Nursing Field Notes / Renal + Fluid · Fundamentals of Nursing

IV Therapy Problems 🚨

Complications of IV therapy — recognize it, then act in the right order

NG-085 RENAL + FLUID ADHD-friendly visual edition

Every IV is a hole in a vein you are responsible for. Six things go wrong — infiltration, extravasation, phlebitis, air embolism, fluid overload, infection — and for each one the exam wants two things: the sign you noticed first and your very next action.

📄 Simple Nursing original — opens in Drive →

❄️ Cool · pale · swollenINFILTRATION — fluid leaked into tissue. Stop & remove, elevate.

🔥 Red · hot · cordPHLEBITIS — the vein is inflamed. Stop & remove, warm compress.

💊 Burning + blisterEXTRAVASATION — a vesicant leaked. Stop but LEAVE the catheter in, antidote.

😰 Sudden dyspnea + chest painAIR EMBOLISM — clamp the line, LEFT side, head DOWN, O₂, call.

🗺️

THE MAP

START HERE · WHERE IT GOES WRONG

One catheter, one vein — and six different ways the picture can break.

🗺️ One IV site, six complications

🧠 “Out of the vein · in the vein · in the line · in the body.” Sort every IV problem by where it is: fluid out of the vein (infiltration/extravasation), damage in the vein (phlebitis/hematoma), something wrong in the line (air, germs), or too much in the body (overload).

⭐ The universal first move: STOP THE INFUSION

Almost every answer choice on this topic starts the same way. What changes afterwards is whether the catheter comes out and how you position the client.

STOP the infusion — clamp it. (Fluid overload: slow to a keep-vein-open rate rather than disconnecting, unless ordered otherwise.)

ASSESS the site and the client — skin temp, color, swelling, pain, blood return, vital signs, lung sounds.

VESICANT? If yes — leave the catheter in place and aspirate. If no — discontinue the catheter.

ELEVATE / POSITION — elevate the limb; for air embolism it's the whole body: left side, head down.

DOCUMENT & report — site appearance, size of swelling, drug/fluid, time, actions, provider notified. Restart in the opposite extremity.

🧠 “SAVED” — Stop · Assess · Vesicant? · Elevate/position · Document. You SAVED the limb.

💪

AT THE SITE

STEP 1 · LOCAL PROBLEMS

Everything here is felt with your hand — temperature, swelling and the line of the vein.

❄️🔥 The two arms you must be able to tell apart

🧠 “InfilTRATE is cool and TAUT · PhleBITIS BITES and burns.” Put the back of your hand on the site: cold and puffy = infiltration, hot and red = phlebitis. That single touch sorts the two most confused answers on the exam.

❄️ INFILTRATION — non-vesicant fluid into the tissue

What it is: the catheter tip slips out of (or through) the vein and non-vesicant IV fluid leaks into the surrounding tissue.

👀 Recognize:

❄️ Skin cool to touch, pale/blanched, tight and shiny
🎈 Swelling at or above the site; sleeve or ID band feels tight
🩸 No blood return; infusion slows, stops or pump alarms
😐 Dull ache or burning; leaking around the insertion site

🚑 Immediate action:

1️⃣ STOP the infusion
2️⃣ Discontinue (remove) the catheter
3️⃣ Elevate the extremity
4️⃣ Apply a compress — warm for most isotonic fluids to aid absorption; cool is used for some solutions. Practice varies — follow your facility's policy.
5️⃣ Restart the IV in the OTHER arm, above nothing that just leaked
6️⃣ Measure and document the swelling; monitor circulation, sensation, movement

🧠 “Infiltration = the fluid took a detour.” Cool, pale, puffy, no blood return — pull it and put it in the other arm.

💊 EXTRAVASATION — the same leak, but the drug burns

What it is: a VESICANT (tissue-damaging) drug leaks into the tissue. This is the emergency version of infiltration — it can cause blistering, tissue necrosis, nerve damage and loss of function.

💊 Classic vesicants: many chemotherapy agents · vasopressors (norepinephrine, dopamine, vasopressin) · concentrated potassium · calcium · promethazine · phenytoin · vancomycin · contrast dye · TPN · D50.

👀 Recognize: burning or stinging pain out of proportion, redness that turns dusky, blistering, cool/swollen skin, later ulceration and sloughing.

🚑 Immediate action — the order matters:

1️⃣ STOP the infusion immediately
2️⃣ DO NOT remove the catheter yet — aspirate residual drug back through it first
3️⃣ Notify the provider NOW — ask about an antidote: phentolamine for vasopressor extravasation, hyaluronidase for many others (agent-specific)
4️⃣ Mark the border of the affected area, measure it, and photograph per policy
5️⃣ Elevate the limb; apply warm or cold per the specific drug protocol
6️⃣ Remove the catheter only after the antidote step is complete, then document fully

🧠 “EXTRA bad = EXTRAvasation. Don't pull the straw before you sip back.” The catheter is your only route to aspirate the drug and instill the antidote — pulling it first throws that away.

🔥 PHLEBITIS — inflammation of the vein wall

Three causes: mechanical (catheter too big, poorly secured, joint movement) · chemical (irritating drug, high osmolarity, wrong dilution) · bacterial (contamination — the most dangerous).

👀 Recognize:

🔥 Redness, warmth, tenderness along the vein
➰ Red streak and a palpable, hard, cord-like vein
🎈 Site swelling; pain with infusion; sometimes low-grade fever
🩸 Thrombophlebitis = phlebitis + a clot — same picture with a firm, painful, immovable vein

🚑 Immediate action: stop the infusion → discontinue the catheter → warm moist compress → elevate → restart in the opposite extremity → notify provider and document (grade it on your facility's 0–4 phlebitis scale). ❌ Never massage or rub the site — you could dislodge a clot.

🧠 “Hot, red, cord = the vein is scorched.” Infiltration gets a cool arm; phlebitis gets a warm compress on a hot arm — the temperature you find and the temperature you apply are opposites there. Never rub it.

🩸 HEMATOMA & the smaller site problems

Hematoma — blood leaks out of the vein: ecchymosis, firm lump, tenderness, often after a difficult stick or on removal. Action: remove the catheter, apply firm direct pressure (longer if on anticoagulants), elevate, then ice early / warm later per policy.
Occlusion / clotted catheter — infusion stops, pump alarms, no blood return. Never forcibly flush a resistant line and never “milk” the tubing — you could push a clot into circulation.
Venous spasm — sudden cramping pain, sluggish flow, often from cold or irritating fluid. Slow the rate and apply warmth.
Nerve, tendon or ligament injury — sharp shooting pain, tingling, numbness during insertion. Stop and remove immediately, notify the provider.
Catheter embolism — a piece shears off. Never reinsert the stylet/needle into the catheter. If suspected: apply a tourniquet high on the extremity, place the client on the left side, notify the provider, anticipate an x-ray.

🧠 “Never force, never rub, never re-thread.” Three verbs that turn a small IV problem into a big one.

📊 Infiltration vs Extravasation vs Phlebitis — the table to memorize

	❄️ INFILTRATION	💊 EXTRAVASATION	🔥 PHLEBITIS
What leaked	Non-vesicant fluid	Vesicant drug	Nothing — the vein is inflamed
Skin temp	COOL	Cool at first	WARM / HOT
Skin color	Pale, blanched, shiny	Red → dusky → blistered	Red streak along the vein
Swelling	Yes, taut	Yes	Some, plus a hard cord
Pain	Dull ache	Burning, severe	Tender along the vein
Blood return	Absent	Absent or sluggish	May be present
Remove the catheter?	Yes — right away	NOT YET — aspirate + antidote first	Yes — right away
Compress	Warm (or cool) per policy	Drug-specific protocol	Warm, moist
Worst outcome	Compartment syndrome	Necrosis, loss of function	Thrombophlebitis, sepsis

🧠 “Cool = the fluid fell. Hot = the vein is hell. Burning = call, and leave the catheter in the wall.” Three rhymes, three answers.

🫀

WHOLE BODY

STEP 2 · SYSTEMIC EMERGENCIES

These do not show up in the arm — they show up in the lungs, the heart and the level of consciousness.

🚨 AIR EMBOLISM — sudden dyspnea + chest pain during an infusion

What it is: air enters the vascular system through the tubing, a loose connection, or an open central line, travels to the right side of the heart, and forms an air lock that blocks blood from reaching the lungs. Highest risk: central lines — during insertion, tubing changes and removal.

👀 Recognize: sudden dyspnea · chest pain · hypotension · tachycardia · anxiety and a sense of doom · cyanosis · lightheadedness, altered LOC · possible churning “mill-wheel” murmur.

🚑 Immediate action, in order:

1️⃣ CLAMP / occlude the line — stop more air entering
2️⃣ Position: LEFT lateral, head DOWN (Trendelenburg) — Durant's maneuver
3️⃣ Oxygen — high flow, as ordered
4️⃣ Call the provider / rapid response and stay with the client
5️⃣ Monitor vitals, pulse ox and LOC continuously

🛡️ Prevent: prime tubing completely, use Luer-lock connections, keep the system closed, have the client perform the Valsalva maneuver during central line insertion/removal, and apply an occlusive dressing after a central line is pulled.

🧠 “Air goes LEFT and DOWN.” Air floats up — so you turn the client so “up” is the harmless corner of the right ventricle. Left side, head down, oxygen, call.

🚨 FLUID VOLUME OVERLOAD — too much, too fast

Who: heart failure, kidney failure, older adults, infants — and anyone whose pump was set too high or whose bag was “caught up.”

👀 Recognize: crackles in the bases · dyspnea, orthopnea · bounding pulse · ↑BP · JVD · dependent/pitting edema · puffy eyelids · ↑CVP · frothy pink sputum (pulmonary edema) · sudden weight gain 1 kg = 1 L · urine output that doesn't match intake.

🚑 Immediate action:

1️⃣ Slow the infusion to a keep-vein-open (KVO) rate — don't just walk away from the line
2️⃣ Sit the client up — HIGH FOWLER'S to ease the work of breathing
3️⃣ Oxygen as ordered; pulse oximetry
4️⃣ Notify the provider; anticipate a loop diuretic (e.g. furosemide) and repeat labs
5️⃣ Strict I&O, daily weight, lung sounds and vitals on a schedule

⚠️ Remember the escalation from the fluids page: FVO → BP over 180 systolic = HTN crisis → risk for CVA.

🧠 “Wet lungs sit UP.” Overload gets high Fowler's; air embolism gets head down on the left. Two emergencies, two opposite positions — practice saying them back to back so you never swap them.

🚨 SPEED SHOCK — the bolus that went too fast

What it is: a drug or fluid enters the circulation faster than the body can handle, flooding the heart and brain with a sudden concentration.

👀 Recognize: flushed face · pounding headache · tightness in the chest · irregular pulse · dizziness · hypotension progressing to shock and cardiac arrest.

🚑 Action: stop the drug immediately, keep the line open with a safe fluid at KVO, call the provider / rapid response, monitor vitals continuously, treat symptoms as ordered.

🛡️ Prevent: Never “catch up” a behind-schedule infusion by opening the roller clamp. Use a pump, know the safe push rate for every IV drug, and dilute as directed.

🧠 “Speed shock = the drug arrived before the body was ready.” Flushed, throbbing head, tight chest — think rate before you think allergy.

🚨 The other systemic ones to name

Catheter embolism — a sheared catheter fragment travels in the bloodstream. Signs: sudden chest pain, dyspnea, hypotension, weak pulse. Action: tourniquet high on the extremity, left side-lying, notify provider, prepare for x-ray. Never reinsert a needle/stylet into a catheter.
Allergic / anaphylactic reaction — hives, itching, wheeze, swelling of the face and tongue, hypotension. Action: stop the infusion, keep the line with normal saline, call for help, anticipate epinephrine, antihistamines and steroids, protect the airway.
Electrolyte imbalance from the fluid itself — check sodium and potassium; watch for arrhythmias, muscle cramps, weakness and neuro changes.

🧠 “Sudden chest pain + dyspnea during IV therapy is never nothing.” Air, catheter fragment, overload or anaphylaxis — stop the line and get help while you sort it out.

🦠

INFECTION

STEP 3 · THE PREVENTABLE ONE

Local redness is a problem. A fever with rigors during an infusion is an emergency.

🦠 Local site infection ➜ bloodstream infection ➜ sepsis

👀 Recognize — local: redness, warmth, swelling and purulent drainage at the site, tenderness, foul odor. Systemic: fever and chills/rigors (often starting soon after a flush or infusion), tachycardia, hypotension, malaise, confusion in older adults, ↑WBC, positive blood cultures.

🚑 Immediate action:

1️⃣ Stop the infusion and do not flush the line
2️⃣ Assess vital signs — this client can decompensate fast
3️⃣ Notify the provider; anticipate blood cultures (peripheral and, if ordered, from the line) before antibiotics
4️⃣ Culture the site; if the catheter is removed, send the tip for culture if ordered
5️⃣ Remove the catheter as ordered and restart in a new site with new tubing and new fluid
6️⃣ Give antibiotics and fluids as ordered; monitor lactate, urine output and LOC

🧠 “Cultures before antibiotics.” Once the antibiotic is in, the culture may never tell you what you were fighting. Draw first, hang second — unless the delay would harm the client.

✅ PREVENTION — the part that is entirely in your hands

🧼 Every single time

Hand hygiene before and after any contact with the line
Scrub the hub with alcohol before each access and let it dry
Aseptic technique and skin antisepsis (chlorhexidine-based) at insertion
Keep the dressing clean, dry and intact; change it if damp, loose or soiled
Label tubing and dressings with the date; check the bag for cracks, cloudiness, particles, expiration

👀 Every shift & every round

Assess the site at least every shift and with every infusion — many facilities require hourly for continuous or vesicant infusions
Ask the client: “Any burning, pain or tightness?” Discomfort is the earliest sign of all of these
Remove the line as soon as it is no longer needed — the single biggest infection reducer
Change administration sets and rotate sites per facility policy (schedules differ between fluids, lipids and blood)
Choose the smallest gauge that does the job, avoid areas of flexion, and secure the catheter well

❌ Never take a blood pressure or draw blood above an active IV site. ❌ Never leave a line in “just in case” once it is no longer indicated.

🧠 “Clean hands · Clean hub · Check the site · Cut the line loose.” Four C's, and the last one prevents more infections than the first three combined.

⭐ Which complication is it? — a 4-question sort

🧠 “Touch the arm, then look at the whole client.” If the finding is in the limb, it's local. If the finding is in the breathing, it's systemic. If the finding is a fever, it's infection. Three doors, and you already know what's behind each one.

⚡

QUICK RECALL

SAY IT OUT LOUD

❄️ Cool, pale, no blood returnInfiltration → stop, remove, elevate, restart other arm.

💊 Vesicant burningExtravasation → stop, leave the catheter, aspirate, antidote, call.

🔥 Red streak & cordPhlebitis → stop, remove, warm moist compress, never massage.

🫁 Two positionsAir embolism = LEFT side, head DOWN · Overload = HIGH FOWLER'S.

🎯 Cover & check — 8 rapid-fire questions

Q1: The IV site is cool, pale, swollen and has no blood return. What is it and what do you do first?

Infiltration. Stop the infusion, discontinue the catheter, elevate the extremity, apply a compress per policy, and restart the IV in the opposite arm. Measure and document the swelling.

Q2: A client receiving IV norepinephrine reports severe burning and the site is blistering. What must you NOT do?

Do NOT remove the catheter yet. This is extravasation of a vesicant — stop the infusion, aspirate residual drug through the catheter, notify the provider for an antidote (phentolamine for vasopressors), mark and measure the area, then remove the catheter afterward.

Q3: How do you tell infiltration from phlebitis with your hand?

Temperature. Infiltration is COOL, pale and taut. Phlebitis is WARM/hot and red with a streak and a hard, cord-like vein.

Q4: Phlebitis is confirmed. Which nursing action is contraindicated?

Massaging or rubbing the site — it can dislodge a clot. Do stop the infusion, remove the catheter, apply a warm moist compress, elevate, restart elsewhere and document.

Q5: During a central line dressing change the client becomes suddenly dyspneic, has chest pain and drops her BP. Position?

Air embolism — clamp/occlude the line, place her in LEFT lateral position with the head of bed DOWN (Trendelenburg), give oxygen, call for help and stay with her.

Q6: A client in heart failure on IV fluids develops crackles, JVD, a bounding pulse and 2 kg of weight gain. What do you do with the IV?

Fluid overload — slow the infusion to a KVO rate (don't simply disconnect), sit the client up in high Fowler's, give oxygen, notify the provider, anticipate a loop diuretic, and start strict I&O with daily weights. 1 kg = 1 L.

Q7: An hour after a peripheral line is flushed, the client spikes a fever with shaking chills and a BP of 84/50. Priority?

Suspect a catheter-related bloodstream infection. Stop the infusion, take vital signs, notify the provider, obtain blood cultures before antibiotics, remove/culture the catheter as ordered, and restart with new site, new tubing and new fluid.

Q8: The catheter will not thread. May you reinsert the stylet?

Never. Reinserting the needle can shear the catheter and cause a catheter embolism. If embolism is suspected: tourniquet high on the extremity, place the client on the left side, notify the provider and prepare for an x-ray.