iv complications
TRANSCRIPT
IV Complications
Infiltration and Extravasation: Definitions and Misc. Info
Infiltration: the process in which a substance enters or infuses into another substance or a surrounding area. Infiltration may be an intentional or unintentional process
Extravasation: the actual unintentional escape or leakage of material from a vessel into the surrounding tissue
Vesicant: an agent that is irritating and causes blistering
Infiltration and Extravasation: Etiology
1 of 2 Puncture of distal vein wall during
venipuncture Puncture of any portion of the vein wall by
mechanical friction from the catheter/needle cannula
Dislodgement of the catheter/needle cannula from the intima of the vein
Poorly secured IV device Poor vein or site selection
Infiltration and Extravasation: Etiology
2 of 2 Improper cannula size High delivery rate or pressure of the infusate Over manipulation of the IV device, the site,
or both Irritating infusate that inflames the intima of
the vein and causes it to weaken
Infiltration and Extravasation: Signs and Symptoms
1 of 2 Pain at or near the insertion site Swelling proximal to or distal to the IV site Puffiness of the dependent part of limb or
body Taut, rigid skin around IV site Blanching and coolness of skin around IV site Damp or wet dressing Slowed infusion rate
Infiltration and Extravasation: Signs and Symptoms
2 of 2 No back flow of blood into IV tubing when
clamp is full opened and solution container is lowered below IV site
No back flow of blood into IV tubing when tubing is pinched above cannula hub
Infusion stops running The infusion continues to infuse when
pressure is applied to the vein above the tip of the cannula
Infiltration and Extravasation: Interventions
The use of warm compresses to treat infiltration has become controversial. It has been found that cold compresses may be better for some infiltrated infusates and warm compresses may be more effective for others. It has also been documented that elevation of the infiltrated extremity may be painful for the patient. To act in the best interest of the patient, following IV infiltration, consult with the physician for order regarding compresses and elevation.
Infiltration and Extravasation: Clinical Criteria
1 of 3No symptoms
Skin blanchedEdema <1 inch in any directionCool to touchWith or without pain
Skin blanchedEdema 1-6 inches in any directionCool to touchWith or without pain
Infiltration and Extravasation: Clinical Criteria
2 of 3Skin blanched, translucent
Gross edema >6 inches in any directionCool to touchMild-moderate painPossible numbness
Skin blanched, translucent
Infiltration and Extravasation: Clinical Criteria
3 of 3(continued from previous slide)
Deep pitting tissue edemaCirculatory impairmentModerate-severe painInfiltration or any amount of blood product, irritant, or vesicant
Catheter and Needle Displacement:
Definitions and Misc. Info
Displacement: cannula has shifted from it's intended placement site in the vein, or is inadvertently removed from the vein.
Catheter and Needle Displacement
Etiology1 of 1 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 Interventions1 of 1 Explain to the patient prior insertion their role
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 PatencyEtiology
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 PatencySigns 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 2Erythema 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 edemaStreak formationPalpable venous cord
Phlebitis:Grading Criteria
2 of 2Pain 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:
Etiology1 of 1 Usually the sequela of phlebitis, meaning it is
a consequence of it. A clot forms when the blood vessel becomes traumatized.
Thrombosis and Thrombophlebitis
Signs and Symptoms1 of 2 Slowed or stopped infusion rate
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 Symptoms2 of 2 Malaise
Swelling and edema of the extremity Diminished arterial pulses Pallor
Thrombosis and Thrombophlebitis:
Interventions1 of 2 IV must be discontinued and restarted elsewhere
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
1 of 2 Chills 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