Chapter 8: IV Therapy
8.2 Intravenous Therapy: Guidelines and Potential Complications
Critical Thinking Exercises: Questions, Answers, and Sources / References
- A patient is two days post op with nausea and vomiting. The prescriber orders to “saline lock the IV.” As the nurse, describe your subsequent actions.
Answer: Prior to saline locking an IV, the nurse should assess a number of things including:
- Oral intake: to provide insight into the patient’s ability to maintain adequate hydration and nutrition
- Urinary output: volume and color might provide insight into hydration status
- Blood pressure: to provide some insight into hydration status. Assessing oral intake helps to determine the patient’s ability to maintain adequate
- Temperature for evidence of infection. If fever is present the IV might provide additional hydration and provide a route for IV medications if they are ordered.
- GI function: to determine if the patient is able to maintain adequate hydration and nutrition without aid of an IV.
In this situation the patient has nausea and vomiting. The nurse should investigate possible causes, discuss any decision to not saline loc the IV with the prescriber
2. During night shift rounds, the patient who was restless all night has pulled apart their IV tubing. The CVC remains in situ. As the nurse, describe your subsequent actions.
Answer: the nurse should consider:
- That the CVC is likely contaminated therefore the patient is at risk of sepsis. If reconnection to a new tubing is to be done, the connections will have to be cleaned well with agency approved antiseptic ie. alcohol or chlorhexidine
- That an open line presents risk of air emboli to the patient. Therefore kink / occlude the line and call for help. Assess the patient.
- There is a high risk of BBF exposure for the nurse. Therefore donne clean gloves.
- The CVC may have been pulled out and the tip is not in the correct position. Therefore measure the external length and aspirate for blood using a 10 ml syringe. If the external length has increased and blood can be aspirated, flush and lock the CVC until further assessment through XRAY / PICC nurse. Assess the patient.
Source: Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby.
3. A first year nursing student is shadowing you, the nurse, for the day and asks how you would know if someone is experiencing fluid overload from their IV therapy. How might you respond?
Answer: As the nurse I would explain that fluid overload from IV therapy is a condition caused by excess fluid accumulation in the lungs due to excess fluid in the circulatory system and / or inability of the body to manage the IV fluid being infused. Signs and symptoms include ↓SpO2, ↑respiratory rate, dyspnea, coughing up pink frothy sputum, auscultation of dependent fine crackles, anxiety. Knowing the patient’s history can provide insight into conditions that put some patients more than others at higher risk for fluid overload. Definitive diagnosis cannot be done by the RN. Timely consultation with respiratory therapy and / or the prescriber is important for better patient outcomes.
Sources:
Fraser Health Authority. (2014). Clinical practice guidelines: Intravenous therapy. http://physicians.fraserhealth.ca/media/2014%2005%2015%20IV%20Therapy%20CPG%20FINAL.pdf.
Fulcher, E. M., & Frazier, M. S. (2007). Introduction to intravenous therapy for health professionals. St. Louis, MO: Elsevier.
Interior Health. (2012). Parenteral practices manual. http://insidenet.interiorhealth.ca/Clinical/parenteralccr/Pages/Manual.aspx.
McCallum L., & Higgins, D. (2012). Care of peripheral venous cannula sites. Nursing Times, 108(34-35), 12-15.
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby.
Singh, A., Kaur, A., Singh, M., & Kaur, S. (2015). CT guided removal of iatrogenic foreign body: a broken intravenous cannula. Journal of Clinical & Diagnostic Research, 9(9), PD28-PD29. https://dx.doi.org/10.7860%2FJCDR%2F2015%2F14344.6549.
- Which of the following are potential systemic complications of IV therapy? (Select all that apply)
| Distractors | ||
| a. | Phlebitis | Incorrect: this is a local complication. Characterized by redness, ropey vein at insertion site, discomfort |
| b. | Pulmonary emboli | Correct: this is a free floating clot that enters venous circulation and completely or partially blocks a pulmonary artery. The resulting hypoxic injury to lobe(s) of the lung result in circulatory issues. |
| c. | Catheter fracture | Incorrect: this is an equipment complication caused by using syringes smaller than 10cc that exert too high PSI during flushing. |
| d. | Fluid overload | Correct: this is a condition caused by excess fluid accumulation in the lungs due to excess fluid in the circulatory system and / inability of the body to adapt. |
| e. | Catheter-related bloodstream infection (CRBSI) | Correct caused by microorganisms that are introduced into the body during insertion if the device is contaminated, through skin organisms at the time of insertion and afterward, from the IV hub / connector, and / or the solutions. There is greater risk with CVADs because of proximity to central circulation. |
| f. | Infiltration | Incorrect. This is a local complication that occurs when a non-vesicant IV solution is inadvertently administered into surrounding tissue. It is characterized by edema and coolness. |
Sources:
Baskin, J. L., Pui, C. H., Reiss, U., Wilimas, J. A., Metzger, L. M., Ribeiro, R. C., & Howard, S. C. (2009). Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. Lancet, 374(9684), 159. doi: 10.1016/S0140-6736(09)60220-8.
British Columbia Institute of Technology (BCIT). (2015a). CVC complications worksheet. In, NURS 3020. BCIT BSN program. Vancouver, BC: BCIT.
Brunce, M. (2003). Troubleshooting central lines. ModernMedicine Network. http://www.modernmedicine.com/modern-medicine/content/troubleshooting-central-lines.
Fraser Health Authority. (2014). Clinical practice guidelines: Intravenous therapy. http://physicians.fraserhealth.ca/media/2014%2005%2015%20IV%20Therapy%20CPG%20FINAL.pdf.
Fulcher, E. M., & Frazier, M. S. (2007). Introduction to intravenous therapy for health professionals. St. Louis, MO: Elsevier.
Interior Health. (2012). Parenteral practices manual. http://insidenet.interiorhealth.ca/Clinical/parenteralccr/Pages/Manual.aspx.
McCallum L., & Higgins, D. (2012). Care of peripheral venous cannula sites. Nursing Times, 108(34-35), 12-15.
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby.
Prabaharan, B., & Thomas, S. (2014). Spontaneous migration of central venous catheter tip following extubation. Saudi Journal of Anaesthesia, 8(1), 131–133. doi: 10.4103/1658-354X.125975.
Singh, A., Kaur, A., Singh, M., & Kaur, S. (2015). CT guided removal of iatrogenic foreign body: a broken intravenous cannula. Journal of Clinical & Diagnostic Research, 9(9), PD28-PD29. https://dx.doi.org/10.7860%2FJCDR%2F2015%2F14344.6549.
2. Symptoms of air embolism include: Select all that apply
- Dyspnea (Correct)
- Chest discomfort (Correct)
- Low SP02 (Correct)
- Cyanosis (Correct)
- Changed level of consciousness (Correct)
- Bradycardia (Incorrect. Tachycardia is likely due to increased oxygen demands)
3. Air embolisms can be caused by: Select all that apply
- Dry IV bags (Correct)
- Loose connections that allow air to enter the IV line system (Correct)
- Poor technique during tubing changes (Correct)
4. S&S of circulatory overload include: Select all that apply
- Puffy eyelids (Correct)
- Edema (Correct)
- Hypertension (Correct)
- Tachycardia (Correct)
- Shortness of breath (Correct)
- Restlessness (Correct)
- Non productive cough (Correct)
5. Situations that put the client at risk for circulatory overload include: Select all that apply
- Compromised cardiovascular function (Correct)
- Compromised renal function (Correct)
- High creatinine (Correct)
- Low GFR (Correct)
- Overzealous infusion of IV fluids (Correct)
6. IV solutions infusing via PICCs and Central lines should be infused with an IV pump to reduce risk of accidental IV fluid overload true / false
Answer: True…the risk of circulatory overload is great when IVs are infusing into large vessels such as the vena cava & subclavian.
7. Jane has had a central line inserted into her right subclavian vein. 10 minutes following the insertion (and before an XRAY confirms placement) you notice she is short of breath and is using her accessory muscles to breathe. You auscultate her chest and find diminished air entry in the right lung fields, no adventitious sounds. You recognize this as a possible complication of central line insertion. Which complication do the symptoms suggest? Select all that apply.
| Distractors | Answer | |
| a. | Fluid overload | Incorrect. Fluid overload might happen following IV infusion. At this point in the scenario, the central line was inserted only 10 minutes ago. Placement will have to be confirmed before the nurse begins IV therapy through the central line. |
| b. | Pneumothorax | Correct. During insertion of central lines there is risk of accidental puncture of the pleura resulting in pneumothorax. The nurse should always auscultate lung sounds post central line insertion |
| c. | Interstitial | Incorrect. Interstitial means the IV fluid is infusing into the surrounding tissues |
| d. | Phlebitis | Incorrect. Phlebitis is inflammation of the vein |
Source: Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby.
8. Which of the following statements are true in relation to Biofilm and PICCs and central lines: Select all that apply.
| Distractors | Answer | |
| a. | It consists of bacteria that migrates from the skin down to the catheter site which then colonizes the catheter. | Correct |
| b. | It begins to develop within 5 minutes of catheter insertion | Correct. |
| c. | It always results in sepsis | False. Biofilm can be the person’s normal flora |
| d. | Can be eliminated with correct site asepsis (i.e. chlorhexidine 2% isopropyl alcohol 70%) | False. Biofilms might be controlled with site asepsis using the recommended antiseptic solution…but often cannot be completely eliminated |
Source: Center for Disease Control (2017). Guidelines for the prevention of intravascular catheter-related infections: Summary of recommendations. https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html.
9. One of the most important nursing interventions to preventing many IV related complications is:
- Competency testing (Incorrect. This is important but hand hygiene is #1)
- Using macrodrip tubing (Incorrect. this intervention doesn’t’ t make sense)
- Hand hygiene (Correct)
- Reading the IV procedure manual (Incorrect. This is important but hand hygiene is #1)