Lysis, IV Case Study

suzanne4, RN · Jun 9, 2004

I apologize for posting this student case study here, but I've been over this one a few times:
Ms. Thomas is a 40 year old woman, 5'1" tall and weighing 300 lbs. She had emergency abdominal surgery for lysis of adhesions. You are assigned to care for her on her first postop day. As you begin your assessment, you note she has an NG tube that is draining bile colored return. Her IV is D5W in 0.45% NS infusing at 125 ml/hr. The IV is on a pump.
As you observe the IV site, you find it difficult to determine if the site is edematous or it is just her normal appearance. It seems like the area surrounding the site is cooler to the touch than the remaining part of the arm. Ms. Thomas states the IV area is sore. A gauze dressing is placed directly over the IV site, making it difficult to visualize it. The IV fluid seems to be infusing at the prescribed amount and the IV pump alarm is not ringing.
While assessing the IV site, what would you look for if you suspect phlebitis or inflitration? with the initial information provided in the scenario, which of these potential complications do you suspect?
I thought infiltration originally due to pt complaint of soreness at/around IV area of insertion, edematous around IV site, and site cooler to the touch. However, phl can occur after surgery. Could NG be too far? Don't I confirm this is bile first? Help!

First, there should not be gauze over the IV site where it blocks what you can see. You can't assess the site if you can't see it. :)

Phlebitis is not normal at any time, you are thinking of edema. Phlebitis means inflammation................Why do you think that the NG is in to far? It sounds like it is doing exactly what it is supposed to do....How are you going to check for bile? If there is bile-colored drainage coming from the NG tube, where else would it be coming from, if not the stomach?

KristinWW · Jun 9, 2004

First, there should not be gauze over the IV site where it blocks what you can see. You can't assess the site if you can't see it. :)
Phlebitis is not normal at any time, you are thinking of edema. Phlebitis means inflammation................Why do you think that the NG is in to far? It sounds like it is doing exactly what it is supposed to do....How are you going to check for bile? If there is bile-colored drainage coming from the NG tube, where else would it be coming from, if not the stomach?

So check the site more to see if it was infiltrated? Remove some of the bandages, and ask the pt about the pain associated with it and touch for cold/hot skin. If infiltrated, place a warm miost pack and enclose the area from the finger tips to the elbow. Place the extremity in a plastic bag or on a chux and leave in place no more than 10 minutes. If phlebitis, discontinue infusion, and remove the needle.

This is med admin/fluids portion of the course so I thought originally something regarding the IV.

KristinWW · Jun 9, 2004

I've been reading but still confused - how do you determine which? Looks like phlebitis is warm, infil is cold? Can't be right, much too simplistic.

psychomachia · Jun 9, 2004

I've been reading but still confused - how do you determine which? Looks like phlebitis is warm, infil is cold? Can't be right, much too simplistic.

You're right, phlebitis should be warm and an infiltrate cold, but like everything in nursing - the patients don't know or follow the rules...

If the site is cold compared to the surrounding tissues, and you don't get a blood return from the catheter...I would d/c it and restart it.

BAndersonRN · Jun 9, 2004

Phlebitis, which is inflammation of the vessel wall, is associated with an infection of the IV site. Signs and symptoms of phlebitis would be that of a localized infection (ie. warmth, redness, pain, swelling, drainage/discharge). Infiltration of an IV site is a dislodgement of the IV catheter resulting in IV fluids infusing in the surrounding tissues instead of infusing directly into the vessel. Signs and Symptoms of infiltration would be IV site cool to the touch (due to fluids at room temp. infusing into the tissues), edema (puffiness due to the interstitial space being filled with fluid), pain/ discomfort, and often the IV fails to infuse (allthough, if the fluid is on a pump, it may still infuse into the site). Hope this helps a little...

BAndersonRN · Jun 9, 2004

P.S. Like mentioned before.. in either case the IV should be discontinued and a new IV Site (located proximal to the old site) should be started....

Tweety, BSN, RN · Jun 9, 2004

Great answer BAndersonRN! Don't have much to add. Remember the pump doesn't necessarily know there is an IV infiltration and continues to pump into the tissue, so always remove any gauze and redress a site so you can do good assessments. Pain is always your first clue, if a patient ever complains of pain, d/c it, even if you can't figure it out.

Post-op any kind of bowel surgery, the bowels are going to have a post-op ileus which is normal. Meaning the bowels have completely stopped. They of course will soon start up again (here's where post-op ambulation is so important), but initially the stomach contents (bile) will come out of the ng tube and this is a normal finding. As Suzanne indicated bile is one of the indications that the tube is properly placed.

Good luck in your studies!

purplemania, BSN, RN · Jun 9, 2004

I would totally remove all the tape and dressing off the IV site in order to get a good look. I would also take new cathlon, etc. to room and prepare pt. for the fact that the IV may have to be restarted in another location. If in doubt, toss it out. And if you work nights you will learn to REALLY assess all your IV sites, and restart them if needed, before people go to sleep and get awakened by arm blowing up like a balloon. They will not wake up happy.

As for bile, sounds like NG is working. Watch your volume and patient's other I&O's.