Professional Documents
Culture Documents
IV Complications
IV Complications
Cannula was inadedaquatly secured after
insertion
Tape around site becomes loose or detaches
from the skin
Insertion pulled out during transportation or
movement of the client
Catheter and Needle
Displacement
Preventative Interventions
1 of
Explain to the patient 1 insertion their role
prior
in caring for the IV
Appropriate securing of IV line
Frequent assessment of site to ensure patency
IF THE SITE BECOMES DISLODGED,
THE SITE MUST BE MOVED!
Occlusion and Loss of Patency:
Definitions and Misc. Info
Occlusion: occurs when there is some type of
blockage that interferes with the passage of
infusate into the vein. It can occur at any
point within the vein, the cannula, or the
tubing.
Occlusion and Loss of Patency
Etiology
Tubing may be kinked or bent
Transition from electric pump to gravity flow
Not saline-locking the site when infusate runs
out
Fibrin sheath formation around and over the
tip of a cannula
Too large of a cannula
Occlusion and Loss of Patency
Signs and Symptoms
Slowed rate of infusion even if clamp is
opened or height of infusate is raised
Infusion stops infusing
Infusion site pain (with normal appearance)
Blood backs up from the cannula into the IV
tubing
Occlusion and Loss of Patency:
Interventions
For prevention, flush routinely, especially
with intermittent infusion devices
Pinch the IV tubing open and closed or gently
milk it
If the above doesn't work, attempt to irrigate
the line with normal saline
Phlebitis:
Definitions and Misc. Info
Phlebitis: The inflammation of a vein
Inflammation: part of the body's normal
immune response to any type of injury or
invasion
Suppurative phlebitis: phlebitis in which pus
accumulates in the tissue
Phlebitis:
Etiology
Bacterial: Pathogenic organisms can gain
access and stimulate inflammation.
Chemical: caused by irritating or vesicant
solutions.
Mechanical: physical trauma from the skin
puncture and movement of the cannula into
the vein during insertion; any subsequent
manipulation and movement of the cannula;
clotting; or excessively large cannula.
Phlebitis:
Signs and Symptoms
Erythema at the site
Pain or burning at the site and along the
length of the vein
Warmth over the site
Edema at the site
Vein hard, red, and cord like
Slowed infusion rate
Temperature elevation on degree or more
above the baseline
Phlebitis:
Grading Criteria
1 of 2
Erythema at access site with or without pain
No symptoms
Pain at access site with erythema and/or
edema
Pain at access site with erythema and/or
edema
Streak formation
Palpable venous cord
Phlebitis:
Grading Criteria
2 of 2
Pain at access site with erythema and/or
edema
Phlebitis:
Preventative Interventions
Infusion container should be hung 36 inches
higher than the IV site
Clip body hair around the IV site, but DO
NOT SHAVE IT! Shaving may encourage
bacterial contamination.
Insertion should be performed with aseptic
technique
Phlebitis:
Interventions
At the first sign of phlebitis, the IV must be
discontinued and the cannula removed. If the
site shows fever and drainage, contact the
physician.
Warm compresses may be used, according to
agency protocol
Thrombosis and
Thrombophlebitis:
Definitions and Misc. Info
Thrombosis: the formation of a clot
Thrombophlebitis: the inflammation of a
vessel due to the development of a thrombus
Deep Vein Thrombosis (DVT): inflammation
of the larger deeper veins of the extremities
Venous Stasis: the condition wherein blood
flow is inhibited or stopped due to a clot
formation
Thrombosis and
Thrombophlebitis:
Etiology
Usually the sequela1ofof 1
phlebitis, meaning it is
a consequence of it. A clot forms when the
blood vessel becomes traumatized.
Thrombosis and
Thrombophlebitis
Signs and Symptoms
Slowed or stopped 1 of 2 rate
infusion
Aching or burning sensation at the infusion
site
Elevation in temperature on degree or more
above baseline
Skin warm and red around IV site
Cording of the infusion vein
Thrombosis and
Thrombophlebitis
Signs and Symptoms
Malaise 2 of 2
Swelling and edema of the extremity
Diminished arterial pulses
Pallor
Thrombosis and
Thrombophlebitis:
Interventions
1 ofand2 restarted elsewhere
IV must be discontinued
immediately
Physician should be consulted as to whether the
extremity should be elevated and warm, moist
compresses applied.
Physician may order antiembolic stockings
and/or the use of sequential compression devices
(SCDs)
Anticoagulants and anti-inflammatories and a
balanced routine of active and passive activity
and rest
Hematoma:
Definitions and Misc. Info
Hematoma: the accumulation of clotted blood
in the tissue interstices
Ecchymosis: a black and blue skin
discoloration
Hematoma:
Etiology
Faulty venipuncture technique, where the
cannula passes through the distal vein wall
Infiltration following cannulation of a vein
Flow control clamp for infusion is opened
before tourniquet is removed
Vessel rupture due to large cannula
Inadequate pressure applied following a
blood sampling stick or the discontinuation of
an infusion or heparin/saline lock.
Hematoma:
Signs and Symptoms
Ecchymosis over and around insertion area
Pain at the site
Swelling and hardness at the insertion site
Inability to advance the cannula all the way
into the vein during insertion
Inability to flush the IV line
Hematoma:
Interventions
IV line discontinued, and a 2X2 inch gauze
pressure dressing applied
Alcohol should not be used when removing
the cannula because it enhances bleeding and
may cause stinging
Once bleeding has stopped, the extremity
may be elevated and warm moist compresses
applied, depending on the severity
Venous Spasm:
Definitions and Misc. Info
Venous spasm: a sudden involuntary
movement or contraction of a vessel wall as a
result of trauma or irritation; usually painful.
Cramp: a strong, painful spasm
Venous Spasm:
Etiology
Administration of an irritating infusate with a
high osmolarity or a high or low pH
Delivery of cold or viscous infusates
For some patients, entrance of IV cannula,
especially if cannula is too large
Too rapid infusion of infusate
Venous spasm:
Signs and Symptoms
Slowed infusion rate
Stopped infusion rate
Severe pain from the IV site radiating up the
extremity
Blanching over the IV site
Redness over and around the IV site
Venous Spasm:
Interventions
Prevention: use a large vein and a small-
gauge cannula so that blood flow is
unrestricted and allows for dilution of the
infusate; administer fluids at room
temperature
Once it occurs:
− Decrease infusion rate
− Apply warm compress if infusate is cold
− Pharmacist should be contacted about adding a
buffer if infusate is irritating
Vessel Collapse:
Definitions and Misc. Info
Vessel collapse: the walls of a vein or artery
retract abnormally
Vessel Collapse:
Etiology
Decreased circulation, as seen with excessive
blood or fluid loss and shock
Vessel Collapse:
Signs and Symptoms
Inability to see a vein
Inability to feel a vein
Loss of vessel elasticity
Vessel feels flat or flaccid
Reduced or stopped infusion flow
Vessel Collapse:
Interventions
Restart the IV elsewhere, preferably in a larger vein
If patient is in shock a physician may need to insert
a central line
− Stay with patient
− Provide reassurance
− Assist with central venous cannulation
− Keep the patient warm
− Lower head and elevate legs to promote venous
return
− Carefully monitor vital signs
Cellulitis:
Definitions and Misc. Info
Cellulitis: the diffuse inflammation and
infection of cellular and subcutaneous tissue.
It is bacterial in nature.
Peau d'orange: site feels warm and the skin
has the roughened appearance of an orange
peel
Cellulitis:
Etiology
Invasion and multiplication of bacteria into
the IV site
Cellulitis:
Signs and Symptoms
1 of 2
Tenderness
Pain
Warmth
Edema
Induration
Red streaking on skin
Peau d'orange
Vesicles
Cellulitis:
Signs and Symptoms
2 of 2
Abscess formation with pus
Ulceration
Fever
Chills
Malaise
Cellulitis:
Interventions
Discontinue IV and start elsewhere
Physician may need to incise and drain an abscess
Limb may be elevated to reduce edema
Cool compresses to promote comfort often
alternated with war, moist compresses to promote
circulation
Sterile dressings should be used
Antibiotics, analgesics, and antipyretics are
generally administered
Nerve, Tendon, Ligament and
Limb Damage:
Etiology
Incorrect insertion and placement of the IV
cannula, or improper securing and
stabilization of the cannula and IV line after
insertion
Nerve, Tendon, Ligament and
Limb Damage:
Signs and Symptoms
Tingling
Numbness
Loss of sensation
Loss of movement
Cyanosis
Pallor
Deformity
Paralysis
Nerve, Tendon, Ligament and
Limb Damage:
Interventions
Prevent damage by properly placing the IV
line
Frequently assess the extremity in which the
IV is placed
Contamination and Infection:
Definitions and Misc. Info
Contamination: the introduction of
microorganisms or particulate matter into a
normally sterile environment
Contamination and Infection:
Breaks in asepsis during the manufacture,
packaging, and storage of infusates,
medications, and delivery systems
Break in asepsis during setup and
administration of infusion therapy
Contamination and Infection:
Signs and Symptoms
Chills
Malaise
Fever
Elevated leukocyte count
Normal appearance of IV site
Contamination and Infection:
Interventions
IV must be discontinued and move to another
site with fresh equipment
Cannula, connection sites, tubing, and
infusate should be cultured
Sepsis:
Definitions and Misc. Info
Sepsis: the (usually) febrile disease process
that results from the presence of
microorganisms or their toxic products in the
circulatory system.
Sepsis:
Etiology
Most often attributed to Staphylococcus
aureus and S. epidermidis, the Candida
albicans yeast, and the coliform species
Escherichiea, Enterobacter, and Klebsiella.
Sepsis:
Signs and Symptoms
Chills
1 of 2
Malaise
Altered mental status
Fever
Tachycardia
Tachypnea
Leukocytosis
Hypotension
Flushing
Sepsis:
Signs and Symptoms
2 of 2
S/S of Toxic Shock Syndrome:
− Malaise with generalized myalgia and arthralgia
− Vertigo
− Nausea with vomiting
− Edema of hands and feet
− Desquamation of hands and feet
Sepsis:
Interventions
Keep patient flat with legs elevated
Provide oral fluids
Keep warm
Medications as necessary to support blood
pressure, circulation, and promote comfort
Conserve strength
Administer oxygen
Analgesics and antipyretics may be given
Hypersensitivity: Info
Hypersensitivity: the profound physiologic
response of the body to an antigen
Allergy: acquired abnormal immune response
to an allergen following sensitization
Hypersensitivity:
Certain people are especially drug sensitive;
others are simply allergic to some specific
medications
Hypersensitivity:
Signs and Symptoms
1 of 5
Facial edema
Generalized edema
Erythema along veins
Palpitations
Hypotension
Cardiac arrest
Dysphagia
Gastric cramping
Hypersensitivity:
Signs and Symptoms
2 of 5
Intestinal cramping
Nausea
Vomiting
Flushing
Red flare
Rash
IV site edema
Pruritis
Hypersensitivity:
Signs and Symptoms
3 of 5
Urticaria (hives)
Agitation
Anxiety
Confusion
Disorientation
Headache
Paresthesias
Vertigo
Hypersensitivity:
Signs and Symptoms
4 of 5
Nasal congestion
Rhinorrhea (runny nose)
Cough
Sensation of tightness in throat
Mucous membrane edema
Wheezing
Bronshospasm
Respiratory obstruction
Hypersensitivity:
Signs and Symptoms
5 of 5
Respiratory arrest
Watery eyes
Scratchy throat
Tinnitus
Buzzing sound in ears
Throbbing sensation in ears
Tingling/numbness in fingers and /or toes
Hypersensitivity:
Interventions
At the first indication of a hypersensitivity
reaction, the nurse must either discontinue the
infusion and keep the vein open with normal
saline or, if the reaction is mild, slow th IV to a
KVO rate until further orders can be obtained.
NEVER REMOVE THE CANNULA! Vital
signs are to be taken and the physician notified.
The nurse must stay with the patient, reassure
him, and keep him warm. Emergency equipment
must be readily available. Emergency drugs are
administered according to agency policy and
physician orders.
Embolism:
Definition and Misc. Info
Embolus: an aggregate of undissolved material
in the blood that is carried by circulatory flow.
Endogenous embolus: clotted blood, tissue
particles, tumor cell mass, or fat globules
Exogenous embolus: particulate matter, liquids,
gaseous material.
Ischemia: obstruction of a vessel due to
embolus.
Infarction: an area of necrosis following the
loss of blood supply.
Embolism:
Etiology
Blood clot
Air embolism: through severed IV lines,
tubings that are not primed with infusate,
vented infusion containers that are allowed to
run dry, or disconnected and loose tubing
junctions
Catheter embolism: a portion of the catheter
breaks off
Any small, particulate matter that can enter
the bloodstream from the IV site
Embolism:
Signs and Symptoms
1 of 2
Dyspnea
Tachypnea
Cardiac arrhythmia
Hypotension
Diaphoresis
Anxiety
Substernal pressure
Embolism:
Signs and Symptoms
2 of 2
Chest pain with inhalation and exhalation
Localized decreased breath sounds
Pleural friction rub
Cough (often with hemoptysis)
Embolism:
Interventions
1 of 2
Blood clot
− Low dose heparin or oral anti-coagulants
− Plan activity and movement
− Promote comfort and gas exchange by elevating
the head of the bed, assisting with coughing and
deep breathing, administering analgesics, and
maintaining a restful environment
Embolism:
Interventions
2 of 2
Air embolism
− Mostly preventative and supportive
Catheter embolism
− Apply tourniquet above IV site
− Prepare for surgery
Speed Shock:
Definitions and Misc. Info
Speed shock: the systemic reaction to the
rapid or excessive infusion of medication or
infusate into the circulation
Speed shock:
Etiology
Flow control clamp is inadvertently left
completely open
EID (electronic infusion device) programmed
incorrectly
Speed Shock:
Signs and Symptoms
Flushing of head and neck
Feeling of apprehension
Hypertension
Pounding headache
Dyspnea
Chest pain
Chills
Loss of consciousness
Cardiac arrest
Speed Shock:
Interventions
Best intervention is prevention. Do not give a
medication without reading and following the
manufacturer's guidelines.
When it occurs:
− Slow or stop infusion
− Notify physician
− Observe for cardiac arrest