Which of the following would be a common indication of infiltration of a peripheral intravenous infusion?

Appeared in: GMCH Chandigarh - 2019

Explanation

Infiltration is the leakage of IV fluid into the surrounding subcutaneous tissue.
The fluid is typically at room temperature, which is cooler than body temperature, causing the skin at the site to feel cool to the touch.
The accumulation of this fluid in the tissue leads to localized swelling (edema) and tautness of the skin.
While redness is more typical of phlebitis, the combination of cool skin and swelling are the hallmark signs of infiltration.

Option B: A blood return in the cannula indicates that the catheter tip is correctly placed within the vein, which is the opposite of infiltration.
Option C: This is a non-specific sign. While infiltration can cause the flow to slow or stop due to increased tissue pressure, this can also be caused by many other issues like a kinked tubing, a positional catheter, or the flow clamp being incorrectly adjusted.
Option D: Hot and warm skin indicates inflammation. This is a classic sign of phlebitis (inflammation of the vein) or a localized infection, not infiltration.

Clinical Relevance

Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Signs and symptoms of peripheral IV infiltration as background academic context rather than a clinical decision trigger.
Early recognition of IV infiltration is a critical nursing responsibility to prevent further complications, such as significant tissue damage, pain, and nerve compression.
Nurses must perform and document regular assessments of all peripheral IV sites, typically every 1-2 hours for adults, checking for coolness, swelling, pain, and patency.
What if the infiltrated fluid was a vesicant drug like dopamine or chemotherapy? This would be classified as extravasation, a more serious event requiring immediate, specific interventions (like administering an antidote) to prevent severe tissue necrosis. The IV catheter might be left in place temporarily to administer the antidote.

How to Approach the Question

First, identify the core concept of the question, which is 'infiltration' of a peripheral IV.
Recall the pathophysiology of infiltration: non-vesicant fluid leaking from the vein into the surrounding tissue.
Consider the properties of the fluid (room temperature) and the effect of its accumulation (swelling). This leads to the classic signs of coolness and edema.
Evaluate each option against these classic signs.
Eliminate options that describe the opposite condition (e.g., warmth for phlebitis) or a sign of correct placement (blood return).
Select the option that includes the most definitive signs of infiltration.

Concept Tested & Keywords

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E6 Nursing Fundamentals Taylor p. 801-803

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

Practise the full GMCH Chandigarh - 2019

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