Mr. Santhosh is receiving 5% Dextrose in Water at the rate of 100 ml/hour. One hour after the infusion starts, he reports pain at the infusion site. On examination, the site is cool to touch and swollen. The infusion rate becomes sluggish. What might be happening for the patient?

1. A

   Phlebitis

2. B

   Extravasation

3. C

   Allergic reaction

4. D

   Backflow

Appeared in: RUHS, Jaipur, PB B.Sc Nursing Entrance-2019

Explanation

• The patient's symptoms (coolness, swelling, pain, sluggish flow) are the hallmark signs of IV fluid leaking from the vein into the surrounding subcutaneous tissue.
• This complication is known as infiltration or extravasation. While infiltration technically refers to non-vesicant fluids (like D5W) and extravasation to vesicant (tissue-damaging) fluids, the terms are often used interchangeably for the initial signs of leakage.
• Coolness at the site occurs because the IV fluid is infused at room temperature, which is lower than the body's temperature.
• Swelling (edema) is caused by the accumulation of fluid in the interstitial space.
• The infusion becomes sluggish or stops because the increased pressure in the interstitial tissue resists further entry of fluid.

Why Other Options Were Wrong

• Option A: Phlebitis is the inflammation of a vein, which is characterized by warmth, redness, and tenderness along the vein, not coolness and pallor.
• Option C: An allergic reaction is a systemic response and would typically present with symptoms like itching, hives (urticaria), rash, or respiratory distress (wheezing), not localized coolness and swelling at the IV site.
• Option D: Backflow is the presence of blood in the IV tubing. It occurs when venous pressure exceeds the infusion pressure (e.g., the IV bag is too low). It does not cause tissue swelling, coolness, or pain.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Complications of Intravenous (IV) Therapy in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• Prompt identification and management of IV infiltration/extravasation are crucial nursing responsibilities to prevent patient discomfort, significant tissue damage, and the loss of IV access.
• Nurses should assess IV sites at least hourly for continuous infusions, looking for these specific signs of complications.
• What if? - If the patient's IV site was reported as warm, red, and tender to the touch, the correct answer would be Phlebitis. The intervention would be to stop the infusion, remove the cannula, and apply warm compresses to the site.

How to Approach the Question

• First, identify the question type. This is a clinical scenario question requiring you to interpret patient signs and symptoms to identify a complication.
• Carefully read the clinical data provided: The patient has pain, the site is cool and swollen, and the infusion is sluggish.
• Systematically analyze each option against the presented symptoms.
• Evaluate Phlebitis: Does it cause coolness? No, it causes warmth. Eliminate this option.
• Evaluate Allergic Reaction: Are the symptoms systemic (like a rash or wheezing)? No, they are localized. Eliminate this option.
• Evaluate Backflow: Does it cause swelling and coolness? No, it's just blood in the tubing. Eliminate this option.

Concept Tested & Keywords

• Concept Tested: Complications of Intravenous (IV) Therapy
• Stem keywords: 5% Dextrose in Water, IV infusion, pain at the infusion site, cool to touch, swollen, sluggish
• Lead-in keywords: What might be happening
• Clinical cues: The combination of coolness, swelling, and pain is a classic triad for IV infiltration/extravasation.

Question ID

QoCuMb2LNKACzph4ObcRj3

Copy ID

Reference Book

E6 Nursing Fundamentals Taylor p. 801-803

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