IV Essentials and Therapy Class

Dixie Technical College PN Program

Dalene Cummings MSN, RN, CHSE

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Purpose

The purpose/goal of this course is:

• To understand the fundamental concepts of IV therapy needed to provide basic IV care
for patients
• To demonstrate IV therapy techniques and procedures including insertion, assessment,
maintenance, discontinuing, and documentation.

Objectives

After successful completion of this course, the student will be able to:
• List indications, advantages and disadvantages for IV therapy
• Describe characteristics of different types of IV access
• Explain the medical and legal aspects of IV therapy
• Describe the anatomy & physiology of veins and identify commonly used peripheral
veins
• Identify considerations and factors in choosing a vein
• Describe complications associated with IV therapy and accompanying s/s, treatment,
types and grades
• Discuss the role of fluid and electrolytes in the body and problems associated with
imbalances
• Describe the equipment and procedure steps for safe insertion of IV catheters
• Demonstrate IV insertion and discontinuation techniques and procedure
• Discuss IV assessment and IV site care
• Describe patient and family education
• Explain and demonstrate documentation requirements for insertion, site care and
discontinuing IV’s.

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 Introduction
IV therapy is a nursing treatment that most patients have at one time or another during a
hospital stay. The technique and expertise of ‘placing’ an IV takes practice. However, the
theory behind IV placement and management is didactic and can be done in a classroom
setting. The importance of correctly identifying veins, catheter selection, dressings, and
potential complications are all issues that nurses face on a daily basis.

Indications
There are a variety of indications why intravenous (IV) therapy may be ordered for a patient

o Parenteral nutrition
Typically administered to prevent complications and promote healing after most
gastrointestinal procedures. Patients that cannot or should not digest and/or absorb
nutrients via the GI tract, parenteral nutrition is also commonly prescribed.

o Fluid, electrolyte and blood or blood product administration

Hypovolemia and dehydration are common indications for fluid replenishment. Many
patients may also have an electrolyte imbalance which can be treated with IV fluids.
There are a variety of blood products and many types of IV fluids available and each is
used for specific reasons.

o Diagnostics and hemodynamic monitoring

There are diagnostic procedures that use contrast material through IV’s to better
visualize using x-ray’s. An example would be CT scan or Angiography.
A critically-ill patient in an ICU setting will have hemodynamic monitoring through IV
access. This can be in the form of a central line, arterial line or both.

o Medication Administration
The IV route is the fastest (as well as the most dangerous) route of medication
administration. Once the medication is infused, it can not be recalled. Its actions can
only be slowed if there is an antagonist available.

o Precautionary IV access
When a patient is at risk for developing significant complications, IV access may be
established only as a precaution. The patient may be quite stable and may not need
medications of fluids, however due to their underlying diagnosis, the patient is at risk for
developing complications and could potentially require emergency interventions.

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 Advantages and Disadvantages

Advantages

Disadvantages

Types of IV Access

Knowing the purpose of IV therapy is an important element in the decision of the type of IV
access needed. There are three types of IV access. It is important to note that the term
‘access’ is related to where the tip of the catheter will ultimately rest and not indicative of where
the catheter’s insertion point into the body occurs.

o Peripheral IV Access

o Midline IV

o Central IV

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 Medical – Legal Aspects of IV Therapy
History
During the last 50 years, there has been a great deal of change in intravenous therapy
regarding realm of practice. Prior to 1940, IV therapy was considered a medical act and
performed only by physicians. Over time, physicians began to delegate IV therapy to nurses.

The nursing process is an essential component of providing quality care for the patient. It is
always ongoing and requires duty-bound adherence to the individual steps of the nursing
process including assessment, diagnosis, outcome identification, planning, implementation, and
evaluation.

Specific Interventions
With proper training, LPN’s may not:
• Initiate mid-line intravenous catheters
• Administer IV push medications
• Administer chemotherapy
• Administer blood products

Responsibilities Associated with Intravenous Therapy

There are several components involved with the safe administration of IV fluids and
medications.
• First, the nurse must know the purpose for and the effect of the IV fluids and/or
medications being administered. There are many types of IV fluids and each has a
different purpose and effect.
• As with any other medication, the nurse must also know the indications, route, dose,
timing and potential side effects associated with the drug and/or fluid administered. Any
discrepancies related to the physician's order should be called to the physician's
attention before administration begins.

• Follow the Seven Rights of Medication Administration

1. Right ____________________

2. Right ____________________

3. Right ____________________

4. Right ____________________

5. Right ____________________

6. Right ____________________

7. Right ____________________

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 • In addition, there are an additional five rights that need to be followed. The five rights
may be relevant to particular medications and are essential for safe practice

1. Right ______________________

2. Right ______________________

3. Right ______________________

4. Right ______________________

5. Right ______________________

The nurse should routinely check the medication as it is removed from the dispense, cross-
check the medication with the MAR and check the label immediately prior to its administration.
Although minor errors may cause little or no harm to the patient, major errors can be life-
threatening. Regardless of the outcomes of any error, the RN should never dismiss not conceal
it. Upon discovery of an error, the charge nurse and physician should be notified.

Legal Implications
Several of the problems that result from intravenous therapy may potentially result in legal
problems for the nurse and the hospital. With respect to intravenous therapy, the following
patient rights are of particular importance:
• The patient has the right to considerate and respectful care; reasonable continuity of
care; care in a safe setting; and the right to be free from all forms of abuse or
harassment.
• The patient or the patient’s legal guardian for treatment decisions has the right to
information necessary to give consent prior to treatment. They have the right to refuse
treatment and to make informed decisions regarding his or her care.

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Anatomy & Physiology
Skin

Epidermis:

Dermis:

Artery vs Vein

Arteries Veins

Vein

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Common Veins of the Upper Extremity
Vein Description

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 Patient Factors and Vein Condition
Patient’s General Condition. An assessment of the patient’s general physical condition
may yield some information about the duration of the therapy and the kinds of therapy the
patient may need.

Patient’s Current Health Problem and Disease History. It is important to evaluate

the patient’s current health problems their disease history prior to the initiation of IV therapy.
The patient’s history of chronic diseases and disorders, such as chronic obstructive pulmonary
disease (COPD) or diabetes often confounds and complicates a typically simple admission for an
acute disorder, such as a urinary tract infection. Not only is the primary diagnosis considered
when IV therapy is ordered, but comorbidities and underlying chronic diseases and disorders
must also enter into the assessment process when deciding upon the site where the IV lie will
be initiated.

Age of Patient. The anatomy of the venous system, like many other physical attributes, has
age-specific characteristics that must be addressed during the vein selection process. The
elderly tend to have very fragile and delicate veins. A looser tourniquet should be used when
preparing for venipuncture on an elderly patient. Infants have age specific venipuncture
challenges as well. Neonates and infants do not have as many accessible veins as adults do.
For this reason, the feet, hands and antecubital area are usually the venipuncture site of choice.
Scalp veins can be used for infants less than 6 months of age.

Condition of Skin. The condition of the skin is assessed when selecting a site for
venipuncture because the condition of the skin may indicate some alteration of circulation or
venous pathology below the skin. It is recommended that you avoid areas that are reddened,
sore or painful to the touch, tender, blanched, ecchymotic, cool, swollen or with evidence of a
hematoma.

Limb Mobility. A brief assessment of the patient’s upper extremity mobility is also done
before an IV line is inserted.

Fluid Volume Status. The patient’s fluid volume and hydration status should also be
determined and evaluated prior to the initiation of IV therapy, Venous dilation challenges are
often encountered when patients are dehydrated or they have a decreased circulating volume.

Cognitive Level and Psychological Status. A patient’s level of cognition will also
provide data about the venipuncture site of choice. As we continuously strive to have and
maintain a restraint-free environment, we must also carefully select IV therapy sites that will
not be prone to accidental dislodgement by a confused patient. IV sites in the direct line of the
patient’s sight are at risk for dislodgement. Sites that are not easily visualized by confused
patients have a much better chance of success.

Patient Activity and personal Preference. Consider the patient’s activities when
choosing a venipuncture site. Whenever possible ask the patient which arm or hand is
preferable to him or her. Most often the non-dominant side will be chosen and used so the
patient can carry out ADLS’s without compromising the IV.

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Other Specific Considerations. Placement of an intravenous line on the same extremity
as any of the following conditions is contraindicated:
o Mastectomy
o Arteriovenous shunt of fistula
o Hemodialysis shunt
o Graft
o Serious burns of grafts
o Paralysis
o Additional areas to be avoided. Those that have encountered recent complications
related to IV therapy, such as phlebitis sites, sclerosed areas, thrombosed areas; or
edematous areas.

Other Factors to Consider

Anticipated Duration of Therapy. The selection of suitable veins is far greater when the
anticipated duration of therapy is short-lived. However, numerous venipunctures and multiple
sites are often necessary with long-term IV therapy. The choice of veins becomes progressively
more limited because the need to preserve veins must be taken into consideration. In order to
ensure adequate veins for future use, arms should be alternated with the most distally suitable
vein accessed.

Solutions and/or Medications to be Infused. Many medications, including

chemotherapy and IV fluids such as hypertonic solutions, are highly irritating to the veins.
Larger veins, rather than smaller ones, should be used for irritating solutions and medications.

Catheter or Cannula Size. Peripheral venous catheters range in variety from straight steel
and winged needles to catheters to catheters made of silicon, PVC or other materials. They
vary in length and gauge to meet the needs of a wide variety of patients. IV catheters can
range from a small 27-gauge ¼ inch in length to a 14 gauge 3 inches in length.

Dealing with Difficult Veins. Some of the problems that can be encountered during the
venipuncture process include a lack of venous distention, rolling veins and fragile veins.
Venipuncture and catheter insertion cannot be successful unless the vein is adequately
distended to permit the entry and threading of the catheter. If the vein does not dilate enough
with the tourniquet, remove the tourniquet and:
o Apply heat or a warm compress to create vasodilation
o Lower the limb into a dependent position to facilitate a great volume of fluid in the vein
o Gently pat the vein
o Apply a small amount of pressure just above the intended site of insertion
o Run the vein gently in one continuous motion from the proximal to the distal

Rolling veins are also a challenge during the process of venipuncture. If the desired vein starts
to move or roll out of position after you have pierced the skin, perform another gently thrust of
the needle parallel to the skin while holding the area taut. Fragile veins, on the other hand,
may not respond well to a tourniquet. On some rare occasions, it is necessary to avoid the use
of a tourniquet. Tourniquets are also not necessary when a vein is adequately dilated, visible
and palpable without it.

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 Selecting IV Catheter and Site
Vein Selection
Part of initiating IV therapy is choosing a vein suitable for venipuncture. There are four basic
things to consider when selecting a vein.

1- __________________
2- __________________
3- __________________
4- __________________

Upper extremity veins should be used in preference to the lower extremities for IV therapy.
This is because IV’s placed in the lower extremities are associated with stagnant blood flow,
which increased the risk for thrombus and infection.

Inspect. Site should be free from edema, redness, bruising, burns, or infection. Tattoos
should also be avoided due to the trauma already to the skin and chance of infection.

Palpate. Vein should feel round, firm, elastic, and engorged. If patient is cold- warm the
extremity. The vein should not feel hard, bumpy or flat.

Veins to Avoid

Sites to Avoid

Selecting a Catheter
Most IV therapy is delivered peripherally using a
short catheter made of Teflon, silicon or
polyurethane. A 20- or 22-gauge catheter is
used in most situations for adults. A 22- or 24-
gauge can be used for children or older adults or
for patients with small or fragile veins. In cases
where rapid infusion is preferred an 18-gauge
may be used.

The vein is usually accessed using an over-the

needle catheter. Once the vein is successfully
penetrated by the introducer needle, blood may
be seen in the flash back chamber at which point
the catheter is threaded into the vein.

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 Special Considerations
Elderly
o Veins in the elderly are less smooth and the lining is thickened.
o Vein lumens are smaller and may affect threading of catheter.
o Muscle fibers are replaced with collagen, fatty plaque, and calcium deposits which hardens
the lumen decreasing the elasticity.
o Remove the tourniquet as soon as possible to avoid leaking at the insertion site from
increased pressure. Some elderly may not need to have a tourniquet to insert the IV

Pediatric
o Vein lumen is smaller and more fragile. This increases the risk for infiltration.
o Don’t use ankles/feet if walking – this increased the risk of phlebitis
o Never attempt IV insertion alone on a infant or a young child

Insertion of a Peripheral IV Line

The first step in the insertion of a peripheral IV line is to obtain a physician’s order. Always
check and verify the order. IV therapy, with or without added medications, require an order.
Also, the type of catheter, fluid and tubing is determined by the type of fluid, medication and/or
the purpose of the venipuncture ordered.

After the order is obtained, verify the patient by at least two methods. Next you will want to
provide patient and/or family education regarding the procedure and obtain consent as
appropriate. You will then gather your materials and prepare for IV insertion.

STEP 1: Gather your Equipment

You will absolutely need:
♦ Antiseptic solution
♦ Gloves
♦ Tourniquet
♦ Peripheral IV catheter
♦ 2X2 gauze pads
♦ Occlusive dressing
♦ Tape
♦ Flush solution and syringe
♦ Sharps container
♦ Primed lock or IV tubing with ordered solution

Optional Item:
♦ Arm Board
♦ Warm packs
♦ Local anesthetic
♦ Scissors

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STEP 2: Select Your Device
Consider This:
♦ Your choice of cannula should be of the smallest gauge that will accommodate the
prescribed therapy. This will allow for sufficient blood flow around the cannula.
♦ Only one device should be utilized for each attempt
♦ Stylets shall never be reinserted into the cannula when attempting IV access.

Winged infusion set:

Purpose: Short term therapy for any cooperative adult, therapy of any
duration for an infant, child or elderly patient with fragile veins.

Advantages: Some claim it is the easiest IV device to insert and ideal for
IV push drugs

Disadvantages: Can easily infiltrate due to rigidity of the catheter

Over-the-Needle Catheter:
Purpose: Longer-term therapy for the agitated or active patient

Advantages: Accidental puncture of the vein is less likely than

with a needle, more comfortable for the patient

Disadvantage: More difficult to insert

STEP 3: Position the Patient’s Arm

Consider this:

♦ Dependent positions increase capillary refill and may increase the likelihood you will be
successful in inserting the IV.
♦ For cold skin, warm it by rubbing or stroking the skin or applying warm packs for 5-10
minutes as needed

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STEP 4: Apply the Tourniquet
♦ Apply 6” above insertion site to dilate the vein
♦ Check for distal pulse. (if no pulse, remove tourniquet and reapply as not to occlude the
arterial blood flow).
♦ Lightly palpate vein with your index finger and middle fingers, while stretching it to
prevent rolling.
o If the vein feels hard or rope-like, select another site!
o If the vein is easily palpable, but not sufficiently dilated you may try these things
to promote engorgement of the vessel with blood
 Tap the skin over the vein lightly
 Place vein in a more dependent position
 Warm the vessel
 Have patient open and close fist a few times
♦ If the patient is elderly, apply the tourniquet carefully as not to pinch the skin. It may
cause skin tears. IF necessary, apply it over the patient gown.

STEP 5: Select Your Insertion Site

AVOID
Consider this: ♦ Antecubital fossa
♦ Use a vein in the non-dominant arm if possible ♦ Lower extremities (legs/feet) unless
specifically ordered by physician or
♦ Use smallest catheter possible for anticipated needs
necessitated by the patient’s condition
♦ Save antecubital for emergencies if possible
♦ Previously used veins and injured
♦ Use most distal sites so you can move proximally as sclerotic veins
needed ♦ Vein in the arm on the side of a
♦ Assess the patient’s condition, vein condition, vein size mastectomy
and location, patient age, and the type and duration ♦ Veins in the arm of a dialysis AV
of therapy to insure ideal and safe IV access. fistula

STEP 6: Prepare the Site

♦ Wash Your Hands!
♦ Put on gloves
♦ Wash the insertion site if visibly soiled
♦ Clean the site
o Use the antiseptic solution by applying in a circular motion,
outward from the insertion site to approximately 2” to 4”
o Use friction to ‘scrub’ the site in this circular fashion
o The key is providing enough friction to ‘scrub’ the site
o Allow the cleansing agent to dry thoroughly
♦ If ordered, you may administer a topical, local anesthetic

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 ♦ Hold the skin taut (This stabilized the vein!)
♦ Grasp needle or catheter bevel up
o If using a winged infusion set, grasp by both wings between the thumb and
forefinger of the dominant hand
o When using the over-the-needle catheter, grasp the plastic hub with your
dominant hand, remove the cover and examine catheter tip. Use the opposite
hand to keep the vein stabilized by holding the skin taut below the insertion site.
♦ Lightly palpate the vein (The vein should be engorged, round, firm, and resilient).
♦ If you run your finger down the vein and it feels like a cat’s tail – AVOID
♦ Forcing a cannula into a hardened vein can fray or kink the cannula damaging the vein
lining

Use lower extremities only after consulting with MD/LIP and as a last resort due to higher risk
for phlebitis and thrombosis. NO lower extremity IV’s in diabetics or patients with Peripheral
vascular disease

STEP 7: Venipuncture Itself

♦ Confirm the integrity of the product and insert the device always per manufacture
guidelines
♦ Warn the patient that you are ready to insert the IV
♦ Insert the device. Different nurses may use different approaches.
Both are acceptable. You will need to choose the approach that
works best for you and gives you the greatest likelihood of success.
o The direct approach, enter the skin directly over the vein at a
30 to 40-degree angle
o The indirect approach, enter the skin slightly adjacent to the
vein and direct the device into the side of the vein wall at a 30
to 40-degree angle
♦ Advance the device slowly and steadily until you meet resistance
o Don’t penetrate the vein!
o Lower the needle to a 15 to 20-degree angle, THEN slowly pierce the vein
o You may feel a “pop” or a sensation of release when the needle enters the vein
♦ Observe flashback!
o This ensures that the catheter is in the vein
o If using a winged infusion set, advance needle slowly, secure needle and open
roller clamp to IV solution to check for free flow
o If you fail to see flashback, pull the catheter slightly back and rotate slightly. If
you still fail to see flashback, remove the catheter and try again with a new IV
needle
♦ Tilt the needle very slightly upward to advance the needle without penetrating the lower
wall of the vein
♦ Advance the catheter device so that needle is held stationary at the hub
♦ Withdraw the needle while holding the catheter at the hub so that it doesn’t move
o As you withdraw, press slightly on the catheter to prevent bleeding
♦ Advance catheter tip or hub until it is fully inserted or you meet resistance
♦ Release the tourniquet

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 ♦ Remove stylet
♦ Attach IV fluids or saline lock
♦ Check for placement for the cannula in the vein either by opening the roller-clamp on the
IV, or flushing with saline. If the device is resistant to flushing or you notice a “wheal” of
fluid developing under the skin, remove the cannula immediately. It is not in the vein
and should not be used for IV therapy.
♦ After two unsuccessful attempts at insertion of an IV, consult with another professional to
initiate therapy.

STEP 8: Secure the Device and Dress the Site

♦ The device should be secured at the hub of the cannula to the skin so that the device is
secure and will not move around.
♦ The insertion site should remain visible for assessment and maintenance

Using a transparent semipermeable membrane to dress the site

An advantage to using this type of dressing is that the insertion site of the cannula can be
routinely visualized. Additionally, the dressing can be changed when the site is changed unless
soiled or there is noticeable moisture under the dressing. If a transparent dressing is applied
over gauze, then it is considered a gauze dressing and should be changed every 48 hours at
minimum

♦ Cleanse the site as needed before applying the dressing

♦ Position the dressing over the insertion site
♦ Gently smooth the dressing from the center to the edges. Do not apply excessive tension
as skin shearing may result.
♦ Do not seal the dressing edges with tape and do not cover the dressing with roller gauze
♦ If near a moveable joint, secure device with an arm board as necessary

Documentation Guidelines
Documentation is important and should be completed as soon as possible after the procedure.
♦ Date and time of venipuncture
♦ Type and gauge of needle and catheter
♦ The location of the insertion site – Use anatomical names of the veins
♦ Reason IV was changed (if necessary)
♦ Number of attempts at venipuncture (REMEMBER – Only stick a patient twice before
getting another professional to try)
♦ The type and flow rate of the IV solution (if any)
♦ Any adverse reactions and actions taken to correct them
♦ Patient teaching and evidence of patient understanding
♦ How the patient tolerated the procedure
♦ Your name and initials

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 IV Management
IV sites should be assessed and monitored at established intervals to insure the device is
working properly. This inspection includes both site and equipment.

o Asses for temperature of skin surrounding the insertion site.

o Signs of IV-related infections or complications including:
o Temperature
o Discoloration
o Pain, tenderness, numbness
o Edema
o Localized swelling
o Induration with palpable cord
o Monitor for signs of infection, hyper/hypovolemia
o Verify that the correct fluid is hanging the tubing is intact and connected properly and that
the IV is infusing at the correct rate

General Practice Tips

o Assess IV site and extremity with every assessment and document any abnormalities
o Avoid infusing cold solutions. This can cause vasospasms. If vasospasm occurs, apply
heat above the IV site to reduce spasm
o Reduce patient anxiety by
o Educate
o Give patient opportunity to ask questions
o Appear calm and confident
o Do not rush process
o If vein doesn’t dilate
o Position limb in a dependent position
o Tap vein lightly – this releases histamine causing dilation
o Wrap limb in warm towels for 5-10 minutes before attempting venipuncture
o Avoid areas of flexion or extension
o Allow prepping agent to dry completely
o Stabilize catheter
o Use single-use flus solutions rather than multidose vials to prevent possible bacterial
contamination
o Do not leave tourniquet on for more than one minute at a time
o Causes false lab results if you draw blood
o Causes discomfort
o Causes disruption in tissue oxygenation
o Causes venous pooling

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 Removal of Peripheral IV line
A peripheral catheter should be removed with an order from the physician when therapy is
completed, during routine site rotation, when contamination or IV-related complication is
suspected, or when the tip location is not longer appropriate for the prescribed therapy.

Procedure

♦ Gather necessary supplies: gloves, sterile gauze and tape

♦ Stop the infusion of fluid
♦ Wash hands
♦ Put on gloves
♦ Remove the dressing from site
♦ Inspect cannulation site
♦ Hold the sterile gauze against the insertion site
♦ Gently pull the catheter our parallel to the skin surface
♦ Look at the catheter to ensure that it is still intact and unbroken
♦ Apply pressure to the site for about two minutes. Apply longer if patient is taking
anticoagulation medication.
♦ Apply sterile dressing to the old site
♦ Discard the catheter and old dressing in the proper manner for biohazard waste
♦ Document the removal
o Procedure
o Site condition
o Catheter condition
o Interventions (if any)
o Patient response

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 Complications of Peripheral IV Therapy

Catheter Occlusion
Occlusion occurs when fluid or medication cannot enter the vein. The IV flow is interrupted and
blood may be backed up in the tubing or saline lock.

Treatment includes attempting to flush with mild pressure. If the catheter does not flush, do
NOT force it. Remove the IV and start a new one in a new site.

Local Infection
Local infections are a common complication associated with IV therapy. The infection is
generally cause by two sources of contamination: the cannula or fluid being infused.
Contamination of the cannula is the most common source. It can occur during venipuncture or
anytime during therapy from unclean skin at the insertion site.

Infections are preventable by maintaining aseptic technique, good hand-washing technique,

inspection of IV fluid and containers before hanging, and frequent assessment of IV site looking
for signs of infiltration, infection and irritation. By following these basic preventable measures,
the incidence of local infection is greatly reduced.

Symptoms associated with local infection include redness, swelling and tenderness at the site,
possible drainage and elevated temperature. If local infection does occur, the physician should
be notified

Treatment includes discontinuing IV and changing the IV site and doing a culture of the
drainage and/or catheter tip (if ordered by physician). The physician may also order
medications to treat the infection.

Phlebitis
Phlebitis is an inflammation of the vein. It is the most common of the local complications. The
vein can become inflamed in a number of ways including: poor catheter insertion technique,
mechanical irritation from the catheter (too large, not secured), chemical irritation from acidic
or vesicant fluid.

Measures that will help prevent phlebitis include: good venipuncture technique, choosing an
appropriately sized vein for the catheter, dilution of irritating medications and/or infusing into a
larger vein, and choosing the correct access device based on length of stay, treatment and
diagnosis

Symptoms associated with phlebitis include redness, area warm to touch, local swelling, pain
along the course of the vein and possibly an elevated body temperature

Treatment includes immediately discontinuing the infusion and restarting the IV in a

different extremity; elevate the extremity and application of warm, moist packs to the affected
area.

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Infiltration
An infiltration is the seepage or infusion of non-caustic IV solution (e.g. normal saline) into the
surrounding tissue. Typically, the causes of infiltration include: dislodgment of the catheter out
of the vein or phlebitis causing fluid to leak at the site of the catheter insertion.

Measures that help prevent infiltration include: securing the catheter and tubing well with tape,
using an arm board (if necessary) to prevent dislodgement, checking the site and tubing often,
choosing the right types of vascular access for the diagnosis and meds the patient is receiving.

Symptoms of infiltration include dependent edema, cool blanched and/or taut skin, slow or
sluggish IV infusion and patient may complain of pain or pressure.

Treatment include discontinuing the IV, elevating the extremity and applying warm
compresses to the site. The warm packs assist in reabsorption of the fluid (do not use on
neonates). {Special note: do not apply warm compresses or elevate an extremity without a
physician’s order}

Extravasation
Extravasation is a form of infiltration in which the fluid is caustic to the tissues and can cause
permanent damage. The agents are termed vesicant fluids and include 10% Dextrose, Dilantin
and any cytotoxic agents used in chemotherapy.

Symptoms include severe pain and burning at the site, blotchy redness and swelling. May also
have tingling sensations, blistering, ulceration or tissue necrosis.

Treatment of extravasation includes stopping the infusion immediately and notifying the
physician. Attempt to withdraw up to 5 mL of fluid from the catheter. This may help in
stopping the agent. Do NOT remove the IV until you verify the medication to treat the
extravasation doesn’t need to be infused through the catheter. Some of the agents have
antidotes, which can reduce or reverse some of the action of the involved agents. Elevate the
extremity and follow treatment orders from the physician.

Hematomas occur when blood leaks into the extravascular space. The patient will have
tenderness at the site, a bruise may be evident at the site, and the infusion will not flow. The
IV catheter must be removed and restarted elsewhere. Additionally, you should apply pressure
until the bleeding stops and warm soaks to aid in the absorption of the blood.

Venous Spasms occur due to severe vein irritation, administration of cold fluids or blood, and
a very rapid flow rate. The patient will experience pain at the VI site, the flow rate will become
sluggish even if the roller clamp is wide open, and the skin will be blanched over the vein.
Treatment includes warm soaks over the vein and reduction in the flow rate of the infusion.

Thrombosis occurs when the platelets adhere to the tunica intima of the vein due to vessel
injury during venipuncture. The vein will appear painful, red and swollen. The IV infusion will
not run quickly. If thrombosis occurs, you will need to remove the IV catheter and restart the
IV in the opposite arm if at all possible. Warm soaks can also be applied.

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Nerve, tendon, or ligament damage occurs due to improper venipuncture technique, tight
taping or improper arm board application. The patient will experience extreme pain at the
insertion site, numbness, muscle contraction and eventually may exhibit paralysis, numbness
and deformity.

Vasovagal reactions can occur when the patient experiences vasospasms from anxiety or
pain. The vein suddenly collapses during venipuncture and causes the patient to become pale,
diaphoretic, faint, dizzy and nauseated. The patient may also have a sudden drop in blood
pressure. If this occurs, lower the head of the bed and have the patient take slow deep breaths
while you monitor vital signs. The reaction should resolve quickly.

Circulatory Overload
Circulatory overload can occur when the IV roller clamp is loosened and the infusion is allowed
to run into the vein quickly.

Symptoms: The patient may be anxious, experience respiratory distress, crackles in the lung
bases, increased blood pressure and neck engorgement.

Treatment includes raising the head of the bed, administering oxygen and IV furosemide as
ordered, and prompt notification of the physician.

Systemic Infection (Septicemia)or Bacteremia

Systemic infection of bacteremia can occur as a result of phlebitis, poor taping that allows the
venipuncture device to move in and out of the vein, prolonged dwell time of the catheter and
failure to maintain aseptic techniques during insertion or site care.

Symptoms: The patient may experience malaise, fever, and chills.

Treatment includes contacting the physician, culturing the site and device, administering
antibiotics and hemodynamic support.

Air Embolism
Air embolism occurs when the solution container runs empty and the added container pushes
air down the line into the patient. The patient will experience respiratory distress, unequal
breath sounds, a weak pulse, increased central venous pressure, decreased blood pressure, and
loss of consciousness. If air embolism is suspected, discontinue the infusion, place the patient
in Trendelenburg, administer oxygen and notify the physician.

Allergic reaction may occur when the patient is allergic to the catheter that has been
inserted or the medications being administered. The patient will itch, develop watery eyes and
nose, experience bronchospasm, wheezing, and possibly anaphylaxis. If a reaction does occur,
stop the infusion or discontinue the catheter. Emphasis should be placed on notification of the
physician and airway support. Administration of an antihistamine, a steroid, or epinephrine may
be indicated.

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Developed November 2019