A client receiving IV fluids suddenly complains of chest pain and difficulty breathing. The nurse quickly assesses the client’s vital signs and observes decreased blood pressure and weak pulse. The nurse should suspect which complication of IV therapy?
A.
Infiltration
B.
Phlebitis
C.
Fluid overload
D.
Anaphylaxis
The Correct answer and Explanation is: The correct answer is D. Anaphylaxis.
Explanation:
Anaphylaxis is a severe, potentially life-threatening allergic reaction that can occur rapidly after exposure to an allergen, including IV medications, fluids, or other substances administered intravenously. It is a medical emergency requiring immediate intervention.
When a client receiving IV therapy suddenly complains of chest pain and difficulty breathing, with accompanying symptoms such as decreased blood pressure and a weak pulse, anaphylaxis is a likely complication. Anaphylaxis involves widespread vasodilation, increased capillary permeability, and bronchoconstriction. These processes lead to a sudden drop in blood pressure (hypotension) due to fluid leaking from the bloodstream into surrounding tissues, causing a weak pulse. The bronchoconstriction causes airway narrowing, leading to difficulty breathing and chest tightness.
Differential Diagnosis:
- Infiltration (Option A): Infiltration occurs when IV fluids leak into surrounding tissues rather than staying within the vein. It typically presents with localized symptoms like swelling, coolness, pallor, and discomfort at the IV site. It does not cause systemic symptoms such as chest pain, difficulty breathing, or hypotension.
- Phlebitis (Option B): Phlebitis is inflammation of the vein due to irritation from the IV catheter or infusate. It presents with localized pain, warmth, redness, and swelling along the vein. Like infiltration, it does not cause systemic symptoms like hypotension or respiratory distress.
- Fluid Overload (Option C): Fluid overload occurs when excessive IV fluids are infused too quickly, leading to symptoms like edema, increased blood pressure, and respiratory distress due to pulmonary edema. However, it does not typically cause the sudden onset of chest pain and hypotension.
Conclusion: Given the acute presentation of chest pain, difficulty breathing, decreased blood pressure, and weak pulse, the nurse should suspect anaphylaxis. Immediate interventions include stopping the IV infusion, maintaining the airway, administering epinephrine, oxygen, antihistamines, and corticosteroids as prescribed, and preparing for advanced life support if necessary. Early recognition and prompt treatment are crucial to prevent progression to anaphylactic shock and ensure the client’s survival.