Question

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration?

1) Redness and warmth at the site
2) Coolness and pallor at the site
3) Pain and tenderness at the site
4) Swelling and leakage of fluid at the site

Answer 1

Signs of infiltration at the IV site include coolness, pallor, swelling, and leakage of fluid. These signs are different from the signs of inflammation like redness, warmth, and pain which indicate an infection.

Step-by-step explanation:

A nurse caring for a client who is receiving fluid through a peripheral IV catheter should identify signs of infiltration at the IV site. Infiltration occurs when IV fluid leaks into the surrounding tissue. The nurse should look for symptoms that include coolness and pallor at the IV site, as well as swelling and leakage of fluid, which are indicative of infiltration. These are contrasted with symptoms of inflammation such as redness, warmth, and pain that would suggest a local infection or irritation rather than infiltration.

It is critical that the nurse distinguishes between the signs of infiltration and infection as they require different interventions. In the scenario described, options 2 (Coolness and pallor at the site) and 4 (Swelling and leakage of fluid at the site) would indicate infiltration of the IV catheter, requiring immediate attention to prevent tissue damage.