SIGNS AND SYMPTOMS

POSSIBLE CAUSES

INTERVENTIONS

Local complications

Phlebitis

♦ Tenderness at the tip of and above the venipuncture device

♦ Redness at the tip of the catheter and along the vein

♦ Puffy area over the vein

♦ Vein hard on palpation

♦ Possible fever

♦ Poor blood flow around the venipuncture device

♦ Tip of the catheter located next to the vessel wall

♦ Friction from movement of the catheter in the vein

♦ Venipuncture device left in the vein too long

♦ Clotting at the catheter tip (thrombophlebitis)

♦ Drug or solution with a high or low pH or high osmolarity

♦ Remove the venipuncture device.

♦ Apply warm soaks. Elevate the extremity if edema is present.

♦ Notify the physician. Document the patient’s condition and your interventions.

PREVENTION

♦ Restart the infusion according to facility policy, preferably in the other arm, using a larger vein for an irritating solution, or restart with a smaller-gauge device to ensure adequate blood flow.

♦ Tape the device securely to prevent motion.

Extravasation

♦ Swelling at and above the I.V. site (may extend along the entire limb)

♦ Discomfort, burning, or pain at the site (but may be painless)

♦ Tight feeling at the site

♦ Decreased skin temperature around the site

♦ Blanching at the site

♦ Continuing fluid infusion even when the vein is occluded (although the rate may decrease)

♦ Venipuncture device dislodged from the vein or perforated vein

♦ Vesicant in the tissue

♦ Remove the venipuncture device. Notify the physician and follow facility policy.

♦ Monitor the patient’s pulse and capillary refill time.

♦ Restart the infusion in another limb.

♦ Notify the physician. Document the patient’s condition and your interventions.

PREVENTION

♦ Check the site often.

♦ Don’t obscure the area above the site with tape.

♦ Teach the patient to observe the I.V. site and advise him to report pain or swelling.

Catheter dislodgment

♦ Catheter partially backed out of the vein

♦ Solution infiltrating the tissue

♦ Loosened tape or tubing snagged in the bed linens, resulting in partial retraction of the catheter

♦ Catheter pulled out by a confused patient

♦ Remove the I.V. catheter.

PREVENTION

♦ Tape the venipuncture device securely on insertion.

Occlusion

♦ I.V. fluid that doesn’t flow

♦ I.V. flow interrupted

♦ Saline lock not flushed

♦ Backflow of blood in the line when the patient walks

♦ Line clamped too long

♦ Use a mild flush injection. Don’t force it. If you’re unsuccessful, reinsert the I.V. line.

PREVENTION

♦ Maintain the I.V. flow rate.

♦ Flush the line before and after intermittent piggyback administration, according to facility policy.

♦ Have the patient walk with his arm folded to his chest to reduce the risk of blood backflow.

Vein irritation or pain at the I.V. site

♦ Pain during infusion

♦ Possible blanching if vasospasm occurs

♦ Red skin over the vein during infusion

♦ Rapidly developing signs of phlebitis

♦ Solution with a high or low pH or high osmolarity, such as 40 mEq/L of potassium chloride, phenytoin, and some antibiotics (erythromycin, nafcillin, and vancomycin)

♦ Decrease the flow rate.

♦ Try using an electronic flow device to achieve a steady flow.

♦ Change the I.V. site.

PREVENTION

♦ Dilute the solutions before administration. For example, give antibiotics in a 250-ml solution rather than a 100-ml solution.

♦ If long-term therapy with an irritating drug is planned, ask the physician to use a central I.V. line.

Severed catheter

♦ Leakage from the catheter shaft

♦ Catheter inadvertently cut by scissors

♦ Reinsertion of the needle into the catheter

♦ If a broken part is visible, attempt to retrieve it. If you’re unsuccessful, notify the physician.

♦ If a portion of the catheter enters the bloodstream, place a tourniquet above the I.V. site to prevent progression of the broken part. Immediately notify the physician and radiology department.

♦ Document the patient’s condition and your interventions.

PREVENTION

♦ Don’t use scissors around the I.V. site.

♦ Never reinsert a needle into the catheter.

♦ Remove an unsuccessfully inserted catheter and needle together.

Hematoma

♦ Tenderness at the venipuncture site

♦ Bruised area around the site

♦ Vein punctured through the opposite wall at the time of insertion

♦ Leakage of blood into the tissue

♦ Remove the venipuncture device and restart the infusion in the opposite limb.

♦ Apply pressure and cold compresses to the affected area.

♦ Recheck the site for bleeding.

♦ Document the patient’s condition and your interventions.

PREVENTION

♦ Choose a vein that can accommodate the size of the venipuncture device.

♦ Release the tourniquet as soon as a successful insertion is achieved.

Venous spasm

♦ Pain along the vein

♦ Sluggish flow rate when the clamp is completely open

♦ Blanched skin over the vein

♦ Severe vein irritation as a result of irritating drugs or fluids

♦ Administration of cold fluids or blood products

♦ Very rapid flow rate (with fluids at room temperature)

♦ Apply warm soaks over the vein and surrounding area.

♦ Decrease the flow rate.

PREVENTION

♦ Use a blood warmer for blood or packed red blood cells.

Vasovagal reaction

♦ Sudden collapse of the vein during venipuncture

♦ Sudden pallor, sweating, faintness, dizziness, and nausea

♦ Decreased blood pressure

♦ Vasospasm as a result of anxiety or pain

♦ Lower the head of the bed.

♦ Have the patient take deep breaths.

♦ Check the patient’s vital signs.

PREVENTION

♦ To relieve the patient’s anxiety, prepare him for the procedure.

♦ Use a local anesthetic to prevent pain.

Thrombosis

♦ Painful, reddened, and swollen vein

♦ Sluggish or stopped I.V. flow

♦ Injury to the endothelial cells of the vein wall, allowing platelets to adhere and thrombi to form

♦ Remove the venipuncture device. Restart the infusion in the opposite limb, if possible. Notify the physician.

♦ Apply warm soaks.

♦ Watch for an I.V. therapyrelated infection.

PREVENTION

♦ Use proper venipuncture techniques to reduce injury to the vein.

Thrombophlebitis

♦ Severe discomfort at the site

♦ Reddened, swollen, and hardened vein

♦ Thrombosis and inflammation

♦ Follow the interventions for thrombosis. Notify the physician.

PREVENTION

♦ Check the site frequently. Remove the venipuncture device at the first sign of redness and tenderness.

Nerve, tendon, or ligament damage

♦ Extreme pain (similar to electrical shock when the nerve is punctured), numbness, and muscle contraction

♦ Delayed effects, including paralysis, numbness, and deformity

♦ Improper venipuncture technique, resulting in injury to the surrounding nerves, tendons, or ligaments

♦ Tight taping or improper splinting with an arm board

♦ Stop the procedure.

PREVENTION

♦ Don’t repeatedly penetrate tissues with the venipuncture device.

♦ Don’t apply excessive pressure when taping; don’t encircle the limb with tape.

♦ Pad the arm boards and the tape securing the arm boards, if possible.

Systemic complications

Circulatory overload

♦ Discomfort

♦ Jugular vein distention

♦ Respiratory distress

♦ Increased blood pressure

♦ Crackles

♦ Increased difference between fluid intake and output

♦ Roller clamp loosened to allow run-on infusion

♦ Flow rate too rapid

♦ Miscalculation of fluid requirements

♦ Raise the head of the bed.

♦ Administer oxygen, if needed.

♦ Reduce the infusion rate to a keep-vein-open rate and notify the physician.

♦ Give drugs as ordered.

PREVENTION

♦ Use a pump, controller, or rate minder for an elderly or compromised patient.

♦ Recheck calculations of the patient’s fluid requirements.

♦ Monitor the infusion frequently.

Systemic infection (septicemia or bacteremia)

♦ Fever, chills, and malaise for no apparent reason

♦ Contaminated I.V. site, usually with no visible signs of infection at the site

♦ Failure to maintain aseptic technique during insertion or site care

♦ Severe phlebitis, causing organism growth

♦ Poor taping that permits the venipuncture device to move, introducing organisms into the bloodstream

♦ Prolonged indwelling time

♦ Compromised immune system

♦ Notify the physician.

♦ Administer medications, as prescribed.

♦ Culture the site and the device.

♦ Monitor the patient’s vital signs.

PREVENTION

♦ Use scrupulous aseptic technique when handling solutions and tubing, inserting a venipuncture device, and discontinuing the infusion.

♦ Secure all connections.

♦ Change the I.V. solutions, tubing, and venipuncture device at the recommended times.

♦ Flushed face, headache

♦ Tightness in the chest

♦ Irregular pulse

♦ Syncope

♦ Rapid hypertension

♦ Shock

♦ Cardiac arrest

♦ Too rapid injection of drug, causing plasma levels to become toxic

♦ Improper administration of a bolus infusion (especially additives)

♦ Discontinue the infusion.

♦ Begin an infusion of dextrose 5% in water at a keep-vein-open rate.

♦ Notify the physician.

PREVENTION

♦ Check the infusion guidelines before giving a drug.

♦ Dilute the drug with a compatible solution.

Air embolism

♦ Respiratory distress

♦ Unequal breath sounds

♦ Chest pain, dyspnea

♦ Anxiety

♦ Weak, rapid pulse

♦ Increased central venous pressure

♦ Decreased blood pressure

♦ Altered consciousness

♦ Solution container empty

♦ Tubing disconnected

♦ Discontinue the infusion.

♦ Place the patient in left lateral Trendelenburg’s position to allow air to enter the right atrium and disperse through the pulmonary artery.

♦ Administer oxygen.

♦ Notify the physician.

♦ Document the patient’s condition and your interventions.

PREVENTION

♦ Purge the tubing of air completely before starting an infusion.

♦ Use the air-detection device on the pump or an air-eliminating filter proximal to the I.V. site.

♦ Secure all connections.

Allergic reaction

♦ Itching

♦ Watery eyes and nose

♦ Bronchospasm

♦ Wheezing

♦ Urticarial rash

♦ Anaphylactic reaction, which may occur within minutes (flushing, chills, anxiety, agitation, itching, palpitations, paresthesia, throbbing in the ears, wheezing, coughing, seizures, cardiac arrest)

♦ Allergens such as medications

♦ If a reaction occurs, stop the infusion immediately.

♦ Maintain a patent airway.

♦ Notify the physician.

♦ Administer an antihistaminic corticosteroid and antipyretic, as ordered.

♦ Give 0.2 to 0.5 ml of 1:1,000 aqueous epinephrine subcutaneously, as ordered. Repeat every 10 to 15 minutes as needed.

PREVENTION

♦ Obtain the patient’s allergy history. Look for cross-allergies.

♦ Assist with test dosing.

♦ Monitor the patient carefully during the first 15 minutes of administering of a new drug.

SIGNS AND SYMPTOMS

POSSIBLE CAUSES

INTERVENTIONS

Pneumothorax, hemothorax, chylothorax, hydrothorax

♦ Chest pain

♦ Dyspnea

♦ Cyanosis

♦ Decreased breath sounds on the affected side

♦ With hemothorax, decreased hemoglobin levels because of blood pooling

♦ Abnormal findings on chest X-ray

♦ Apprehension

♦ Lung puncture by the catheter during insertion or exchange over a guide wire

♦ Large blood vessel puncture with bleeding inside or outside the lung

♦ Lymph node puncture with leakage of lymph fluid

♦ Infusion of solution into the chest area through an infiltrated catheter

♦ Notify the physician and stop the infusion.

♦ Remove the catheter or assist with removal, as ordered.

♦ Administer oxygen, as ordered.

♦ Set up and assist with chest tube insertion.

♦ Document all interventions.

PREVENTION

♦ Position the patient head-down with a rolled towel between his scapulae to dilate and expose the internal jugular or subclavian vein as much as possible during catheter insertion.

♦ Assess the patient for early signs of fluid infiltration (swelling in the shoulder, neck, chest, and arm).

♦ Ensure that the patient is immobilized and prepared for insertion.

♦ Minimize the patient’s activity after insertion, especially with a peripheral catheter.

Air embolism

♦ Respiratory distress

♦ Chest pain

♦ Unequal breath sounds

♦ Weak, rapid pulse

♦ Increased central venous pressure

♦ Decreased blood pressure

♦ Churning murmur over the precordium

♦ Alteration in consciousness or loss of consciousness

♦ Anxiety

♦ Intake of air into the central venous system during catheter insertion or tubing changes, or inadvertent opening, cutting, or breaking of the catheter

♦ Clamp the catheter immediately.

♦ Place the patient in left lateral Trendelenburg’s position so that air can enter the right atrium and pulmonary artery. Make sure that he remains in this position for 20 to 30 minutes.

♦ Don’t recommend Valsalva’s maneuver because a large air intake worsens the condition.

♦ Administer oxygen.

♦ Notify the physician.

♦ Document all interventions.

PREVENTION

♦ Purge all air from the tubing before hookup.

♦ Teach the patient to perform Valsalva’s maneuver during catheter insertion and tubing changes.

♦ Use air-eliminating filters or an infusion device with air-detection capability.

♦ Use luer-lock tubing, tape the connections, or use locking devices for all connections.

Thrombosis

♦ Edema at the puncture site

♦ Erythema

♦ Ipsilateral swelling of the arm, neck, and face

♦ Pain along the vein

♦ Fever, malaise

♦ Jugular vein distention

♦ Sluggish flow rate

♦ Composition of the catheter material (polyvinyl chloride catheters are more thrombogenic)

♦ Hematopoietic status of the patient

♦ Infusion of irritating solutions

♦ Repeated or long-term use of the same vein

♦ Preexisting cardiovascular disease

♦ Simultaneous administration of incompatible medications or inadequate flushing between administration of incompatible medications

♦ Irritation of the vein during insertion of a central venous catheter

♦ Improper location of catheter in the subclavian or brachiocephalic vein

♦ Notify the physician.

♦ Stop the infusion.

♦ Infuse a dose of heparin or a thrombolytic, if ordered.

♦ Don’t use the limb on the affected side for subsequent venipuncture.

♦ Verify thrombosis with diagnostic studies.

PREVENTION

♦ Verify placement of the catheter tip in the superior vena cava (SVC) before using the catheter. If the tip isn’t in the SVC, the catheter shouldn’t be used.

Infection

♦ Redness, warmth, tenderness, and swelling at the insertion or exit site

♦ Possible exudate of purulent material

♦ Local rash or pustules

♦ Fever, chills, malaise

♦ Leukocytosis

♦ Nausea and vomiting

♦ Elevated urine glucose level

♦ Failure to maintain aseptic technique during catheter insertion or care

♦ Failure to comply with the dressing-change protocol

♦ Wet or soiled dressing remaining on the site

♦ Immunosuppression

♦ Irritated suture line

♦ Contaminated catheter or solution

♦ Frequent opening of the catheter

♦ Monitor the patient’s temperature and vital signs frequently.

♦ Culture the site if drainage is present.

♦ Re-dress the site using aseptic technique.

♦ Use an antibiotic ointment locally, as needed.

♦ Treat the patient systemically with an antibiotic or an antifungal, depending on the culture results and the physician’s order.

♦ Draw central and peripheral blood cultures; if the same organism appears in both, then the catheter is the primary source of infection and should be removed. Staphylococcus epidermidis is the most common organism.

♦ If the cultures don’t match but are positive, the catheter may be removed or the infection may be treated through the catheter.

♦ Treat the patient with an antibiotic, as ordered.

♦ If the catheter is removed, culture its tip.

♦ Document all interventions.

PREVENTION

♦ Maintain sterile technique using sterile gloves, masks, and gowns, when appropriate.

♦ Observe dressing-change protocols.

♦ Teach the patient about restrictions on swimming, bathing, and other physical activities.

♦ Change a wet or soiled dressing immediately.

♦ Change the dressing more frequently if the catheter is located in the femoral area or near a tracheostomy. Perform tracheostomy care after catheter care.

♦ Examine the solution for cloudiness and turbidity before infusing; check the fluid container for leaks.

♦ Monitor the urine glucose level in the patient who’s receiving total parenteral nutrition (TPN); if the level is greater than 2+, he may have early sepsis.

♦ Use a 1.2-micron filter for three-in-one TPN solutions.

♦ Change the catheter according to facility protocol.

♦ Keep the system closed as much as possible.

PROBLEMS

INTERVENTIONS

Air in the line

While setting up, make sure that all air is out of the line, including air trapped in Y-injection sites. Also, check that the connections are secure and that the container is filled properly. Withdraw any air from a piggyback port with a syringe or an air-eliminating filter. A wet-air detector may give a false reading.

Infusion completed

Reset the pump, as ordered, or discontinue the infusion. A slow keepveinopen rate usually keeps the I.V. line patent as long as enough fluid remains.

Empty container

Check for adequate fluid levels in the I.V. container and have another container available before the last one runs out.

Low battery

Battery life varies; keep the machine plugged in on AC power as much as possible, especially while the patient is in bed. If the alarm goes off, plug in the machine immediately, or power may be lost for a while (usually a half-hour to several hours).

Occlusion

Check that all clamps are open, look for kinked tubing, and check the patency of the venipuncture device.

Rate change

Check that the infusion control device displays the ordered rate. The patient or a family member may have tampered with the controls.

Open door

The door should be closed. It may not shut if the device isn’t set up properly (for example, if the cassette isn’t inserted all the way).

Malfunction

A mechanical failure usually must be handled by the biomedical engineering department or the manufacturer. Disconnect the infusion control device. Label it clearly with a sign that says DO NOT USE, and indicate the specific problem.

PROBLEMS AND POSSIBLE CAUSES

INTERVENTIONS

Flow rate too fast

Clamp manipulated by the patient or a visitor

Instruct the patient not to touch the clamp and place tape over it. Administer the I.V. solution with an infusion pump or a controller, if necessary. Set the safety on the back of the pump.

Tubing disconnected from the catheter

Using alcohol, wipe the distal end of the tubing with luerlock connections. Reinsert the end of the tubing firmly into the catheter hub and apply tape at the connection site.

Change in the patient’s position

Use an infusion pump or a controller to ensure the correct flow rate.

Flow clamp drifting as a result of patient movement

Place tape below the clamp.

Flow rate too slow

Venous spasm after insertion

Apply warm soaks over the site.

Venous obstruction as a result of bending the patient’s arm

Secure the I.V. line with a padded arm board, if necessary. Frequently check the patient’s neurovascular status, and monitor him according to facility policy.

Pressure change (as a result of decreased fluid in the bottle)

Readjust the flow rate.

Elevated blood pressure

Readjust the flow rate. Use an infusion pump or a controller to ensure the correct rate.

Cold solution

Allow the solution to warm to rom temperature before hanging the bag.

Change in the viscosity of the solution from an added drug

Readjust the flow rate.

I.V. container that’s too low or a patient’s arm or leg that’s too high

Hang the container higher or remind the patient to keep his arm below the level of his heart.

Excess tubing dangling below the insertion site

Replace the tubing with a shorter piece or tape the excess tubing to the I.V. pole below the flow clamp (making sure that the tubing isn’t kinked).

Venipuncture device that’s too small

Remove the venipuncture device in use and insert a largerbore venipuncture device, or use an infusion pump.

Infiltration or clotted venipuncture device

Remove the venipuncture device in use and insert a new one.

Kinked tubing

Check the tubing over its entire length and unkink it.

Tubing compressed at the clamped area

Massage or milk the tubing by pinching and wrapping it around a pencil four or five times. Then quickly pull the pencil out of the coiled tubing.