Complications of IV Therapy: Infiltration Air embolus

Can occur when changing bags, or when opening the

Occurs when fluid or medication leaks out of the
vein into the tissue
Often there will be edema around the site and the
tissue will feel cool
Infusion is discontinued and another site is initiated
to continue therapy
Fluid that is in the tissue will usually reabsorb
within 24 hours
INFILTRATION
EXTRAVASATION –occurs when vesicant solution
(medication) is administered
Complications of IV Therapy: Phlebitis
Caused by irritation of the vein by the needle,
catheter, medications, or additives in the IV solution
Signs: erythema, warmth, swelling, tenderness
IV must be discontinued and another site found
Warm compresses to the inflamed site will decrease
Discomfort
Complications of IV Therapy: Bloodstream
Infection
line
of a subclavian catheter
Speed shock
Occurs when fluids or medications given by bolus
are administered too rapidly
Circulatory overload – due to rapid infusion
Trouble Shooting Intravnous Infusion
No flow is visible – determine if solution container is
empty. Check the
position of IV site, reposition extremities to
determine if flow resumes.
Unable to see drops because drip chamber is full –
close roller clamp,
invert solution container and squeeze drip chamber to
depress half of
content back into the solution chamber.
Flow rate too fast – instruct the client not to touch the
clamp. Adjust the
height of the container to achieve gravitational flow.
Solution flow is slower than desired rate – observe
for signs of venous
infiltration or phlebitis.

Occurs when infectious pathogens introduced into the Visible clots in tubing – determine if IV is positional.
bloodstream Assess splint is
constricting site. Do not attempt to remove by
May occur from breaks in sterile technique during flushing.
cannula insertion or any time the system is opened to
change the bag or tubing Large air spaces in tubing 10-15ml of air – air is
removed from tubing to
Signs and symptoms: fever, chills, pain, headache, prevent air emboli.
nausea, vomiting, extreme fatigue
Evaluation
Blood cultures ordered and aggressive antibiotic
therapy Constant assessment of the patient
is started
Evaluation of the effect of IV therapy relates to the
IV site is immediately discontinued reason
Other Complications of IV Therapy it was given

Catheter embolus If fluids are given to hydrate the patient, check for
good
Occurs when a piece of the catheter breaks off and skin turgor, adequate urine output, and moist mucous
travels membranes
in the vein until it lodges
If TPN is given, assess patient’s weight gain and
monitor
blood glucose level

When a blood product is administered, monitor the

blood
count to see if values improve

Monitor for signs/symptoms of transfusion reaction

Evaluation (cont’d)

Documentation

Documentation of IV medication is done on the

medication record. IV site is accessed every 1 to 2
hours
according to agency policy and observations are
entered
on a flow sheet or in nurses’ notes

IV fluid counted as intake and recorded on I&O sheet

Common Nursing Diagnoses for Patients

Undergoing IV Therapy

Risk for deficient fluid volume

Imbalanced Nutrition: Less than body requirements,

related to decreased oral intake

Ineffective tissue perfusion, related to loss of red

blood cells or volume