AIIMS Delhi NO - 2018
Medical & Surgical Nursing
Easy
A client feels redness and warmth at the cannulation site. This indicates?
Appeared in: AIIMS Delhi NO - 2018
Explanation
- Phlebitis is defined as the inflammation of a vein's inner layer (the tunica intima).
- The cardinal signs of inflammation are redness (erythema), warmth, pain, and swelling, which directly match the symptoms described in the question.
- These symptoms occur as the body responds to irritation from the cannula itself (mechanical), the infused solution/medication (chemical), or bacteria (infectious).
- The presence of both redness and warmth are hallmark indicators used to identify and grade the severity of phlebitis at a cannulation site.
Why Other Options Were Wrong
- Option B: A hypersensitivity reaction to a medication would typically involve more systemic symptoms like a rash, itching (pruritus), or hives (urticaria), and potentially respiratory distress, not just localized redness and warmth.
- Option C: Similar to medication hypersensitivity, a reaction to the cannula material (e.g., an allergy to a component of the plastic) would more likely cause itching and a localized rash rather than the classic inflammatory signs of warmth along the vein.
- Option D: Thrombophlebitis is inflammation of a vein associated with a blood clot (thrombus). While it includes redness and warmth, its distinguishing feature is a palpable, hard, cord-like vein. The question does not mention this key sign.
Related Visual
Clinical Relevance
- Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Identification of local complications of intravenous (IV) therapy as background academic context rather than a clinical decision trigger.
- Early detection and management of phlebitis are critical nursing responsibilities to prevent more serious complications like thrombophlebitis, infection, and bloodstream infections (sepsis).
- Nurses regularly use a phlebitis scale (e.g., the Visual Infusion Phlebitis Scale) to objectively assess and document the severity of the condition, ensuring consistent monitoring and communication.
- What if? If the site was cool, pale, and swollen instead of red and warm, the correct answer would be Infiltration. This is because those signs indicate the IV fluid is leaking into the surrounding subcutaneous tissue, not causing vein inflammation.
How to Approach the Question
- First, analyze the keywords in the question: 'redness' and 'warmth' at a 'cannulation site'.
- Recognize that these are two of the classic signs of inflammation.
- Evaluate the options in the context of IV complications. 'Phlebitis' literally means 'inflammation of a vein'.
- Differentiate phlebitis from the other options. Hypersensitivity involves an allergic component (often itching). Thrombophlebitis is a more advanced stage with a clot (palpable cord).
- Conclude that the signs described in the stem are the most direct and primary indicators of phlebitis.
Concept Tested & Keywords
- Concept Tested: Identification of local complications of intravenous (IV) therapy.
- Stem keywords: redness, warmth, cannulation site
- Lead-in keywords: indicates
- Clinical cues: The combination of redness and warmth points specifically to an inflammatory process at the IV site.
Question ID
QSj6QPOOKHLZ1OsD88WO94
Reference Book
E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 74-76
E6 Nursing Fundamentals Taylor p. 801-803
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