Comment

ntravenous (IV) therapy should not be

painful; it is a necessary method of delivering
life-saving treatments with an immediate
therapeutic effect and indicated for those
drugs limited to the IVroute. It is a common
procedure (Dougherty, 2008a; Endacott et al,
2009; Higginson and Parry, 2011) and more
than 80% of patients admitted to hospital will
require IV cannulation (Dougherty, 2008b;
Ingram and Murdoch, 2009). This route of
administration carries with it a high risk to the
patient (Ogston-Tuck, 2011).
Although the majority of patients will only
have a vascular access device (VAD) inserted
for a few hours or days, others may require
IVtherapy for a greater length of time (Gabriel,
2008). In comparison with other parenteral
routes, the IVroute carries with it many risks.
Therefore when pain is reported, it should
not be ignored as often this is an indication of
an associated risk such as occlusion, phlebitis
or infection (Gabriel, 2006) that can lead to
devastating patient injuries. As the number of
patients with peripheral IVcatheters increases
each year, patient safety is the main goal for
those who are responsible for inserting these
devices, monitoring existing IV sites, and
administering IVtherapy.
Cannulation in itself is not without risk and
is the most commonly performed invasive
procedure (Dougherty, 2008a). For patients,
this can be uncomfortable, distressing and even
painful. Higher pain distress results with failed
IV insertions have been reported (Jacobson,
1999) and where the patient has had a previous
negative experience or is needle-phobic, this too
can heighten their pain response (Dougherty,
2008a). Pain is defined as an unpleasant sensory
experience. It is subjective, and it is personal.
More importantly, it is a warning sign and a
means of defence through nociceptive receptors.
However, the IVroute, once a catheter is in situ,
should not be associated with pain.
In order to deliver IV therapies as needed,
VADs must function without complications.
Both the vein and the catheter must remain
open and allow fluids to flow freely through
and around the device. Loss of free flow can
result from something as simple as a patients
position or from more complex causes.
Some of the most commonly recognised
complications of IV therapy include phlebitis,
occlusion, infiltration and extravasation, and
infection (Gabriel, 2008). At worst, permanent
damage to the vasculature and lifelong

S10

discomfort can result. Early recognition

can prevent complications such as these.
Complications of device insertion may include
haematoma (this often results from unsuccessful
or failed venepuncture) or infiltration of blood
(Higginson and Parry, 2011). During IVtherapy,
occlusion, phlebitis and infection can also
occur. A serious associated risk is extravascular
drug administration (extravasation).
Peripheral catheter-related phlebitis is caused
by the inflammation of the tunica intima of a
superficial vein (Gabriel, 2010; Royal College
of Nursing (RCN), 2010). The inflammation
is a result of irritation of the tunica intima
by mechanical, chemical or bacterial sources.
The most common symptoms of any form of
phlebitis are erythema and swelling along the
venous track, leading to hardened, cord-like
veins (Endacott et al, 2009). The area can feel
warm and patients may experience pain or
discomfort during drug administrationif this
pain persists between administrations, it must

When pain is reported

it should not be
ignored as often this
is an indication of an
associated risk such
as occlusion, phlebitis
or infection.

not be ignored. It is estimated that in the UK

2080% of patients with a peripheral device
develop phlebitis (Panadero et al, 2002). If left
untreated, it can lead to infection or thrombus
formation (RCN, 2010).
Although most devices are made of a
polyurethane sheath that is hypoallergenic,
mechanical phlebitis can result from the device
itself. Often this occurs from movement of
the cannula within the vein, causing friction
and subsequent inflammation (Stokowski et al,
2009).This is often the result of using a cannula
that is too big for the selected vein (Martinho
and Rodrigues, 2008), or inserting the device
near a joint or venous valve, causing irritation
to the vessel wall with the tip of the cannula
(Macklin, 2003).
Infective phlebitis is caused by the introduction
of bacteria into the vein. Infection is all too
common with IV therapy and appropriate
infection control and aseptic practice can greatly
reduce its occurrence. Poor practices during

drug administration and a higher frequency of

drug administration have been found to increase
the risk of infective phlebitis (Uslusoy and Mete,
2008). This can lead to more serious conditions
and put the patient at risk of sepsis, which can
be life-threatening.
Chemical phlebitis is caused by the drug
or fluid being infused through the cannula
(Higginson and Parry, 2011)this is less likely
in central venous devices where the high
flow rate of blood circulating rapidly dilutes
the infusion. This type of irritation of the
vein and surrounding tissue can be caused by
longer infusion times (Richardson and Bruso,
1993; Gabriel, 2008), by the composition of
the solution (i.e. pH balance or drug additive)
(Kohno et al, 2009), by the drug itself, i.e.
amiodarone (Slim et al, 2007; Martinho and
Rodrigues, 2008), and by antibiotics with a low
pH level (Macklin, 2003).
Vesicant infusions (agents that can cause tissue
damage) can result in extravasation, where
the infusion infiltrates the surrounding tissue
(Gabriel, 2006; RCN, 2010).This is serious and
can lead to severe complications, permanent
damage or injury. Phlebitis remains a significant
complication associated with amiodarone doses
exceeding 2 mg/ml via peripheral infusions
(Slim et al, 2007).
Occlusion can occur with any intravascular
device (Ogston-Tuck, 2010). The occlusion
may be inside or outside the lumen
intraluminal occlusion is more commonly
associated with reflux of blood into the lumen
and can lead to thrombus formation (Tomford
et al, 1984; Gabriel, 2008). It can also occur as
a consequence of drug or infusate precipitation
(Gabriel, 2006). This may be painful for the
patient, and early assessment is recommended.
Prevention of complications and safe
IV management and care requires assessment;
this can prevent devastating patient injuries
(Higginson and Parry, 2011). All patients with
an IV access device should have the access
site checked every shift for signs of phlebitis
(Gallant and Schultz, 2006; LaRue and Peterson,
2011) and more often if warranted. Frequent
and thorough assessment for the patient and
treatment is vital, to determine the source of
pain and rule out associated complications.
Pain is a warning sign where complications
such as phlebitis or irritation occur at/near
the insertion site, and is often an associated
symptom where infection or other reactions
occur in relation to the device or treatment.

British Journal of Nursing, 2014 (IV Therapy Supplement), Vol 23, No 2

2014 MA Healthcare Ltd

Patient safety and pain in IV therapy

Nurses need to ensure that they regularly

update their skills and knowledge to ensure
patients receive appropriate advice and care
(Gabriel, 2008). Specialist knowledge and
training, as was once the norm in practice with
IV therapy teams (Tomford et al, 1984), can
decrease the overall incidence of phlebitis and
other serious complications. Correct flushing
technique can minimise the potential for
intraluminal VAD occlusion as a consequence
of drug or infusate precipitation (Gabriel, 2010;
RCN, 2010). Design features (i.e. advanced
integrated stabilisation technology) can
minimise catheter movement, improve patient
comfort, reduce IV catheter restarts, extend
dwell times, and significantly reduce overall
complications of existing short-peripheral
IV catheters. The use of in-line filters for
the prevention of phlebitis with peripheral
IV infusions of vesicant therapies can be
effective in reducing phlebitis (Slim et al, 2007).
It is essential for nurses to be able to
identify patients who are at risk of developing
phlebitis. In turn, early recognition will enable
prompt intervention, minimising disruption to
treatment.With the exception of the emergency
situation, it is crucial that the patients
individual clinical and personal preferences
are taken into account when deciding which
VAD will be most suitable for them (Gabriel,
2008). Prevention of complications, reduction
of pain and improved comfort for patients
can result from planning care, assessment, and
wider considerations before treatment begins.
This can ensure the patient receives the most
appropriate device to match their needs, and
also ensures the potential for complications is
minimised (Gabriel, 2006).
Considerations must include the type of
infusate or drug and intended length of therapy;
the patients history; vein integrity; previous
experiences; patient choice (right or left arm)
for insertion site and device; and clinical needs
of the patient. To be inclusive of the patient is
important, so that they are part of the decisionmaking relating to their care and therefore
also involved through information-giving and
education. Further, the nurse undertaking the
cannulation, device management, administration
of IV therapy and patient monitoring and
assessment, must have the knowledge and skills
to care for the specific type of VAD being
considered for the patient (Gabriel, 2011).
Peripheral venous cannulation is a common
procedure used in hospital to deliver fluid and

L Carlier

2014 MA Healthcare Ltd

Comment

Frequent and thorough assessment is vital to determine the cause of pain and rule out associated complications

medicine and it has recognised associated risks

such as phlebitis, which can be painful. Pain is
not associated with complication-free therapy,
and patient reports of pain should be included
in the assessment and ongoing management
and care of IV therapy. Good practice with
cannula insertion and infection control should
help to prevent pain and other associated
complications. It is vital that nurses are capable
of making clinical decisions as a result of their
assessment and understanding, ensuring safe
and best practice (Ogston-Tuck, 2010). BJN
Dougherty L (2008a) Obtaining peripheral venous access. In:
Dougherty L, Lamb J, eds, Intravenous Therapy in Nursing
Practice. 2nd edn. Blackwell, Oxford
Dougherty L (2008b) Peripheral cannulation. Nurs Stand 22
(52): 49-56
Endacott R, Jevon P, Cooper P (2009) Clinical Nursing Skills,
Core and Advanced. Oxford University Press, Oxford
Gabriel J (2006) Vascular access. In: Grundy M, ed, Nursing in
Haematological Oncology. 2nd edn. Baillire Tindall, London
Gabriel J (2008) Long-term central venous access. In:
Dougherty L, Lamb J, eds, Intravenous Therapy in Nursing
Practice. 2nd edn. Blackwell, Oxford.
Gabriel J (2010) Vascular access devices: securement and
dressings. Nurs Stand 24(52): 41-6
Gabriel J (2011) Vascular device occlusion: causes, prevention
and management. Nurs Stand 25(44): 49-55
Gallant P, Schultz AA (2006) Evaluation of a visual infusion
phlebitis scale for determining appropriate discontinuation
of peripheral intravenous catheters. J Infus Nurs 29(6):
338-45
Higginson R, Parry A (2011) Phlebitis: treatment, care and
prevention. Nurs Times 107(36):18-21
Ingram P, Murdoch MF (2009) Aseptic non-touch technique
in intravenous therapy. Nurs Stand 24(8): 49-57
Jacobson AF (1999) Intradermal normal saline solution,
self-selected music, and insertion difficulty effects on
intravenous insertion pain. Heart Lung 28(2): 114-22
Kohno E, Murase S, Matsuyama K, Okamura N. (2009)

British Journal of Nursing, 2014 (IV Therapy Supplement), Vol 23, No 2 

Effects of corticosteroids on phlebitis induced by

intravenous infusion of antineoplastic agents in rabbits. Int
J Med Sci 6(4): 218-23
LaRue GD, Peterson M (2011) The impact of dilution on
intravenous therapy. J Infus Nurs 34(2): 11712
Macklin D (2003) Phlebitis, a painful complication of
peripheral IV catheterization that may be prevented. Am
J Nurs 103(2): 55-60
Martinho RFS, Rodrigues AB (2008) Occurrence of
phlebitis in patients on intravenous amiodarione. Einstein
6(4): 459-62
Ogston-Tuck S (2010) Intravenous therapy: guidance on
devices, management and care. Br J Comm Nurs 17(10):
474-84
Ogston-Tuck S (2011) Preventing infections related to
catheter occlusion. Br J Nurs 20(Sup11): S4
Panadero A, Iohom G, Taj J, Mackay N, Shorten G (2002)
A dedicated intravenous cannula for postoperative use:
effect on incidence and severity of phlebitis. Anaesthesia
57: 921-5
Richardson D, Bruso P (1993) Vascular access devices:
management of common complications. J Intraven Nurs
16(1): 44-9
Royal College of Nursing (2010) Standards for Infusion
Therapy. Royal College of Nursing, London
Slim AM, Roth JE, Dufiy B, Boyd SYN, Rubal BJ (2007)
The incidence of phlebitis with intravenous amiodarone
at guideline dose recommendations. Mil Med 172(12):
1279-83
Stokowski G, Steele D, Wilson D.l (2009) The use of
ultrasound to improve practice and reduce complication
rates in peripherally inserted central catheter insertions:
final report of investigation. J Infus Nurs 32(3): 14555
Tomford JW, Hershey CO, McLaren CE, Porter DK, Cohen
DI (1984) Intravenous therapy team and peripheral
venous catheter-associated complications: a prospective
controlled study. Arch Intern Med 144(6): 1191-4
Uslusoy E, Mete S (2008) Predisposing factors to phlebitis in
patients with peripheral intravenous catheter: a descriptive
study. J Am Acad Nurse Pract 20(4): 172-80

Sherri Ogston-Tuck

Senior Lecturer,
Institute of Health & Society,
University of Worcester
Worcester

S11

Copyright of British Journal of Nursing is the property of Mark Allen Publishing Ltd and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.