IV Complications

which pts are at risk for development of phlebitis? (6)

-pts with fragile vessels -females -old people -predisposition toward thrombosis (hypercoagulable) -high Hgb levels -pts with underlying medical disease (ex: diabetes, immunodeficiency)

complications of CVAD insertion (4)

-air embolism -pneumothorax -hemothorax -nerve damage

venous spasm treatments (2)

-apply warm compress to the site -keep infusion running

symptoms of air embolism (6)

-chest pain -dyspnea -tachycardia -hypotension -cyanosis -decreased LOC

symptoms of IV infiltration (7)

-cool skin/decreased skin temperature -damp dressing -local swelling at site -pallor -numbness -pain -slowed rate of infusion

fluid/circulatory overload: respiratory symptoms (4)

-crackles -dyspnea -wheezing -cough

symptoms of speed shock (6)

-dizziness -flushing -headache -hypotension -irregular pulse -chest pain

septicemia symptoms (4)

-fever -chills -hypotension -tachycardia

symptoms of phlebitis (3)

-heat -redness -tenderness

symptoms of catheter occlusion (3)

-inability to aspirate blood -inability to flush/infuse -sluggish slow

causes of catheter occlusion in CVADs (4)

-mechanical causes (ex: clamped catheter, kinked IV tubing) -catheter malposition -drug precipitate -thrombotic occlusion

treatment for phlebitis (4)

-remove IV -apply a warm compress -restart infusion in another extremity -monitor the site for postinfusion phlebitis for 48 hrs

symptoms of venous spasm (2)

-sharp pain at IV site -slowed infusion

To prevent air embolism during CVAD removal, the nurse should (Select all that apply): a. instruct the pt to deep breathe during the procedure b. have pt in the supine position during removal c. apply an occlusive dressing after removal d. have pt lie in bed for 1 hr after removal

b. have pt in the supine position during removal c. apply an occlusive dressing after removal

Signs and symptoms of catheter tip migration during the dwell time include: a. loss of hearing b. palpitations c. increased respiratory rate d. fever

b. palpitations

Which of the following are local complications associated with infusion therapy? a. speed shock, septicemia, and venous spasm b. phlebitis, venous spasm, and hematoma c. septicemia, thrombophlebitis, and hematoma d. phlebitis, pulmonary edema, and speed shock

b. phlebitis, venous spasm, and hematoma

You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention? a. Slow the rate to keep vein open until next bag is due at noon. b. Notify the health care provider and complete an incident report. c. Listen to the patient's lung sounds and assess respiratory status. d. Asses the patient's cardiovascular status by checking pulse and blood pressure.

c. Listen to the patient's lung sounds and assess respiratory status. (pt is at risk for circulatory overload) MS ch 16

While a solution is infusing, which of the following is a treatment for venous spasm? a. apply a cold pack to the site b. increase the flow rate of the solution c. apply a warm compress to the site d. administer pain medication

c. apply a warm compress to the site

A nurse assessing a client's IV catheter insertion site notes a hematoma. Which of the following actions should the nurse take? (Select all that apply) a. stop the infusion b. apply alcohol to the insertion site c. apply warm compress to the insertion site d. elevate the client's arm e. obtain a specimen for culture at the insertion site

c. apply warm compress to the insertion site d. elevate the client's arm -hematoma does not affect patency of the line, so it is not necessary to stop the infusion -alcohol will be uncomfortable for the pt and can increase capillary bleeding -hematoma is not a result of infection so a culture is not necessary ATI

Signs and symptoms of circulatory overload include: a. low blood pressure b. weight loss of 2 lbs over 1 day c. bounding pulse d. fever

c. bounding pulse (fluid overload = hypertension, bounding pulse)

A nurse is assessing a client's IV infusion site. Which of the following findings should the nurse identify as an indication of phlebitis? (Select all that apply) a. pallor b. dampness c. erythema d. coolness e. pain

c. erythema e. pain -pallor, dampness, coolness = infiltration ATI

You are performing a venipuncture and an ecchymosis forms over and around the insertion area, which has become raised and hardened. You are unable to advance the cannula into the vein. These are signs of: a. phlebitis b. infiltration c. hematoma d. occlusion

c. hematoma

When you assess pain and redness at a vascular access device (VAD) site, which action do you take first? a. Apply a warm, moist compress b. Monitor the pt's blood pressure c. Aspirate the infusing fluid from the VAD d. Stop the infusion and discontinue the intravenous infusion

d. Stop the infusion and discontinue the intravenous infusion (pain and redness = phlebitis) Fund ch 42

A nurse manager is reviewing the facility's policies for IV therapy with the members of his team. The nurse manager should remind the team that which of the following techniques helps minimize the risk of catheter embolism? a. performing hand hygiene before and after IV insertion b. rotating IV sites at least every 72 hr c. minimizing tourniquet time d. avoiding reinserting the needle into an IV catheter

d. avoiding reinserting the needle into an IV catheter ATI

You check an infusion site on a pt and find swelling and cool skin temperature. Also, the pt's skin appears blanched and feels rigid, and the infusion rate has slowed. These are signs of: a. phlebitis b. catheter embolus c. hematoma d. infiltration

d. infiltration

infiltration

escape of a nonvesicant medication/solution from the vein into the surrounding tissue (vesicant = medication or fluid capable of causing tissue injury, such as necrosis or tissue damage, when it escapes from the vein)

extravasation

escape of a vesicant medication/solution from the vein into the surrounding tissue (vesicant = medication or fluid capable of causing tissue injury, such as necrosis or tissue damage, when it escapes from the vein)

symptoms of IV extravasation (2)

in addition to the symptoms of infiltration: -burning or stinging at insertion site -blisters

circulatory overload

increased blood volume, often caused by transfusions or excessive IV fluid administration

pallor at IV site: phlebitis or infiltration?

infiltration

phlebitis

inflammation of the inner layer (tunica intima) of a vein

nursing interventions for thrombotic catheter occlusion

inject alteplase (tPA) into catheter and allow to dwell for 30 min then assess for blood return

thrombotic catheter occlusion

occurs when fibrin or blood within and around the CVAD slows down or disrupts catheter flow - fibrin tail, fibrin sheath

warmth at IV site: phlebitis or infiltration?

phlebitis

postinfusion phlebitis

phlebitis that appears 48-96 hrs after catheter removal

thrombophlebitis

when phlebitis (inflammation of a vein) causes the development of a clot

IV fluids have been infusing at 100mL/hr via a central line catheter in the right internal jugular approx. 24 hrs to increase urine output and maintain the client's blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on previously known data? 1. excessive bleeding 2. crackles in the lungs 3. incompatibility of the infusion 4. chest pain radiating to the left arm

2. crackles in the lungs (symptoms of fluid overload = rapid breathing, dyspnea, moist cough, and crackles) NCLEX

A nurse is caring for a client who is receiving IV therapy via peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? a. Redness at the infusion site b. Edema at the infusion site c. Warmth at the infusion site d. Oozing of blood at the infusion site

b. Edema at the infusion site -redness = phlebitis or infection -warmth = phlebitis or infection -oozing = IV system not intact ATI

treatment for extravasation (5)

-stop infusion -leave catheter in place (antidote) -apply cold compress (vasoconstriction limits dispersion of the drug) -elevate the extremity -administer antidote (if appropriate)

treatment for IV infiltration (6)

-stop infusion -remove catheter -apply a warm or cool compress depending on the solution infusing -elevate the extremity -encourage active ROM -restart infusion proximal to the site or in another extremity

fluid overload: nursing interventions (4)

-stop or slow rate of infusion (depending on severity of symptoms) -raise HOB (to facilitate breathing) -administer oxygen -administer diuretics

fluid/circulatory overload: cardiovascular symptoms (4)

-tachycardia -bounding pulse -hypertension -distended neck veins (jugular venous distention)

phlebitis scale

0 = no clinical symptoms 1 = erythema at access site with or without pain 2 = pain at access site, with erythema and/or edema 3 = pain at access site with erythema and/or edema, streak formation, and palpable venous cord 4 = pain at access site with erythema and/or edema, streak formation, palpable venous cord > 1" length, purulent drainage

The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse should document in the medical record that the client experienced which condition? 1. Phlebitis of the vein 2. Infiltration of the IV line 3. Hypersensitivity to the IV solution 4. Allergic reaction to the IV catheter material

1. Phlebitis of the vein NCLEX

A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which action(s) in the care of this client? (Select all that apply.) 1. Remove the IV catheter at the site 2. Apply warm moist packs to the site 3. Notify the health care provider 4. Start a new IV line in a proximal portion of the same vein 5. Document the occurrence, actions taken, and the client's response

1. Remove the IV catheter at the site 2. Apply warm moist packs to the site 3. Notify the health care provider 5. Document the occurrence, actions taken, and the client's response (symptoms of phlebitis) NCLEX

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The IV bag has 400 mL remaining. The nurse should take which action first? 1. slow the IV infusion 2. sit the client up in bed 3. remove the IV catheter 4. call the health care provider

1. slow the IV infusion (symptoms of circulatory overload - 1st slow infusion, then sit pt up in bed to facilitate breathing) NCLEX

The nursing is making rounds on the nursing unit to assess the conditions of assigned clients. Which assessment findings are consistent with infiltration? Select all that apply: 1. Pain and erythema 2. Pallor and coolness 3. Numbness and pain 4. Edema and blanched skin 5. Formation of a red streak and purulent drainage

2. Pallor and coolness 3. Numbness and pain 4. Edema and blanched skin NCLEX

The nurse notes that the client's intravenous (IV) site is cool, pale, and swollen and that the solution is not infusing. What is the nurse's priority action? 1. Elevate the extremity. 2. Remove the IV catheter. 3. Assess for signs of infection. 4. Decrease the rate of infusion.

2. Remove the IV catheter. (symptoms of infiltration) NCLEX

Which of the following will reduce the risk for infiltration? a. use of pumps or controllers to manage the IV rate b. avoiding placing the cannula in areas of flexion c. use of needleless systems d. use of larger-bore catheters

b. avoiding placing the cannula in areas of flexion

The nurse is assessing a client's peripheral IV site after completion of vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best? 1. check for the presence of blood return 2. remove the IV site and restart at another site 3. document the findings and continue to monitor the IV site 4. call the health care provider and request that the vancomycin be given orally

2. remove the IV site and restart at another site (symptoms of phlebitis - nurse should remove IV line and insert a new IV line at a different site, in a vein other than the one that has developed phlebitis) NCLEX

A client who is receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On assessment, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which complication has occurred? 1. Infection 2. Phlebitis 3. Infiltration 4. Thrombosis

3. Infiltration (coolness and swelling = infiltration) NCLEX

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client's intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which complication has occurred? 1. Infection 2. Phlebitis 3. Infiltration 4. Thrombosis

3. Infiltration NCLEX

A client with the recent diagnosis of myocardial infarction and impaired renal function is recuperating on the step-down cardiac unit. The client's blood pressure has been borderline low and intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 24 hours to increase renal output and maintain the blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that the client is most likely experiencing which complication of IV therapy? 1. Hematoma 2. Air embolism 3. Systemic infection 4. Circulatory overload

4. Circulatory overload NCLEX

nursing interventions for a lipid catheter occlusion

70% ethanol

A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply) A. "The temperature around the IV site is cooler." B. "The rate of the infusion increases." C. "The skin at the IV site is red." D. "The IV dressing is damp." E. "The tissue around the venipuncture site is swollen."

A. "The temperature around the IV site is cooler." D. "The IV dressing is damp." E. "The tissue around the venipuncture site is swollen." ATI Fundamentals

An intravenous (IV) fluid is infusing more slowly than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply) A.) Infiltration at vascular access device (VAD) site B.) Patient lying on tubing C.) Roller clamp wide open D.) Tubing kinked in bedrails E.) Circulatory overload

A.) Infiltration at vascular access device (VAD) site B.) Patient lying on tubing D.) Tubing kinked in bedrails Fund ch 42

A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (Select all that apply.) A. "I feel lightheaded." B. "I feel as though my heart is racing." C. "I feel a little short of breath." D. "The nurse's aide told me that my blood pressure was 150/90." E. "I think my ankles are less swollen."

B. "I feel as though my heart is racing." C. "I feel a little short of breath." D. "The nurse's aide told me that my blood pressure was 150/90." (fluid overload = tachycardia, dyspnea, hypertension) ATI Fundamentals

A nurse educator is teaching a module about preventing IV infections during new employee orientation. Which of the following statements by a newly hired nurse indicates understanding of the teaching? A. "I will leave the IV catheter in my client after the IV antibiotics are completed." B. "As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt." C. "If my client needs to use the rest room, it would be safer to disconnect his IV infusion as long as I clean the injection port thoroughly with an antiseptic swab." D. "I will replace any IV catheter when I suspect contamination during insertion."

D. "I will replace any IV catheter when I suspect contamination during insertion." ATI Fundamentals

A nurse is assessing a client who is receiving IV therapy and reports pain in his arm, chills, and "not feeling well." The nurse notes warmth, edema, induration, and red streaking on the client's arm close to the IV insertion site. Which of the following actions should the nurse plan to do first? A. Obtain a specimen for culture. B. Apply a warm compress. C. Administer analgesics. D. Discontinue the infusion.

D. Discontinue the infusion. ATI Fundamentals

speed shock

a systemic reaction that occurs when a substance is rapidly introduced into circulation

A pt states that his IV site is sore. You assess the site and note redness and swelling but no signs of palpable cord or streak. Using the criteria for infusion phlebitis, what is the severity of this phlebitis? a. 3+ b. 2+ c. 1+ d. 0

a. 2+

When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress, and the vital signs show hypotension and tachycardia. What is the nurse's priority action? a. Administer oxygen. b. Notify the physician. c. Rapidly administer more IV fluid. d. Reposition the patient to the right side.

a. Administer oxygen. (The cap off the central line could allow entry of air into the circulation, causing an air embolus. To manage an air embolus, oxygen is administered; the catheter is clamped, and the patient is positioned on the left side with the head down. Then the health care provider is notified.) MS ch 16

Assessment of a patient's peripheral IV site reveals that phlebitis has developed over the past several hours. Which intervention should the nurse implement first? a. Remove the patient's IV catheter. b. Apply an ice pack to the affected area. c. Decrease the IV rate to 20 to 30 mL/hr. d. Administer prophylactic anticoagulants.

a. Remove the patient's IV catheter. (priority intervention for superficial phlebitis is removal of the IV catheter) MS ch 37