Pharm Basics, part 8: IV Complications
by Cathy Parkes August 13, 2021 Updated: November 20, 2021 9 min read
This article covers IV complications. This series follows along with our Pharmacology Basics and Safe Medication Administration Flashcards for Nursing Students, which are intended to help RN and PN nursing students build a strong foundation going into pharmacology and as preparation for the ATI, HESI, and NCLEX.
Phlebitis is an inflammation of the veins. Remember that when a word ends in "-itis," it means inflammation of the part of the body referenced in the first part of the word. Here, "phleb-" is Greek for "vein," hence, “phlebitis,” inflammation of the veins. We created ourMedical Terminology flashcards to make breaking down words into their parts easy, so you never have to be confused by an unfamiliar word on an exam!
The causes of phlebitis include mechanical irritation, for example, a catheter rubbing against the vein, causing irritation and inflammation. Phlebitis may also be caused due to the pH or osmolality (the concentration of dissolved particles of chemicals and minerals) of the medication that's being infused.
The signs and symptoms of phlebitis include erythema (redness of the skin), edema (swelling), warmth, and pain. The vein may be indurated (hardened). Or you might observe a red streak that follows the superficial vein.
Phlebitis nursing care
If the patient is exhibiting these symptoms, discontinue the IV, elevate the extremity, and apply warm, moist compresses. If indicated, obtain a specimen for a culture to determine if there is an infection.
Infiltration is when IV fluids or medications leak out of the vein and into the surrounding tissue.
Symptoms of infiltration include swelling, coolness, dampness, and a slowed rate of IV infusion. Additionally, fluid may leak from the IV site itself.
A real-life example features a patient hospitalized during pregnancy, who was receiving IV fluids. The nurse was very busy, too busy to notice that the IV had infiltrated to the point that the patient's arm was twice as big as her other arm. The affected arm was swollen, it was cool to the touch, and it felt damp — all indications that the IV had infiltrated. The patient, not knowing what was causing her discomfort, sat there and waited until someone eventually noticed and took out the IV.
Infiltration nursing care
In the event of infiltration, discontinue the IV, elevate the extremity, and apply warm or cold compresses, depending on what was infusing. Use warm compresses for normal- or high-pH solutions, and use cold compresses for low-pH solutions.
Extravasation is another type of infiltration, but with a vesicant agent, meaning a medication that can cause serious tissue damage.
Signs and symptoms of extravasation can include erythema, pain, edema, and the formation of blisters. Necrotic tissue, such as slough or eschar, may be observed, as well as ulceration.
Extravasation nursing care
First, stop the infusion and aspirate (pull back on the syringe plunger) to remove any residual medication from the IV line. Then, administer antidote per facility policy.
Following the administration of antidote, discontinue the IV (remove it), elevate the extremity, and apply a warm or cold compress, depending on the solution's pH, as noted above in the previous section.
A catheter embolus is when an IV catheter fragment breaks off into the patient's venous system. Any time an IV is discontinued, it is important to look at the catheter tip to make sure it is fully intact. “Embolus” is another word for something that causes a blockage — a blood clot (thrombus), an air bubble, or another object that enters the bloodstream.
Catheter embolus symptoms
If a piece of the catheter tip is missing, that is a sign that there may be a catheter embolus present in the patient's venous system.
Other symptoms of a catheter embolus include pain along the vein, which can be severe, as well as a weak, thready pulse and hypotension (low blood pressure).
Catheter embolus nursing care
Place a tourniquet high on the extremity and prepare the patient for surgery to remove the catheter fragment.
An air embolus is when air enters the venous system from the IV catheter and causes a blockage.
Air embolus symptoms
Air embolus nursing care
If the patient experiences an air embolism, clamp the catheter, then place the patient in a Trendelenburg position, which is when their head is lower than their feet. Administer oxygen and notify the provider. Trendeleburg and other patient positions that you need to know are covered in our Fundamentals of Nursing Flashcards.
A thrombosis is a blood clot. During the administration of an IV — and despite the flushing of peripheral IVs and central venous catheters to help prevent the formation of a thrombosis — a vein may become occluded with a thrombosis anyway.
Symptoms of thrombosis include slowed IV flow, the inability to draw blood from a central line, and swelling and/or pain at the site.
When attempting to draw blood or give medications to a patient with a PICC line, and you aspirate but there is no blood return, that is a sign of a possible thrombosis. Note that providers often issue standing orders for a thrombolytic agent such as alteplase to be used in patients with PICC lines, in the event that a blood clot occurs.
Thrombosis nursing care
In a peripheral IV, discontinue the IV, apply a cold compress, and elevate the extremity.
For a central line, administer thrombolytics, such as alteplase, as ordered. Let it instill in the area for about 30 minutes, then check the patency of the line.
Fluid overload is when too much volume is introduced into the circulatory system.
Fluid overload symptoms
Signs of fluid overload include shortness of breath, crackles (in the lungs), hypertension, jugular vein distention, edema, and tachycardia.
Fluid overload nursing care
If the patient experiences fluid overload, raise the head of the bed to make it easier for them to breathe. Slow the infusion rate so as not to overwhelm the patient's circulatory system. Monitor the patient's oxygen and vital signs. It needed, administer diuretics as ordered by the provider.
An IV infection occurs when there is an invasion of microorganisms at the insertion site.
IV infection symptoms
Symptoms can be local or systemic.
Local symptoms include pain, warmth, edema, induration (hardness), and malodorous drainage.
Systemic symptoms include fever, chills, malaise, and an elevated white blood cell count.
IV infection nursing care
Hi. I'm Cathy with Level Up RN. In this video, we are going to talk about IV complications. I'm going to go through many of the complications that you can find here in our Pharmacology Basics flashcard deck but not every single one. At the end of the video, I'm going to test your knowledge about some of the information I'll be covering here by giving you a little quiz, so definitely stay tuned for that.
Let's talk about phlebitis first. So any time you see that "itis" at the end of a word, it means inflammation, an inflammation of whatever's at the first part of the word. So in this case, "phleb" is Greek for "vein", so inflammation of the veins. So what can cause phlebitis? It may be due to mechanical irritation. So that catheter could be rubbing against the vein, causing that irritation and inflammation. It could also be due to the pH or osmolality of the medication that's being infused. In terms of the signs and symptoms of phlebitis, those will include erythema, which is a fancy word for redness, as well as warmth, pain. You also may find that the vein there is indurated, which is also a fancy term for being hard. So you'll have a hardened vein. And you may see a red streak as well. So those are all symptoms of phlebitis. If your patient is exhibiting these symptoms, you're going to want to discontinue the IV, elevate the extremity, and apply warm, moist compresses.
All right. Next complication is infiltration. This is where IV fluids or medications leak into the surrounding tissue. So they are outside the vein. Symptoms of infiltration include swelling, coolness, dampness, a slowed rate of IV infusion, and fluid may be leaking from the IV site itself. So when I was hospitalized during my pregnancy, which was a lot, and I was receiving IV fluids, my nurse during one shift was very busy. And my IV infiltrated such that my arm was twice as big as my other arm. It was huge, and it was cool to the touch, and it kind of felt damp. And I didn't know at the time that that's what that meant, that my IV had infiltrated, or else I would've discontinued my own IV myself. But I sat there and waited until finally someone came and took that IV out. So in terms of nursing care, you want to discontinue the IV, elevate the extremity, and apply warm or cold compresses, depending on what was infusing. So we would use warm compresses for normal- or high-pH solutions, and we would use cold compresses for low-pH solutions.
Next, we have extravasation. So with extravasation, this means infiltration, like we just talked about, but with a vesicant agent, meaning a medication that can really cause tissue damage. So signs and symptoms of extravasation can include erythema, pain, edema, the formation of blisters. You may also see necrotic tissue, such as slough, and ulceration may also be present. In terms of nursing care for extravasation, you're going to want to stop the infusion, you're going to want to aspirate any residual medication in the IV line, and then you're going to administer an antidote per facility policy. Then after the administration of that antidote, you can discontinue the IV, elevate the extremity, and apply a warm or cold compress, depending on the solution.
Next, we have a catheter embolus. This is where a IV catheter fragment breaks off into the patient's venous system. So anytime we discontinue an IV, we always want to look at the catheter tip to make sure it is fully intact. If we look at the tip and we see that a piece of it is missing, that is obviously a sign that there may be a catheter embolus present in the patient's venous system. Other symptoms of a catheter embolus include pain along the vein. It may be severe pain. Also, a weak, thready pulse and hypotension are other symptoms of a catheter embolus. If you suspect that this may be the case for your patient, you're going to want to place a tourniquet high on that extremity and prepare that patient for surgery to remove the catheter fragment.
Next, we have an air embolus. This is where air enters the venous system from the IV catheter. And symptoms can include hypotension, tachycardia, tachypnea, and cyanosis. If your patient has an air embolism, you're going to want to clamp the catheter, place the patient in a Trendelenburg position. So this is where their head is lower than their feet. You're going to want to administer oxygen and notify the provider.
All right. Next, we have a thrombosis, which is a blood clot. So we do all the flushing of peripheral IVs and central venous catheters to help prevent the formation of a thrombosis or blood clot, but sometimes they occur. So when a patient gets a PICC line inserted, for example, when they come back to the floor, there are often standing orders in place for a thrombolytic agent, such as alteplase, that the nurse can use in the event that a blood clot occurs. So when your patient has a PICC line, and you go in the room to try to do a blood draw or to give medications, and you try to aspirate, you're not getting a blood return, then that is definitely a sign that you may have a thrombosis. So you'll need to pull that alteplase or whatever thrombolytic medication is ordered, let it instill in the area for about 30 minutes, and then come back and check the patency of that line.
Last complication I'm going to go over is fluid overload. This is where too much volume is introduced into the circulatory system such that your patient will exhibit signs such as shortness of breath, crackles, hypertension, jugular vein distention, edema, and tachycardia. If your patient has fluid overload, you're going to want to raise the head of the bed so it's easier for them to breathe. You're going to want to slow the infusion rate so we're not overwhelming the circulatory system. And then we're going to monitor the patient's oxygen and vital signs, and we may also need to administer diuretics as ordered by the provider.
Okay, you guys ready for your quiz? I have three questions for you.
First question. Coolness, dampness, and swelling are signs of what IV complication?
If you said infiltration, you are correct.
Second question. If you suspect an air embolism, what position should you place your patient in?
The answer is Trendelenburg.
Third question. If your patient is exhibiting signs of fluid volume overload, you should discontinue the IV. True or false?
False. Most times, this is not necessary. We just need to slow the infusion rate of the IV fluids.
Hopefully, this video's been helpful. If so, be sure to like it and leave me a comment. Thank you so much for watching.
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