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Techniques of Peripheral and Central Vascular Access
Techniques of Peripheral and Central Vascular Access ( 5 Questions)
A nurse is caring for a client who has a peripheral venous access in the cephalic vein. The nurse notices that the site is red, warm, and tender to touch. The nurse should suspect that the client has developed:
Infiltration. This is when the IV fluid leaks into the surrounding tissue, causing swelling, coolness, and pallor. This does not match the symptoms of redness, warmth, and tenderness.
Extravasation. This is when the IV fluid is a vesicant, meaning it can cause tissue damage or necrosis if it leaks into the surrounding tissue. This can cause pain, burning, blistering, or skin sloughing. This does not match the symptoms of redness, warmth, and tenderness.
Phlebitis. This is when the vein becomes inflamed due to mechanical, chemical, or bacterial irritation. This can cause redness, warmth, tenderness, and a palpable cord along the vein. This matches the symptoms of the client.
Thrombophlebitis. This is when a blood clot forms in the vein, causing inflammation and obstruction. This can cause pain, swelling, redness, warmth, and a palpable cord along the vein. However, this is more likely to occur in larger veins such as the femoral or saphenous veins, not in the cephalic vein.
Choice A reason: Infiltration. This is when the IV fluid leaks into the surrounding tissue, causing swelling, coolness, and pallor. This does not match the symptoms of redness, warmth, and tenderness.
Choice B reason:
Extravasation. This is when the IV fluid is a vesicant, meaning it can cause tissue damage or necrosis if it leaks into the surrounding tissue. This can cause pain, burning, blistering, or skin sloughing. This does not match the symptoms of redness, warmth, and tenderness.
Choice C reason:
Phlebitis. This is when the vein becomes inflamed due to mechanical, chemical, or bacterial irritation. This can cause redness, warmth, tenderness, and a palpable cord along the vein. This matches the symptoms of the client.
Choice D reason:
Thrombophlebitis. This is when a blood clot forms in the vein, causing inflammation and obstruction. This can cause pain, swelling, redness, warmth, and a palpable cord along the vein. However, this is more likely to occur in larger veins such as the femoral or saphenous veins, not in the cephalic vein.