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

Appeared in: PGIMER Sangrur NO - 2023

Explanation

IV infiltration is the leakage of non-vesicant IV fluid into the surrounding subcutaneous tissue.
The accumulation of room-temperature fluid makes the site feel cool to the touch compared to body temperature.
The fluid collection causes swelling (edema) and a pale or blanched appearance due to decreased circulation.
Stretching of the tissue by the fluid leads to pain, tenderness, or a burning sensation at the site.

Option A: A slowed infusion rate is a non-specific finding. While it can occur with infiltration, it is also commonly caused by mechanical issues like kinked tubing, a clogged filter, or the patient's position affecting the line.
Option B: Redness, heat, and swelling are the hallmark signs of phlebitis, which is inflammation of the vein. This is a different complication from infiltration.
Option C: A rise in body temperature (fever) is a systemic sign, indicating a body-wide issue such as an infection (sepsis) or a pyrogenic reaction. Infiltration is a localized complication.

Clinical Relevance

Nursing practice connection: Use the key finding related to Assessment of IV Complications (Infiltration) to guide bedside assessment, documentation, and the next nursing action.
Nurses must perform regular checks of IV sites (at least hourly for continuous infusions) to promptly detect complications like infiltration and phlebitis, preventing further tissue damage.
Early detection and intervention for infiltration are crucial to prevent complications such as pain, nerve damage, and compartment syndrome in severe cases.
What if? If the infiltrated fluid was a vesicant (a drug that damages tissue), such as chemotherapy, the complication would be called extravasation. This is a medical emergency requiring immediate, specific interventions, often including an antidote, to prevent severe tissue necrosis.

How to Approach the Question

Identify the core clinical question: The question asks for the specific signs of IV infiltration.
Analyze each option as a potential assessment finding.
Differentiate between local site complications and systemic complications. A fever (Option C) is systemic, making it less likely to be the primary sign of a local site issue.
Compare the remaining local signs. Redness and heat (Option B) are classic signs of inflammation (phlebitis). Pallor and coolness (Option D) are signs of fluid leaking into the tissue.
Evaluate the specificity of the finding. A slow infusion rate (Option A) is non-specific and can have many causes.
Select the option that describes the classic, textbook signs of IV infiltration.

Concept Tested & Keywords

Qas2aznyvOVpPRDaBVcZSO

E6 Nursing Fundamentals Taylor p. 801-803

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

Practise the full PGIMER Sangrur NO - 2023

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