A patient who is receiving IV fluids notifies the nurse that his arm feels tight. Upon assessment, the nurse notes that the arm is swollen and cool to the touch. What should the nurse's first action be?
a. Discontinue the IV site, and apply a warm compress.
b. Attached a syringe, and pull back on the plunger to aspirate the IV fluid.
c. Start a new IV site distal from the site.
d. Stop the IV fluids, and notify the physician immediately.
A
An IV site that is puffy, swollen, and cool to the touch indicates infiltration. The IV site should be discontinued immediately because it is no longer a viable access point. Pulling back on the syringe will not result in fluid return because there is no longer venous access. A new IV should be started in the opposite arm after the old IV has been removed. The IV should be removed; it is not sufficient to only stop the fluids.
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