m
m 


 


?


÷ formations resulting from the infiltration of blood
into the tissues at the venipuncture site
÷ Causes: nicking the vein during an unsuccessful
venipuncture attempt, discontinuing the I.V.
cannula or needle without pressure, applying a
tourniquet too tightly above a previously
attempted venipuncture site
÷ Signs/symptoms: black-and-blue skin
discoloration, site swelling and discomfort,
inability to advance the cannula all the way into
the vein during insertion, inability to flush the IV
line
ë NURSING ASSESSMENT
÷ Although hematoma formation cannot always be
avoided, the incidence can be reduced with
thorough assessment of the client·s skin and vein
integrity.
÷ Identification of a hematoma is fairly easy
because the area around the venipuncture site is
usually ecchymotic.
ëNURSING MANAGEMENT
÷ The method of vein cannulation may need to be
altered, especially for clients with fragile veins,
paper-thin skin, or veins that roll³those that
move laterally when manipulated. For fragile
veins, it may be necessary to enter the vein bevel-
down rather than bevel-up and not use a
tourniquet. For veins that roll, it may be
preferable to enter the vein indirectly from the
side, rather than over the vein.
÷ Once a hematoma is identified, discontinue the
IV and apply a small pressure dressing.
÷ The extremity may be elevated and warm moist
compresses applied, depending on the severity of
the hematoma and agency protocols.
M? 
÷ An inflammation of the vein in which the
endothelial cells of the venous wall
become irritated and cells roughen,
allowing platelets to adhere and
predispose the vein to inflammation-
induced phlebitis
÷ Types
a Mechanical
a Chemical
a Bacterial
a Post-infusion
÷ ›
  

inflammation caused by pathogenic organisms
÷ 6

  


caused by irritation of the venous endothelium

÷ m 
 

inflammation due to irritating or vesicant
infusates³usually those with high or low
osmolarities or those with high or low pH
÷ 6

 

inflammation resulting from physical trauma to
the intima of the vein
÷ Signs/symptoms: redness at site, site warm to
touch, local swelling, palpable cord along the
vein, sluggish infusion rate, increase in basal
temperature of 1 degree C or more
ëNURSING ASSESSMENT
÷ Know what infusates will be administered ²
expected outcomes, side effects, pH, and
osmolalities.
÷ Assess containers, tubings, and insertion devices
to be sure there are no breaks in their integrity.
÷ Assess infusates for clarity, the presence of
particulate matter, and discoloration.
÷ Assess proposed IV site, and determine whether
the intended vein is appropriate for the infusate
that will be delivered.
ëNURSING MANAGEMENT
÷ Discontinue IV, and remove cannula.
÷ Notify physician if there is fever or purulent
drainage at the IV site.
÷ Culture the catheter and IV site, per agency
policy.
÷ Apply warm compresses, per agency protocols.

÷ Restart the IV at another site, using new

infusate and tubing.
? 

÷ Catheter-related obstructions can be categorized
as mechanical or non-thrombotic ( 42% of all
obstructions) or thrombotic (58% of all
obstructions),
÷ Signs/symptoms: fever and malaise, slowed or
stopped infusion rate, inability to flush licking
device
? 
M? 
÷ Thrombosis and inflammation.
÷ Signs/symptoms: sluggish flow rate, edema in the
limbs, tender and cordlike vein, site warm to
touch, visible red line above venipunture site,
diminished arterial pulses, and mottling and
cyanosis of the extremities
ëNURSING ASSESSMENT (FOR
THROMBOSIS & THROMBOPHLEBITIS)
÷ Assess proposed IV site, and determine whether
the intended vein is appropriate for the infusate
that will be delivered.
÷ Assess extremities for warmth and tenderness.

÷ Assess for Homans· sign³pain in the calf upon

flexion of the foot.
ëNURSING MANAGEMENT FOR
THROMBOSIS AND THROMBOPHLEBITIS
÷ Prevention is the best intervention for thrombosis and
thrombophlebitis.
÷ Discontinue IV, and remove cannula.
÷ Notify physician if there is fever or purulent drainage at
the IV site.
÷ Culture the catheter and IV site, per agency policy.
÷ Apply warm compresses, per physician·s order and agency
protocols.
÷ Restart the IV at another site, using new infusate and
tubing.
÷ Apply antiembolic stockings or use sequential compression
devices (SCDs) per physician·s order.
÷ Administer anticoagulants and anti-inflammatory agents
as ordered.
÷ Initiate a balanced routine of active and passive activity
and rest.

 

÷ Inadvertent administration of a nonvesicant

solution into surrounding tissue
÷ Signs/symptoms: coolness of skin around site,
taut skin, dependent edema, absence of blood
backflow, a pinkish blood return, infusion rate
slows but the fluid continues to infuse
   

÷ The inadvertent administration of a vesicant

solution into surrounding tissue
÷ Signs/symptoms: complaints of pain or burning;
swelling proximal to or distal to the IV site;
puffiness of the dependent part of the limb; skin
tightness at the venipuncture site; blanching and
coolness of the skin; slow or stopped infusion;
damp or wet dressing
ëNURSING ASSESSMENT (INFILTRATION &
EXTRAVASATION)

÷ Pain at or near the IV site may or may not be

present, depending on the chemical nature of the
infusate, the amount of infiltration, the client·s
pain threshold, or the client·s level of
consciousness. The nurse must assess for
circulatory competence by checking for capillary
refill and pulses proximal and distal to the area.
ëNURSING MANAGEMENT FOR
INFILTRATION & EXTRAVASATION
÷ Stop the infusion.
÷ Remove the catheter or needle.

÷ Arrest any bleeding at the site with firm

pressure.
÷ Warm or cool compresses, depending on the type
and amount of infiltration, and the physician·s
order.
÷ For extravasation, the proper antidote must be
immediately initiated.
÷ Restart the IV at another site.

 M

÷ A sudden involuntary contraction of a vein or an
artery resulting in temporary cessation of blood
flow through a vessel.
÷ Signs/symptoms: sharp pain at the IV site that
travels up the arm, which is caused by a piercing
stream of fluid that irritates or shocks the vein
wall; slowing of the infusion
ëNURSING ASSESSMENT
÷ The nurse should assess for a large vein so that
blood flow is unrestricted and the infusate can be
well diluted.
÷ Assess the client·s anxiety level.

÷ Assess pain threshold.

ëNURSING MANAGEMENT
÷ Use measures to help the client relax.
÷ Use the smallest gauge cannula that will
accommodate the prescribed infusate.
÷ Administer infusates at room temperature.

÷ Dilute irritating infusates.

÷ Once spasm is identified, slow the infusion rate.

÷ Apply warm compresses to the site of spasm.

÷ Consult with the pharmacist or physician

regarding buffering irritating infusates.
÷ Discontinue the IV if spasm continues in spite of
measures used to stop it.
 M

÷ Septicemia: a febrile disease process that results
from the presence of microorganisms or their
toxic products in the circulatory system
÷ S/S: fluctuating fever, tremors, chattering teeth,
profuse cold sweat, nausea and vomiting,
diarrhea, abdominal pain, tachycardia, increased
respirations or hyperventilation, altered mental
status, hypotension
ëNURSING ASSESSMENT
÷ Assess VS and LOC.
÷ Assess for internal bleeding.

÷ Assess for DIC.

÷ Assess for pressure sore areas.

÷ Do regular head-to-toe, system-by-system

assessment for septic shock.
ëNURSING MANAGEMENT
CARE IS DIRECTED TOWARD SUPPORTING THE CLIENT AS SYMPTOMS DEVELOP. THESE
INCLUDE BUT ARE NOT LIMITED TO THE FOLLOWING:

÷ Aggressive measures to prevent septic shock and death

÷ Antibiotics, analgesics, and antipyretics administration as
ordered
÷ Oral hydration
÷ IV hydration and antibiotic administration using strict
aseptic technique.
÷ Prevent chilling
÷ Pressure and cool compresses to sites of bleeding
÷ Blood or blood product replacement
÷ Protection from injury
÷ Promotion of self-care, within limitations
÷ Encourage therapeutic communication
÷ Support for client to conserve strength and allow for rest
÷ Emotional and psychological support for client and family

 

÷ Microbial contamination of the cannula or

infusate
÷ Signs/symptoms: redness and swelling at the site;
possible exudate of purulent material; increased
quantity of white blood cells; elevated
temperature

ëNursing Assessment
÷ Assess for signs and symptoms of systemic
infection and sepsis.
ëNURSING MANAGEMENT
÷ Discontinue the infusion.
÷ Start the IV elsewhere with new infusate and
tubing.
÷ The infection control department must be
notified.
÷ The cannula, connection sites, tubing, and
infusate should be cultured.
÷ Administer antibiotics and analgesics as ordered.
 
÷ diffuse inflammation of connective tissue with
severe inflammation of dermal and subcutaneous
layers of the skin
Signs/Symptoms Etiology/Contributing Factors :
÷ Diffuse inflammation and infection of cellular
and subcutaneous connective tissue
÷ Fever

÷ Chills

÷ Malaise
÷ Pain
÷ Induration

÷ Site feels warm

÷ Edema: localized with poorly defined borders that

spreads to surrounding areas by way of watery
seepage that extends along tissue spaces
÷ If severe, abscess formation and ulceration of
body·s deeper tissues
÷ Evidence of lymphatic system involvement
identified by red streaks on the skin over the
vessels
÷ Vesicles may form and there is often purulent
exudate
ëNURSING ASSESSMENT
÷ The nurse must assess for circulatory competence
by checking for capillary refill and pulses
proximal and distal to the area.
÷ Assess for signs and symptoms of systemic
infection and sepsis.
ëNURSING MANAGEMENT
÷ Discontinue the infusion.
÷ Start the IV elsewhere.
÷ Elevate extremity to reduce edema.
÷ Alternate cool compresses with warm, moist
compresses to promote circulation, depending on
medical directives and agency protocols.
÷ Apply meticulous hand hygiene.
÷ Wear gloves when tending to cellulites.
÷ Apply sterile dressings.
÷ Assist physician with incision and drainage of
abscess, if necessary.
÷ Administer antibiotics and analgesics as ordered.
    M

 


÷ Caused by infusing excessive amounts of isotonic
or hypertonic crystalloid solutions tot rapidly,
failure to monitor the IV infusion or too-rapid
infusion of any fluid in a patient compromised by
cardiopulmonary or renal disease
÷ S/S: restlessness, headache, increased in pulse
rate, weight gain over a short period of time,
cough, presence of edema, hypertension, wide
variance between intake and output, distended
neck veins, SOB
ëNURSING MANAGEMENT
÷ Prevention: monitor I&O, be aware of client
history. Carefully monitor infusion flow rates,
may need to use pump or volutrol or hang
smaller bags.
÷ Treatment: slow IV down, do assessment, elevate
HOB, call MD. MD may order Lasix.



÷ Air entering the central vein, which is quickly
trapped in the blood as it flows forward.
Prevention is the key.
÷ S/S: complaints of palpitations, lightheadedness
and weakness, pulmonary findings: dyspnea,
cyanosis, tachypnea, expiratory, wheezes, cough,
and pulmonary edema. Cardiovascular: ´mill
wheelµ murmur; weak, thready pulse;
tachycardia; substernal chest pain; hypotension;
and jugular venous distention. Neurologic
findings: change in mental status, confusion,
coma, anxiousness, and seizures
ëNURSING MANAGEMENT
÷ Prevention: be sure connections are tight, lure
locks should be tight.
÷ Treatment: clamp central line and get new
tubing.
M ?
÷ Occurs when a foreign substance usually a
medication is rapidly introduced into the
circulation
÷ S/S: dizziness, facial flushing, headache,
tightness in the chest, hypotension, irregular
pulse, progression of shock.
÷ Prevention: use a pump.

÷ Treatment: show IV down and call MD.





 




Signs/Symptoms Etiology:
÷ Tingling , numbness, loss of sensation, loss of
movements, cyanosis, pallor, deformity, paralysis
Contributing factors:
÷ Incorrect insertion and placement of the IV
cannula
÷ Improper securing and stabilization of the
cannula and infusion line
ëNURSING ASSESSMENT
÷ The nurse must assess for circulatory competence
by checking for capillary refill and pulses in the
extremity where the IV is in place.
÷ Assess for movement and sensation in the
extremity.
ëNURSING MANAGEMENT
÷ Access the appropriate vein for infusion therapy.
÷ Avoid moving the cannula back and forth in the
subcutaneous tissue in an attempt to find a vein.
 ?  

 M



m

 
 
   
÷ The cannula was inadequately secured after its
insertion into the vein.
÷ The tape around the site becomes loose or
detaches from the skin.
÷ When infiltration occurs, the cannula can be
physically pushed out of its position in the vein
from the pressure of the fluid in the tissues
surrounding the needle or catheter.
÷ Cannulas that are placed in the radial or
metacarpal veins can easily become dislodged or
pulled out during routine movements.
ëNURSING ASSESSMENT
÷ Prior to inserting an IV cannula, the nurse must
make a detailed assessment of the client·s level of
consciousness, activity, movement, and
comprehension of the need for infusion therapy.
By using the most appropriate site and the
correct type of tape and dressing, the IV device
should remain intact. The dressing should allow
for frequent inspection of the site so that any
change in cannula position can be expediently
recognized.
ëNURSING MANAGEMENT
÷ Remove the IV device.
÷ Apply appropriate treatment to the site of
displacement.
÷ Restart the IV at another site.
 

   M


÷ Infusion stops running.

÷ Infusion site pain, in spite of normal appearance
÷ Backflow of venous blood into the cannula tubing (when the
infusate runs out and is not immediately replaced)³if left
unchecked, the backed-up blood will clot and the IV line
may be lost.
÷ Tubing that is kinked or bent because the client has rolled
over onto it
÷ Insertion of IV device near a joint, such as the antecubital
space
÷ Client, visitors, or untrained personnel manipulating the
line
÷ Line is changed from an electronic infusion device to
gravity flow (such as during showering or ambulation)
÷ Line is kept open at too slow a rate, causing the fluid flow
to cease (especially if the client is hypertensive)
÷ Loss of gravitational flow that is overtaken by
venous pressure
÷ Damage to the intima of the vein during
cannulation, precipitating platelet attachment to
the injured area and obstructing flow
÷ Use of too large a cannula to access the vein (so
the tip of the catheter presses against the wall of
the vein)
÷ Improper routine flushing for veins kept open
with intermittent infusion devices
÷ Loss of patency can easily be prevented. The
nurse can usually maintain the integrity of the
IV thorough assessment of the client·s position,
the IV site, and the flow of infusate through the
IV tubing.

ëNursing Management
÷ If an obstruction occurs, despite all measures to
prevent the loss of patency, the nurse must
intervene appropriately. If there are no problems
with the position of the cannula, the taping, the
tubing, or the height of the infusate (which
should be maintained at 36 inches above the IV
site) but the flow is impeded, the nurse should
try the following:
÷ Using the fingertips, pinch the IV tubing open
and closed or gently milk it in an attempt to free
a cannula tip that is positioned against the vein
wall and obstructing flow.
÷ If the fluid still doesn·t infuse properly, attempt
to irrigate the line with normal saline in a 3 or 5
ml syringe (2 ml of normal saline (NS) in a 3 ml
syringe; 3²4 ml in a 5 ml syringe ). Should there
be any resistance when light pressure is applied
to the plunger, stop.
÷ Discontinue the IV, and restart the infusion in
another location.