A patient has a peripheral IV. The nurse should assess the IV site for what primary signs and symptoms of infiltration? (Select all that apply.)
a. Redness
b. Swelling
c. Pallor
d. Warmth
e. Red streaks
B, C
An infiltration occurs when IV fluids leak into the subcutaneous tissue around the venipuncture site because the catheter tip no longer is in the vein. Infiltration causes swelling (from increased interstitial fluid), paleness, and coolness (from decreased circulation) around the venipuncture site. The IV infusion may slow or stop. Pain may occur, increasing as the infiltration progresses. Phlebitis is inflammation of a vein. Signs and symptoms include redness, tenderness, and warmth along the course of the vein starting at the access site, with possibly a red streak and/or palpable cord along the vein.
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