Chapter 8: IV Therapy
8.2 Intravenous Therapy: Guidelines and Potential Complications
Critical Thinking Exercises: Questions, Answers, and Sources / References
- A patient is two days post op with nausea and vomiting. The prescriber orders to “saline lock the IV.” As the nurse, describe your subsequent actions.
Answer: Prior to saline locking an IV, the nurse should assess a number of things including:
- Oral intake: to provide insight into the patient’s ability to maintain adequate hydration and nutrition
- Urinary output: volume and color might provide insight into hydration status
- Blood pressure: to provide some insight into hydration status. Assessing oral intake helps to determine the patient’s ability to maintain adequate
- Temperature for evidence of infection. If fever is present the IV might provide additional hydration and provide a route for IV medications if they are ordered.
- GI function: to determine if the patient is able to maintain adequate hydration and nutrition without aid of an IV.
In this situation the patient has nausea and vomiting. The nurse should investigate possible causes, discuss any decision to not saline loc the IV with the prescriber
2. During night shift rounds, the patient who was restless all night has pulled apart their IV tubing. The CVC remains in situ. As the nurse, describe your subsequent actions.
Answer: the nurse should consider:
- That the CVC is likely contaminated therefore the patient is at risk of sepsis. If reconnection to a new tubing is to be done, the connections will have to be cleaned well with agency approved antiseptic ie. alcohol or chlorhexidine
- That an open line presents risk of air emboli to the patient. Therefore kink / occlude the line and call for help. Assess the patient.
- There is a high risk of BBF exposure for the nurse. Therefore donne clean gloves.
- The CVC may have been pulled out and the tip is not in the correct position. Therefore measure the external length and aspirate for blood using a 10 ml syringe. If the external length has increased and blood can be aspirated, flush and lock the CVC until further assessment through XRAY / PICC nurse. Assess the patient.
Source: Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby.
3. A first year nursing student is shadowing you, the nurse, for the day and asks how you would know if someone is experiencing fluid overload from their IV therapy. How might you respond?
Answer: As the nurse I would explain that fluid overload from IV therapy is a condition caused by excess fluid accumulation in the lungs due to excess fluid in the circulatory system and / or inability of the body to manage the IV fluid being infused. Signs and symptoms include ↓SpO2, ↑respiratory rate, dyspnea, coughing up pink frothy sputum, auscultation of dependent fine crackles, anxiety. Knowing the patient’s history can provide insight into conditions that put some patients more