Dealing with infiltration

Nursing, Jun 1997 by Barbone, Marijane

A COMMON COMPLICATION OF I.V. therapy, infiltration occurs when an I.V. needle or catheter becomes dislodged or the vein wall is disrupted. Nonvesicant I.V. fluid then leaks into the tissue surrounding the insertion site. (When a vesicant leaks into tissue, extravasation occurs.) Watch for signs

Fluid leaking from an I.V. needle or catheter into the tissue can lead to tissue damage and other serious problems (such as nerve damage), so closely monitor your patient's I.V. site for telltale signs. Here's what to watch for:

swelling around the I.V. site. As fluid accumulates, tissue around the site swells.

blanching and cooling of skin. The infusing fluid pooling in the tissue is cooler than body temperature. This cools the skin and causes it to lighten in color.

slowed infusion rate. When accumulated fluid creates pressure on the catheter (which inhibits fluid from infusing quickly) or the tissue reaches its saturation point, the flow rate slows down and may stop. Confirm infiltration

If a patient shows any of these signs, assess for infiltration. First, palpate the site to confirm swelling. Then, palpate the area above the catheter tip and rapidly flush the line with 0.9% sodium chloride. (Stop flushing if you meet resistance-the line may be occluded). If fluid is infiltrating, you'll feel bubbling under the skin.

Don't try to check for a blood return to assess for an infiltration-this is an unreliable test. Failing to obtain blood return doesn't necessarily indicate infiltration. A narrow vein lumen or low blood pressure can also inhibit blood return.

Likewise, obtaining a blood return doesn't necessarily rule out infiltration. The stylet may have nicked the vein wall, causing infiltration as well as adequate blood return.

Take action

Once you've confirmed infiltration, perform these nursing interventions: Remove the needle or catheter immediately.

Assess for complications, such as limited range of motion and limb numbness.

Notify the physician. Monitor the site closely. Document the time of the infiltration, the estimated amount of fluid that infiltrated, and a description of the I.V. site.

Avoid applying a warm compress to the I.V. site. Increased circulation may facilitate fluid or medication absorption into the tissue, resulting in more damage.

BY MARIJANE BARBONE, RN Infusion Therapy Educator Perivascular Nurse Consultants, Inc. Rockledge, Pa.