A patient is very restless while receiving IV fluids to treat dehydration. The IV catheter has slipped out

of the vein and fluid is delivered to the surrounding tissues under the skin, cousing swelling. Which

term best describes this occurance?

1. A

   Infection

2. B

   Fluid overload

3. C

   Infiltration

4. D

   Extravasation

Appeared in: NORCET 1 - 2020

Explanation

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• Infiltration is the correct term for the leakage of intravenous fluid into the subcutaneous tissue surrounding the venipuncture site.
• The fluid being administered for dehydration is a non-vesicant (non-tissue-damaging) solution, which is a key characteristic of infiltration.
• The primary sign described in the scenario—localized swelling—is a hallmark symptom of infiltration, often accompanied by coolness and pallor of the skin at the site.

Why Other Options Were Wrong

• Option A: Infection would present with signs of inflammation such as redness, warmth, and potentially purulent drainage, none of which are mentioned in the scenario.
• Option B: Fluid overload is a systemic complication, not a localized one. It affects the entire circulatory system and would present with symptoms like shortness of breath, crackles in the lungs, and hypertension.
• Option D: Extravasation is the leakage of a vesicant (a substance that can cause tissue damage and necrosis), such as a chemotherapy agent. The fluid for dehydration is non-vesicant.

Related Visual

• Visual 1: Diagram - An illustration comparing a correctly placed IV catheter within a vein versus an infiltrated catheter that has pierced the vein wall, showing fluid accumulating in the subcutaneous tissue.
• Visual 2: Photograph - A clinical photo showing the typical appearance of an infiltrated IV site: visible swelling, taut and pale (blanched) skin, compared to a healthy IV site.
• Visual 3: Chart - A comparison table outlining the signs, symptoms, and immediate nursing actions for local IV complications (Infiltration, Extravasation, Phlebitis) versus systemic complications (Fluid Overload, Air Embolism).

Clinical Relevance

• Nursing practice connection: Use the key finding related to Complications of Intravenous (IV) Therapy to guide bedside assessment, documentation, and the next nursing action.
• Nurses must perform regular and frequent assessments of IV sites (at least every 1-2 hours for adults) to detect early signs of complications like infiltration, ensuring patient safety and treatment efficacy.
• Prompt identification and management of infiltration prevent patient discomfort, reduce the risk of skin breakdown or compartment syndrome (in severe cases), and avoid delays in therapy.
• What if the leaking fluid was a chemotherapy drug like vincristine? The complication would be classified as extravasation, a medical emergency. The nurse would immediately stop the infusion, attempt to aspirate the drug from the catheter, administer a specific antidote per protocol, and notify the provider. Cold compresses are typically used, unlike the warm compresses sometimes used for infiltration.

How to Approach the Question

• First, analyze the clinical scenario. The key elements are: an IV catheter, fluid administration, the catheter slipping out of the vein, and localized swelling.
• Next, evaluate the nature of the problem. Is it localized to the IV site or systemic (affecting the whole body)? The swelling is at the IV site, so it's a local issue. This helps eliminate 'Fluid overload'.
• Consider the signs and symptoms. The primary sign is swelling from fluid. This points away from 'Infection', which would involve redness, warmth, and pus.
• Differentiate between the remaining local complications. The choice is between 'Infiltration' and 'Extravasation'. This distinction depends on the type of fluid. Since the fluid is for 'dehydration', it's a standard, non-vesicant solution.
• Therefore, 'Infiltration' (leakage of non-vesicant fluid) is the correct term, while 'Extravasation' (leakage of vesicant fluid) is incorrect in this context.

Concept Tested & Keywords

• Concept Tested: Complications of Intravenous (IV) Therapy
• Stem keywords: IV fluids, dehydration, catheter slipped out, surrounding tissues, swelling
• Lead-in keywords: best describes
• Clinical cues: The key cue is localized swelling at the IV site after the catheter slipped, indicating a local problem with fluid placement, not a systemic issue or infection.

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