6 managing complications of ivt

8/10/2019 6 Managing Complications of IVT

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Risks1. Needlestick

injury

2. Infectious

organism

exposure


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Needlestick InjuryAn AIDS patient became agitated and tried toremove the intravenous catheters. Hospital staff

struggled to restrain the patient. During the

struggle, an IV infusion line was pulled,exposing the connector needle. A nurse

recovered the connector needle at the end ofthe IV line and attempted to reinsert it. The

patient kicked her arm, pushing the needle intothe hand of the second nurse. Three months

later, the nurse who sustained the needlestickinjury tested positive for HIV1.


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Prevention:Avoid the use of needles where safe andeffective alternatives are available.

Avoid recapping needles.

Report all needlestick and other sharpsrelated injuries to ensure that youreceive appropriate follow-up care.

Create/maintain a safe, comprehensivedisposal system.


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Infectious Organism

ExposurePrevention:

Do proper hand hygiene.Do not reuse tourniquets.

Wear gloves.

Cleanse insertion sites with therecommended solutions.


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IV Therapist, How Safe Are

You? In a CDC study, 89 percent of HCW

exposure to HIV were caused by

percutaneous injuries.As many as 40 percent of HCW who

sustain needlesticks become infected

with HBV In 2004, more than 1,000 HCW

became infected with HBV


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Occupational Risks

Associated With IV Therapy

Physical hazards;

Accidents , abrasions, contusionsand chemical exposure

Exposure to Infectious Agents


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The following list is a summary ofsome of the rules to be observed in

the workplace:HEPATITIS B vaccineSTANDARD PRECAUTIONSSHARPS AND WASTE DISPOSALPROTECTIVE

DEVICE/EQUIPMENTGLOVES

LAUNDRYCOMMUNICATING HAZARDS


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COMPLICATIONS

ASSOCIATED WITH IVT


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Mechanical

Risks

Possible

Causes

Signs/

Symptoms

Nursing

Interventions

Prevention

Measures

1. Phlebitis *Clotting at the

catheter tip

(thrombophlebitis)*Device left in the

vein too long

*Friction from

catheter

movement in the

vein

*Poor blood flow

around the

device

*Solution with

high or low pH or

high osmolarity

*Redness at

the tip of the

catheter andalong the vein

*Tenderness

at the tip of

device and

above

*Vein hard on

palpation

*Remove the

device

*Apply a warmpack

*Notify the

physician

*Document the

patients

condition and

your

interventions

*Restart the

infusion using

a larger veinfor initiating

infusate, or

restart with a

smaller-gauge

device to

ensure

adequate

blood flow

*Tape the

device

securely to

prevent

movement


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Mechanical

Risks

Possible

Causes

Signs/

Symptoms

Nursing

Interventions

Prevention

Measures

2. Infiltration *Device

dislodged

from vein or

perforatedvein

*Blanching at

site

*Continuing

fluid infusioneven when vein

is occluded,

although rate

may decrease

*Cool skin

around site*Discomfort,

burning, or pain

at site

*Feeling of

tightness at site

*Slower flow

rate

*Swelling at and

above IV site

(may extend

along entirelimb)

*Remove the

venipuncture

device

*Periodicallyassess

circulation by

checking for

pulse and

capillary refill

*Restart theinfusion in

another limb

*Notify the

physician

*Check the

IV site

frequently

(especiallywhen using

an IV pump)

*Dont

obscure the

area above

the site withtape

*Teach the

patient to

observe the

IV site and

report

discomfort,

pain or

swelling


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Mechanical

Risks

Possible

Causes

Signs/

Symptoms

Nursing

Interventions

Prevention

Measures

3.Catheter

dislodge-

ment

*Loosened tape

or tubing

snagged inbedclothes,

resulting in

partial retraction

of the catheter

*Dislodged by a

confused patientattempting to

remove it

*Catheter

backed out of

the vein*Infusate

infiltrating into

tissue

*Remove the

catheter

*Tape device

securely on

insertion*Use armboard

M h i l P ibl Si / N i P ti


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Mechanical

Risks

Possible

Causes

Signs/

Symptoms

Nursing

Interventions

Prevention

Measures

4. Severed

catheter

*Catheter

inadvertently cut

by scissors

*Reinsertion ofthe needle into

the catheter

*Leakage

from the

catheter shaft

*If the broken

portion of the

catheter is

visible, attemptto retrieve it. If

unsuccessful,

notify the

physician

*If the broken

portion of thecatheter enters

the

bloodstream,

place a

tourniquet

above the IV

site to prevent

its progression

*Notify the

physician and

radiology

department

*Avoid using

scissors around

the IV site

*Never reinsertthe needle into

the catheter

*Remove the

unsuccessfully

inserted

catheter andneedle together


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Mechanical

Risks

Possible

Causes

Signs/

Symptoms

Nursing

Interventions

Prevention

Measures

5.

Hematoma

*Leakage of

blood into tissue

*Vein punctured

through ventral

wall at time of

venipuncture

*Bruising

around

venipuncture

site

*Tenderness

at

venipuncture

site

*Remove the

venipuncture

device

*Apply

pressure and

cold

compresses to

the affectedarea

*Recheck for

bleeding

*Document the

patients

condition andyour

interventions

*Choose a vein

that can

accommodate

the size of the

intended

venous access

device

*Release thetourniquet as

soon as

successful

insertion is

achieved


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Mechanical

Risks

Possible

Causes

Signs/

Symptoms

Nursing

Interventions

Prevention

Measures

6. Venous

spasm

*Administration

of cold fluids or

blood

*Severe vein

irritation from

irritating drugs or

fluids

*Very rapid flowrate (with fluids

at room

temperature)

*Blanched

skin over the

vein

*Pain along

the vein

*Sluggish

flow rate

when theclamp is

completely

open

*Apply warm

soaks over the

vein and

surrounding

area

*Slow the flow

rate

*Use a blood

warmer for

blood or

packed red

blood cells

when

appropriate


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Mechanical

Risks

Possible

Causes

Signs/

Symptoms

Nursing

Interventions

Prevention

Measures

7.Nerve,

tendon, or

ligamentdamage

*Improper

venipuncture

technique,resulting in

injury to

surrounding

nerves,

tendons, or

ligaments*Tight taping or

improper

splinting with

arm board

*Delayed

effects,

includingparalysis,

numbness, and

deformity

*Extreme pain

(similar to

electric shockwhen nerve is

punctured)

*Numbness

and muscle

contraction

*Stop

procedure

*Notify thephysician

*Dont

repeatedly

penetratetissues with

the

venipuncture

device

*Dont apply

excessivepressure

when taping

or encircling

the limb with

tape

*Pad the arm

board and, if

possible, pad

the tape

securing the

arm board


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Mechanical

Risks

Possible

Causes

Signs/

Symptoms

Nursing

Interventions

Prevention

Measures

8.Circulatoryoverload *Flow rate toorapid

*Miscalculation

of fluid

requirements

*Roller clamp

loosened toallow run-on

infusion

*Crackles*Discomfort

*Increased

blood

pressure

*Large

positive fluidbalance

(intake is

greater than

output)

*Neck vein

engorgement*Respiratory

distress

*Raise head ofthe bed

*Administer

oxygen as

needed

*Notify the

physician*Administer

medications

(probably

furosemide) as

ordered

*Use apump,

controller, or

rate minder

for elderly or

compromise

d patients*Recheck

calculations

of fluid

requirements

*Monitor the

infusionfrequently

Mechanical Possible Signs/ N rsing Pre ention


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Mechanical

Risks

Possible

Causes

Signs/

Symptoms

Nursing

Interventions

Prevention

Measures

9. Systemic

infection

*Failure to

maintain aseptic

technique during

insertion or sitecare

*Immunocompro

mised patient

*Poor taping

that permits the

access device to

move, which

can introduce

organisms into

the bloodstream

*Prolongedindwelling time

of device

*Severe

phlebitis, which

can set up ideal

conditions fororganism

*Contaminated

IV site usually

with no visible

signs ofinfection

*Fever, chills,

and malaise for

no apparent

reason

*Notify the

physician

*Administer

prescribedmedications

*Culture the site

and the device

*Monitor vital

signs

*Use

scrupulous

aseptic

techniquewhen handling

solutions and

tubings,

inserting the

venipuncture

device, and

discontinuing

the infusion

*Secure all

connections

*Change IVsolutions,

tubing, and the

access device

at

recommended

times.

Mechanical Possible Signs/ Nursing Prevention


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Mechanical

Risks

Possible

Causes

Signs/

Symptoms

Nursing

Interventions

Prevention

Measures

10.Air

embolism

*Empty solution

container

*Secondary

solutioncontainer

empties; next

container

(primary) pushes

air down line

*Disconnected

tubing

*Decreased

blood pressure

*Increased

central venouspressure

*Loss of

consciousness

*Respiratory

distress

*Unequal

breath sounds

*Weak pulse

*Discontinue the

infusion

*Place the

patient inTrendelenburgs

position to allow

air to enter the

right atrium and

disperse

through the

pulmonary

artery

*Administer

oxygen

*Notify the

physician

*Document the

patients

condition and

your

interventions

*Purge the

tubing of air

completely

beforeinfusion

*Use the air-

detection

device on the

pump or the

air-

eliminating

filter proximal

to the IV site

*Secure

connections


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Mechanical

Risks

Possible

Causes

Signs/

Symptoms

Nursing

Interventions

Prevention

Measures

11.Allergic

reaction

*Allergens such

as medications

*Bronchospas

m

*Itching

*Tearing eyes

and runny

nose

*Urticarial rash

*Wheezing

RED FLAG:

An

anaphylactic

reaction can

occur withinminutes after

exposure,

including

flushing, chills,

anxiety,

agitation,

*If reaction

occurs, stop the

infusion

immediately

*Maintain a

patent airway

*Notify the

physician*Administer an

antihistaminic

steroid, an anti-

inflammatory,

and antipyretics

drugs, asordered

*Give 0.2 to 0.5

ml of 1:1,000

aqueous

epinephrine

subcutaneously

*Obtain the

patients

allergy

history. Be

aware of

cross-

allergies

*Assist withtest dosing

*Monitor the

patient

carefully

during the

first 15minutes of

administratio

n of a new

drug


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Mechanical

Risks

Possible

Causes

Signs/

Symptoms

Nursing

Interventions

Prevention

Measures

generalized

itching,

palpitations,

paresthesia,

throbbing in

ears,

wheezing,

coughing,seizures, and

cardiac arrest

*Repeat the

epinephrine

dose at 3-

minute intervals

and as needed,

as ordered

*Administer

cortisone ifordered


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Mechanical

Risks

Possible

Causes

Signs/

Symptoms

Nursing

Interventions

Prevention

Measures

12.

Occlusion

*Blood backup in

the line when thepatient walks

*Hypercoagulabl

e patient

*Intermittent

device not

flushed*Line clamped

too long

*IV flow

interrupted

*Use mild flush

pressure duringinjection

*Dont force the

flush

*If unsuccessful,

reinsert the IV

device

*Maintain IV

flow rate*Flush

promptly

after

intermittent

piggyback

administration.

*Have the

patient walk

with his arm

folded to his

chest toreduce the

risk of blood

backup


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Mechanical

Risks

Possible

Causes

Signs/

Symptoms

Nursing

Interventions

Prevention

Measures

13.

Thrombophlebitis

*Thrombosis and

inflammation

*IV Reddened,

swollen, andhardened vein

*Severe

discomfort

*Remove the

device; restartthe infusion in

the opposite

limb if possible

*Apply warm

soaks

*Watch for IVtherapy-related

infection

(thrombi provide

an excellent

environment for

bacterial growth*Notify the

physician

*Check the

sitefrequently

*Remove the

device at the

first sign of

redness and

tenderness


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Mechanical

Risks

Possible

Causes

Signs/

Symptoms

Nursing

Interventions

Prevention

Measures

14.

Thrombosis

*Injury to the

endothelial cellsof the vein wall,

allowing platelets

to adhere and

thrombus to form

*Painful,

reddened, andswollen vein

*Sluggish or

stopped IV

flow

*Remove the

device; restartthe infusion in

the opposite

limb if possible

*Apply warm

soaks

*Watch for IVtherapy-related

infection

(thrombi provide

an excellent

environment for

bacterial growth*Notify the

physician

*Use proper

venipuncturetechniques to

reduce injury

to the vein

Mechanical Possible Signs/ Nursing Prevention


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Mechanical

Risks

Possible

Causes

Signs/

Symptoms

Nursing

Interventions

Prevention

Measures

15. Vein

irritation at

the IV site

*Solution with a

high or low pH or

high osmolarity,

such as 40mEq/L of

potassium

chloride,

phenytoin, and

some antibiotics

(such asvancomycin and

nafcillin)

*Pain during

the infusion

*Possible

blanching ifvasospasm

occurs

Rapidly

developing

signs of

phlebitis*Red skin over

the vein during

infusion

*Slow the flow

rate

*Try using an

electronic flowdevice to

achieve a

steady

regulated flow

*Dilute

solutions

before

administration. For

example,

give

antibiotics in

a 250-ml

solutionrather than

100 ml

*If the drug

has a low

pH, ask a

pharmacist ifit can be

buffered with

sodium

bicarbonate

(refer to

facility policy)


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Mechanical

Risks

Possible

Causes

Signs/

Symptoms

Nursing

Interventions

Prevention

Measures

*If long-term

therapy of an

irritating drug

is planned,

ask the

physician to

use a central

IV line


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PROCEDURAL

PROBLEMS

ASSOCIATED WITH IV

THERAPY


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Fluctuating flow rate

Runaway IV

Sluggish IV

Tubing / loose connection/

disconnection

Blood back up in tubing


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IV line obstruction/kinking

of IV tubingClogged filter

Break in aseptic technique

Leaks; due to inappropriate

device


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TROUBLESHOOTING

PROMPTLY AND

EFFECTIVELY


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I.V. therapy is the preferred mode oftreatment because of its rapid onset.

Nurses are assuming more nursing

responsibilities in I.V. therapy.More nursing time is allotted to I.V.

therapy

I.V. Therapy is a risk specialty area.


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INFUSION SLOWS DOWN ORSTOPS

1.Assess the I.V. system to locate

the problem. Start at the insertion

side. Check for infiltration,extravasation, or phlebitis.

2.Check for patency. Obstruction offlow is caused or affected by the

following factors:


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2.1 Patients limb is flexed;

patient lying on the side.

Reposition limb to release venous

pressure.

2.2 Tip of needle or cannula isagainst the vein wall. Lift or pull-

back the needle or cannula a little.

2.3 Adhesive taping maybe tootight, release every apply tapes.


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2.4. Small cannulas or tubing may kink or

fold, gently adjust.

2.5. Local edema or poor tissue perfusion

from disease can block venous flow. Transfer

I.V. line to an unaffected site.

2.6. Presence of precipitates in solution

either from incompatibility of fluids and

medications or from infusion. Replace the

entire venipuncture device and solution. Itmay expose the patient to embolism.


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3. Check the clamps. Some sets havetwo:

the roller clamp and the side clamp.

Check if both are open or if these areproperly adjusted.

4. Check the patency of the air vent;

reposition it if needed.


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5. Check fluid level: if empty replaceas prescribed. If solution is too cold, it

may cause venous spasm and

decrease the flow; keep roomtemperature regulated. Check the

spike of the set; push it more inside

the fluid bag or adjust it.


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6. Check filters: ordinary sets usuallydo not have in-line filters. If it has,

follow the manufacturers guide

instructions. Blood transfusion filtersretain blood product debris. If flow rate

decreases or stops after more than

one unit has been transfused you mayhave to change the set.


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7. Check tubings: if patient is lying on

it or if it is kinked or it may be

crimped with too tight roller clamps,release and round-up the tubing to its

original shape

8. Is gauge of the needle too small? Isfluid container too low above the

venipuncture site? Adjust it around

36-48 inches above the site.


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REFERENCES Association of Nursing Service Administrators ofthe Philippines, Inc. (ANSAP). 2000. NursingStandards on Intravenous Practice 7th EDITION.

Cahil, Matthew. I.V. Therapy made Incredibly Easy.Springhouse Corporation, Pennsylvania.

Dionne, Lynn. Manualof I.V. Therapeutics. Philips,F.A., Davis Co. Philadelphia.


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IntravenousNursing Society, Supplement toJournal of Intravenous Nursing, Jan./February1998 vol.21, Fresh Pond Square, 10 Faucett street,

Cambridge, MAO 218. Lippincott Williams and Wilkins. 2005. JUST THE

FACTS I.V. Therapy.

Nursing Journal May and July 2000.

6 managing complications of ivt

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