Complications of IV Therapy with Nursing Interventions – Flashcards

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question
What is circulatory overload?
answer
IV solution infused too rapidly or in too great an amount
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Assessment Findings of circulatory overload?
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ECV EXCESS-crackles in lungs, SOB, dependent edema, hyponatremia,hypernatermia (confusion, seizures) hyperkalemia- muscle weakness, cardiac dysrhythmias
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Circulatory overload nursing interventions?
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if sx appear, reduce IV flow rate and notify HCP ECV excess, raise head of bead;administer oxygen and diuretics if ordered monitor vitals and lab reports of serum levels
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What is Infiltration or extravasation?
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IV fluid entering subcutaneous tissue around venipuncture site
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Assessment findings of INFILTRATION?
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Skin around catheter is taut, blanched, cool to touch, edematous, may be painful; infusion may slow or stop
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Nursing Intervention for INFILTRATION?
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Stop infusion Discontinue IV if no vesicant drug If vesicant drug, disconnect IV tubing and aspirate drug from catheter Elevate extremity Contact HCP if solution contained KCL, a vasoconstrictor or other potential vesicant Apply warm, moist or cold compress according to procedure for type of solution infiltrated Start new IV in other extremity
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What is Phlebitis?
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Inflammation of inner layer of a vein
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Assessment findings for phlebitis?
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Redness, tenderness, pain, warmth along course of vein starting act access site; possible red streak and or palpable cord along vein
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Nursing Interventions for Phlebitis?
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Stop infusion and discontinue IV line Start new IV line in other extremity or proximal to previous insertion site if continued IV therapy is necessary Apply warm, moist compress or contact IV therapy team or HCP if area needs additional treatment
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What is a Local Infection?
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Infection at catheter-skin entry point during infusion or after removal of IV catheter
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Assessment findings for local infection?
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redness, heat, swelling at catheter-skin entry point; possible purulent drainage
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Nursing interventions for local infection?
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culture any drainage (if ordered) Clean skin with alcohol; remove catheter and save for culture; apply sterile dressing notify HCP start new IV in other extremity Initiate appropriate wound care if needed
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What is bleeding at venipuncture site?
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Oozing or slow, continuous seepage of blood from venipuncture site
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Assessment findings for bleeding at venipuncture site?
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Fresh blood at venipuncture site, sometimes pooling under extremity
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Nursing Interventions for bleeding at venipuncture site?
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Assess IV system is intact If catheter is within vein, apply pressure dressing over site or change dressing Start new IV line in other extremity or proximal to previous insertion site if VAD is dislodged. IV is disconnected, or bleeding from site does not stop
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