Complications of IV Therapy and Nursing Management

- Complications of IV therapy are problems that may arise from inserting, maintaining, or removing an IV catheter or administering IV fluids or medications. Some of the possible complications of IV therapy and their nursing management are:

Infiltration

- Infiltration is the leakage of fluid or medication into the surrounding tissue due to dislodgement or puncture of the vein by the catheter. Signs and symptoms of infiltration include:

• Swelling, pallor, coolness, or pain at or near the insertion site
• Decreased or stopped flow rate
• Absence of blood return
• Edema or tightness of skin
• Blanching or blisters

- Nursing management for infiltration includes:

- Stop the infusion immediately and disconnect the tubing from the catheter.

- Remove the catheter gently and apply pressure to the site with gauze until the bleeding stops.

- Elevate the affected extremity above heart level to reduce swelling.

- Apply a warm or cold compress depending on the type of fluid infiltrated.

- Start a new IV line in another site, preferably on another extremity.

- Document the incident, the actions taken, and the patient’s response.

Phlebitis

- Phlebitis is the inflammation of a vein due to mechanical, chemical, or bacterial irritation from the catheter or fluid. Signs and symptoms of phlebitis include:

• Redness, warmth, tenderness, or pain along the course of the vein
• Swelling or induration at or near the insertion site
• Palpable cord along the vein
• Fever or chills
• Purulent drainage from the site

- Nursing management for phlebitis includes:

- Stop the infusion immediately and disconnect the tubing from the catheter.

- Remove the catheter gently and apply pressure to the site with gauze until bleeding stops.

- Apply a warm compress to the affected area to relieve pain and inflammation.

- Start a new IV line in another site, preferably on another extremity.

- Culture the catheter tip and the site if infection is suspected.

- Administer antibiotics, analgesics, or anti-inflammatory agents as ordered.

- Document the incident, the actions taken, and the patient’s response.

Infection

- Infection is the invasion of microorganisms into the bloodstream or the insertion site due to poor aseptic technique, prolonged use of the same catheter, or contamination of the fluid or equipment. Signs and symptoms of infection include:

• Fever, chills, malaise, or headache
• Redness, warmth, tenderness, or pain at or near the insertion site
• Purulent drainage from the site
• Swelling or induration at or near the insertion site
• Positive blood culture

- Nursing management for infection includes:

• Stop the infusion immediately and disconnect the tubing from the catheter.
• Remove the catheter gently and apply pressure to the site with gauze until bleeding stops.
• Culture the catheter tip and the site to identify the causative organism.
• Start a new IV line in another site, preferably on another extremity.
• Administer antibiotics, antipyretics, or analgesics as ordered.
• Monitor the patient’s vital signs, white blood cell count, and temperature.
• Document the incident, the actions taken, and the patient’s response.

Hematoma

- Hematoma is the collection of blood in the tissue due to puncture of an artery or a vein by the needle or catheter. Signs and symptoms of hematoma include:

• Ecchymosis or bruising at or near the insertion site
• Swelling or bulging at or near the insertion site
• Pain or discomfort at or near the insertion site
• Difficulty advancing the catheter into the vein
• Arterial blood return instead of venous blood return

Nursing management for hematoma includes:

Stop the infusion immediately and disconnect the tubing from the catheter.

Remove the catheter gently and apply pressure to the site with gauze until bleeding stops.

Apply a cold compress to the affected area to reduce swelling and pain.

Elevate the affected extremity above heart level to reduce bleeding.

Start a new IV line in another site, preferably on another extremity.

Document the incident, the actions taken, and the patient’s response.

Nerve Damage

- Nerve damage is the injury to a nerve due to compression, stretching, or puncture by the needle or catheter. Signs and symptoms of nerve damage include:

• Numbness, tingling, or burning sensation at or near the insertion site
• Sharp pain radiating along the nerve pathway
• Weakness or paralysis of the affected extremity
• Difficulty moving or flexing the affected extremity
• Loss of sensation or function of the affected extremity

- Nursing management for nerve damage includes:

• Stop the infusion immediately and disconnect the tubing from the catheter.
• Remove the catheter gently and apply pressure to the site with gauze until bleeding stops.
• Assess the neurovascular status of the affected extremity by checking the pulse, the capillary refill, the sensation, and the movement.
• Notify the physician and report the findings and the incident.
• Administer analgesics, anti-inflammatory agents, or steroids as ordered.
• Refer the patient to a neurologist or a physical therapist as needed.
• Document the incident, the actions taken, and the patient’s response.

Extravasation

- Extravasation is the leakage of vesicant fluid or medication into the surrounding tissue due to dislodgement or puncture of the vein by the catheter. Vesicants are fluids or medications that can cause severe tissue damage such as necrosis, ulceration, or blistering if they escape from the vein. Examples of vesicants include chemotherapy agents, potassium chloride, calcium chloride, sodium bicarbonate, and phenytoin. Signs and symptoms of extravasation include:

• Swelling, redness, pain, burning, or stinging at or near the insertion site
• Decreased or stopped flow rate
• Absence of blood return
• Blistering, ulceration, necrosis, or sloughing of skin
• Tissue damage that may extend to tendons, nerves, muscles, or bones

- Nursing management for extravasation includes:

• Stop the infusion immediately and disconnect the tubing from the catheter.
• Remove the catheter gently and apply pressure to the site with gauze until the bleeding stops.
• Identify the type and amount of vesicant that extravasated.
• Notify the physician and report the findings and the incident.

Administer an antidote or a neutralizing agent as ordered. Some examples of antidotes or neutralizing agents are:

- Hyaluronidase: for phenytoin, norepinephrine, dopamine, or vinca alkaloids

- Sodium thiosulfate: for cisplatin

- Dimethyl sulfoxide (DMSO): for anthracyclines

- Nitroglycerin paste: for vasopressors

- Cold compress: for vinca alkaloids, etoposide, or mitomycin C

- Warm compress: for anthracyclines, mannitol, or calcium gluconate

Apply a sterile dressing to the site and monitor for signs of tissue damage.

Document the incident, the actions taken, and the patient’s response.