A patient receiving IV infusion develops swelling, pain, and cool skin at the IV site. What complication is most likely?

Appeared in: AIIMS Delhi NO- 2019

Explanation

Infiltration is the leakage of non-vesicant IV fluid into the surrounding subcutaneous tissue.
The classic signs presented in the question—swelling (edema), pain, and coolness at the site—are hallmark symptoms of infiltration.
The coolness occurs because the IV fluid is typically at room temperature, which is lower than body temperature. As this fluid accumulates in the tissue, it makes the skin feel cool to the touch.

Option A: Phlebitis is the inflammation of a vein. Its key signs are warmth, redness (erythema), and tenderness along the vein, not coolness.
Option C: A local infection at the IV site would present with signs of inflammation such as redness, warmth, and swelling, but would also likely include purulent drainage and potentially systemic symptoms like fever.
Option D: Hemorrhage is active bleeding. This would manifest as obvious bleeding from the insertion site or a rapidly forming hematoma (bruise), not the specific combination of swelling and coolness.

Clinical Relevance

Nursing practice connection: Use the key finding related to Assessment and identification of local complications of intravenous (IV) therapy to guide bedside assessment, documentation, and the next nursing action.
Nurses must perform routine and frequent checks of IV sites (at least hourly for continuous infusions) to detect complications early and prevent significant tissue damage.
The immediate nursing action for infiltration is to stop the infusion and remove the catheter to prevent further fluid accumulation and potential tissue necrosis.
What if? If the fluid that infiltrated was a vesicant (a drug that can cause tissue damage, like chemotherapy), the complication would be termed extravasation, which is a medical emergency requiring specific antidotes and more aggressive management.

How to Approach the Question

First, identify the key assessment findings provided in the clinical scenario: swelling, pain, and cool skin at an IV site.
Focus on the most specific and differentiating sign among the options. In this case, 'cool skin' is the critical clue.
Systematically evaluate each option against the presented symptoms.
Recall the pathophysiology of each complication: Infiltration involves room-temperature fluid leaking into tissue, causing coolness. Phlebitis is inflammation, which generates heat.
Eliminate phlebitis because it causes warmth, not coolness.
Eliminate infection and hemorrhage as they have other distinct signs (purulence, fever, active bleeding) not mentioned in the stem.

Concept Tested & Keywords

Concept Tested: Assessment and identification of local complications of intravenous (IV) therapy.
Stem keywords: IV infusion, swelling, pain, cool skin, IV site
Lead-in keywords: most likely
Clinical cues: The combination of swelling, pain, and cool skin is a classic triad for a specific IV complication.
Negative lead-in flag: false

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E6 Nursing Fundamentals Taylor p. 801-803

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

Practise the full AIIMS Delhi NO- 2019

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