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Table 8-3

ComplicationAssessmentNursing Care Plan/Implementation
Subjective Data Objective Data
Infiltration—fluid infusing into surrounding tissue rather than into vesselPain around needle nsertion
  1. Infusion rate slow
  2. Swelling, hardness, coolness, blanching of tissue at site of needle
  3. Blood does not return into tubing when bag/bottle lowered
  4. Puffiness under surface of arm
  1. Stop IV
  2. Apply warm towel to area
  3. Restart at another site
  4. Record
Thrombophlebitis—inflammatory changes in vessel; thromboemboli—the development of venous clots within the inflamed vesselPain along the veinRedness, swelling around affected area (red line)
  1. Stop IV
  2. Notify physician
  3. Cold compresses or warm towel, as ordered
  4. Restart in another site
  5. Rest affected limb; do not rub
  6. See nursing care of thrombophlebitis, Chapter 6. Physiological Integrity, Physiological Integrity
Pyrogenic reaction—contaminated equipment/solution
  1. Headache
  2. Backache
  3. Nausea
  4. Anxiety
  1. ↑ Temperature
  2. Chills
  3. Face flushed
  4. Vomiting
  5. ↓ BP
  6. Cyanosis
  1. Discontinue IV
  2. Vital signs
  3. Send equipment for culture/analysis
  4. Antibiotic ointment, as ordered, at injection site
  5. Prevention: change tubing q24–48h; meticulous sterile technique; check for precipitation, expiration dates, damage to containers, tubings, etc.; refrigerate hyperalimentation fluids; discard hyperalimentation fluids that have been at room temperature for 8–12 hr and use new bag regardless of amount left in first bag (change, to prevent infection—excellent medium for bacterial growth)
Fluid overload—excessive amount of fluid infused; infants/elderly at risk
  1. Headache
  2. Shortness of breath
  3. Syncope
  4. Dyspnea
  • ↑ Pulse, venous pressure
  • Venous distention
  • Flushed skin
  • Coughing
  • ↑ Respirations
  • Cyanosis, pulmonary edema
  • Shock
  1. Stop IV
  2. infoImageSemi-Fowler’s position
  3. Notify physician
  4. Be prepared for diuretic therapy
  5. Preventive measures: monitor flow rate and client’s response to IV therapy (see Chapter 6. Physiological Integrity, Fluid volume excess, Physiological Integrity, for subjective and objective data)
Air emboli—air in circulatory systemLoss of consciousness
  1. Hypotension, cyanosis
  2. Tachycardia
  3. ↑ Venous pressure
  4. Tachypnea
  1. infoImageTurn on left side, with head down
  2. Administer oxygen therapy
  3. Medical emergency—call physician
Nerve damage—improper position of limb during infusion or tying limb down too tight during infusion → damage to nerveNumbness: fingers, handsUnusual position for limb
  1. Untie
  2. Passive ROM exercises
  3. Monitor closely for return of function
  4. Record limb status
Pulmonary embolism—blood clot enters pulmonary circulation and obstructs pulmonary arteryDyspnea
  1. Orthopnea
  2. Signs of circulatory and cardiac collapse
  1. Slow IV to keep vein open (rate: 5–6 drops/min)
  2. Notify physician
  3. Medical emergency
  4. Be prepared for lifesaving measures and anticoagulation therapy