Complications of IV therapy Flashcards
At or near the insertion site or as a result of mechanical failure. Occur as adverse reactions to the surrounding venipuncture site. Assessing and monitoring are the key components to early intervention. Good venipuncture is the main factor r/t the prevention of most ___ complications associated with IV therapy. Hematoma, thrombosis, phlebitis, thrombophlebitis, infiltration, extravasation, local infection, and venospasm.
Local complication
Occur within the vascular system, remove from the IV site. can be serious and life-threatening
Systemic complications
Formations resulting from the infiltration of blood into the tissues at the venipuncture site. Can be a starting point for other complications: thrombophlebitis and infection.
R/t: venipuncture technique, use of large bore cannula (trauma to the vein during insertion), discontinuing IV without application of adequate pressure, applying the tourniquet to tightly above a previously attempted puncture site, pts receiving anticoagulation therapy and long-term steroids.
S/S: discoloration of the skin, site swelling and discomfort, inability to advance the cannula all the way into the vein during insertion, resistance to positive pressure during the lock flushing procedure
Hematoma
Hematoma prevention
Use of an indirect method (go in at side of vein then angle into vein). Apply tourniquet just before venipuncture. Use a small needle in elderly and pts on steroids, or pts with thin skin. Use blood pressure cuff to apply pressure. Use smallest cath to do the job you need to do. Be gentle
Hematoma treatment
Apply direct, light pressure for 2-3 minutes after needle removal. Have pt elevate extremity. Apply ice. DOCUMENT.
Types of occlusions
Nonthrombotic (42%): mechanical (clamp on), malpositioned tip, infest precipitates or residue.
Thrombotic (58%): clot or thrombus, within/around device or in surrounding vessel.
Occlusions may be caused by more than one factor.
Diagnosing catheter malfunction
No blood return. Increase in tension or pressure when flushing. Fluctuating flow. Mechanical occlusion. Abrupt cessation of flow. Venogram (see whats happening)
Interruption in pt care d/t catheter occlusions
Delay therapies. Increase risk of infection and vascular trauma. Reduce number of sites for future venous access. Cause pt discomfort during replacement procedure.
Catheter-related obstructions can be mechanical or non-thrombotic. Trauma to the endothelial cells of the venous wall causes RBCs to adhere to the vein wall, forms a clot or ____. Drip rate slows, line does not flush easily, resistance is felt. NEVER forcibly flush a catheter.
Thrombosis
Types of thrombotic occlusions:
Fibrin tail, fibrin sheath (can go entire length of catheter), mural thrombus (trauma to vein wall with insertion, inserted too rapidly, too large. Fibrin grows around the catheter and adheres to the vein wall), intraluminal thrombus
Complete vs partial occlusions
Complete: unable to infuse or aspirate
Partial/withdrawal occlusion: can infuse but not aspirate
Structured community of microorganisms enclosed in a self protective matrix where they cooperate to protect themselves from a hostile environment. Occurs on virtually all indwelling VADs
Biofilm
Biofilm formation
Microbes attach to internal and external catheter surfaces. Resident flora deep in skin layers are not removed during skin prep- attach to external catheter surface, catheters dwelling less than 10 days have more biofilm on external surface. Internal surfaces through all hub manipulation- medication administration. Tubing and cap changes. Flushing procedures. Catheters dwelling more than 30 days have more biofilm on internal surfaces.
The body’s response to catheter insertion
Cathether introduction starts biofilm/fibrin layer formation. Blood on catheter surface forms a fibrin layer. Catheter is colonized by pathogens in biofilm. Some bacteria proceed barrier to body’s defenses
Fibrin Tail
Can’t draw blood, sluggish=not totally patent cath, treat with cath flow. part-occluded.
May cause back flow to insertion site. Most familiar with as nurses. Point at which we should treat or clot can grown and become a fibrin tail.
Fibrin sheath
Leakage of nonvesicant solution into surrounding tissue
Infiltration
Leakage of vesicant solution into surrounding tissue. High risk of infection, septicemia, pt doesn’t get their meds.
Extravasation
Types of thrombosis or occlusion
Thrombosis related to: hypertensive pt; blood backing up. Low flow rate. Location of the IV cannula (peripheral-@place where arm bends=irritation). Compression of the IV line for an extended period of time. Trauma to the wall of the vein.
S/S: Fever and malaise. Slowed or stopped infusion rate. Inability to flush.
Prevention: Use pumps and controllers to manage flow rate. Micro drip tubing for rate below 50 mL/hr. Avoid areas of flexion. Avoid lower extremities.
Thrombosis
Thrombosis treatment
Never flush a cannula to remove an occlusion (causes damage to the vessel. Use cathflo!). Peripheral line: discontinue the cannula. Central line: treat with cathflo. Notify the physician and assess the site for circulatory impairment. DOCUMENT.
Infusion standards of practice
Patency prior to admin of meds and solutions should be established. A catheter should not be forcibly flushed. Resistance or absence of blood aspirate should be further evaluated. Thrombolytic agents specifically indicated for dissolving clots shall be administered based upon the order of an authorized prescriber.
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 _____. Tender to touch and can be very painful.
Phlebitis
Mechanical causes of phlebitis
Too large a catheter for the size of the vein.
Manipulation of the catheter, improper stabilization.
Chemical causes of phlebitis
Vein becomes inflamed by irritating or vesicant solutions or medication. Irritating medication or solution. Improperly mixed or diluted. Too-rapid infusion. Presence of particulate matter. The more the acidic the solution, the greater the risk. Additives: K+ really hard on veins. Type of material. Length of dwell (change peripheral catheters as needed). The slower the rate of infusion, the less irritation
Also called septic phlebitis: least common but more serious. Inflammation of the intimal of the vein. Contributing factors: poor aseptic technique. Failure to detect breaks in the integrity of the equipment. Poor insertion technique. Inadequate stabilization. Failure to perform site assessment. Aseptic preparation of solutions. Hand washing and preparing the skin.
Bacterial phlebitis
Post-infusion phlebitis
Inflammation of the vein 48-96 hours after discontinued. Usually resolves itself. Factors that contribute: Insertion technique. Condition of the vein used to start with. Type, compatibility, pH of solution used. Gauge, size, length, and material. Dwell time. Infrequent dressing change. Host factors: age, gender, and presence of disease.
S/S: redness at site. Site warm to touch. Local swelling. Palpable cord along the vein. Sluggish infusion rate. Increase in basal temperature of 1*C or more.
Prevention: use larger veins for hypertonic solutions. Central lines for infusions lasting longer than 5 days.
Phlebitis
Phlebitis scale
0- no clinical symptoms
1- erythema at access site with or without pain
2- Pain at access sit, with erythema and/or edema
3- Pain at access site with erythema and/or edema, streak formation, and palpable venous cord
4- Pain at access site with erythema and/or edema, streak formation, palpable venous cord >1 inch, purulent drainage.
Twofold injury: thrombosis and inflammation. Related to: use of veins in the lower extremity, use of hypertonic or highly acidic infusion solutions, causes similar to those of phlebitis
Thrombophlebitis
S/S: sluggish flow rate. Edema in the limbs. Tender and cord like vein. Site warm to the touch. Visible red line above venipuncture site. Diminished arterial pulses. Mottling and cyanosis of the extremities.
Prevention: Use veins in the forearms rather than the hands. Do not use veins in a joint. Assess site q4hr in adults, q2hr in children. Catheter securement. Infuse at rate prescribed. Use the smallest size catheter to do the job. Proper dilution
Thrombophlebitis
_____ thrombophlebitis can be prevented: appropriate skin preparation, aseptic technique in the maintenance of infusion, proper hand hygiene.
Septic
The inadvertent administration of a non-vesicant solution into surrounding tissue. Dislodgment of the catheter from the vein. Second to phlebitis as a cause of IV therapy morbidity.
Related to: puncture of the distal vein wall during access. puncture of the vein wall by mechanical friction. Dislodgment of the catheter from the intimal of the vein. poor securement. high delivery rate. over manipulation
Infiltration
S/S: coolness of the skin around the site (fluids in the tissues, constriction of blood vessels and nerves). taut skin. dependent edema. absence of blood return. “pinkish” blood return. infusion rate slows.
Infiltration
Complications of infiltration
Ulceration and possible tissue necrosis. Compartment syndrome. Complex regional pain syndrome
Inadvertent administration of a vesicant solution into surrounding tissue. Vesicant is a fluid or medication that causes the formation of blisters, with subsequent sloughing of tissues occurring from the tissue necrosis.
Related to: Puncture of the distal wall, mechanical friction, dislodgment of the catheter.
Extravasation
Examples of vesicants
phenergan pH is 4-5.5 Dilantin pH is 12 (draino is 14) High concentration KCL pH is 5-7.8 Calcium gluconate pH is 6.2 Amphotericin B pH is 5.7-8 Dopamine pH is 2.5-5 Nipride pH is 3.5-6 10%,20%,50% dextrose pH is 3.5-6.5 Sodium bicarbonate pH is 7-8.5
S/S: 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.
Extravasation
Prevention of extravasation
Use of skilled practitioners. Knowledge of vesicants. Condition of the pts veins. Site of venous access. Condition of the pt: vomiting, coughing, retching; sedated; unable to communicate. Drug admin technique: if continuous give in CVAD; only use with brisk blood return of 3-5 cc; use of a free flow IV; do not use a pump on vesicants given peripherally; assess for blood return frequently;
Inspect catheter and pt
Systematically check for external mechanical obstructions: IV bag or bottle dry. Pump off or IV tubing clamped. Tubing kinked or pt lying on tubing. Leaking, wetness of dressing d/t breakage or hole. Too tight of a suture. If port- check huber needle placement.
Prevention of catheter occlusion
Use of valves that are NOT negative displacement (positive displacement or neutral). Flush with adequate volume (10 mL NS). 20 mLs after blood draws, TPN, or giving blood. Some prefilled syringes cause reflux of blood into the catheter tip. Use turbulent technique- push, pause, push.
Inspect exit site, port pocket or tunnel for
Area where pt complains of pain or burning. Swelling of affected arm if PICC or arm port. Swelling of neck, arm or face (total venous thrombosis). Distention of superficial neck or chest veins.
If total vein thrombosis is suspected:
Notify physician immediately. Late signs require a radiologist to perform a diagnostic workup (i.e. ultrasound, venogram). MD may initiate systemic thrombolytic therapy or anticoagulant therapy
Which of the following are local complications associated with infusion therapy?
a) speed shock, septicemia, and venous spasm
b) Phlebitis, venous spasm, and hematoma
c) septicemia, thrombophlebitis, and hematoma
d) phlebitis, pulmonary edema, and speed shock
b) Phlebitis, venous spasm, and hematoma
Which of the following will reduce the risk for infiltration?
a) use of pumps or controllers to manage the IV rate
b) avoiding placing the catheter in areas of flexion
c) use of needleless systems
d) use of larger-bore catheters
b) avoiding placing the catheter in areas of flexion
A pt states that his IV site is sore. You assess the site and note redness and swelling but no signs of palpable cord or streak. Using the criteria for infusion phlebitis, what is the severity of this phlebitis?
a) 3+
b) 2+
c) 1+
d) 0
b) 2+
While a solution is infusion, which of the following is a treatment for venous spasm?
a) apply a cold pack to the site
b) increase the flow rate of the solution
c) apply a warm compress to the site
d) administer pain medication
c) apply a warm compress to the site
You check an infusion site on a patient and find swelling and cool skin temperature. Also, the pt’s skin appears blanched and feels rigid, and the infusion rate has slowed. These are signs of:
a) phlebitis
b) catheter embolus
c) hematoma
d) infiltration
d) infiltration
You are performing a venipuncture and an ecchymosis forms over and around the insertion area, which has become raised and hardened. You are unable to advance the cannula into the vein. These are signs of:
a) phlebitis
b) infiltration
c) hematoma
d) occlusion
c) hematoma
Strategies for VAD-related infection prevention include:
a) changing the needleless connector daily
b) hand hygiene
c) wearing a mask during IV administration
d) daily bathing with betadine soln
b) hand hygiene
S/S of catheter tip migration during the dwell time include:
a) loss of hearing
b) palpitations
c) increased resp. rate
d) fever
b) palpitations
