A patient has an IV infusion, if the IV infusion infiltrates, the nurse should first?

Appeared in: NHM MP Staff Nurse - 2015

Explanation

The primary principle in managing IV infiltration is to immediately stop the source of the problem.
Discontinuing the infusion is the first action because it prevents more IV fluid from leaking into the subcutaneous tissue.
This action minimizes further swelling, pain, and potential complications like compartment syndrome or tissue damage.
All other interventions, such as elevation or applying compresses, are secondary and should be performed only after the infusion has been stopped.

Option A: Elevating the IV site is a helpful intervention to reduce swelling, but it is not the first priority. The infusion must be stopped first to prevent the condition from worsening.
Option B: Applying a warm, moist soak is a therapeutic measure to increase comfort and help absorb the infiltrated fluid. It is a secondary action, not the initial response.
Option C: Attempting to flush the tube is contraindicated. It will force more fluid into the infiltrated tissue, increasing pressure, pain, and the area of swelling, thereby worsening the injury.

Clinical Relevance

Nursing practice connection: Use the key finding related to Priority nursing action for IV infiltration to guide bedside assessment, documentation, and the next nursing action.
Patient Safety: The immediate cessation of the infusion is a critical patient safety measure to prevent complications ranging from discomfort to severe tissue damage or nerve compression.
Assessment is Key: Nurses must frequently assess IV sites for signs of infiltration (swelling, coolness, tenderness, stopped flow) to detect problems early.
What if?: If the infiltrated fluid was a vesicant (e.g., chemotherapy, vancomycin), this is termed extravasation. The protocol is different: the nurse would stop the infusion but might be required to leave the catheter in place to administer an antidote before removal. Always follow facility-specific extravasation protocols.

How to Approach the Question

Identify the question type: This is a priority-based question, asking for the 'first' nursing action.
Analyze the clinical problem: The problem is IV infiltration, meaning fluid is actively leaking into the tissue.
Think about the primary goal: The immediate goal is to stop any further harm.
Evaluate the options based on the primary goal:
Does elevating the site stop the leak? No, it only helps with swelling.
Does applying a warm soak stop the leak? No, it's a later treatment.

Concept Tested & Keywords

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E6 Nursing Fundamentals Taylor pp. 818-820, 827-829, 835-837

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