The nurse is caring for a client receiving IV medications. After infusing an IV antibiotic, the nurse assesses the IV site and finds it to be red and edematous, and the client is complaining of pain at the site
Which would the nurse document in the nursing notes regarding the infiltration?
Select all that apply.
1. Incident report
2. Health care provider notification and any orders received
3. Amount of fluid infused per shift on the intake and output record
4. Size and location of erythematous area
5. Actions taken to correct the problem
Correct Answer: 4,5
The size of the erythematous area should be measured, marked, and documented in the nursing notes for continuity of care. Actions taken, such as discontinuation of the IV, should also be documented in the nursing notes. The nurse would complete an incident report anytime an IV infiltrates; however, this should not be included in the nursing notes. Although the health care provider might be notified, orders received would be written on the health care provider order sheet and not documented in the nursing record. Intake from IV fluid would be documented on the intake and output record, not in the nursing notes.
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