Which assessment finding would lead the nurse to suspect that a patient's IV has infiltrated?

AIIMS Bhatinda NO - 2019

Medical & Surgical Nursing

Easy

Appeared in: AIIMS Bhatinda NO - 2019

Explanation

The classic signs of IV infiltration are a pale, cool, swollen, and painful site.
This occurs because room-temperature IV fluid leaks from the vein into the surrounding subcutaneous tissue.
The coolness is due to the fluid being cooler than body temperature.
The paleness (pallor) and swelling (edema) are caused by the accumulation of fluid in the tissue, which can also compress local blood vessels.
Pain results from the pressure of the fluid on nerve endings in the tissue.

Option A: A slow infusion rate is a non-specific finding. While it can be a sign of infiltration due to increased tissue pressure, it can also be caused by many other factors, such as kinked tubing, a positional catheter, or the clamp being set too low.
Option B: A red, hot, and swollen insertion site are the classic signs of phlebitis, which is the inflammation of the vein. The redness (erythema) and warmth are due to the inflammatory response.
Option C: A rise in temperature (fever) is a systemic sign of infection. While a localized IV site can become infected (presenting with redness, warmth, and purulent drainage), fever indicates a more widespread reaction, not simple infiltration.

Clinical Relevance

Nursing practice connection: Use the key finding related to Assessment of Intravenous (IV) Therapy Complications to guide bedside assessment, documentation, and the next nursing action.
Nurses must perform regular (at least hourly) assessments of IV sites to ensure patency and quickly identify complications.
Early detection of infiltration prevents further fluid accumulation, patient discomfort, and potential complications like tissue damage or compartment syndrome.
What if? If the infiltrated fluid was a vesicant (a drug that can cause tissue damage), such as chemotherapy or vancomycin, the complication is called extravasation. This is a medical emergency requiring immediate, specific interventions beyond those for simple infiltration, including stopping the infusion, attempting to aspirate the drug, and administering a specific antidote to prevent severe tissue necrosis.

How to Approach the Question

First, identify the key concept in the question: the specific assessment findings for IV infiltration.
Recall the definitions of common IV complications: infiltration (fluid in tissue), phlebitis (vein inflammation), and infection (pathogen presence).
Analyze the pathophysiology of infiltration: room-temperature fluid leaking into the surrounding tissue. This logically leads to coolness, paleness, and swelling.
Evaluate each option against this understanding.
Option B (red, hot) points to inflammation (phlebitis).
Option C (fever) points to a systemic infection.

Concept Tested & Keywords

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