During an Intravenous (IV) infusion of saline, you observe that the infusion has stopped and there is mild swelling around the IV site. The skin is cool and puffy. This suggests:

1. A

   Infiltration

2. B

   Phlebitis

3. C

   Air Embolism

4. D

   Atherosclerosis

Appeared in: GMCH - 2016

Explanation

• The clinical presentation of a stopped infusion, localized swelling (edema), and skin that is cool and puffy are the classic signs of IV infiltration.
• Infiltration happens when the IV cannula slips out of the vein, causing the IV fluid to infuse into the surrounding subcutaneous tissue instead of the bloodstream.
• The coolness of the skin is a key diagnostic sign, resulting from the room-temperature IV fluid pooling in the tissues, which is significantly cooler than the body's core temperature.
• The pressure from the accumulated fluid in the tissue can also cause the infusion to slow down or stop completely.

Why Other Options Were Wrong

• Option B: Phlebitis is the inflammation of a vein, which presents with signs of inflammation such as redness, pain, and warmth at the site, not coolness.
• Option C: Air embolism is a systemic, life-threatening complication that presents with sudden respiratory distress, chest pain, and hypotension. It does not cause localized swelling and coolness at the IV site.
• Option D: Atherosclerosis is a chronic disease characterized by the buildup of plaque inside arteries. It is completely unrelated to acute complications of peripheral IV therapy.

Related Visual

Clinical Relevance

• Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Assessment and Management of Intravenous (IV) Therapy Complications as background academic context rather than a clinical decision trigger.
• Prompt recognition and management of infiltration are crucial nursing responsibilities to prevent further tissue damage, nerve compression, or, in severe cases, compartment syndrome.
• Nurses use standardized scales, such as the INS Infiltration Scale, to grade the severity of infiltration, which helps guide intervention and ensures consistent documentation.
• What if? If the infused fluid was a vesicant (e.g., chemotherapy, vasopressors), this complication would be termed extravasation. Extravasation is a medical emergency requiring immediate, specific protocols (which may include aspirating the drug and administering an antidote) to prevent severe tissue necrosis.

How to Approach the Question

• First, carefully read the clinical scenario and identify all the signs and symptoms presented. Key details here are: stopped infusion, swelling, cool skin, and puffiness at the IV site.
• Consider the pathophysiology of each option. Mentally connect the signs to their underlying causes.
• Focus on the key differentiating symptom: 'cool' skin. Ask yourself which complication causes coolness versus warmth.
• Eliminate Phlebitis because it is an inflammatory process that causes warmth.
• Eliminate Air Embolism and Atherosclerosis as they do not fit the localized symptoms. Air embolism is a systemic respiratory/cardiac emergency, and atherosclerosis is a chronic arterial disease.
• Conclude that the collection of symptoms—especially the coolness and swelling—perfectly matches the definition of infiltration.

Concept Tested & Keywords

• Concept Tested: Assessment and Management of Intravenous (IV) Therapy Complications
• Stem keywords: Intravenous (IV) infusion, infusion has stopped, mild swelling, IV site, cool and puffy
• Lead-in keywords: suggests
• Clinical cues: The combination of swelling with cool skin is a hallmark sign of infiltration, differentiating it from the warmth associated with inflammation or infection.
• Negative lead-in flag: false

Question ID

Qns3qK59ClnLnQmF8i9B_Z

Copy ID

Reference Book

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

E6 Nursing Fundamentals Taylor p. 801-803