TABLE 11-5 Complications of IV Therapy
Assesment
Complication Subjective Data Objective Data Nursing Care Plan/Implementation
Infiltration-fluid infusing into surrounding tissue rather than into vessel
Pain around needle insertion
  1. Infusion rate slow
  2. Swelling, hardness, coolness, blanching of tissue at site of needle
  3. Blood does not return into tubing when bag/bottle lowered
  4. Puffiness under surface of arm
  1. Stop IV
  2. Apply warm towel to area
  3. Restart at another site
  4. Record
Thrombophlebitis -inflammatory changes in vessel; thromboemboli -the development of venous clots within the inflamed vessel
Pain along the vein
Redness, swelling around affected area (red line)
  1. Stop IV
  2. Notify physician
  3. Cold compresses or warm towel, as ordered
  4. Restart in another site
  5. Rest affected limb; do not rub
  6. Mursing care of thrombophlebitis
Pyrogenic reaction -contami- nated equipment/solution
  1. Headache
  2. Backache
  3. Nausea
  4. Anxiety
  1. Temperature increased
  2. Chills
  3. Face flushed
  4. Vomiting
  5. 1BP
  6. Cyanosis
  1. Discontinue IV
  2. Vital signs
  3. Send equipment for culture/analysis
  4. Antibiotic ointment, as ordered, at injection site
  5. Prevention: change tubing q24-48h; meticulous sterile technique; check for precipitation, expiration dates, damage to containers, tubings, etc.; refrigerate hyperalimentation fluids; discard hyperalimentation fluids that have been at room temperature for 8-12 hr and use new bag regardless of amount left in first bag (change, to prevent infection- excellent medium for bacterial growth)
Fluid overload -excessive amount of fluid infused; infants/elderly at risk
  1. Headache
  2. Shortness of breath
  3. Syncope
  4. Dyspnea
  1. Pulse increased, venous pressure
  2. Venous distention
  3. Flushed skin
  4. Coughing
  5. Respirations increased
  6. Cyanosis, pulmonary edema
  7. Shock
  1. Stop IV
  2. Semi-Fowler s position
  3. Notify physician
  4. Be prepared for diuretic therapy
  5. Preventive measures: monitor flow rate and patient’s response to IV therapy.
Air emboli -air in circulatory system
Loss of consciousness
  1. Hypotension, cyanosis
  2. Tachycardia
  3. venous pressure
  4. Tachypnea
  1. Turn on left side, with head down
  2. Administer oxygen therapy
  3. Medical emergency-call physician
Nerve damage -improper position of limb during infusion or tying limb down too tight during infusion-damage to nerve
Numbness: fingers, hands
Unusual position for limb
  1. Untie
  2. Passive ROM exercises
  3. Monitor closely for return of function
  4. Record limb status
Pulmonary embolism- blood clot enters pulmonary circulation and obstructs pulmonary artery
Dyspnea
  1. Orthopnea
  2. Signs of circulatory and cardiac collapse
  1. Slow IV to keep vein open (rate: 5-6 drops/minutes)
  2. Notify physician
  3. Medical emergency
  4. Be prepared for lifesaving measures and anticoagulation therapy