Problem
Mrs. Beatty is a 40 year old client, 51 tall, 300 lbs. She underwent emergency abdominal surgery for lysis of adhesions. You are assigned to care for the patient on her first postoperative day. As she begins her evaluation, she notes that she has a nasogastric tube that is draining a colored return of bile. Her IV is D5% in 0.45NS infused at 125 mL/h. The track is connected to a pump. When looking at the IV site, you find it difficult to determine if the site is edematous or just normal in appearance. It seems that the area around it is cooler to the touch than the rest of the arm. Mrs. Beatty claims that the area of the track is sore. A gauze bandage is placed directly over the IV site, making it difficult to visualize.
i. What is your priority action in this situation?
ii. After completing the first priority, what is your second priority?
iii. As you assess the site of the line, what would you look for if you suspect phlebitis or infiltration? With the initial information provided in the scenario, which of these are the possible complications? Justify your answer
iv. How will you check the IV to determine if the client has an infiltration?
v. Indicate your priority intervention if you determine that the client has an infiltrated intravenous line.
vi. Indicate your priority intervention if you determine that the client has early signs of phlebitis.