The nurse assesses the client's peripheral intravenous site and notes that it is cool, pale, swollen and not infusing. The nurse should document in the client's record that which of the following has probably occurred?

1. A

   Phlebitis

2. B

   Infection

3. C

   Infiltration

4. D

   Thrombosis

Appeared in: DHS Staff Nurse - 2018 (Shift-2nd)

Explanation

• The combination of a cool, pale, and swollen intravenous site where the infusion has stopped are the hallmark signs of infiltration.
• Infiltration occurs when the IV cannula dislodges from the vein, causing non-vesicant IV fluid to leak into the surrounding subcutaneous tissue.
• The site feels cool because the IV fluid is at room temperature, which is lower than body temperature.
• Swelling (edema) and pallor (paleness) result from the fluid accumulation in the tissue, which increases tissue pressure and can slow or stop the infusion.

Why Other Options Were Wrong

• Option A: Phlebitis is vein inflammation, presenting with warmth, redness (erythema), and a palpable venous cord, which are opposite to the cool and pale site described.
• Option B: An infection would cause signs of inflammation like warmth, redness, and possibly purulent drainage, not coolness and pallor.
• Option D: Thrombosis is a blood clot, which would stop the infusion and may cause tenderness and swelling, but it does not typically cause the site to become cool and pale.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Assessment and identification of peripheral intravenous (IV) therapy complications to guide bedside assessment, documentation, and the next nursing action.
• Prompt recognition of IV infiltration is a critical nursing skill to prevent further tissue damage, such as compartment syndrome, and ensure the patient receives the prescribed therapy.
• Nursing intervention includes immediately stopping the infusion, removing the catheter, elevating the limb to promote fluid reabsorption, and applying either warm or cold compresses based on the type of fluid infiltrated.
• What if? If the infiltrated fluid was a vesicant (e.g., chemotherapy drug like vincristine), the complication would be extravasation, a much more severe event causing tissue necrosis. The immediate nursing action would involve notifying the physician and administering a specific antidote, not just applying compresses.

How to Approach the Question

• First, identify the key assessment findings provided in the clinical scenario: the IV site is cool, pale, swollen, and the infusion has stopped.
• Next, systematically evaluate each option against this set of findings.
• Recall the classic signs of phlebitis (warmth, redness) and infection (warmth, redness, pus). Note that these contradict the 'cool' and 'pale' findings in the question.
• Recall the signs of thrombosis (occlusion, tenderness), which don't fully align with all the given signs.
• Recognize that the triad of coolness, pallor, and swelling is the textbook presentation of IV infiltration, where fluid leaks into the surrounding tissue.
• Select the option that perfectly matches the clinical picture described.

Concept Tested & Keywords

• Concept Tested: Assessment and identification of peripheral intravenous (IV) therapy complications.
• Stem keywords: peripheral intravenous site, cool, pale, swollen, not infusing
• Lead-in keywords: document, probably occurred
• Clinical cues: cool, pale, swollen site: classic triad for IV infiltration

Question ID

QKb38mjT47Gz1Qniz2IyCc

Copy ID

Reference Book

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

E6 Nursing Fundamentals Taylor p. 801-803