When a patient develops thrombophlebitis from an intravenous infusion, which of the following initial symptoms should the CHO/Nurse look for?

1. A

   Mottling and Coolness

2. B

   Erythema, Pain, and Heat

3. C

   Leakage fluid and numbness

4. D

   Pallor and swelling

Appeared in: MP CHO -2021 (Shift 1st)

Explanation

• Thrombophlebitis is a combination of vein inflammation (phlebitis) and blood clot formation (thrombus).
• The body's response to this condition involves the classic signs of inflammation.
• These signs include redness (erythema), localized warmth (heat), and pain or tenderness along the vein.
• A palpable cord-like vein may also be felt upon assessment.

Why Other Options Were Wrong

• Option A: Mottling and coolness are characteristic signs of IV infiltration, not phlebitis. The coolness is due to the room-temperature IV fluid leaking into the subcutaneous tissue.
• Option C: Leakage of fluid is a direct sign of infiltration, where the catheter is no longer in the vein. Numbness can result from nerve compression due to severe swelling from infiltration.
• Option D: Pallor (paleness) and swelling are hallmark signs of infiltration. The tissue swells with IV fluid and appears blanched or pale.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Signs and symptoms of IV therapy complications: Thrombophlebitis to guide bedside assessment, documentation, and the next nursing action.
• Early recognition and management of thrombophlebitis are critical nursing responsibilities to prevent more serious complications, such as deep vein thrombosis (DVT), embolism, or bloodstream infection.
• The nurse's first action upon suspecting phlebitis is to stop the infusion and remove the catheter to prevent further irritation and damage to the vein.
• What if? If the patient also developed a fever and purulent drainage at the site, the nurse should suspect an IV-related infection. The priority would be to notify the healthcare provider, remove the catheter, and prepare to send the catheter tip for culture to guide antibiotic therapy.

How to Approach the Question

• First, identify the key term in the question: 'thrombophlebitis'.
• Break down the medical term: 'thrombo-' refers to a clot, 'phleb-' refers to a vein, and '-itis' means inflammation.
• Combine the parts: Thrombophlebitis is inflammation of a vein with a clot.
• Recall the cardinal signs of inflammation: redness, heat, swelling, and pain.
• Scan the options to find the one that best matches the signs of inflammation.
• Option B, 'Erythema (redness), Pain, and Heat,' directly corresponds to the classic inflammatory response, making it the correct answer.

Concept Tested & Keywords

• Concept Tested: Signs and symptoms of IV therapy complications: Thrombophlebitis
• Stem keywords: thrombophlebitis, intravenous infusion, initial symptoms
• Lead-in keywords: which of the following
• Negative lead-in flag: false

Question ID

Qh-CTLT7jdtZbpUHXIca-q

Copy ID

Reference Book

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

E6 Nursing Fundamentals Taylor p. 801-803