What are the recommended nursing interventions when an IV becomes infiltrated?
Peripheral intravenous catheters (PIVCs) are the most commonly used intravenous devices in hospitalised paediatric patients. They are primarily used for therapeutic purposes such as administration of medications, fluids, and blood products. Show
Illustration by The Royal Children's Hospital, Melbourne AimThe aim of this guideline is to provide an outline of the ongoing maintenance and management of the PIVC for patients in hospital, outpatient, and home healthcare settings. For information related to insertion of PIVC, please refer to intravenous access guideline (https://www.rch.org.au/clinicalguide/guideline_index/Intravenous_access_Peripheral/). Nurses who are deemed competent in IV insertion could continue to insert PIVC in consultation with NUM/CSN’s. Definition of terms
AssessmentPatient and IV site assessments should be done on a regular basis. PIVC assessment includes:
ManagementAdministration of intravenous fluid, drug infusions or blood products a) Continuous infusion of IV fluidsAssessment and documentation of findings are to be completed hourly to determine effective delivery of prescribed medications and fluid.
Infusion Pump PressurePressure limit defaults for intravascular infusion pumps are programmed by Biomedical Engineering, based on the manufacturer’s recommendations. Upper limit infusion pump pressure can be manually increased with clinical discretion to accommodate:
If pump pressure exceeds the recommended limits, check the patency of the PIVC. Special consideration: Patients admitted to the Neonatal Unit should have line pressure documented within the Peripheral IV Cannula Lines, Drains, and Airway (LDA) tab. b) Administration of bolus/loading doses:Administering drugs:Drugs administered via PIVC may be
The most appropriate method should be selected depending on volume of diluent required, patient condition, fluid balance and intended rate of delivery.
Flushing of PIVC’s
Change of PIVC dressing and securement of cannula:
Change of Extension sets
IV Fluid Considerations via Peripheral IV lineWhich Fluids and how much fluids to use
Labeling infusions:
Table 1.Changing IV bags and lines TaskMinimum frequency of changesAseptic technique method (based on risk assessment)Fluid bag/syringe with additiveEvery 24 hoursStandard aseptic techniqueFluid bag/syringe with no additiveEvery seven daysStandard aseptic techniqueGiving set with lipid or blood productsEvery 24 hoursStandard aseptic techniqueGiving set (with no TPN)Every seven daysStandard aseptic techniqueGiving set with TPN and in-line filterWith every new bag of nutrientStandard aseptic techniqueGiving set with in-line filter and no TPNEvery 96 hoursStandard aseptic techniqueNeedleless connectors, extension sets or three-way tapsEvery seven daysSurgical aseptic techniqueNOTE:
Removal of PIVCs:There is no evidence for routine replacement of PIVC unless clinically indicated. PIVC’s should be maintained with regular assessment and documentation of complications. The possible reasons for removal of PIVC’s include a number of complications which range from infiltration, extravasation, phlebitis, occlusion, dislodgement and migration. Once the child’s treatment is over, the PIVC should be removed to avoid any additional complications.
Management of complicationsThere are a range of complications that could occur with the presence of a PIVC in situ. Some of these complications can be prevented by the correct use of aseptic technique for insertion and maintenance as well as assessing the device as indicated. Common complications are:
RCH specific informationFor assistance with difficult intravenous access 0730 - 1730 (Mon – Fri): Anaesthetics ASCOM 52000 After hours / public holidays: PICU ASCOM 52327 Companion DocumentsReferences
Evidence TableThe evidence table can be found here. Please remember to read the disclaimer. The development of this nursing guideline was coordinated by Eloise Borello, CNC Quality & Improvement, and Lauren Nichols, CSN PICU, approved by the Nursing Clinical Effectiveness Committee. Updated December 2022. What are the nursing interventions when an IV becomes infiltrated?If you are concerned an IV is infiltrated, follow your facility policy and as a general guideline, discontinue the site and relocate the IV. If the infiltration is severe, apply warm compresses, elevate the arm, monitor the site and be sure to inform the healthcare provider.
What is the nursing care for an infiltration?Infiltration nursing care
In the event of infiltration, discontinue the IV, elevate the extremity, and apply warm or cold compresses, depending on what was infusing. Use warm compresses for normal- or high-pH solutions, and use cold compresses for low-pH solutions.
What is the treatment for an infiltrated IV?Treatments for IV infiltration consist of removing the vascular access device, elevating the limb, and applying a warm or cold compress.
Which nursing intervention can help prevent the complication of IV infiltration?Apply a tourniquet several inches above the venipuncture site and observe the gravity fluid flow. Compression from the tourniquet should stop or significantly slow the fluid flow. If you see little or no change, the fluid could be leaking into the subcutaneous tissue rather than flowing into the vein.
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