Issaiah Nicolle L. Cecilia Nov.

21, 2020

3 BSN A Prof. Herman Zoleta

COMPLICATIONS OF IV THERAPY

I. AIR EMBOLISM
A. CAUSES
A bolus of air enters the vein through an inadequately primed IV line, from a loose connection,
during tubing change, or during removal of the IV.
B. CLINICAL MANIFESTATION
 Tachycardia
 Chest pain and dyspnea
 Hypotension
 Cyanosis
 Decreased level of consciousness
C. PREVENTIVE MEASURES AND NURSING INTERVENTION
1. Prime tubing with fluid before use, and monitor for any air bubbles in the tubing.
2. Secure all connections.
3. Replace the IV fluid before the bag or bottle is empty.
4. Monitor for signs of air embolism; if suspected, clamp the tubing, turn the client on the left
side with the head of the bed lowered (Trendelenburg position) to trap the air in the right
atrium, and notify the HCP.

II. CATHETER EMBOLISM

A. CAUSES
An obstruction that results from breakage of the catheter tip during IV line insertion or removal.
B. CLINICAL MANIFESTATION
 Decrease in blood pressure
 Pain along the vein
 Weak, rapid pulse
 Cyanosis of the nail beds
 Loss of consciousness
C. PREVENTIVE MEASURES AND NURSING INTERVENTION
1. Remove the catheter carefully.
2. Inspect the catheter when removed.
3. If the catheter tip has broken off, place a tourniquet as proximally as possible to the IV site
on the affected limb, notify the HCP immediately, prepare to obtain a radiograph, and
prepare the client for surgery to remove the catheter piece(s), if necessary.
III. CIRCULATORY OVERLOAD
A. CAUSES
Also known as fluid overload; results from the administration of fluids too rapidly, especially in a
client at risk for fluid overload.
B. CLINICAL MANIFESTATION
 Increased blood pressure
 Distended jugular veins
 Rapid breathing
 Dyspnea
 Moist cough and crackles
C. PREVENTIVE MEASURES AND NURSING INTERVENTION
1. Identify clients at risk for circulatory overload.
2. Calculate and monitor the drip (flow) rate frequently.
3. Use an electronic IV infusion device and frequently check the drip rate or setting (at least
every hour for an adult).
4. Add a time tape (label) to the IV bag or bottle next to the volume markings. Mark on the
tape the expected hourly decrease in volume based on the mL/hour calculation
5. Monitor for signs of circulatory overload. If circulatory overload occurs, decrease the flow
rate to a minimum, at a keep-vein-open rate; elevate the head of the bed; keep the client
warm; assess lung sounds; assess for edema; and notify the HCP.
NURSING ALERT! Clients with respiratory, cardiac, renal, or liver disease; older clients; and very young
persons are at risk for circulatory overload and cannot tolerate an excessive fluid volume.

IV. ELECTROLYTE OVERLOAD

A. CAUSES
An electrolyte imbalance is caused by too rapid or excessive infusion or by use of an inappropriate
IV solution.
B. CLINICAL MANIFESTATION
Signs depend on the specific electrolyte overload imbalance.
C. PREVENTIVE MEASURES AND NURSING INTERVENTION
A. Assess laboratory value reports.
B. Verify the correct solution.
C. Calculate and monitor the flow rate.
D. Use an electronic IV infusion device and frequently check the drip rate or setting (at least
every hour for an adult).
E. Add a time tape (label) to the IV bag or bottle
F. Place a red medication sticker on the bag or bottle if a medication has been added to the
IV solution.
G. Monitor for signs of an electrolyte imbalance, and notify the HCP if they occur.
NURSING ALERT! Lactated Ringer’s solution contains potassium and should not be administered to clients
with acute kidney injury or chronic kidney disease.
V. HEMATOMA
A. CAUSES
The collection of blood in the tissues after an unsuccessful venipuncture or after the venipuncture
site is discontinued and blood continues to ooze into the tissue.
B. CLINICAL MANIFESTATION
Ecchymosis, immediate swelling and leakage of blood at the site, and hard and painful lumps at
the site
C. PREVENTIVE MEASURES AND NURSING INTERVENTION
1. When starting an IV, avoid piercing the posterior wall of the vein.
2. Do not apply a tourniquet to the extremity immediately after an unsuccessful venipuncture.
3. When discontinuing an IV, apply pressure to the site for 2 to 3 minutes and elevate the
extremity; apply pressure longer for clients with a bleeding disorder or who are taking
anticoagulants.
4. If a hematoma develops, elevate the extremity and apply pressure and ice as prescribed.
5. Document accordingly, including taking pictures of the IV site if indicated by agency policy.

VI. INFECTION
A. CAUSES
a. Infection occurs from the entry of microorganisms into the body through the venipuncture site.
b. Venipuncture interrupts the integrity of the skin, the first line of defense against infection.
c. The longer the therapy continues, the greater the risk for infection.
d. Infection can occur locally at the IV insertion site or systemically from the entry of
microorganisms into the body.
B. AT-RISK CLIENTS
a. Immunocompromised clients with diseases such as cancer, human immunodeficiency virus or
acquired immunodeficiency syndrome, those receiving biologic modifier response medications
for treatment of autoimmune conditions, or status post organ transplant are at risk for infection.
b. Clients receiving treatments such as chemotherapywho have an altered or lowered white blood
cell count are at risk for infection.
c. Older clients, because aging alters the effectiveness of the immune system, are at risk for
infection.
d. Clients with diabetes mellitus are at risk for infection.
C. CLINICAL MANIFESTATION
Local—redness, swelling, and drainage at the site
Systemic—chills, fever, malaise, headache, nausea, vomiting, backache, tachycardia
 D. PREVENTIVE MEASURES AND NURSING INTERVENTION
a. Assess the client for predisposition to or risk for infection.
b. Maintain strict asepsis when caring for the IV site.
c. Monitor for signs of local or systemic infection.
d. Monitor white blood cell counts.
e. Check fluid containers for cracks, leaks, cloudiness, or other evidence of contamination.
f. Change IV tubing every 96 hours in accordance with CDC recommendations or according to
agency policy; change IV site dressing when soiled or contaminated and according to agency
policy.
g. Label the IV site, bag or bottle, and tubing with the date and time to ensure that these are
changed on time according to agency policy.
h. Ensure that the IV solution is not hanging for more than 24 hours.
i. If infection occurs, the HCP is notified; discontinue the IV, and place the venipuncture device in a
sterile container for possible culture.
j. Prepare to obtain blood cultures as prescribed if infection occurs and document accordingly.
k. Restart an IV in the opposite arm to differentiate sepsis (systemic infection) from local infection
at the IV site.
l. Document accordingly, including taking pictures of the IV site if indicated by agency policy.
NURSING ALERT! A client with diabetes mellitus usually does not receive dextrose (glucose) solutions
because the solution can increase the blood glucose level.

VII. INFILTRATION
A. CAUSES
a. Infiltration is seepage of the IVfluid out of the vein and into the surrounding interstitial spaces.
b. Infiltration occurs when an access device has become dislodged or perforates the wall of the
vein or when venous backpressure occurs because of a clot or venospasm.
B. CLINICAL MANIFESTATION
Edema, pain, numbness, and coolness at the site; may or may not have a blood return
D. PREVENTIVE MEASURES AND NURSING INTERVENTION
a. Avoid venipuncture over an area of flexion.
 b. Anchor the cannula and a loop of tubing securely with tape.
c. Use an arm board or splint as needed if the client is restless or active.
d. Monitor the IV rate for a decrease or a cessation of flow.
e. Evaluate the IV site for infiltration by occluding the vein proximal to the IV site. If the IV fluid
continues to flow, the cannula is probably outside the vein (infiltrated); if the IV flow stops after
occlusion of the vein, the IV device is still in the vein.
f. Lower the IV fluid container below the IV site, and monitor for the appearance of blood in the
IV tubing; if blood appears, the IV device is most likely in the vein.
g. If infiltration has occurred, remove the IV device immediately; elevate the extremity and
apply compresses (warm or cool, depending on the IV solution that was infusing and the
HCP’s prescription) over the affected area.
h. Do not rub an infiltrated area, which can cause hematoma.
i. Document accordingly, including taking pictures of the IV site if indicated by agency policy.

VIII. PHLEBITIS AND THROMBOPHLEBITIS

A. CAUSES
a. Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication)
trauma or from a local infection.
b. Phlebitis can cause the development of a clot (thrombophlebitis).
B. CLINICAL MANIFESTATION
Phlebitis - Heat, redness, tenderness at the site
Not swollen or hard
Intravenous infusion sluggish
Thrombophlebitis - Hard and cordlike vein
Heat, redness, tenderness at site
Intravenous infusion sluggish
C. PREVENTIVE MEASURES AND NURSING INTERVENTION
a. Use an IV cannula smaller than the vein, and avoid using very small veins when
administering irritating solutions.
b. Avoid using the lower extremities (legs and feet) as an access area for the IV.
 c. Avoid venipuncture over an area of flexion.
d. Anchor the cannula and a loop of tubing securely with tape.
e. Use an armboard or splint as needed if the client is restless or active.
f. Change the venipuncture site every 72 to 96 hours in accordance with CDC
recommendations and agency policy.
g. If phlebitis occurs, remove the IV device immediately and restart it in the opposite
extremity; notify the HCP if phlebitis is suspected, and apply warm, moist compresses, as
prescribed.
h. If thrombophlebitis occurs, do not irrigate the IV catheter; remove the IV, notify the HCP,
and restart the IV in the opposite extremity.
i. Document accordingly, including taking pictures if indicated by agency policy.

IX. TISSUE DAMAGE

A. CAUSES
a. Tissues most commonly damaged include the skin, veins, and subcutaneous tissue.
b. Tissue damage can be uncomfortable and can cause permanent negative effects.
c. Extravasation is a form of tissue damage caused by the seepage of vesicant or irritant solutions
into the tissues; this occurrence requires immediate HCP notification so that treatment can be
prescribed to prevent tissue necrosis.
B. CLINICAL MANIFESTATION
Skin color changes, sloughing of the skin, discomfort at the site
B. PREVENTIVE MEASURES AND NURSING INTERVENTION
a. Use a careful and gentle approach when applying a tourniquet.
b. Avoid tapping the skin over the vein when starting an IV.
c. Monitor for ecchymosis when penetrating the skin with the cannula.
d. Assess for allergies to tape or dressing adhesives.
e. Monitor for skin color changes, sloughing of the skin, or discomfort at the IV site.
f. Notify the HCP if tissue damage is suspected.
g. Document accordingly, including taking pictures if indicated by agency policy.
NURSING ALERT! Always document the occurrence of a complication, assessment findings, actions taken,
and the client’s response according to agency policy.