A client receiving an infusion of Dextrose 5% and water complains of a burning pain along the course of the vein. The site is red, warm, and is mildly edematous. Which term should the nurse use when documenting these findings?
1. Phlebitis at the IV insertion site
2. IV infiltrate
3. Extravasated vesicant drug
4. Extravasation
1
Rationale 1: Redness, warmth, edema, and pain that runs along the course of the vein characterize phlebitis.
Rationale 2: An infiltrate is defined as fluid entering the tissues, resulting in swelling, coolness, pallor, and discomfort at the site. This client's site is red and warm, not cool and pale, so it is not an infiltrate.
Rationale 3: Dextrose and water are not vesicants, and do not require immediate intervention.
Rationale 4: Extravasation includes a vesicant drug (one that causes blistering when in the tissues but not in the vascular system), so this is not an extravasation.
Global Rationale: Redness, warmth, edema, and pain that runs along the course of the vein characterize phlebitis. Dextrose and water are not vesicants, and do not require immediate intervention. An infiltrate is defined as fluid entering the tissues, resulting in swelling, coolness, pallor, and discomfort at the site. This client's site is red and warm, not cool and pale, so it is not an infiltrate. Extravasation includes a vesicant drug (one that causes blistering when in the tissues but not in the vascular system), so this is not an extravasation.
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