A nurse is caring for a client who has a peripheral IV infusion and notes that the client’s arm is edematous, cool, and tender at the catheter insertion site. Which of the following complications of IV therapy should the nurse suspect?
A.
Nerve damage
B.
Infection
C.
Infiltration
D.
Phlebitis
The Correct answer and Explanation is:
The correct answer is C. Infiltration.
Infiltration is a common complication of IV therapy, where the IV fluid or medication unintentionally leaks into the surrounding tissue instead of being delivered into the vein. This typically occurs when the catheter slips out of the vein or when the vein’s wall is damaged, allowing the IV fluid to seep into the surrounding tissues.
Signs and Symptoms of Infiltration:
- Edema (Swelling): The most apparent sign of infiltration is swelling at or around the IV site. This happens because the fluid accumulates in the tissue rather than staying within the vein.
- Coolness: The infiltrated area often feels cool to the touch due to the infusion of the IV fluid into the surrounding tissues. This is especially noticeable if the fluid being infused is colder than the body temperature.
- Tenderness or Pain: The client may report discomfort or tenderness around the IV site. The infiltration of fluid into the tissue can cause pain due to increased pressure and irritation of the surrounding nerves.
- Blanching or Pallor: The skin around the insertion site may appear pale or blanched, reflecting the accumulation of fluid under the skin and reduced blood flow in the area.
Nursing Actions:
Upon recognizing signs of infiltration, the nurse should take immediate action to prevent further tissue damage and complications:
- Stop the Infusion: The first step is to stop the IV infusion to prevent more fluid from leaking into the surrounding tissue.
- Remove the IV Catheter: Carefully remove the catheter to prevent any further leakage.
- Elevate the Affected Limb: Elevating the affected arm can help reduce swelling and promote the reabsorption of the infiltrated fluid.
- Apply a Warm or Cold Compress: Depending on the type of fluid infiltrated, a warm or cold compress may be applied to alleviate pain and reduce swelling. Warm compresses are generally preferred as they promote vasodilation and absorption.
- Assess the Extent of Infiltration: The nurse should assess the extent of the infiltration and document findings. If the infiltration is severe, additional medical treatment may be necessary.
- Restart the IV in a Different Site: If the client still requires IV therapy, the nurse should select a new IV site, preferably on a different limb, to continue treatment.
Differentiation from Other Complications:
- Nerve Damage: This is characterized by shooting pain or tingling along the nerve path, but not typically by swelling or coolness at the IV site.
- Infection: Infection at the IV site usually presents with warmth, redness, and possibly purulent drainage, not coolness.
- Phlebitis: This involves inflammation of the vein and is marked by warmth, redness, and pain along the vein, but not the coolness or widespread edema seen with infiltration.
Early detection and intervention are crucial to minimizing the adverse effects of infiltration and ensuring patient safety.