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22 terms

IV problems

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Infiltration: Definition and Causes
Definition: The escape of fluid into the subcutaneous tissue.
Causes: Dislodged needle Penetrated vessel wall.
Infiltration: Signs and Symptoms
Signs and Symptoms:
Swelling, pallor, coldness or pain around the infusion site Significant decrease in flow rate.
Infiltration: Nursing considerations
Nursing Considerations:
Check the infusion site often for symptoms.
Discontinue the infusion.
Restart the infusion at a different site.
Limit the movement of the extremity with the IV
Phlebitis: Definition and Causes
Definition: An inflammation of a vein.
Causes: Mechanical trauma from needle or catheter.
Chemical trauma from solution.
Septic (due to contamination)
Phlebitis: Signs and Symptoms
Signs and Symptoms: Local, acute tenderness
Redness
Warmth
Slight edema of the vein above the insertion site
Phlebitis: Nursing consideration
Nursing Considerations:
Discontinue the infusion immediately.
Apply warm, moist compresses to the affected site.
Avoid further use of the vein.
Restart the infusion in another vein.
Thrombus: Definition and Causes
Definition: A blood clot
Causes: Tissue trauma from needle or catheter
Thrombus: Signs and symptoms
Signs and Symptoms:
Local, acute tenderness
Redness
Warmth
Slight edema of the vein above the insertion site
IV fluid flow may cease if clot obstructs needle.
Thrombus: Nursing considerations
Nursing Considerations:
Stop the infusion immediately.
Apply warm compresses as ordered by the physician.
Restart the IV at another site
Do not rub or massage the affected area.
Speed shock: Definition and Causes
Definition: The body's reaction to a substance that is injected into the circulatory system too rapidly.
Causes: Too rapid a rate of fluid infusion into circulation.
Speed shock: Signs and Symptoms
Signs and Symptoms:
Pounding headache
Fainting
Rapid pulse rate
Chills
Back pain
Dyspnea
Speed shock: Nursing considerations
Nursing Considerations:
If symptoms develop discontinue the infusion immediately.
Report symptoms of speed shock to the physician asap
Monitor vital signs if symptoms develop.
Use the proper IV tubing.
Use microset on all pediatric clients
Carefully monitor the rate of fluid flow.
Check the rate frequently for accuracy.
Fluid overload: Definition and Causes
Definition: The condition caused when too large a volume of fluid infuses into the circulatory system. Causes: Too large a volume of fluid infused into circulation.
Fluid overload: Signs and Symptoms
Signs & Symptoms:
Engorged neck veins
Increased blood pressure
Difficulty in breathing (dyspnea)
Fluid overload: Nursing consideration
Nursing Considerations:
If symptoms develop, slow the rate of infusion.
Notify the physician immediately.
Monitor vital signs.
Carefully monitor the rate of fluid flow.
Check the rate frequently for accuracy.
Embolus: Definition & Causes
Definition: Is any detached, traveling intravascular mass (solid, liquid, or gaseous) carried by circulation, which is capable of clogging arterial capillary beds (create an arterial occlusion) at a site distant from its point of origin.

Causes: Thrombus dislodges and circulates in the blood. Air enters the vein through the infusion line.
Embolus: Signs & Symptoms
Signs and Symptoms: Dependent on whether the embolism causes an obstruction or infarction in the circulatory system.
Embolus: Nursing consideration
Nursing Considerations:
Check the site regularly to identify signs of phlebitis.
Do not allow air to enter the infusion line.
Treat phlebitis with the utmost caution.
Report any sudden pain or breathing difficulty immediately.
Infection: Definition & Causes
Definition: An invasion of pathogenic organisms into the body.
Causes: Non-sterile technique used in starting the infusion. Improper care of infusion site. Contaminated IV solution.
Infection: Signs and Symptoms
Signs and Symptoms: Fever Malaise Pain, swelling, inflammation or discharge at IV insertion site.
Infection: Nursing considerations
Nursing Considerations:
Use scrupulous aseptic technique when starting an infusion.
Change the dressing over the site regularly.
Change IV tubing every 24 hours if agency policy permits.
Always wash hands before working with the IV.
IV therapy complications
1. Infection
2. Infiltration
3. Phlebitis
4. Speed shock
5. Fluid overload
6. Thrombus
7. Embolus