Risks

1. Needlestick
injury
2. Infectious
organism
exposure

Needlestick Injury

An AIDS patient became agitated and tried to

remove the intravenous catheters. Hospital staff
struggled to restrain the patient. During the
struggle, an IV infusion line was pulled,
exposing the connector needle. A nurse
recovered the connector needle at the end of
the IV line and attempted to reinsert it. The
patient kicked her arm, pushing the needle into
the hand of the second nurse. Three months
later, the nurse who sustained the needlestick
injury tested positive for HIV1.

Prevention:
Avoid the use of needles where safe and

effective alternatives are available.

Avoid recapping needles.
Report all needlestick and other sharps
related injuries to ensure that you
receive appropriate follow-up care.
Create/maintain a safe, comprehensive
disposal system.

Infectious Organism
Exposure
Prevention:
Do proper hand hygiene.
Do not reuse tourniquets.
Wear gloves.
Cleanse insertion sites with the
recommended solutions.

IV Therapist, How Safe Are

You?
In a CDC study, 89 percent of HCW

exposure to HIV were caused by

percutaneous injuries.
As many as 40 percent of HCW who
sustain needlesticks become infected
with HBV
In 2004, more than 1,000 HCW
became infected with HBV

Occupational Risks
Associated With IV Therapy
Physical hazards;
Accidents , abrasions, contusions

and chemical exposure

Exposure to Infectious Agents

 The following list is a summary of

some of the rules to be observed in

the workplace:
HEPATITIS B vaccine
STANDARD PRECAUTIONS
SHARPS AND WASTE DISPOSAL
PROTECTIVE
DEVICE/EQUIPMENT
GLOVES
LAUNDRY
COMMUNICATING HAZARDS

COMPLICATIONS
ASSOCIATED WITH IVT

Mechanical
Risks
1. Phlebitis

Possible
Causes
*Clotting at the
catheter tip
(thrombophlebitis)
*Device left in the
vein too long
*Friction from
catheter
movement in the
vein
*Poor blood flow
around the
device
*Solution with
high or low pH or
high osmolarity

Signs/
Symptoms
*Redness at

Nursing
Interventions

*Remove the
the tip of the
device
catheter and
*Apply a warm
along the vein pack
*Tenderness
*Notify the
at the tip of
physician
device and
*Document the
above
patients
*Vein hard on condition and
palpation
your
interventions

Prevention
Measures
*Restart the
infusion using
a larger vein
for initiating
infusate, or
restart with a
smaller-gauge
device to
ensure
adequate
blood flow
*Tape the
device
securely to
prevent
movement

Mechanical
Risks
2. Infiltration

Possible
Causes
*Device
dislodged
from vein or
perforated
vein

Signs/
Symptoms
*Blanching at
site
*Continuing
fluid infusion
even when vein
is occluded,
although rate
may decrease
*Cool skin
around site
*Discomfort,
burning, or pain
at site
*Feeling of
tightness at site
*Slower flow
rate
*Swelling at and
above IV site
(may extend
along entire
limb)

Nursing
Interventions
*Remove the
venipuncture
device
*Periodically
assess
circulation by
checking for
pulse and
capillary refill
*Restart the
infusion in
another limb
*Notify the
physician

Prevention
Measures
*Check the
IV site
frequently
(especially
when using
an IV pump)
*Dont
obscure the
area above
the site with
tape
*Teach the
patient to
observe the
IV site and
report
discomfort,
pain or
swelling

Mechanical
Risks
3.Catheter
dislodgement

Possible
Causes
*Loosened tape
or tubing
snagged in
bedclothes,
resulting in
partial retraction
of the catheter
*Dislodged by a
confused patient
attempting to
remove it

Signs/
Symptoms

Nursing
Interventions

*Catheter
*Remove the
backed out of catheter
the vein
*Infusate
infiltrating into
tissue

Prevention
Measures
*Tape device
securely on
insertion
*Use armboard

Mechanical
Risks
4. Severed
catheter

Possible
Causes
*Catheter
inadvertently cut
by scissors
*Reinsertion of
the needle into
the catheter

Signs/
Symptoms

Nursing
Interventions

Prevention
Measures

*Leakage
from the
catheter shaft

*If the broken

portion of the
catheter is
visible, attempt
to retrieve it. If
unsuccessful,
notify the
physician
*If the broken
portion of the
catheter enters
the
bloodstream,
place a
tourniquet
above the IV
site to prevent
its progression
*Notify the
physician and
radiology
department

*Avoid using
scissors around
the IV site
*Never reinsert
the needle into
the catheter
*Remove the
unsuccessfully
inserted
catheter and
needle together

Mechanical
Risks
5.
Hematoma

Possible
Causes

Signs/
Symptoms

Nursing
Interventions

Prevention
Measures

*Leakage of
blood into tissue
*Vein punctured
through ventral
wall at time of
venipuncture

*Bruising
around
venipuncture
site
*Tenderness
at
venipuncture
site

*Remove the
venipuncture
device
*Apply
pressure and
cold
compresses to
the affected
area
*Recheck for
bleeding
*Document the
patients
condition and
your
interventions

*Choose a vein
that can
accommodate
the size of the
intended
venous access
device
*Release the
tourniquet as
soon as
successful
insertion is
achieved

Mechanical
Risks
6. Venous
spasm

Possible
Causes
*Administration
of cold fluids or
blood
*Severe vein
irritation from
irritating drugs or
fluids
*Very rapid flow
rate (with fluids
at room
temperature)

Signs/
Symptoms

Nursing
Interventions

Prevention
Measures

*Blanched
skin over the
vein
*Pain along
the vein
*Sluggish
flow rate
when the
clamp is
completely
open

*Apply warm
soaks over the
vein and
surrounding
area
*Slow the flow
rate

*Use a blood
warmer for
blood or
packed red
blood cells
when
appropriate

Mechanical
Risks

7.Nerve,
tendon, or
ligament
damage

Possible
Causes

Signs/
Symptoms

*Improper
venipuncture
technique,
resulting in
injury to
surrounding
nerves,
tendons, or
ligaments
*Tight taping or
improper
splinting with
arm board

*Delayed
effects,
including
paralysis,
numbness, and
deformity
*Extreme pain
(similar to
electric shock
when nerve is
punctured)
*Numbness
and muscle
contraction

Nursing
Interventions

*Stop
procedure
*Notify the
physician

Prevention
Measures

*Dont
repeatedly
penetrate
tissues with
the
venipuncture
device
*Dont apply
excessive
pressure
when taping
or encircling
the limb with
tape
*Pad the arm
board and, if
possible, pad
the tape
securing the
arm board

Mechanical
Risks

Possible
Causes

Signs/
Symptoms

Nursing
Interventions

Prevention
Measures

8.Circulatory
overload

*Flow rate too

rapid
*Miscalculation
of fluid
requirements
*Roller clamp
loosened to
allow run-on
infusion

*Crackles
*Discomfort
*Increased
blood
pressure
*Large
positive fluid
balance
(intake is
greater than
output)
*Neck vein
engorgement
*Respiratory
distress

*Raise head of
the bed
*Administer
oxygen as
needed
*Notify the
physician
*Administer
medications
(probably
furosemide) as
ordered

*Use a
pump,
controller, or
rate minder
for elderly or
compromise
d patients
*Recheck
calculations
of fluid
requirements
*Monitor the
infusion
frequently

Mechanical
Risks
9. Systemic
infection

Possible
Causes

Signs/
Symptoms

Nursing
Interventions

Prevention
Measures

*Failure to
maintain aseptic
technique during
insertion or site
care
*Immunocompro
mised patient
*Poor taping
that permits the
access device to
move, which
can introduce
organisms into
the bloodstream
*Prolonged
indwelling time
of device
*Severe
phlebitis, which
can set up ideal
conditions for
organism

*Contaminated
IV site usually
with no visible
signs of
infection
*Fever, chills,
and malaise for
no apparent
reason

*Notify the
physician
*Administer
prescribed
medications
*Culture the site
and the device
*Monitor vital
signs

*Use
scrupulous
aseptic
technique
when handling
solutions and
tubings,
inserting the
venipuncture
device, and
discontinuing
the infusion
*Secure all
connections
*Change IV
solutions,
tubing, and the
access device
at
recommended
times.

Mechanical
Risks
10.Air
embolism

Possible
Causes

Signs/
Symptoms

Nursing
Interventions

Prevention
Measures

*Empty solution
container
*Secondary
solution
container
empties; next
container
(primary) pushes
air down line
*Disconnected
tubing

*Decreased
blood pressure
*Increased
central venous
pressure
*Loss of
consciousness
*Respiratory
distress
*Unequal
breath sounds
*Weak pulse

*Discontinue the
infusion
*Place the
patient in
Trendelenburgs
position to allow
air to enter the
right atrium and
disperse
through the
pulmonary
artery
*Administer
oxygen
*Notify the
physician
*Document the
patients
condition and
your
interventions

*Purge the
tubing of air
completely
before
infusion
*Use the airdetection
device on the
pump or the
aireliminating
filter proximal
to the IV site
*Secure
connections

Mechanical
Risks
11.Allergic
reaction

Possible
Causes
*Allergens such
as medications

Signs/
Symptoms

Nursing
Interventions

Prevention
Measures

*If reaction
occurs, stop the
infusion
immediately
*Maintain a
patent airway
*Notify the
physician
*Administer an
RED FLAG:
antihistaminic
An
steroid, an antianaphylactic
inflammatory,
reaction can
and antipyretics
occur within
drugs, as
minutes after
ordered
exposure,
*Give 0.2 to 0.5
including
ml of 1:1,000
flushing, chills, aqueous
anxiety,
epinephrine
agitation,
subcutaneously

*Obtain the
patients
allergy
history. Be
aware of
crossallergies
*Assist with
test dosing
*Monitor the
patient
carefully
during the
first 15
minutes of
administratio
n of a new
drug

*Bronchospas
m
*Itching
*Tearing eyes
and runny
nose
*Urticarial rash
*Wheezing

Mechanical
Risks

Possible
Causes

Signs/
Symptoms

Nursing
Interventions

generalized
itching,
palpitations,
paresthesia,
throbbing in
ears,
wheezing,
coughing,
seizures, and
cardiac arrest

*Repeat the
epinephrine
dose at 3minute intervals
and as needed,
as ordered
*Administer
cortisone if
ordered

Prevention
Measures

Mechanical
Risks
12.
Occlusion

Possible
Causes

Signs/
Symptoms

*Blood backup in *IV flow

the line when the interrupted
patient walks
*Hypercoagulabl
e patient
*Intermittent
device not
flushed
*Line clamped
too long

Nursing
Interventions

Prevention
Measures

*Use mild flush

pressure during
injection
*Dont force the
flush
*If unsuccessful,
reinsert the IV
device

*Maintain IV
flow rate
*Flush
promptly
after
intermittent
piggyback
administratio
n.
*Have the
patient walk
with his arm
folded to his
chest to
reduce the
risk of blood
backup

Mechanical
Risks
13.
Thrombophl
ebitis

Possible
Causes

Signs/
Symptoms

*Thrombosis and *IV Reddened,

inflammation
swollen, and
hardened vein
*Severe
discomfort

Nursing
Interventions

Prevention
Measures

*Remove the
device; restart
the infusion in
the opposite
limb if possible
*Apply warm
soaks
*Watch for IV
therapy-related
infection
(thrombi provide
an excellent
environment for
bacterial growth
*Notify the
physician

*Check the
site
frequently
*Remove the
device at the
first sign of
redness and
tenderness

Mechanical
Risks

Possible
Causes

Signs/
Symptoms

Nursing
Interventions

Prevention
Measures

14.
Thrombosis

*Injury to the
endothelial cells
of the vein wall,
allowing platelets
to adhere and
thrombus to form

*Painful,
reddened, and
swollen vein
*Sluggish or
stopped IV
flow

*Remove the
device; restart
the infusion in
the opposite
limb if possible
*Apply warm
soaks
*Watch for IV
therapy-related
infection
(thrombi provide
an excellent
environment for
bacterial growth
*Notify the
physician

*Use proper
venipuncture
techniques to
reduce injury
to the vein

Mechanical
Risks
15. Vein
irritation at
the IV site

Possible
Causes

Signs/
Symptoms

*Solution with a
high or low pH or
high osmolarity,
such as 40
mEq/L of
potassium
chloride,
phenytoin, and
some antibiotics
(such as
vancomycin and
nafcillin)

*Pain during
the infusion
*Possible
blanching if
vasospasm
occurs
Rapidly
developing
signs of
phlebitis
*Red skin over
the vein during
infusion

Nursing
Interventions
*Slow the flow
rate
*Try using an
electronic flow
device to
achieve a
steady
regulated flow

Prevention
Measures
*Dilute
solutions
before
administratio
n. For
example,
give
antibiotics in
a 250-ml
solution
rather than
100 ml
*If the drug
has a low
pH, ask a
pharmacist if
it can be
buffered with
sodium
bicarbonate
(refer to
facility policy)

Mechanical
Risks

Possible
Causes

Signs/
Symptoms

Nursing
Interventions

Prevention
Measures
*If long-term
therapy of an
irritating drug
is planned,
ask the
physician to
use a central
IV line

PROCEDURAL
PROBLEMS
ASSOCIATED WITH IV
THERAPY

Fluctuating flow rate

Runaway IV
Sluggish IV

Tubing / loose connection/

disconnection
Blood back up in tubing

IV line obstruction/kinking

of IV tubing
Clogged filter
Break in aseptic technique
Leaks; due to inappropriate
device

TROUBLESHOOTING
PROMPTLY AND
EFFECTIVELY

 I.V. therapy is the preferred mode of

treatment because of its rapid onset.

Nurses are assuming more nursing
responsibilities in I.V. therapy.
More nursing time is allotted to I.V.
therapy
I.V. Therapy is a risk specialty area.

WHAT TO DO WHEN
INFUSION SLOWS DOWN OR
STOPS
1.Assess the I.V. system to locate

the problem. Start at the insertion

side. Check for infiltration,
extravasation, or phlebitis.
2.Check for patency. Obstruction of
flow is caused or affected by the
following factors:

2.1 Patients limb is flexed;

patient lying on the side.
Reposition limb to release venous
pressure.

2.2 Tip of needle or cannula is

against the vein wall. Lift or pullback the needle or cannula a little.

2.3 Adhesive taping maybe too

tight, release every apply tapes.

2.4. Small cannulas or tubing may kink or

fold, gently adjust.

2.5. Local edema or poor tissue perfusion

from disease can block venous flow. Transfer
I.V. line to an unaffected site.

2.6. Presence of precipitates in solution

either from incompatibility of fluids and
medications or from infusion. Replace the
entire venipuncture device and solution. It
may expose the patient to embolism.

 3. Check the clamps. Some sets have

two:
the roller clamp and the side clamp.
Check if both are open or if these are
properly adjusted.
4. Check the patency of the air vent;
reposition it if needed.

 5. Check fluid level: if empty replace

as prescribed. If solution is too cold, it

may cause venous spasm and
decrease the flow; keep room
temperature regulated. Check the
spike of the set; push it more inside
the fluid bag or adjust it.

 6. Check filters: ordinary sets usually

do not have in-line filters. If it has,

follow the manufacturers guide
instructions. Blood transfusion filters
retain blood product debris. If flow rate
decreases or stops after more than
one unit has been transfused you may
have to change the set.

 7. Check tubings: if patient is lying on

it or if it is kinked or it may be
crimped with too tight roller clamps,
release and round-up the tubing to its
original shape
8. Is gauge of the needle too small? Is
fluid container too low above the
venipuncture site? Adjust it around
36-48 inches above the site.

REFERENCES

Association of Nursing Service Administrators of

the Philippines, Inc. (ANSAP). 2000. Nursing
Standards on Intravenous Practice 7th EDITION.
Cahil, Matthew. I.V. Therapy made Incredibly Easy.
Springhouse Corporation, Pennsylvania.
Dionne, Lynn. Manual of I.V. Therapeutics. Philips,
F.A., Davis Co. Philadelphia.

Intravenous Nursing Society, Supplement to

Journal of Intravenous Nursing, Jan./February
1998 vol.21, Fresh Pond Square, 10 Faucett street,
Cambridge, MAO 218.
Lippincott Williams and Wilkins. 2005. JUST THE
FACTS I.V. Therapy.
Nursing Journal May and July 2000.