A nurse is caring for a client receiving a continuous fluid therapy infusion. During the hourly assessment, the nurse notices the area around the insertion site is swollen, cool, and pale. What is the most appropriate nursing intervention?
Reinforce the dressing around the site and monitor for further changes in the area.
Increase the flow rate and place a pressure dressing to reduce swelling around the insertion point.
Apply a warm compress to the affected area and allow the infusion to continue.
Pause the infusion, remove the catheter, elevate the affected limb, and re-establish access at a different site.
The symptoms described—swelling, coolness, and pallor around the insertion site—are classic indications of infiltration, which occurs when the infused solution leaks into surrounding tissues. The correct intervention is to pause the fluid therapy to prevent further leakage and remove the catheter from the site. Elevating the affected limb helps reduce swelling, and notifying the health care provider is essential for further evaluation or treatment. Restarting the therapy at an alternative location ensures the continuation of necessary care. Applying heat is contraindicated in infiltration because it can increase the risk of tissue damage. Tight bandages or increasing the rate of infusion would worsen complications and should be avoided.
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