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, causing swelling. Which term best describes this occurrence?

Appeared in: NORCET 1 - 2020

Explanation

Infiltration is the leakage of non-vesicant (non-tissue-damaging) IV solution into the surrounding subcutaneous tissue.
The scenario describes a patient receiving fluids for dehydration, which are typically non-vesicant solutions like normal saline.
The key signs presented in the question—catheter dislodgement followed by localized swelling—are the classic presentation of IV infiltration.
Assessment findings for infiltration include coolness to the touch, skin blanching, tautness, and edema around the insertion site.

Option A: Infection at an IV site would present with signs of inflammation such as redness, warmth, tenderness, and possible purulent drainage (pus), which are not described in the scenario.
Option B: Fluid overload (hypervolemia) is a systemic complication where the body has too much fluid. It manifests with symptoms like shortness of breath, crackles in the lungs, and generalized edema, not localized swelling at the IV site.
Option D: Extravasation is similar to infiltration but specifically involves the leakage of a vesicant—a fluid or medication that can cause severe tissue damage, blistering, and necrosis.

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.
Prompt recognition and management of IV infiltration are crucial nursing responsibilities to prevent discomfort, compromised circulation, and the need for more invasive interventions.
Nurses must perform regular assessments of all IV sites, checking for pain, swelling, coolness, and blood return, especially in patients who are restless, confused, or unable to communicate discomfort.
What if the fluid had been a vesicant like potassium chloride or a chemotherapy agent? The complication would be classified as extravasation, a more serious event requiring immediate, specific interventions (like aspirating the drug and administering an antidote) to prevent severe tissue necrosis.

How to Approach the Question

First, analyze the clinical scenario: A patient is receiving IV fluids, the catheter has slipped, and there is localized swelling.
Identify the key sign: The primary problem is fluid leaking into the tissue around the vein, causing swelling.
Evaluate the options based on their definitions. Ask yourself: Does the sign (localized swelling) match the definition of the term?
Differentiate between local and systemic complications. 'Fluid overload' is systemic, while the problem described is local to the IV site, eliminating that option.
Differentiate between similar local complications. Both 'Infiltration' and 'Extravasation' involve fluid leakage. The key difference is the type of fluid. Since the fluid is for simple dehydration, it's non-vesicant, making 'Infiltration' the correct term.

Concept Tested & Keywords

Concept Tested: Complications of Intravenous (IV) Therapy
Stem keywords: IV fluids, dehydration, catheter slipped out, swelling
Lead-in keywords: best describes
Clinical cues: Localized swelling at the IV site is a key indicator of a local complication rather than a systemic one.

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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.