During a clinical rotation at an orthopedic unit, a nursing student is caring for a 67-year-old patient who has undergone a knee replacement. The patient is complaining of pain at the IV site

Question

The nursing student assesses the site and finds that the site is cool and pale. The student stops the IV and reports the situation to the nurse. What does the nursing student suspect? a. Phlebitis
b. Infiltration
c. Thrombophlebitis
d. Local inflammation

Answer 1

B
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. Phlebitis can be dangerous because blood clots (thrombophlebitis) can form, increasing the risk for an embolus, a clot that becomes dislodged and can travel to the lungs. Lo-cal infection at the VAD site is possible. The insertion site will be red and/or edematous; exudate may occur.