish intravenous patency and kinking.) If an electronic flow-rate regulator is in use. Document interventions and assessments. remove the needle or catheter and restart infusion. 2.) Pull back the cannula because it may be lying against wall of vein. cutting off fluid flow flow Secure the intravenous well with tape Clot at the end of the Alarm of flow and an arm board. Reassure the patient. MECHANICAL FAILURE (SLUGGISH INTRAVENOUS FLOW) Causes Clinical Manifestations Preventive Measures Needle lying against Check the intravenous often for the side of the vein.) Remove tape and check for kinking of tubing or catheter. vein valve. air will rise to right atrium. 4. if necessary. Administer oxygen as needed. 3. HEMORRHAGE Causes Clinical Manifestations Preventive Measures Cap all central lines with luer-lock adapters and connect luer-lock tubing to the cap—not directly to the line. Tape all catheters securely—use Loose connection of Oozing or trickling of tubing or injection port blood from intravenous site or Inadvertent removal of catheter peripheral or central .) 5.) Move the patient’s arm to new position.) Lower the solution container to below the level of patient’s heart and observe for blood backflow. or vein bifurcation.) If none of the preceding steps produces the desired flow. 5. coolness of skin Kinking of the tubing or catheter Nursing Interventions: 1. Notify the health care provider immediately. check its integrity.2. 6.
) Heat c. 2.) Reassure the patient and institute appropriate therapy: a.) Stop fluids immediately and notify health care provider.) Elevation of affected extremities d. Tape the remaining catheter lumens and tubing in a loop so tension is not directly on the catheter.) Nursing Interventions: 1. Keep pressure on sites where catheters have been removed (a minimum of 10 minutes for a patient taking anticoagulants). intravenous infusion or inability to draw Ensure superior vena cava catheter tip blood from the placement for irritating solutions. Infection along central line catheter may preclude this Swelling and pain in syndrome the area of catheter or in the extremity Clot formation proximal to the around the intravenous line.catheter Hematoma Anticoagulant therapy transparent dressing when possible for peripheral and central catheters. catheter (This clot will eventually occlude the vein.) Antibiotics . VENOUS THROMBOSIS Clinical Causes Manifestations Infusion irritating solutions Preventive Measures of Slowing of Ensure proper dilution of irritating substances.) Anticoagulants b.
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