A nurse is performing a routine assessment of an IV site in a patient receiving both IV fluids and medications through the line. Which of the following would indicate the need for discontinuation of the IV line as the next nursing action?
A. The patient complains of pain from movement.
B. The area proximal to the insertion site is reddened, warm, and painful.
C. The IV solution is infusing too slowly, particularly when the limb is elevated.
D. A hematoma is visible in the area of the IV insertion site.
Correct Answer: B. The area proximal to the insertion site is reddened, warm, and painful.
An IV site that is red, warm, painful and swollen indicates that phlebitis has developed and the line should be discontinued and restarted at another site. Phlebitis is inflammation of a vein. It is usually associated with acidic or alkaline solutions or solutions that have a high osmolarity. Phlebitis can also occur as a result of vein trauma during insertion, use of an inappropriate I.V. catheter size for the vein, or prolonged use of the same I.V. site.
Option A: Pain on movement should be managed by maneuvers such as splinting the limb with an IV board or gently shifting the position of the catheter before making a decision to remove the line. Apply warm, moist compresses to the area. Document the patient’s condition and interventions.
Option C: An IV line that is running slowly may simply need flushing or repositioning. Monitor administration rates and inspect the I.V. site frequently. Change the infusion site according to the facility’s policy.
Option D: A hematoma at the site is likely a result of minor bleeding at the time of insertion and does not require discontinuation of the line. Avoid veins that are small and/or fragile, veins in areas of flexion, veins in extremities with preexisting edema, or veins in areas with known neurologic impairment.