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?

Appeared in: NORCET 1 - 2020

Explanation

Infiltration is the correct term for the leakage of non-vesicant IV fluid into the surrounding subcutaneous tissue.
The scenario describes classic signs of infiltration: a dislodged catheter leading to localized swelling as the IV fluid collects under the skin.
Key assessment findings for infiltration include swelling (edema), coolness of the skin, pallor (blanching), and discomfort at the IV site.

Option A: Infection is characterized by signs of inflammation such as redness, warmth, and purulent drainage, which are not mentioned in the scenario.
Option B: Fluid overload is a systemic complication affecting the entire circulatory system, not a localized issue at the IV site. Its signs include shortness of breath and crackles in the lungs.
Option D: Extravasation is a more severe form of infiltration involving the leakage of a vesicant (tissue-damaging) drug. The fluid for dehydration is non-vesicant.

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.
Regular and frequent assessment of IV sites (at least every 1-2 hours for adults) is a critical nursing responsibility to promptly detect complications like infiltration, ensuring patient safety and treatment efficacy.
Patient education is key. Instruct patients to report any pain, swelling, or discomfort at their IV site immediately.
What if? If the leaking fluid was a chemotherapy agent (a vesicant), the complication would be termed extravasation. The immediate nursing action would be more complex: stop the infusion, but leave the catheter in place to attempt aspiration of the drug and possibly administer a specific antidote before removal to prevent severe tissue necrosis.

How to Approach the Question

First, analyze the clinical scenario: An IV catheter has dislodged, and fluid is causing localized swelling.
Identify the core problem: The issue is localized to the IV insertion site, not systemic.
Evaluate the options based on this localization. 'Fluid overload' is a systemic issue, so it can be eliminated.
Differentiate the remaining local complications. 'Infection' involves signs of inflammation (redness, heat, pus), which are not described.
Distinguish between 'Infiltration' and 'Extravasation'. Infiltration is the general term for leakage of non-irritating fluid. Extravasation is specific to tissue-damaging (vesicant) fluids.
Since the fluid is for simple dehydration (a non-vesicant), 'Infiltration' is the most accurate and best term.

Concept Tested & Keywords

QdwtSpDBc7xAB0OR8Ss8qF

E6 Nursing Fundamentals Potter Perry 12e Part 5 pp. 73-75, 74-76

Practise the full NORCET 1 - 2020

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