What is possible complication if patient complain pain, redness, tenderness and warmth on IV site?

Appeared in: NORCET 1 - 2020

Explanation

Phlebitis is the inflammation of the inner layer of a vein.
The classic signs of this inflammation are pain, erythema (redness), warmth, and tenderness along the course of the vein, starting at the access site.
The patient's reported symptoms directly match the assessment findings for phlebitis.

Option A: Infiltration is characterized by coolness, pallor (paleness), and swelling. The patient's site is warm and red, which is inconsistent with infiltration.
Option C: Extravasation is the leakage of a vesicant (tissue-damaging) drug. While it causes pain and redness, its hallmark is severe tissue damage, such as blistering and necrosis, which are not mentioned in the question.
Option D: A hematoma is a collection of blood in the tissue, presenting as a bruise (ecchymosis) and swelling. It is not primarily an inflammatory condition and is not associated with warmth.

Visual 1: Comparison Chart - An infographic showing side-by-side images and symptoms of Phlebitis, Infiltration, and Extravasation to highlight the key visual differences (e.g., red/warm vs. pale/cool).

Clinical Relevance

Nursing practice connection: Use the key finding related to Identification of IV therapy complications based on clinical signs to guide bedside assessment, documentation, and the next nursing action.
Nurses must perform routine assessments of IV sites at least every 1-2 hours for adults to promptly identify and manage complications, preventing further patient harm.
Early detection and intervention for phlebitis can prevent more serious complications like thrombophlebitis (inflammation with a blood clot) and bloodstream infections.
What if? If the patient's IV site was cool, pale, and swollen, the correct complication would be Infiltration, and the immediate nursing action would be to stop the infusion, remove the catheter, and elevate the limb. A warm compress would not be the initial treatment; a cold compress might be used depending on the fluid.

How to Approach the Question

First, identify the key signs and symptoms presented in the question: pain, redness, tenderness, and warmth.
Recall the definitions and classic presentations of the common IV complications listed in the options.
Systematically compare the patient's symptoms to each option.
Infiltration is associated with coolness and pallor, so it can be eliminated.
Hematoma is a bruise, which doesn't fit the primary signs of warmth and redness.
Extravasation involves tissue-damaging drugs and more severe signs like blistering.

Concept Tested & Keywords

Concept Tested: Identification of IV therapy complications based on clinical signs.
Stem keywords: IV site, pain, redness, tenderness, warmth
Lead-in keywords: possible complication
Negative lead-in flag: false

QVFLXRhW-6en7AaLYMqsfA

Practise the full NORCET 1 - 2020

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