MANAGING COMPLICATIONS OF IV THERAPY

Risks Associated with IVT

Risks
1. Needlestick injury 2. Infectious organism exposure

Needlestick Injury
An AIDS patient became agitated and tried to remove 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 of the IV line and attempted to reinsert it. The patient kicked her arm, pushing the needle into the hand of the second nurse. Three months later, the nurse who sustained the needlestick injury tested positive for HIV1.

Prevention:
Avoid the use of needles where safe and effective alternatives are available. Avoid recapping needles. Report all needlestick and other sharps related injuries to ensure that you receive appropriate follow-up care. Create/maintain a safe, comprehensive disposal system.

Infectious Organism Exposure

Prevention: Do proper hand hygiene. Do not reuse tourniquets. Wear gloves. Cleanse insertion sites with the recommended solutions.

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

Occupational Risks Associated With IV Therapy

Physical hazards; Accidents , abrasions, contusions and chemical exposure Exposure to Infectious Agents

 The following list is a summary of some of the rules to be observed in the workplace: HEPATITIS B vaccine STANDARD PRECAUTIONS SHARPS AND WASTE DISPOSAL PROTECTIVE DEVICE/EQUIPMENT GLOVES LAUNDRY COMMUNICATING HAZARDS

COMPLICATIONS ASSOCIATED WITH IVT

Mechanical Risks 1. Phlebitis

Possible Causes

Signs/ Symptoms

Nursing Interventions

Prevention Measures *Restart the infusion using a larger vein for initiating infusate, or restart with a smaller-gauge device to ensure adequate blood flow *Tape the device securely to prevent movement

*Clotting at the *Redness at the*Remove the catheter tip tip of the device (thrombophlebitis) catheter and *Apply a warm *Device left in the along the vein pack vein too long *Tenderness at *Notify the *Friction from the tip of device physician catheter movement and above *Document the in the vein *Vein hard on patients *Poor blood flow palpation condition and around the device your *Solution with high interventions or low pH or high osmolarity

Mechanical Risks 2. Infiltration

Possible Causes *Device dislodged from vein or perforated vein

Signs/ Symptoms

Nursing Interventions

Prevention Measures

*Blanching at site *Remove the *Check the IV *Continuing fluid venipuncture site frequently infusion even device (especially when vein is *Periodically when using an occluded, assess circulation IV pump) although rate by checking for *Dont obscure may decrease pulse and capillary the area above *Cool skin around refill the site with site *Restart the tape *Discomfort, infusion in another *Teach the burning, or pain limb patient to at site *Notify the observe the IV *Feeling of physician site and report tightness at site discomfort, *Slower flow rate pain or *Swelling at and swelling above IV site (may extend along entire limb)

Mechanical Risks

Possible Causes

Signs/ Symptoms

Nursing Interventions

Prevention Measures *Tape device securely on insertion *Use armboard

3.Catheter *Loosened tape or dislodge-ment tubing snagged in bedclothes, resulting in partial retraction of the catheter *Dislodged by a confused patient attempting to remove it

*Catheter *Remove the backed out of catheter the vein *Infusate infiltrating into tissue

Mechanical Risks 4. Severed catheter

Possible Causes

Signs/ Symptoms

Nursing Interventions

Prevention Measures

*Catheter *Leakage from inadvertently cut by the catheter scissors shaft *Reinsertion of the needle into the catheter

*If the broken *Avoid using portion of the scissors around catheter is the IV site visible, attempt to *Never reinsert retrieve it. If the needle into unsuccessful, the catheter notify the *Remove the physician unsuccessfully *If the broken inserted catheter portion of the and needle catheter enters together the bloodstream, place a tourniquet above the IV site to prevent its progression *Notify the physician and radiology department

Mechanical Risks

Possible Causes

Signs/ Symptoms *Bruising around venipuncture site *Tenderness at venipuncture site

Nursing Interventions

Prevention Measures

5. Hematoma *Leakage of blood into tissue *Vein punctured through ventral wall at time of venipuncture

*Remove the *Choose a vein venipuncture that can device accommodate *Apply pressure the size of the and cold intended venous compresses to access device the affected area *Release the *Recheck for tourniquet as bleeding soon as *Document the successful patients insertion is condition and achieved your interventions

Mechanical Risks 6. Venous spasm

Possible Causes

Signs/ Symptoms

Nursing Interventions

Prevention Measures

*Administration of *Blanched skin *Apply warm *Use a blood cold fluids or blood over the vein soaks over the warmer for blood *Severe vein *Pain along the vein and or packed red irritation from vein surrounding area blood cells when irritating drugs or *Sluggish flow *Slow the flow appropriate fluids rate when the rate *Very rapid flow clamp is rate (with fluids at completely room temperature) open

Mechanical Risks 7.Nerve, tendon, or ligament damage

Possible Causes

Signs/ Symptoms

Nursing Interventions

Prevention Measures

*Improper *Delayed effects, *Stop procedure *Dont venipuncture including *Notify the repeatedly technique, paralysis, physician penetrate resulting in injury numbness, and tissues with the to surrounding deformity venipuncture nerves, tendons, *Extreme pain device or ligaments (similar to *Dont apply *Tight taping or electric shock excessive improper when nerve is pressure when splinting with punctured) taping or arm board *Numbness and encircling the muscle limb with tape contraction *Pad the arm board and, if possible, pad the tape securing the arm board

Mechanical Risks

Possible Causes

Signs/ Symptoms

Nursing Interventions

Prevention Measures

8.Circulatory overload

*Flow rate too *Crackles rapid *Discomfort *Miscalculation *Increased of fluid blood pressure requirements *Large positive *Roller clamp fluid balance loosened to allow(intake is run-on infusion greater than output) *Neck vein engorgement *Respiratory distress

*Raise head of the bed *Administer oxygen as needed *Notify the physician *Administer medications (probably furosemide) as ordered

*Use a pump, controller, or rate minder for elderly or compromised patients *Recheck calculations of fluid requirements *Monitor the infusion frequently

Mechanical Risks 9. Systemic infection

Possible Causes

Signs/ Symptoms

Nursing Interventions

Prevention Measures *Use scrupulous aseptic technique when handling solutions and tubings, inserting the venipuncture device, and discontinuing the infusion *Secure all connections *Change IV solutions, tubing, and the access device at recommended times.

*Failure to *Contaminated IV*Notify the maintain aseptic site usually with physician technique during no visible signs *Administer insertion or site of infection prescribed care *Fever, chills, medications *Immunocompromand malaise for *Culture the site ised patient no apparent and the device *Poor taping that reason *Monitor vital permits the signs access device to move, which can introduce organisms into the bloodstream *Prolonged indwelling time of device *Severe phlebitis, which can set up ideal conditions for organism growth.

Mechanical Risks 10.Air embolism

Possible Causes

Signs/ Symptoms

Nursing Interventions

Prevention Measures

*Empty solution *Decreased *Discontinue the *Purge the container blood pressure infusion tubing of air *Secondary *Increased *Place the patient completely solution container central venous in before infusion empties; next pressure Trendelenburgs *Use the aircontainer (primary) *Loss of position to allow detection pushes air down consciousness air to enter the device on the line *Respiratory right atrium and pump or the *Disconnected distress disperse through air-eliminating tubing *Unequal breath the pulmonary filter proximal sounds artery to the IV site *Weak pulse *Administer *Secure oxygen connections *Notify the physician *Document the patients condition and your interventions

Mechanical Risks 11.Allergic reaction

Possible Causes

Signs/ Symptoms

Nursing Interventions

Prevention Measures

*Allergens such as *Bronchospasm medications *Itching *Tearing eyes and runny nose *Urticarial rash *Wheezing

*If reaction *Obtain the occurs, stop the patients infusion allergy history. immediately Be aware of *Maintain a patent cross-allergies airway *Assist with *Notify the test dosing RED FLAG: An physician *Monitor the anaphylactic *Administer an patient reaction can antihistaminic carefully occur within steroid, an anti- during the first minutes after inflammatory, and 15 minutes of exposure, antipyretics drugs, administration including as ordered of a new drug flushing, chills, *Give 0.2 to 0.5 anxiety, ml of 1:1,000 agitation, aqueous epinephrine subcutaneously

Mechanical Risks

Possible Causes

Signs/ Symptoms generalized itching, palpitations, paresthesia, throbbing in ears, wheezing, coughing, seizures, and cardiac arrest

Nursing Interventions *Repeat the epinephrine dose at 3-minute intervals and as needed, as ordered *Administer cortisone if ordered

Prevention Measures

Mechanical Risks 12. Occlusion

Possible Causes

Signs/ Symptoms

Nursing Interventions *Use mild flush pressure during injection *Dont force the flush *If unsuccessful, reinsert the IV device

Prevention Measures *Maintain IV flow rate *Flush promptly after intermittent piggyback administration. *Have the patient walk with his arm folded to his chest to reduce the risk of blood backup

*Blood backup in *IV flow the line when the interrupted patient walks *Hypercoagulable patient *Intermittent device not flushed *Line clamped too long

Mechanical Risks

Possible Causes

Signs/ Symptoms

Nursing Interventions

Prevention Measures

13. *Thrombosis and *IV Reddened, Thrombophle inflammation swollen, and bitis hardened vein *Severe discomfort

*Remove the *Check the site device; restart the frequently infusion in the *Remove the opposite limb if device at the possible first sign of *Apply warm redness and soaks tenderness *Watch for IV therapy-related infection (thrombi provide an excellent environment for bacterial growth *Notify the physician

Mechanical Risks 14. Thrombosis

Possible Causes

Signs/ Symptoms

Nursing Interventions

Prevention Measures

*Injury to the *Painful, endothelial cells of reddened, and the vein wall, swollen vein allowing platelets *Sluggish or to adhere and stopped IV flow thrombus to form

*Remove the *Use proper device; restart the venipuncture infusion in the techniques to opposite limb if reduce injury possible to the vein *Apply warm soaks *Watch for IV therapy-related infection (thrombi provide an excellent environment for bacterial growth *Notify the physician

Mechanical Risks

Possible Causes

Signs/ Symptoms

Nursing Interventions

Prevention Measures *Dilute solutions before administration. For example, give antibiotics in a 250-ml solution rather than 100 ml *If the drug has a low pH, ask a pharmacist if it can be buffered with sodium bicarbonate (refer to facility policy)

15. Vein *Solution with a irritation at the high or low pH or IV site high osmolarity, such as 40 mEq/L of potassium chloride, phenytoin, and some antibiotics (such as vancomycin and nafcillin)

*Pain during the *Slow the flow infusion rate *Possible *Try using an blanching if electronic flow vasospasm device to achieve occurs a steady Rapidly regulated flow developing signs of phlebitis *Red skin over the vein during infusion

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

PROCEDURAL PROBLEMS ASSOCIATED WITH IV THERAPY

 Fluctuating flow rate Runaway IV Sluggish IV Tubing / loose connection/ disconnection Blood back up in tubing

 IV line obstruction/kinking of IV tubing Clogged filter Break in aseptic technique Leaks; due to inappropriate device

TROUBLESHOOTING PROMPTLY AND EFFECTIVELY

 I.V. therapy is the preferred mode of treatment 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.

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 of flow is caused or affected by the following factors:

WHAT TO DO WHEN INFUSION SLOWS DOWN OR STOPS

 2.1 Patients limb is flexed; patient lying on the side. Reposition limb to release venous pressure. 2.2 Tip of needle or cannula is against the vein wall. Lift or pullback the needle or cannula a little. 2.3 Adhesive taping maybe too tight, release every apply tapes.

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. It may expose the patient to embolism.

 3. Check the clamps. Some sets have two: the roller clamp and the side clamp. Check if both are open or if these are properly adjusted. 4. Check the patency of the air vent; reposition it if needed.

 5. Check fluid level: if empty replace as prescribed. If solution is too cold, it may cause venous spasm and decrease the flow; keep room temperature regulated. Check the spike of the set; push it more inside the fluid bag or adjust it.

 6. Check filters: ordinary sets usually do not have in-line filters. If it has, follow the manufacturers guide instructions. Blood transfusion filters retain blood product debris. If flow rate decreases or stops after more than one unit has been transfused you may have to change the set.

 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? Is fluid container too low above the venipuncture site? Adjust it around 3648 inches above the site.

REFERENCES
Association of Nursing Service Administrators of the Philippines, Inc. (ANSAP). 2000. Nursing Standards on Intravenous Practice 7th EDITION. Cahil, Matthew. I.V. Therapy made Incredibly Easy. Springhouse Corporation, Pennsylvania. Dionne, Lynn. Manual of I.V. Therapeutics. Philips, F.A., Davis Co. Philadelphia.

 Intravenous Nursing Society, Supplement to Journal of Intravenous Nursing, Jan./February 1998 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.