A nurse assesses the insertion site of a peripheral I.V. catheter and notes that the site is red, warm to touch, and slightly edematous proximal to the I.V. cannula. The client reports discomfort when the site is touched. The nurse should interpret that these signs are most likely due to:

Question

Quizplus · Accepted Answer

The redness, warmth, and edema around the insertion site along with discomfort when touched are all classic signs of phlebitis, which is an inflammation of the vein. This can occur as a result of irritation from the catheter, chemical irritation from the I.V. solution, or from mechanical trauma to the vein during insertion. Venous spasm would not cause these symptoms, and hypersensitivity would present with different symptoms such as itching or a rash. Infiltration would present with swelling and coolness around the insertion site rather than warmth.

A Nurse Assesses the Insertion Site of a Peripheral I