Patient complains of pain and has redness with swelling at the site of IV. The nurse must

ESIC Nursing Officer - 2019 (Shift-2)

Medical & Surgical Nursing

Medium

Appeared in: ESIC Nursing Officer - 2019 (Shift-2)

Explanation

The patient's signs (pain, redness, swelling) are classic indicators of phlebitis, which is inflammation of the vein.
The immediate priority in managing phlebitis is to remove the source of irritation to prevent further venous damage and complications like thrombophlebitis.
Stopping the infusion and removing the cannula is the definitive first step, directly addressing the cause of the inflammation.

Option B: Applying a warm pack is a therapeutic measure for phlebitis, but it is not the first and most critical action. The source of the irritation must be removed first.
Option C: The patient's symptoms are localized to the IV site and do not indicate any respiratory compromise or hypoxia. Administering oxygen is not indicated.
Option D: This action fails to address the root problem, which is the inflammation of the vein at the insertion site. A new site must be chosen.

Visual 1: Image - A clear photograph showing an arm with an IV site exhibiting redness, swelling, and streaking characteristic of phlebitis.
Visual 2: Comparison Chart - A table visually comparing the signs, symptoms, and immediate nursing interventions for Phlebitis, Infiltration, and Extravasation.

Clinical Relevance

Nursing practice connection: Use the key finding related to Management of Intravenous (IV) Complications to guide bedside assessment, documentation, and the next nursing action.
Nurses must perform routine assessments of IV sites (typically every 1-2 hours for adults) to detect complications early. This includes checking for pain, redness, swelling, and coolness, and ensuring the dressing is clean, dry, and intact.
Early detection and management of phlebitis are crucial to prevent more severe complications such as thrombophlebitis (inflammation with a blood clot), infection, and sepsis.
What if the IV site was cool, pale, and swollen without redness? This would indicate infiltration. The priority action is still to stop the infusion and remove the cannula, but subsequent care would involve elevating the limb and applying either a warm or cold compress depending on the specific fluid that infiltrated.

How to Approach the Question

First, analyze the clinical signs presented in the question: pain, redness, and swelling at an IV site.
Recognize this classic triad as the signs and symptoms of phlebitis.
Recall the nursing protocol for managing phlebitis. The core principle is to remove the cause of the inflammation.
Evaluate the options based on priority. The action that removes the cause (the cannula and infusate) must be performed before any symptom-relief measures.
Select the option that represents the immediate, priority action, which is stopping the infusion and removing the cannula.

Concept Tested & Keywords

Concept Tested: Management of Intravenous (IV) Complications
Stem keywords: pain, redness, swelling, site of IV
Lead-in keywords: must
Clinical cues: The combination of pain, redness, and swelling at an IV site is a classic triad for phlebitis.

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