4 Infusion Monitoring and Complications
Learn how to assess infusion sites, recognize common complications, respond safely to pump alarms and urgent symptoms, and document care.
Routine site assessment
Assess both the patient and the IV site, including when a patient reports new discomfort. Inspect and palpate the site as appropriate for pain, swelling, redness, warmth, and changes in infusion function. A pump that is running does not establish that the catheter remains in the vein.
Recognizing site complications
New pain, swelling, redness, warmth, or a change in flow calls for reassessment and appropriate action. Ask patients with a peripheral IV to report new pain, burning, stinging, swelling, redness, wetness, or other changes at the site promptly, even if the discomfort seems minor.
Warmth, tenderness, redness, and a palpable cord along the vein are signs consistent with . Stop using the affected or malfunctioning peripheral catheter, remove it according to facility policy, assess the patient, and notify the appropriate clinician as indicated.
Responding to and
When a non- infusion site becomes puffy and cool and the infusion slows, stop the infusion and assess the site and patient. If is suspected, discontinue the affected catheter and manage the site according to facility policy; elevate the limb if appropriate. Do not force a flush or simply increase the pump rate.
Burning at a site with new swelling during a infusion raises concern for . Stop the infusion immediately and do not flush the catheter. Follow the drug-specific protocol, which may direct the nurse to leave the catheter in place temporarily to aspirate residual medication or give an antidote. Promptly notify the appropriate clinician and pharmacist. Apply compresses or administer an antidote only as directed by the applicable protocol.
Troubleshooting infusion alarms
For a alarm, first assess the patient and IV site. Then trace the tubing and connections for a closed clamp, kink, disconnection, or other obstruction. Correct an identified cause according to policy, verify the prescribed medication and rate, and reassess before restarting. Do not bypass the alarm, increase the pressure limit and restart without assessment, or use force to overcome resistance.
Responding to possible
New shortness of breath and crackles during IV fluid administration require prompt evaluation. Assess breathing and vital signs, promptly notify the appropriate clinician, and follow orders or emergency procedures. Do not continue an unchanged infusion without reassessing the patient and clarifying the plan.
Documenting a complication
After suspected or , document the time and assessment findings, including the site, symptoms, and relevant changes. Record the fluid or medication and infusion rate, actions taken, whom you notified and when, any orders or protocol-guided treatment, and the patient's response and follow-up assessments. Use the facility's required event-reporting process as well; an event report does not replace clinical documentation.