Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

SKILL 15-3

Monitoring an IV Site and Infusion (Continued)

Comments

12.Check for local manifestations (redness, pus, warmth,

induration, and pain) that may indicate an infection is

present at the site, or systemic manifestations (chills, fever,

tachycardia, hypotension) that may accompany local infec-

tion at the site. If signs of infection are present, discontinue

the IV and notify the primary care provider.Be careful not

to disconnect IV tubing when putting on patient’s hospital

gown or assisting the patient with movement.

13. Be alert for additional complications of IV therapy.
    a.Fluid overload can result in signs of cardiac and/or
    respiratory failure. Monitor intake and output and
    vital signs. Assess for edema and auscultate lung
    sounds. Ask if patient is experiencing any shortness of
    breath.
    b. Check for bleeding at the site.


14. If possible, instruct patient to call for assistance if any dis-
    comfort is noted at site, solution container is nearly empty,
    flow has changed in any way, or if the electronic pump
    alarm sounds.

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