NCLEX-PN

●​ Infection : Signs and symptoms of intravenous therapy-related infection include swelling, tenderness, redness at the insertion site, pain, and fever. This complication can be mitigated by limiting intravenous therapy to necessary cases, promptly discontinuing catheters and intravenous therapy, and adhering to strict sterile asepsis during site care and dressing changes. In response to infection, nurses should document the complication, inform the physician, cease the intravenous flow, elevate the affected limb, apply warm compresses, and administer prescribed antipyretic and/or antibiotic medications. ●​ Infiltration : This occurs when intravenous fluid is mistakenly infused into subcutaneous tissues rather than the vein. Signs of infiltration include site pain, localized swelling, coolness of the skin near the site, decreased infusion rate, and skin pallor around the insertion site. The nurse's response involves halting the infusion, removing the catheter, elevating the affected limb, and applying warm compresses. ●​ Extravasation : This is a severe form of infiltration and occurs when caustic medications infiltrate the surrounding tissue. Symptoms include lack of blood return, slowed infusion rate, burning, tingling, severe limb pain, erythema, swelling, redness, and blistering. In advanced cases, extravasation can lead to necrosis . Immediate actions include stopping the infusion, aspirating any blood and fluid, limb elevation, warm compresses followed by cold compresses to reduce swelling, and administering specific medications like dexrazoxane . ●​ Hematoma : Related to intravenous therapy and other injuries present with ecchymosis (bruising). Treatment involves discontinuing intravenous therapy, catheter removal, applying pressure and a pressure dressing, limb elevation, and warm compresses. Hematomas from intravenous therapy typically do not lead to serious complications. ●​ Phlebitis : Linked to intravenous therapy manifests as redness, swelling, pain, fever, slowed infusion, and sometimes a palpable red streak extending from the insertion site. Management includes halting the intravenous therapy, limb elevation, warm compresses, and administering analgesics and/or antipyretics as needed. ●​ Embolus Formation : Signs of embolus formation may include chest pain and shortness of breath. Nurses must immediately notify the physician, monitor for life-threatening complications, and apply a tourniquet above the site to prevent further migration of catheter fragments. ●​ Fluid Overload : This can occur if the intravenous fluid rate surpasses the client's capacity to handle the volume. Indications include hypertension, abnormal breath sounds (e.g., rales and crackles), tachycardia, shortness of breath, distended neck veins, and edema. Elderly clients and those with heart failure are particularly at risk. Nurses who suspect fluid overload should notify the physician and reduce the intravenous fluid rate to prevent further overload.

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