A practical nurse is caring for a client receiving continuous peripheral intravenous (IV) fluids. During data collection, the nurse observes that the IV insertion site is swollen, cool to the touch, and pale. Arrange the following nursing actions in the correct sequence to manage this finding. All options must be used.
- 1Stop the continuous intravenous fluid infusion.
- 2Remove the peripheral intravenous catheter.
- 3Elevate the affected extremity.
- 4Apply a compress to the site based on facility policy.
- 5Document the assessment findings and interventions.
Answer
The correct sequence is to first stop the infusion, then remove the catheter, elevate the extremity, apply a compress, and finally document the event.
When an IV infiltration occurs, the immediate priority is to stop the flow of fluid into the subcutaneous tissue to prevent further edema and damage. Next, the catheter must be removed as it is no longer safely positioned in the vein. Following removal, elevating the extremity and applying a compress will help reduce swelling and discomfort. Finally, the nurse must document the incident, the interventions performed, and the client's response. This sequence ensures risk reduction and client safety.
Step-by-Step Solution
Key Concept
Management of Intravenous Infiltration