Comprehensive Intravenous Therapy Practice Flashcards

Fundamentals of Intravenous Therapy & Pre-Infusion Assessment

• Intravenous (IV) Therapy Purpose & Scope:

  • IV therapy involves delivering fluids, medications, and nutrients directly into the central circulation, allowing substances to impact the entire body in less than $1\,minute$.

  • In practical nursing, specific certification is required to perform IV therapy skills and procedures.

  • There are three primary purposes for administering IV therapy:

    • Maintenance Therapy:

      • Designed to meet the body's daily baseline fluid, electrolyte, and nutrient requirements, with water being the primary priority.

      • Dosage and flow rates depend on patient age, overall health status, and specific metabolic needs.

      • Indicated for patients who are NPO (nothing by mouth) or have restricted oral intake (whether intentionally ordered or due to inability to consume oral fluids).

      • Primary goal is the prevention of dehydration.

    • Replacement Therapy:

      • Designed to replenish fluids and electrolytes that have already been lost from the body.

      • Indicated in acute loss scenarios, such as severe vomiting or diarrhea, where fluid cannot be retained orally.

      • While electrolytes may be replaced simultaneously, the main focus is restoring total fluid volume to prevent rapid, severe dehydration.

    • Restorative Therapy:

      • An ongoing, continuous administration of fluids and electrolytes designed to return the body to homeostasis.

      • Requires daily laboratory blood draws (e.g., serum electrolytes, renal function tests).

      • IV fluid orders are continuously adjusted based on recent lab values and the specific nature of ongoing bodily fluid losses.

• Pre-Infusion Renal Assessment:

  • Evaluating renal function is mandatory prior to initiating IV therapy; if the kidneys cannot adequately excrete fluids or electrolytes, administration can cause fatal fluid volume excess or toxic electrolyte imbalances.

  • Assessment parameters for renal function include:

    • Laboratory Values: Blood Urea Nitrogen (BUN) and serum creatinine.

    • Intake and Output (I&O): Quantitative fluid balance monitoring.

    • Voiding Patterns: Checking regular urination history and current voiding status.

    • Physical Parameters: Vital signs, skin turgor, and daily weight changes.

    • Diagnostic Markers: Urine specific gravity testing.

USP Standards & Solution Quality Inspection

• United States Pharmacopeia (USP) Standards:

  • All IV solutions must strictly meet USP standards.

  • IV fluids are mass-produced in large vats in manufacturing plants, poured into flexible bags, and sealed.

  • The manufacturing process itself is not inherently sterile; final sterilization occurs inside the sealed bag via gas sterilization processes.

• Pre-Administration Inspection Steps:

  • Container Integrity: Gently squeeze the fluid bag prior to hanging to check for structural weakness, punctures, or active leaks.

  • Particulate Matter: Inspect the solution with the naked eye for floating particles or debris (referred to colloquially as "Billy Bobs"). If particulate matter is present, discard the solution immediately.

  • Clarity: Ensure the fluid is completely clear. Any unexpected cloudiness indicates contamination or precipitation, requiring immediate disposal.

  • pH Requirements: Verify that the solution meets USP pH standards, which typically range between $3.5\text{ and }7.4$ (often printed on the solution bag).

  • Expiration Date: Confirm the expiration date on the packaging prior to spiking the container.

Solution Tonicity & Specific IV Fluid Categories

• Toxicity Principles & Osmolarity Ranges:

  • Tonicity describes the concentration of dissolved particles in a solution relative to normal blood plasma.

  • Hypotonic Solutions:

    • Osmolarity is less than $240\,mOsm/L$.

    • Concentration is lower (more dilute) than blood plasma.

    • Causes fluid to shift out of the vascular space and into the cellular space, leading to cell swelling and potential cellular rupture (lysis).

  • Isotonic Solutions:

    • Osmolarity is between $240\text{ and }340\,mOsm/L$.

    • Concentration equals normal blood plasma.

    • Fluid stays within the vascular space, effectively expanding blood volume.

    • Rapid infusion carries a high risk of causing circulatory overload.

  • Hypertonic Solutions:

    • Osmolarity is greater than $340\,mOsm/L$.

    • Concentration is higher than blood plasma.

    • Draws water out of the cells and into the vascular space, shrinking the cells and expanding intravascular volume.

    • Highly concentrated and irritating to vein walls; requires administration in larger veins or central lines for rapid blood dilution.

• Dextrose Solutions:

  • Composed exclusively of sugar and water; contains zero electrolytes.

  • Concentrations & Routes:

    • $2.5\%$, $5\%$, and $10\%$ concentrations can be administered via peripheral IV lines.

    • $20\%$, $50\%$, and $70\%$ concentrations must be administered through a central venous line due to extreme osmolarity (exception: a small, rapid IV push of $50\%$ dextrose, or $D_{50}W$, for severe hypoglycemia).

  • Caloric Limitations:

    • Each $1\%$ of dextrose in a $1\,L$ solution provides approximately $34\,kcal$.

    • A $1\,L$ bag of $5\%$ Dextrose in Water ($D_5W$) supplies only $170\,kcal$.

    • Infusing $3\,L/day$ yields only $510\,kcal$, which is completely inadequate for nutrition and cannot replace daily food intake.

  • Toxicity Behavior in the Body:

    • $2.5\%$ Dextrose ($D_{2.5}W$) is hypotonic in the bag and in the body.

    • $5\%$ Dextrose ($D_5W$) is isotonic in the bag, but acts as a hypotonic solution inside the body. The body rapidly metabolizes the dextrose, leaving behind free water that dilutes the blood.

    • Concentrations greater than $5\%$ ($D_{10}W$, $D_{20}W$, $D_{50}W$) are hypertonic.

  • Indications: Dehydration, conservative management of mild hypernatremia (dilutes serum sodium), and mild hyperkalemia reduction (via aldosterone-mediated hormonal shifts).

  • Major Dextrose Complications:

    • Water Intoxication:

      • Occurs when hypotonic dextrose ($\le 5\%$) is infused slowly over an extended period.

      • Insulin drives sugar into cells, leaving free water in the vascular space that dilutes serum sodium.

      • Water shifts into brain cells, causing cerebral edema.

    • Osmotic Diuresis:

      • Occurs when high-concentration dextrose ($\ge 50\%$) is infused rapidly.

      • Pancreatic insulin production cannot keep up with the glucose load, elevating serum osmolarity dramatically.

      • Fluid is pulled out of cells into the vascular space, causing cellular dehydration and intravascular volume expansion.

      • Functioning kidneys excrete the massive glucose and fluid load, causing high urine output (diuresis).

• Sodium Chloride (Saline) Solutions:

  • Used predominantly for fluid replacement; possesses an acidifying effect on the body (can be used therapeutically in mild metabolic alkalosis).

  • Contraindicated in hypernatremia and acidosis.

  • $0.9\%$ Normal Saline (NS):

    • Isotonic with an osmolarity of approximately 308\text{--}309\,mOsm/L$.\n * The **only** IV fluid approved to run simultaneously with blood products (isotonicity prevents hemolysis, and it contains no additives/preservatives).\n * Carries a significant risk of fluid volume overload if infused too rapidly.\n * **Dextrose/Saline Combinations**:\n * D_5NS$(Osmolarity$\sim 559\,mOsm/L$) and$D_{10}NS$(Osmolarity$\sim 812\,mOsm/L) are highly hypertonic solutions used selectively.\n * **Hypertonic Saline (3\%$and$5\% NaCl)**:\n * Extreme osmolarity ranging from 1,000\text{ to }1,600\,mOsm/L$.

    • Reserved strictly for severe, life-threatening hyponatremia accompanied by neurological symptoms (e.g., seizures).

    • Goal of therapy is not full normalization of sodium, but symptom relief.

    • Administration Rules: ICU/monitored setting only, administered strictly via infusion pumps, given in small volumes ($\le 250\,mL$) paired with frequent serum sodium monitoring, often co-administered with loop diuretics (Lasix) to assist renal excretion, and handled carefully due to extreme vesicant properties.

  • Half-Normal Saline ($0.45\%$ NaCl):

    • Hypotonic solution used for extensive cellular dehydration and hypernatremia.

    • Delivers free water and sodium directly to dried-out cells.

    • Risk: Over-administration causes dilutional hyponatremia.

  • Hydrating Solutions ($D_5\frac{1}{2}NS$ and $D_5\frac{1}{4}NS$):

    • Indicated for NPO maintenance or mild dehydration.

    • Use with extreme caution in patients with edema or third-spacing; rapid shifts can trigger acute fluid volume overload.

• Balanced Electrolyte Solutions:

  • Lactated Ringer's (LR):

    • Isotonic solution with an electrolyte composition closely mimicking normal blood plasma (contains Sodium, Chloride, Potassium, Calcium, and Lactate).

    • Metabolic Pathway: Lactate is processed by the liver and converted into bicarbonate, making LR an alkalizing solution.

    • Indications: Isotonic fluid volume deficits, fluid replacement, burn trauma, and mild metabolic acidosis.

    • Contraindications: Active liver disease (liver cannot process lactate) and metabolic alkalosis.

• pH-Modifying Solutions:

  • Most standard IV fluids have an acidifying effect (lowering body pH).

  • The primary alkalizing IV fluids are Lactated Ringer's and $\frac{1}{6}\text{ Molar}$ Sodium Lactate.

  • $\frac{1}{6}\text{ Molar}$ Sodium Lactate:

    • Converts to bicarbonate in the liver to potentate systemic alkalization.

    • Clinical Application: Slowly infused to alkalize urine, allowing dissolution and passage of uric acid kidney stones (trade-off: alkalizing urine increases susceptibility to urinary tract infections).

  • Nursing Risk: Overcorrection can cause severe acid-base shifts:

    • Alkalosis Signs: Neuromuscular irritability, tetany.

    • Acidosis Signs: Kussmaul respirations.

• Colloids (Plasma Expanders):

  • Large-molecule solutions that remain inside the vascular space long-term, dramatically boosting oncotic pressure to pull and hold fluid intravascularly.

  • Hetastarch (Hespan):

    • A synthetic carbohydrate colloid lasting $48\text{ to }72\,hours$ in the vascular space.

    • Used for shock, major trauma, and severe burns.

    • Not a blood product; acceptable for patients with religious objections to blood transfusions (e.g., Jehovah's Witnesses).

  • Albumin:

    • Natural protein colloid extracted from plasma.

    • $5\%$ Albumin: Isoncotic; expands volume and increases serum protein for healing without major fluid shifts.

    • $25\%$ Albumin: Hyperoncotic; aggressively pulls fluid out of interstitial spaces into the vascular bed.

    • Precautions: Monitor closely for allergic reactions and ensure adequate renal function.

• Nutritional Infusions (TPN, PPN, Lipids):

  • Total Parenteral Nutrition (TPN):

    • Hypertonic solution with osmolarity exceeding $2,500\,mOsm/L$.

    • Must be infused exclusively through a central venous line.

    • Customized daily by pharmacy and dietary specialists based on lab values; rich in glucose, amino acids, electrolytes, minerals, and vitamins.

  • Peripheral Parenteral Nutrition (PPN):

    • Lower concentration nutritional formula designed for peripheral line administration.

  • **Lipids (Intralipid 10\%$)**:\n * Milky-white fat emulsion delivering concentrated calories (\sim 1\,kcal/mL) and essential fatty acids to prevent fatty acid deficiency.\n * Can be given peripherally or centrally; used also in lipid rescue therapy for local anesthetic toxicity.\n * Co-administration Rule: Lipids are the **only** substance permitted to be piggybacked into a TPN line (running through the same central line lumen below the filter).\n * Inspection: Discard bag if the emulsion separates into distinct layers or shows discoloration.\n\n# Peripheral IV Access Methods & Selection\n\n* **Peripheral Line Characteristics**:\n * Indicated for short-term therapy using short catheters (a\,few\,centimeters in length) placed in small peripheral veins.\n * Suitable for hydration, non-vesicant medications, routine antibiotics, and pain management.\n * Advantages: Quick and easy insertion, low infection risk compared to central lines, immediate usability.\n * Disadvantages: Cannot handle highly concentrated or vesicant solutions, limited dwell time (changed per facility policy or site breakdown), and restricted flow rates dependent on catheter gauge (e.g., a 22\text{-gauge} catheter in a hand vein cannot support rapid trauma resuscitation).\n\n* **Peripheral Access Device Types**:\n * **Over-the-Needle Catheter (ONC)**:\n * Standard peripheral catheter. A stylet needle punctures the vein, the flexible plastic cannula is threaded forward into the vessel, and the needle is completely withdrawn and discarded.\n * Scope of Practice: Certified LPNs can insert and remove ONCs.\n * **Winged Infusion Set (Butterfly)**:\n * Features plastic "wings" with a rigid needle that remains inside the vein during infusion.\n * Indicated strictly for short-term access (1\,hour maximum, such as single-unit plasma infusions or short blood draws).\n * Scope of Practice: Certified LPNs can insert and remove winged infusion sets.\n\n* **Peripheral Site Selection Principles**:\n * Preferred Location: Forearm veins are ideal due to patient mobility and stability. Always work distal to proximal.\n * Avoidance Zones: Avoid areas of flexion (wrists, antecubital/AC fossa) because joint movement kinks the cannula, causing line occlusion or mechanical trauma.\n * Hand Dominance: Always inspect and select the non-dominant arm first to preserve patient independence.\n * Vein Selection: Choose veins that are soft, bouncy, and palpable (visibility is secondary to palpability) that will not collapse upon needle entry. Avoid lower extremity/foot veins in adults due to severe risks of venous thrombosis and embolism.\n\n# Central Venous Access Devices (CVADs)\n\n* **Central Line Characteristics & Indications**:\n * Catheter tip terminates in a large central vessel, specifically the Superior Vena Cava (SVC) or right atrium.\n * Placed via the subclavian, internal jugular, or femoral veins.\n * Indications: Highly concentrated solutions (TPN osmolarity > 2,500\,mOsm/L), vesicants (chemotherapy, vasopressors), long-term therapy, rapid high-volume fluid resuscitation, or poor peripheral access.\n\n* **Four Major Types of Central Access Devices**:\n 1. **Peripherally Inserted Central Catheter (PICC)**:\n * Inserted into a peripheral arm vein (basilic or cephalic) and advanced until the tip reaches the SVC.\n * Available in single or multiple lumens. Has the lowest infection risk among all central lines.\n * Insertion: Can be placed at the bedside by specially trained Registered Nurses (RNs) using ultrasound guidance.\n * LPN Dwell Care: Certified LPNs can perform dressing changes on PICC lines once trained.\n * **PowerPICC**: Distinct purple catheter rated for high-pressure power injections (e.g., CT scan contrast dye). **Mandatory Rule**: Always use a 10\,mL syringe when flushing any PICC/PowerPICC to prevent excess pressure gradient rupture.\n 2. **Central Venous Line (Non-Tunneled CVL)**:\n * Placed directly into the internal jugular or subclavian vein by a physician; commonly used in ICU or acute emergency settings.\n * Intended for short- to medium-term use; carries a high risk of systemic infection (never used for home discharge).\n * Features multiple lumens (double or triple) that remain completely independent along the internal catheter body.\n * **Insertion Protocol & Verification**: Patient placed flat/Trendelenburg with head turned away. Assist physician, monitor vitals, and obtain immediate chest X-ray verification to confirm tip location and rule out complications prior to initial line fluid infusion.\n * Complication Risks: Pneumothorax, hemothorax, air embolism, infection, thrombosis, catheter migration.\n 3. **Tunneled Catheters (Hickman, Broviac, Groshong)**:\n * Surgically placed; catheter is tunneled under the subcutaneous skin before entering a central vein.\n * Contains a **Dacron cuff** under the skin that anchors the catheter via tissue ingrowth and acts as a barrier to microorganisms.\n * Sutured to skin; multi-lumen. Contains an internal valve mechanism preventing blood backflow, eliminating the requirement for routine heparin flushes.\n 4. **Implanted Ports (Port-a-Cath)**:\n * Surgically implanted entirely under the skin in the upper chest wall; consists of a metal/plastic reservoir with a self-sealing silicone septum.\n * Designed for long-term intermittent therapy (e.g., multi-year chemotherapy regimes).\n * Accessed using a specialized non-coring **Huber needle** featuring extension tubing and safety lock guards.\n * **LPN Scope Restriction**: Certified LPNs are strictly **prohibited** from accessing or deaccessing an implanted port needle. However, once an RN has accessed the port, an LPN **can** administer medications and fluids through the line.\n\n* **Central Line Multi-Lumen Assignments**:\n * **Proximal Lumen**: Closest to insertion site. Used for routine medication administration and blood sampling (has the highest blood return pressure).\n * **Medial Lumen**: Located in the middle. Reserved for blood draws and general medication administration (IV push or IV piggybacks).\n * **Distal Lumen**: Catheter tip terminates furthest away directly in the SVC. Reserved for continuous fluid infusions, TPN, high-volume resuscitation, and vesicant medications.\n\n# Local Complications of IV Therapy\n\n* **Ecchymosis (Bruising)**:\n * Pathophysiology: Infiltration of blood into subcutaneous tissues surrounding the vein due to vascular trauma.\n * Signs/Symptoms: Classic skin discoloration (purple changing to green/yellow), sore/tender site, slightly raised area.\n * Causes: Needle too large for vein, blown vein wall puncture, lack of pressure upon removal, fragile veins (elderly, chronic steroid therapy, anticoagulants), or blind needle probing ("fishing expeditions").\n * Interventions: Discontinue IV if malfunctioning. Apply a **cold compress** immediately to arrest subcutaneous bleeding, and elevate the limb. After 24\,hours, transition to **warm compresses** to promote blood reabsorption.\n * Prevention: Smallest appropriate gauge needle, gentle handling, firm direct pressure for 1\text{ to }2\,minutes upon catheter removal (longer if on anticoagulants).\n\n* **Hematoma**:\n * Pathophysiology: Uncontrolled collection of extravasated blood forming a solid mass outside the vessel tissue.\n * Signs/Symptoms: Hard mass, local swelling, bruising, severe tenderness.\n * Interventions: Discontinue IV site immediately (never leave an IV in an arm with a hematoma). Apply firm, direct pressure for 3\text{ to }5\,minutes (or longer), elevate extremity, and apply cold compresses.\n\n* **Infiltration**:\n * Pathophysiology: Non-vesicant IV fluid or medication leaks out of the vein into surrounding subcutaneous tissue.\n * Causes: Catheter dislodgement, fragile vein rupture, poorly secured line, patient movement.\n * Signs/Symptoms: Localized swelling/edema, skin cool to touch, site discomfort, infusion running sluggish or completely stopping, pump high-pressure alarms, resistance encountered when flushing.\n * Interventions: Stop infusion/IV push immediately. Remove catheter, elevate the limb, and apply warm compresses (fluid dependent). Restart IV in the opposite arm or at a location significantly proximal to the failed site.\n * Nursing Authority: Infiltration management is an independent nursing action; direct provider notification is usually unnecessary unless tissue injury occurs.\n * Prevention: Avoid areas of flexion, use stabilizing dressings and tension tubing loops, monitor site frequently, flush gently (NEVER force flush).\n\n* **Extravasation**:\n * Pathophysiology: Infiltration of a **vesicant** medication or fluid into surrounding tissue, causing severe chemical tissue destruction, blistering, necrosis, permanent functional loss, or deep tissue sloughing requiring surgical debridement.\n * Vesicant Examples: Chemotherapy (antineoplastics), vasopressors (Dopamine, Epinephrine), concentrated antibiotics, hypertonic solutions, concentrated electrolytes (Calcium, Potassium, Sodium Bicarbonate), radiographic contrast media.\n * Signs/Symptoms: Initial swelling and pain/burning sensation along vein path; localized redness, warmth, cool surrounding tissue, blistering, skin breakdown, and slowed/stopped fluid flow.\n * **Emergency Management Protocol**:\n 1. Stop the infusion immediately.\n 2. **DO NOT remove the catheter right away**.\n 3. Attempt to gently aspirate residual vesicant drug out of the line and tissue.\n 4. Administer specific drug antidotes directly through the existing line if ordered per facility protocol.\n 5. Remove the catheter after antidote administration/aspiration.\n 6. Apply a sterile dressing, elevate the extremity, apply ordered hot/cold compresses, notify the healthcare provider stat, document extensively, photograph the site, and complete an incident report.\n * Prevention: Always verify IV line patency with a normal saline flush prior to administering any vesicant.\n\n* **Phlebitis**:\n * Pathophysiology: Inflammation of the inner vein lining (intima).\n * Classifications: Mechanical (catheter motion rubbing inner vein wall), Chemical (irritating/hypertonic solutions), Bacterial (contamination during insertion/care).\n * Signs/Symptoms: Redness tracking along the vein path, localized warmth, tenderness, swelling, palpable hard cord-like vein under skin. Graded on a standardized scale from 0\text{ to }4$.

  • Interventions: Stop infusion, remove catheter, apply warm compresses, and re-site IV in opposite arm.

  • Prevention: Select correct catheter gauge, dilute irritating drugs when allowed, rotate sites per policy, maintain strict aseptic technique.

• Thrombophlebitis:

  • Pathophysiology: Inflammation of the vein wall directly accompanied by blood clot (thrombus) formation.

  • Signs/Symptoms: All phlebitis signs (redness, pain, warmth) plus marked limb edema and a hard, ropey vein along a lengthy segment.

  • Interventions: Discontinue IV line, elevate limb, apply warm compresses. Mandatory Rule: Instruct patient never to massage the area to prevent clot dislodgement. Notify physician immediately for potential anticoagulant therapy evaluation.

• Local IV Site Infection (Cellulitis):

  • Pathophysiology: Bacterial infection localized to the IV entry site and surrounding skin due to improper skin prep, soiled dressings, or dirty technique.

  • Signs/Symptoms: Redness, swelling, warmth, severe tenderness, purulent drainage; can progress to systemic fever.

  • Interventions: Remove catheter, culture the catheter tip per provider order, apply sterile dressing, notify provider, and administer antibiotics as ordered.

• Nerve Irritation & Trauma:

  • Pathophysiology: Needle or catheter tip pierces, grazes, or compresses a peripheral nerve during or after insertion.

  • Signs/Symptoms: Severe, sharp, shooting, or electric shock-like pain during needle advancement; persistent numbness, tingling, burning in fingers/hand; motor weakness. Pain follows a anatomical nerve pathway rather than the vein pathway.

  • Interventions: Stop procedure immediately and withdraw needle gently. Assess area, elevate and immobilize limb, notify provider, and document.

  • Prevention: Avoid high-risk anatomical zones (dorsal radial wrist area, inner antecubital fossa), maintain shallow insertion angles, refrain from blind probing.

• Occluded Cannula:

  • Pathophysiology: Total or partial blockage of the catheter tip by a blood clot (thrombotic occlusion), positional contact against the vein wall, line kinks, or drug crystallization/precipitation.

  • Signs/Symptoms: Meeting resistance when attempting flush, pump alarms, lack of gravity flow, burning/discomfort.

  • Crucial Rule: NEVER forcibly flush an occluded cannula. Forcible flushing can dislodge a blood clot directly into central circulation, triggering a pulmonary embolism, or rupture the vein/catheter.

  • Interventions: Stop infusion. Inspect line for external clamps/kinks. Reposition cannula slightly if pressed against vessel wall. Attempt a very gentle saline flush. If resistance persists, remove cannula and re-site IV.

Systemic Complications of IV Therapy

• Septicemia (Sepsis):

  • Pathophysiology: Pathogens (Staphylococcus, Streptococcus, fungi, or gram-negative bacteria) enter blood circulation from a local IV site infection, spreading systemically.

  • Signs/Symptoms: Sudden fever, chills (pyrogen release), tachycardia (compensatory output), altered mental status/confusion (poor cerebral perfusion), hypotension (hallmark sign of septic shock due to massive systemic vasodilation and vascular capillary leak), fatigue, nausea, vomiting. Can rapidly progress to total vascular collapse, organ failure, and death.

  • Immediate Action Protocol:

    1. Notify physician immediately.

    2. Stop the IV infusion.

    3. DO NOT disconnect the fluid bag and tubing; keep the entire system intact so the lab can culture the fluid bag, tubing, and catheter to isolate the pathogen.

    4. Start a completely new IV line at a different site (preferably opposite arm) using sterile equipment for emergency fluids/meds.

    5. Monitor vital signs extremely closely (every $15\,minutes$ or more frequently).

    6. Draw blood cultures as ordered; prepare to administer IV antibiotics.

  • Prevention: Aseptic central line care, enforcing $24\,-hour$ fluid bag hang limits (warm, stagnant fluid fosters bacterial growth), strict tubing change policies, maintaining closed systems.

• Pulmonary Embolism (PE):

  • Pathophysiology: Undissolved material (blood clot, drug precipitate, or broken catheter fragment) travels through venous circulation into the right heart and lodges in the pulmonary arteries, blocking pulmonary blood flow.

  • Signs/Symptoms: Sudden sharp chest pain (pleuritic, worse on inspiration), dyspnea/shortness of breath, tachycardia, diaphoresis, restlessness, apprehension, sense of impending doom (early hypoxia sign), hemoptysis (bloody sputum), cyanosis.

  • Interventions: Assess vital signs, apply high-flow oxygen immediately (apply without order if emergency, request order retroactively), place patient in semi-Fowler's or higher position to maximize lung expansion, notify physician stat.

  • Prevention:

    • Filtration: Use inline filters for particulate-rich infusions (Blood, TPN). Change filters every $24\,hours$. Never hook lipids to TPN above the inline filter (lipids clog the filter).

    • Vein Selection: Avoid lower extremity veins; use arm veins.

    • Solution Management: Never forcibly flush occluded lines; inspect bags for particulates ("Billy Bobs"); fully reconstitute powdered medications.

• Air Embolism:

  • Pathophysiology: Air enters venous circulation (usually via unprimed lines or open central lines). Air enters the right heart and rises to the top of the right ventricle, creating an air lock that blocks the pulmonic valve and prevents blood from reaching the lungs.

  • Diagnostic Sign: Mill wheel murmur (a distinctive churning, seagull-cooing sound audible over the precordium, often heard without a stethoscope as blood mixes with air in the right ventricle).

  • Signs/Symptoms: Sudden pale or cyanotic skin, rapid and weak pulse, ischemic chest pain, severe hypotension, acute respiratory distress, syncope, loss of consciousness, seizures.

  • Emergency Interventions (Simultaneous Action):

    1. Correct the air source immediately: clamp off the IV line.

    2. Position patient in Left Lateral Trendelenburg position (lying on left side with head down). This traps the air bubble in the apex/atrium of the right heart, holding it away from the pulmonic valve and pulmonary artery.

    3. Administer $100\%$ high-flow oxygen.

    4. Notify physician stat.

    5. Prepare for emergency resuscitation.

  • Prevention: Standardize Luer-lock connections on all central lines, tape connections, never disconnect CVL lines directly, instruct patient to perform Valsalva maneuver (bearing down) during central line insertion and removal, position patient flat or in Trendelenburg during central dressing changes, prime/flush all tubing before connecting, clear air alarms on infusion pumps.

• Circulatory Overload (Fluid Volume Excess & Speed Shock):

  • Pathophysiology: Excessive fluid volume infused into the vascular space, overwhelming cardiac and renal capacity. High risk in infants, elderly, cardiac, and renal patients.

  • Signs/Symptoms: Dyspnea, cough, moist lung sounds (crackles) due to fluid shifting into alveoli, frothy sputum, pitting edema in extremities, jugular venous distention. Triggers Speed Shock symptoms (hypotension, rapid pulse, syncope, systemic shock).

  • Interventions: Stop the IV fluid flow immediately. Maintain line patency with a micro-drip keep-vein-open (KVO) rate for emergency drugs, place patient in high Fowler's position (sitting upright), notify provider, administer prescribed diuretics/oxygen, monitor I&O.

  • Prevention: Use electronic IV infusion pumps for precise rate control. Catch-Up Rule: NEVER increase an IV rate to catch up if an infusion falls behind schedule. (Example: If $100\,mL/hr$ saline was missed for $1\,hour$, do not run the pump at $200\,mL/hr$ the following hour; accept the loss of volume).

• Catheter Embolism:

  • Pathophysiology: A piece of the plastic IV catheter shearing off inside the vein, migrating through circulation.

  • Causes: Reinserting a stylet needle back into an ONC catheter during insertion, moving the cannula over the needle tip, using sharp scissors near IV lines.

  • Signs/Symptoms: Sudden sharp pain at IV insertion site, cyanosis of the distal extremity, impaired venous return, tachycardia, hypotension. May present as delayed discovery (found via diagnostic imaging or during catheter removal routine inspection).

  • Immediate Discovery Protocol:

    1. Apply a tourniquet proximal to the insertion site (above the site) to trap the fragment in the local vein.

    2. Notify physician and house supervisor stat.

    3. Remove catheter remnant and preserve all fragments for inspection.

    4. Monitor circulation distal to tourniquet.

    5. Document extensively.

  • Delayed Discovery / Central Line Protocol: Notify provider stat, RN removes remaining central line, preserve all recovered fragments, send patient for emergency diagnostic X-rays, monitor vital signs, prepare patient for surgical intervention to retrieve fragment.

IV Site Dressing Management & Protocol

• Peripheral IV Dressing Standards:

  • Standard Dressing: Sterile bio-occlusive transparent film dressing completely sealing the skin insertion site.

  • Adhesive Allergies: Use sterile gauze and non-allergenic tape, but change dressings much more frequently.

  • Securing Techniques: U-method tape stabilization; use arm boards to immobilize joint flexing without restricting arm movement.

  • Replacement: Change dressings whenever compromised, loose, damp, or soiled with blood/drainage.

• Central Line Dressing Protocol (Sterile Procedure):

  • Scope of Practice: Certified LPNs can perform central line dressing changes once clinically trained.

  • Procedure Rules:

    1. Place patient flat in bed.

    2. Every person in the room must wear a surgical mask, including the nurse and the patient.

    3. Have the patient turn their head completely away from the insertion site.

    4. Maintain strict sterile field techniques using specialized central line dressing kits.

  • Frequency: Change every $7\,days$ (weekly) per facility policy, or immediately if the seal is compromised, moist, or soiled.

  • Goal: Strict adherence to sterile dressing protocol is vital to eliminate Central Line-Associated Bloodstream Infections (CLABSIs).