Irritation, swelling, warmth and redness at the intravenous infusion site is the sign of

Appeared in: AIIMS Raipur NO- 2019 (shift 3rd)

Explanation

The combination of irritation, swelling, warmth, and redness at an IV site are the cardinal signs of inflammation.
Thrombophlebitis is the inflammation of a vein (phlebitis) associated with the formation of a blood clot (thrombus).
These localized signs are characteristic of a superficial vein inflammation, which is a common complication of peripheral IV catheters.

Option A: Embolism is a systemic complication, not a localized one. It involves a clot traveling through the bloodstream, causing symptoms like shortness of breath or chest pain, not localized redness and warmth at the IV site.
Option C: Venous thrombosis is a broad term for a blood clot in a vein. While thrombophlebitis is a form of venous thrombosis, it is a less specific answer. The term often refers to Deep Vein Thrombosis (DVT), which presents differently (e.g., entire limb swelling) than the localized signs described.
Option D: Bacteraemia is a systemic infection (bacteria in the blood). It would cause systemic symptoms like fever, chills, and malaise, not just localized inflammation at the infusion site.

Clinical Relevance

Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Complications of Intravenous Therapy as background academic context rather than a clinical decision trigger.
Nurses must assess IV sites at least once per shift (or more frequently per policy) for signs of complications like thrombophlebitis.
Prompt identification and intervention (stopping the infusion, removing the catheter) are critical to prevent pain, further vein damage, and more serious complications like infection or embolism.
What if? If the patient reported pain but there was no redness or warmth, and the skin was cool and blanched, the complication would likely be infiltration (leakage of non-vesicant fluid into tissue), not thrombophlebitis. The intervention would still be to stop the infusion and remove the catheter, but a cold compress might be used initially instead of warm.

How to Approach the Question

First, identify the keywords in the question: 'irritation, swelling, warmth, redness' and 'intravenous infusion site'.
Recognize these as the classic signs of localized inflammation.
Evaluate the options based on whether they represent a local or systemic process.
Eliminate 'Embolism' and 'Bacteraemia' as they are systemic complications with different, non-localized symptoms.
Differentiate between 'Thrombophlebitis' and 'Venous thrombosis'. Note that 'Thrombophlebitis' is the most specific and accurate term for inflammation and clotting in a superficial vein at an IV site.
Select 'Thrombophlebitis' as the best fit for the clinical picture described.

Concept Tested & Keywords

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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 Raipur NO- 2019 (shift 3rd)

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