The nurse determines that a child's intravenous infusion has infiltrated. The infused solution is a vesicant. What is the most appropriate nursing action?
a. Stop the infusion and apply ice.
b. End the infusion and notify the practitioner.
c. Slow the infusion rate and notify the practitioner.
d. Discontinue the infusion and apply warm compresses.
ANS: B
A vesicant causes cellular damage when even minute amounts escape into the tissue. The intravenous infusion is immediately stopped, the extremity is elevated, the practitioner is notified, and the treatment protocol is initiated. The applying of heat or ice depends on the fluid that has extravasated. The catheter is left in place until it is no longer needed.
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