IV Questions from a New Nurse

Asystole RN · Oct 21, 2010

When a patient states that their IV is "hurting" should you not use it? I know some medications burn, like phenergan, but I don't want to use an IV that is possibly infiltrated.

Discontinue use, restart the IV. Symptom of infiltration, venous irritation/inflammation. Continued use could destroy that site for further use and/or pose undo risks to the patient...besides it is just cruel. Pain at a previosuly painless site is a cardinal sign that something is wrong, stupid to ignore it.

Another question - My preceptor and I had a patient who had a peripheral IV and said it was hurting. It was due to be rotated the next day, so I was just going to change it. My preceptor went ahead and used it. The next week, the patient was back with cellulitis in the same place that the IV was. So, did my preceptor use an infected site?

Hard to say.

What is the best thing to do when an IV infiltrates? Ice? Elevate? My preceptor didn't do anything on one patient.

Highly depends upon the medication, consult facility policy, infusion team, practitioner, pharmacist for the type of intervention. Some meds you use a warm compress, some cold, some you just leave alone.

And, are you supposed to try to restart the IV in the opposite arm? This patient had an IV in their hand that infiltrated, and it was restarted on the same arm in her AC. If it's above the infiltrated site, that's ok, right?

Try to rotate arms reguardless of infiltration but esp if infiltrated. Don't want to put too much pressure upon a single arm, easy to burn out someone's veins.

Try not to use the AC, use it for emergencies or for drawing labs...not for general PIV use. It is a terrible PIV site for non comatose patients anyways.

At my facility the general rule of thumb is if you have to go to the AC or above for PIV use then it is time to consider a PICC or Midline.

And - This is more of a med question, but - why is it that some nurses give IV phenergan and dilaudid close together, but others wait an hour? I've looked in books to see why they should be an hour apart, but haven't found an exact answer. Just wondering about this for patient safety.

Phenergan is often used in conjunction with dilaudid to potentiate the effect of the analgesic. Basically the use of phenergan and dilaudid together is much more powerful than separate. If you really want to control pain use together, if there is a risk of over sedation then use separate. As always consult your pharmacist and practitioner for their intention.

I have MDs specify the phenergan is not to be used with dilaudid and some say for pain 9-10 to use the phenergan with dilaudid.

Phenergan given on its own, esp when given fast, can cause the "Phenergan Power Hour" which is slang for being really REALLY high.

I feel like I don't know the signs that an IV should possibly be restarted, so I've been trying to read up on it. But I still had some questions, so I thought I'd come here. I hope I don't come off as a clueless nurse, I just want to know more than I do. Thank you so much!!

Only stupid question is the one not asked. Also might want to consult the INS, Infusion Nurse Society. Also check if your facility has an IV team or any CRNIs around, they can help a ton.

vhern246 · Oct 21, 2010

When an IV is infiltrated, the patient will complain of a burning sensation and the area will swell when flushed but it won't give any return.

When an IV IS infiltrated, you remove it, elevate it, and put a warm towel over the area.

I don't know whether or not to restart it in the same arm or even to restart it at all without a supervisors or the MD's suggestion.

(still a student)

I do know that you have to check whether the vein collapsed or the flow needs to be altered or the med affected somehow...

nwrn2010 · Oct 21, 2010

I am a new nurse also and I might can help you with some of your concerns. If an IV has infiltrated...it is pretty noticeable. Usually, a bubble forms and if not, when you feel the area where the catheter should be, it feels "squishy". That needs to be taken out immediately and apply cool compresses (check with your hosp policies if you have to have a doctor order for these). Another way you can verify if the IV site is still working is to take the tubing out of the IVAC and unclamp the tubing halfway or so and if the fluid drips freely, it is fine. It needs to be restarted if the fluid does not drip. Of course, you can pull back on the catheter to ensure it isn't kinked before removing it.

If the site is red and tender, it is probably phlebitis and warm compresses should be applied after removal of the IV.

About the Phenergan/Dilaudid med administration: I have had other nurses tell me that the effects of Phenergan will potentiate the pain meds. In other words, they play off of each other causing a more sedative effect. Correct me if this is wrong fellow nurses!

In fact, I have had pts request them both at the same time, and if it wasn't time for the phenergan (usually scheduled q6) they didn't want the morphine/dilaudid. These patients are usually current/retired medical professionals and usually nurses. :uhoh21:

AnnieOaklyRN, BSN, RN, EMT-P · Oct 21, 2010

You should insist that your hospital provide you with an IV course! It is crazy to expect someone with no previous IV skills to assess them or start them!!

Happy

RevolutioN2013 · Oct 21, 2010

Phenergan given on its own, esp when given fast, can cause the "Phenergan Power Hour" which is slang for being really REALLY high.

:lol2:

You nurses have the best slang.

neatnurse30 · Oct 21, 2010

I can totally relate to you. When I was in nursing school, one of our professor said not to worry about such skills as IV insertion. I don't agree with her. IV skill is important and it takes practice to feel comfortable with it. Nobody taught us how to insert IVs in the clinical setting. Nursing schools these days put so much emphasis on theory, but could care less about practical skills.

nurse2033, MSN, RN · Oct 22, 2010

Sometimes the IV is just uncomfortable from the way it is taped or for whatever reason. You should evaluate an IV complaint, but some patients have a pretty low tolerance for whatever. If it flushes easily with no pain, it is OK. Especially if you can aspirate blood, but not all IVs will do that. To test if it hurts by flushing, distract the patient and flush it when they aren't aware. If they say "ow" you know it hurts and could be a problem. Heat and elevation is used for infiltration. You should know the medications that will cause tissue extravization because they will take further treatment. Restarting in the other arm would be ideal but there could be many other factors. As for phenergen and dilaudid, if you really look into those drugs you will figure out the answer.

OrionQuiltsRN · Oct 22, 2010

I can certainly attest to the "phenergan power hour". I have been a chemo patient all summer. Phenergan was the drug used for my breakthrough nausea when my scheduled Zofran didn't completely work.

Bumashes, MSN, APRN, NP · Oct 22, 2010

If the pt states that it's burning/hurting when only saline or some other isotonic fluid is going in, then that is considered stage I phlebitis, and you should begin looking for a new site pretty quickly. I personally would look in the opposite arm first, if possible. But as long as you go a goodly distance above (more proximal to the pt) the infiltration site, you should be fine. Just, if possible, try to get it in a site that makes it less of a possibility of being the upper part of the same vein.

As for treating an infiltration, it can depend on the med/fluid that was going in when it infiltrated. However, 90% of the time, it seems that warm compresses and elevation of the effected limb work the best. This is b/c the warmth assists the med/fluid that has infiltrated to "circulate" more easily out of that tissue. I would really only use cold tx if the site was inflammed and very painful in order to stop the inflammation and bring some pain relief.

As for the med question, it really depends on your nursing judgement. Both the meds are caustic to the vein, phenergan especially so. So if your pt has very weak/poor veins, then it would probably benefit you to push them separately to decrease the risk of phlebitis/infiltration. Also, both of these drugs can make your pt very drowsy, so if they are a lightweight/elderly/never taken the meds before, then I will push them separately in order to gauge the med's effect on the person so as not to oversedate them.

Ask if you can do a round of IV starts in the ER where you work. Our manager's will usually give new grads a day or 2 if they wish to go down to the ER and just start IVs for them all day. You'll start more there in one day then you will in a couple weeks of working the floor. It's how I got off to a great start with IVs.

iluvivt, BSN, RN · Oct 22, 2010

It is no surprise to me that many new RNs are sorely lacking in the basics of IV therapy. Is is such a daily and demanding aspect of any hospital nurse and one with the potential for serious errors so I am so pleased to that you are asking these questions.

First let me give you a few basics that will help you

Infiltration: The inadvertent administration of IV fluids or medications into the tissue. Yes these can be difficult to detect sometimes. This is what you should assess with every peripheral iv site (PIV)

how old is the IV site ?
What are we infusing through it? What is the ph of the medications (s) and osmolarity. (this will take sometime for you to learn and I can give you a list of the most irritating medications if you want me to. Any med with a ph of less than 5.5 or greater than 9 are VERY irritating to veins so your site will not last as long. A central line is always preferred in these case but is not always done. Blood osmolarity is about 290 so the farther away you get from this the greater the irritation to the vein
Is there pain, redness or swelling. The swelling associated with an infiltration can vary in its pattern depending upon where the PIV is located and what part of the vein has been compromised. Hand infiltrate are easy to detect b/c there is very little tissue there. AC site infiltrates can be difficult...the basilic vein takes a dive a few cms above the ACF and so there is a lot of tissue and space for fluids to go into to. So look at the whole arm as many infiltrates do not just appear as a lump above the site
Is there leaking at the site?
Is there a color change or change in the appearance of the pts skin. ALWAYS ALWAYS compare the PIV site to the opposite limb. (in a few case this may not help you if the pts other arm is edematous) The skin may appear blanched and translucent at the location of an infiltrate
Is the site at an area of flexion? ( higher rate of phlebitis and infiltration)
Is the site secured well? (if there is any tension on the site and its getting tugged on the vein will become easily irritated

Please notice that I did not mention checking for a blood return ..checking for a blood return is NOT a reliable method for assessing for an infiltration or extravasation . The tip of the cannula may puncture the posterior wall of the vein leaving the greater portion of the bevel withing in the vein...so you get a blood return when applying the negative pressure of a syringe and pull back BUT if the infusion continues fluid will continue to seep into the tissue. So always go by all the other parameters of your assessment. An old rick is to apply a tourniquet above the site and let the IV drip by gravity (if you can of course) if it is in the vein it should STOP..if not it will continue to drip..again use all the parameters and not just on thing

So for example. you have a pt that is getting D5 1/2 NS @ 100 cc an hour and has Vancomycin ( low ph of about 2.4 BIG CLUE) q 12 hours. The site is 3 days old ( BIG CLUE) ..the patient is complaining of tightness at the site. You compare the site to the same place on the other arm...it looks a little swollen to you. The patient states that the last dose of the Vancomycin was painful while it was infusing. The site is at an area of flexion? You check for a blood return and are still getting one? What are you going to do?

Nurses often get a bit confused about how to treat infiltrations and extravasation. The subject of treatment of extravastions can be controversial and often there are not clear cut treatment and answers BUT we must all go by current research and practice.

So here is the current recommendation for infiltration

minor no treatment may be necessary
moderate to major depends upon the osmolarity of the infiltration drug or fluid. If hyperosmolar HEAT may may it worse. It can cause tissue maceration.In these situations ALWAYS use cool treatment.
isotonic or hypotonic you can use heat OR cool whatever makes the patient more comfortable

the vinca alkaloids and epipodophylotixins extravasations should always be treated with heat or warmth.

So you must find out what infiltrated and treat appropriately DO NOT just toss on some heat. If you had some NS infiltrate OK try some heat. Heat is the treatment for a phlebitis and some confuse the complications.

As far as elevation goes I still provide some slight elevation but apparently the studies did not show an improvement with this treatment so the advice is DO what makes the pt comfortable and will not further harm them.

So should you have re-sited the pts IV site...absolutely YES :yeah: :yeah:

BowHunterRN · Oct 23, 2010

you all have given such helpful information! I actually just did a day in the ER, where I did get more experience, which made me feel a little better. I guess it just all takes time. Our hospital doesn't have an IV therapy team, so I really want to understand IV therapy. As for those of you who metioned schools these days, I agree. My teacher actually told us that IV's are just a "task" and have nothing to do with nursing. I had no idea how to start an IV or even how to piggyback a med on my first day of work! I understand that this is not what nursing is all about, but in many settings, nurses constantly deal with IV's. I feel more confident now thanks to all of your in depth answers, thank you so much!