Nursing Diagnosis Help Please- Infiltrated IV

[Daytonite, BSN, RN]

I am surprised that there were two IV sites, but the nurse chose the hand to run the vanco.

If I have a choice, I always run in a larger vein. On our ped floor, we have to check IV sites every hour, and IV fluid amounts every two hours.

It's frustrating to wake a sleeping kid if you can't visualize his IV site in the dark, but you've seen a great example of why you need to do it anyway, regardless of what the kid or parent says.

We frequently placed second IV lines when vanco was being infused because vanco was being run over an hour and a half. The second line was needed so other IV medications and fluids could be given.

Impaired Tissue Integrity

Definition: damage to mucous membrane, corneal, integumentary, or subcutaneous tissues.

Related factors (causes): fluid excesses, chemical irritants including medications

Vancomycin is one of the most irritating antibiotics that can be given into a peripheral vein. When I was an IV therapist we encouraged docs to give this IV antibiotic through some type of central IV line when possible because of the phlebitis it caused to peripheral veins. If it infiltrated in this patient, then there would be tissue damage and the diagnosis of impaired tissue integrity would be appropriate.

I have seen severe infiltrations where entire hands and forearms were swollen with IV fluid because the nurses were not performing regular checks of the patient. Infiltrations can be slow leaks of fluid going into the tissues while the majority of the IV fluid is still infusing into the vein so that it can take some time for the swelling to manifest itself. I saw it happen a lot.

This is why the IV site needs to be compared to the opposite limb as well as touched and assessed for tenderness.

[Daytonite, BSN, RN]

Impaired Tissue Integrity R/T infiltrated intravenous fluids

[BluegrassRN]

Just like to point out that it is unlikely that the IV infiltrated sometime during the noc. It probably happened close to the time the IV was pulled. A little fluid infiltrated looks like a ton visually.

The reason I think this is there was no tissue damage; if a kid (or anyone) has an infiltration over 8+ hours, there is likely to be tissue damage. We're talking nerve and vascular damage. If the kid could feel and move his fingers, if there wasn't any signs of vascular damage, if his fingers were warm and had good perfusion, if the infiltration wasn't all the way up his arm, and he was discharged later that day, it probably wasn't an infiltration over hours and hours (unless maybe his fluids were running at 20ccs or less).

Another reason: Most peds units have lower pressure settings on their pumps. They stop infusing and alarm occluded with less resistance than adult pumps. They typically won't pump 100s of ccs of fluid into a kid's arm.

I can't believe an entire bag of vanco plus several hours of fluids ran into this kid's arm without some type of major damage and pain. Could be possible I suppose, but highly unlikely. I just honestly don't see how a 10 year old would be able to tolerate that without screaming his head off about his hand hurting.

Why wasn't the arm elevated and a warm pack applied? Well, maybe someone dropped the ball. Maybe they did that early on, and the kid didn't want to keep his arm up. Who knows?

I am surprised that there were two IV sites, but the nurse chose the hand to run the vanco. If I have a choice, I always run in a larger vein. On our ped floor, we have to check IV sites every hour, and IV fluid amounts every two hours. It's frustrating to wake a sleeping kid if you can't visualize his IV site in the dark, but you've seen a great example of why you need to do it anyway, regardless of what the kid or parent says.

[Daytonite, BSN, RN]

They just didn't check the IV regularly like they were supposed to. I've seen a lot of different ways that IVs infiltrate from flat out gross leaks to slow leaks over time. It's really important to compare limbs. It's easier to see the subtle changes in swelling that may be going on with the slower infiltrations when looking at both arms.

[BluegrassRN]

True, a subtle leak can happen over time, and that is something to always be on the alert for. If the site hurts and there doesn't seem to be any reason for that, the things I look for are inappropriate taping (if the tape is pressing the hub of the IV catheter into the skin, for example, causing pain) or a slow leak.

I can't tell, Daytonite, whether you are expanding upon what I wrote or disagreeing with me, so I just wanted to clarify:

I know why there were two IV sites, I was saying that I didn't understand using the hand site for the vanco when there was a choice of two sites; I would have used the AC.

I know that tissue damage refers to even the slightest infiltration or phlebitis, I was simply pointing out that if this child had had an entire bag of vanco and all his IV fluids infiltrate into his arm all night, there would have been some severe damage. If he was discharged with no problems from the infiltration, the infiltration likely wasn't that terrible and had not been ongoing all night. I've seen kids whose IV fluids infiltrated badly, and it looks horrible and scary; neurovascular checks every 15 minutes, vascular ultrasounds, consults with vascular surgeon, etc. None of this was apparently needed, and the pt was discharged later that day. My point was perhaps it was not as bad as the nursing instructor and the student thought it was, and their dislike of this nurse could be coloring their perceptions. That's all.

In any case, like I said, I'll bet the student never skips IV site checks, be they on peds or elsewhere.

And just public service announcement to those out there in the nursing world-most pumps can be set on a lower pressure. Some older pumps just have two settings: General population and pediatric population. Newer pumps have a variety of settings; our Alaris pumps have pressure settings of 100 to 500, with the standard adult population setting at 375. I don't work peds anymore, so I don't know what the programmed default pediatric setting is. I just wanted to throw out there, though, that with your pts who have bad veins and who are at risk for infiltration (your older pts, those who take chronic steroids, high risk meds, etc), you can always change the pressure on the pump to the pediatric setting. The pump will then alarm sooner, with less pressure, in the event of an infiltration, reducing your pt's tissue damage. I find that many nurses are not aware of this, and *I* did not know it until I went to peds. Now all my at-risk pts get a lower setting. Flip side is their pumps alarm occluded more frequently when it's merely positional, but I'm okay with that.

[Skyfel]

Thank you so much for replying. I will use this the next time I need it. I had to turn in that careplan already but what you said was VERY helpful and I love how you wrote about real life experiences also. I read your comments all the time on the board. Very helpful! Thank you so much!! OH, about the infiltration...yea, that hospital is supposed to do IV checks every single hour also. That's why my instructor was so upset about it. She said to me, "There is NO way the nurse was checking his hand every hour. She was just charting no change in the computer without looking at it." I can't believe that some nurses are so lazy and irresponsible. I don't like the nurse that was in charge of that boy either....I wouldn't want her taking care of my child, that's for sure. I hope she learned her lesson, but maybe not.

[Skyfel]

Thanks for replying. Well, you brought up many valid points. Here's what I know, the IV pump was set at "80" and what was running (my instructor said) was 63.8ml/hr of Vancomycin and the fluids made up the difference. When we arrived in his room at 0730, the night shift and day shift nurse was in there d/c'ing his hand IV because of the infiltration and just hooked everything back up using the ANC IV site that already existed. I never asked the nurse why he had two sites. It was only my 3rd Pediatric patient in my entire life and that nurse had been rude to me for the past 3 weeks so I tried to avoid her at all costs.

His hand looked like that when they went to check on him at 0730, that's why they D/D'd it. So, what do you think happened then? My instructor and I didn't talk all that much about it except she was upset that the NOC nurse could not have done hourly IV checks on that boy or she should have noticed swelling was happening. The boy was complaining more when they D/C'd the IV than when they first went in there and saw it was infiltrated. I just don't understand how nurses can sit there and chart "unchanged assessment" while it's infiltrating. It's just ridiculous.