A patient is getting IV fluid through peripheral cannula, shows redness, cool, oedema and decreased flow rate. The possible diagnosis is?

Appeared in: NORCET 3 - 2022 (Shift-1)

Explanation

Infiltration is the leakage of non-vesicant IV fluid into the surrounding subcutaneous tissue.
The classic signs presented in the scenario—coolness to the touch, swelling (edema), and a decreased or stopped flow rate—are hallmark indicators of infiltration.
Coolness occurs because the IV fluid is at room temperature, which is cooler than the patient's body temperature.
Edema results from the fluid accumulating in the subcutaneous space, causing the tissue to become taut and swollen.
The flow rate decreases or stops because the fluid is no longer flowing freely into the vein and meets resistance in the tissue.

Option B: Phlebitis is the inflammation of a vein. Its primary signs are warmth, redness, pain, and a palpable venous cord, not coolness as described in the question.
Option C: An allergic reaction is a systemic immune response. It would present with generalized symptoms such as hives, itching, rash, and respiratory distress, not localized symptoms at the IV site.
Option D: Hypersensitivity is a type of systemic allergic reaction and is essentially synonymous with it in this context. The symptoms would be systemic, not localized to the IV insertion site.

Clinical Relevance

Nursing practice connection: Use the key finding related to Identification of local complications of intravenous (IV) therapy to guide bedside assessment, documentation, and the next nursing action.
Prompt identification and management of infiltration are crucial nursing responsibilities to prevent patient discomfort, pain, and more severe complications like compartment syndrome or tissue necrosis (if the fluid is a vesicant).
The nurse's first action upon suspecting infiltration is always to stop the infusion and remove the cannula immediately to prevent further fluid from entering the tissue.
What if? - If the patient's skin was warm and tender with a red streak along the vein, the diagnosis would be phlebitis. The intervention would be to stop the infusion, remove the cannula, and apply warm, moist compresses to reduce inflammation and pain.

How to Approach the Question

First, carefully read the clinical scenario and identify all the signs and symptoms presented by the patient.
Focus on the key descriptors provided: 'redness,' 'cool,' 'oedema,' and 'decreased flow rate.'
Systematically compare this cluster of symptoms with the known characteristics of each option (infiltration, phlebitis, allergic reaction).
Recognize that 'coolness' at the site is a strong differentiating sign. Infiltration causes coolness because room-temperature fluid is entering the tissue, whereas phlebitis (inflammation) causes warmth.
Rule out systemic reactions like 'allergic reaction' and 'hypersensitivity' because the symptoms described are localized to the IV site.
Conclude that 'Infiltration' is the only diagnosis that matches all the key signs, especially the combination of coolness and edema.

Concept Tested & Keywords

Concept Tested: Identification of local complications of intravenous (IV) therapy.
Stem keywords: IV fluid, peripheral cannula, redness, cool, oedema, decreased flow rate
Lead-in keywords: possible diagnosis
Clinical cues: The combination of coolness and edema is a strong indicator for infiltration over other complications.

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

Practise the full NORCET 3 - 2022 (Shift-1)

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