What to Do When a Normal Saline Infusion Infiltrates

What initial action should the nurse take when a client's normal saline infusion has infiltrated and they complain of extreme arm pain?

• A. Notify the healthcare provider
• B. Measure the pulse volume and capillary refill distal to the infiltration
• C. Apply a warm compress to the area
• D. Assess the extent of infiltration

Answer: (B)

The most appropriate initial action in response to a normal saline infusion that has infiltrated and caused the client extreme arm pain is to measure the pulse volume and capillary refill distal to the infiltration. This step is crucial because it helps assess the circulation in the area affected by the infiltration. By measuring pulse volume and observing capillary refill time, the nurse can determine if there is adequate blood flow beyond the infiltrated site and assess for potential complications such as compartment syndrome or ischemia. Gathering this information is essential for making informed decisions about the next steps in care and intervention. Proper assessment ensures that the nurse can provide the healthcare provider with clear information on the condition of the limb, which is vital for any further treatment options that may be necessary. While notifying the healthcare provider, applying a warm compress, or assessing the extent of infiltration are important steps, they should follow the primary assessment of vascular status to ensure immediate safety and address any urgent issues regarding blood flow.

When it comes to managing intravenous access in patients, things occasionally take a turn for the worse. One such scenario involves the infiltration of a normal saline infusion. Imagine a patient suddenly complaining of extreme arm pain—what should you do first? It’s a situation that highlights the importance of swift, appropriate nursing assessment.

Now, the first action you should take in this case is to measure the pulse volume and capillary refill distal to the infiltration site. Why is this step critical? It’s all about assessing blood flow. You want to gauge whether there’s adequate circulation beyond the affected area. Could the patient be facing complications like compartment syndrome or ischemia? Better to identify those risks early than to react later.

But what does measuring pulse volume and capillary refill mean in practice? It involves physically examining the limb and checking both the strength of the pulse and how quickly color returns to the skin after blanching. If those capillaries aren't refilling quickly, you might have a more serious issue on your hands.

After ensuring that blood flow remains stable, it's perfectly reasonable to consider the next steps. Notifying the healthcare provider is certainly a priority, as they need to know about the patient's condition and any urgent interventions. Applying a warm compress sounds like a cozy solution, but it’s not your first step—think of it as something you might do afterward to soothe discomfort. Finally, while assessing the extent of infiltration is valuable, that can come after you’ve established whether there’s proper circulation.

So, remember this crucial sequence: assess vascular status first, then move on to other interventions. It’s all about making informed decisions to ensure your patient's safety and well-being, especially when things go sideways. In nursing, being proactive is necessary, but knowing where to focus your efforts initially can make all the difference.