During IV therapy, infiltration is observed at the vascular access device. Which action should the nurse take first?

During IV therapy, infiltration is observed at the vascular access device. Which action should the nurse take first?

• A. Reduce the infusion rate and elevate the affected extremity.
• B. Stop the infusion and remove the intravenous catheter.
• C. Stop the infusion and reposition the intravenous catheter into the vein.
• D. Reduce the infusion rate and apply a warm compress to the site.

Answer: (B)

When IV infiltration occurs, the fluid is leaking into surrounding tissue, which can cause swelling, pain, and tissue damage if the flow continues. The most important first step is to stop the source of leakage, so the IV infusion should be halted and the catheter removed. This immediately prevents any more fluid from filling the tissue and gives you a safe site to assess for extent of infiltration and potential tissue injury. After the catheter is removed, you can evaluate the area, apply appropriate care (such as pressure to control bleeding and dressing), and start a new IV at a different site if continued therapy is needed. Repositioning the same catheter or simply reducing the rate could allow ongoing leakage or fail to address tissue injury, and warming or cooling the site is determined after the initial stop/removal and site assessment.

When IV infiltration occurs, the fluid is leaking into surrounding tissue, which can cause swelling, pain, and tissue damage if the flow continues. The most important first step is to stop the source of leakage, so the IV infusion should be halted and the catheter removed. This immediately prevents any more fluid from filling the tissue and gives you a safe site to assess for extent of infiltration and potential tissue injury. After the catheter is removed, you can evaluate the area, apply appropriate care (such as pressure to control bleeding and dressing), and start a new IV at a different site if continued therapy is needed. Repositioning the same catheter or simply reducing the rate could allow ongoing leakage or fail to address tissue injury, and warming or cooling the site is determined after the initial stop/removal and site assessment.