A nurse is collecting data from a client who is receiving continuous IV fluids in their left forearm. Which of the following findings should the nurse identify as an indication of infiltration at the IV infusion site? (Select all that apply.)

A. "I think you should find other family members who could help your mother." While involving other family members can be helpful, this response may come across as dismissive rather than supportive. The nurse should offer specific resources or interventions to assist with caregiver burden.
B. "Let me give you some information about respite care for your mother." Respite care provides temporary relief for caregivers by allowing trained professionals to care for the client. This helps reduce caregiver stress, prevents burnout, and allows the son to rest while ensuring his mother receives appropriate care.
C. "You should think about placing your mother in a long-term care facility." Suggesting placement in a facility without first assessing the son’s willingness or ability to continue caregiving may be inappropriate. The nurse should offer less drastic options, such as respite care, before discussing long-term placement.
D. "You owe it to your mother to take care of her now that she needs you." This statement could induce guilt and increase stress for the caregiver. The nurse should provide emotional support and resources rather than making the son feel obligated to provide care without assistance.

Anticipated:

• Apply a cool compress to the extremity. A cool compress can reduce swelling, relieve discomfort, and help minimize the tightness in the skin caused by edema. The cold temperature helps constrict blood vessels, reducing fluid buildup in the tissues. This intervention is appropriate for managing IV infiltration-related symptoms.
• Assist in inserting a new IV catheter in a site distal to the infiltration site. If the IV site becomes infiltrated, the correct approach is to stop the current infusion and insert a new catheter in a different location, preferably distal to the infiltration site. This ensures continued IV access without further aggravating the infiltrated site.
• Elevate extremity. Elevating the affected extremity can help reduce swelling by promoting venous return. Elevation improves circulation and decreases the pressure caused by fluid accumulation in the tissues. This is an effective intervention for managing swelling in the right upper extremity due to infiltration.

Not Anticipated:

• Phytonadione (vitamin K) is typically used to reverse the effects of anticoagulation medications or treat vitamin K deficiency. This is not indicated for the client, as there is no evidence of bleeding or an anticoagulation issue that requires vitamin K. The client's current problem is an IV infiltration, not a clotting disorder.
• Send the catheter tip for culture. At this point, there are no signs of infection such as redness, warmth, or discharge from the IV site. The primary concern is managing the infiltration, so sending the catheter tip for culture is unnecessary unless infection is suspected. Culture collection is reserved for cases where an infection is present.
• Suggest irrigating the IV catheter. Irrigating an infiltrated IV catheter could worsen the situation by pushing fluids further into the surrounding tissue or introducing bacteria. The proper action is to discontinue the infusion, remove the IV, and insert a new catheter at a different site rather than attempting to irrigate an already compromised catheter.