A client is receiving IV fluids and develops tenderness, erythema and pain at the site. The nurse suspects which of the following?

Appeared in: AIIMS Rishikesh & Jodhpur NO - 2017

Explanation

The patient's symptoms of localized tenderness, erythema (redness), and pain at the IV insertion site are the classic clinical manifestations of phlebitis.
Phlebitis is defined as the inflammation of the inner layer of a vein (tunica intima).
It can be caused by mechanical irritation from the catheter, chemical irritation from the IV solution, or bacterial contamination.
These signs of inflammation distinguish phlebitis from other IV complications like infiltration, which presents with coolness and pallor.

Option A: Fluid overload is a systemic, not a local, complication. Its signs include shortness of breath, crackles in the lungs, and dependent edema, which are not present in this scenario.
Option B: Sepsis is a systemic infection characterized by symptoms like fever, chills, tachycardia, and hypotension. The client's symptoms are localized to the IV site.
Option D: Infiltration occurs when IV fluid leaks into the surrounding tissue. The key signs are swelling, coolness to the touch, and pallor (blanched skin), not the redness and warmth seen in phlebitis.

Clinical Relevance

Nursing practice connection: Use the key finding related to Identification of intravenous (IV) therapy complications to guide bedside assessment, documentation, and the next nursing action.
Prompt recognition and management of phlebitis are crucial to prevent more serious complications like thrombophlebitis (inflammation with a blood clot) and bloodstream infections.
The standard nursing action for phlebitis is to immediately stop the infusion and remove the catheter to prevent further irritation and damage to the vein.
Nurses use a standardized phlebitis scale (e.g., the INS Phlebitis Scale) to assess, document, and communicate the severity of the condition, ensuring consistent care.

How to Approach the Question

First, analyze the clinical scenario: a patient is receiving IV fluids.
Next, identify the key assessment findings presented in the question: tenderness, erythema (redness), and pain at the IV site.
Categorize these symptoms. Are they local (at the site) or systemic (affecting the whole body)? These are local signs of inflammation.
Evaluate the options based on this categorization. Fluid overload and sepsis are systemic complications, so they are less likely.
Differentiate between the local complications. Phlebitis is characterized by inflammation (redness, warmth, pain), while infiltration is characterized by fluid leakage into tissue (swelling, coolness, pallor).
Match the patient's signs (redness, pain, tenderness) to the correct definition. These are the hallmark signs of phlebitis.

Concept Tested & Keywords

Concept Tested: Identification of intravenous (IV) therapy complications.
Stem keywords: IV fluids, tenderness, erythema, pain, IV site
Lead-in keywords: suspects which of the following
Clinical cues: The combination of localized tenderness, erythema (redness), and pain are hallmark signs of inflammation at an IV site.

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E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 74-76

E6 Nursing Fundamentals Taylor p. 801-803

Practise the full AIIMS Rishikesh & Jodhpur NO - 2017

Attempt every question from this paper in a timed mock, then review the full solution for each one.