recognition matrix comparison

IV Complications Recognition Matrix: Local vs Systemic

An IV site that looks cool and puffy is not the same as one that is warm and streaky — but under exam pressure students grab the wrong finding and choose an intervention that delays care. Knowing whether the problem is local tissue damage or a systemic emergency determines whether you slow the rate or call a code.

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Comparison

Side-by-side6 compared
Comparevs
Dimension
Infiltration
Extravasation
Phlebitis
Speed Shock
Air Embolism
Fluid Overload
Cause / mechanism
  • Local: non-vesicant fluid leaks into tissue
  • Local: vesicant drug leaks into tissue
  • Local: vein inflammation / irritation
  • Systemic: drug infused too rapidly
  • Systemic: air enters line / disconnection
  • Systemic: excess volume / too-fast rate
Signs & symptoms
  • Cool, puffy, taut skin
  • Dull ache, tightness
  • Cool, puffy, taut skin
  • Burning, stinging at site
  • Warm, red streak along vein
  • Tenderness along vein
  • minimal edema
  • Chest tightness, pounding headache
  • Flushed face, irregular pulse, syncope
  • Sudden chest pain, dyspnea
  • Churning sound over precordium
  • Dyspnea
  • distended neck veins
  • Crackles, bounding pulse, I > O
Assessment clues
  • Flow sluggish/stopped
  • cool, swollen, non-vesicant
  • Flow sluggish/stopped
  • vesicant infusing
  • May keep flowing
  • warm red streak along vein
  • Onset right after a too-rapid infusion
  • Disconnection or air visible in the line
  • Running too fast
  • I > O on the record
Nursing priorities
  • Stop infusion
  • elevate extremity
  • Stop infusion
  • aspirate residual drug
  • DO NOT flush
  • notify provider
  • Stop infusion
  • restart at new site
  • Stop infusion
  • place supine
  • monitor VS
  • Clamp tubing
  • left Trendelenburg
  • Call provider
  • Slow rate
  • elevate HOB
  • notify provider
Management
  • Warm compress to site
  • Antidote per drug if available
  • Warm compress to site
  • Restart at new IV site
  • Supportive care
  • treat reaction
  • 100% O₂
  • resuscitate as needed
  • O₂
  • diuretics as ordered
Prevention
  • Secure site
  • report swelling or coolness
  • Give vesicants via patent central line
  • Rotate sites
  • dilute irritating drugs
  • Use infusion pump
  • verify rate
  • Prime tubing
  • Luer-lock all connections
  • Pump-control rate
  • monitor I&O
Red flags — escalate
  • Severe swelling, blanching, ↓ pulse
  • Blistering, necrosis then tissue loss
  • Purulence + fever then catheter infection
  • Syncope, cardiac arrest
  • Hypotension, cyanosis, collapse
  • Pink frothy sputum then pulmonary edema
Complications
  • Compartment syndrome (large volume)
  • Tissue necrosis
  • loss of function
  • Thrombophlebitis
  • bloodstream infection
  • Cardiovascular collapse
  • Stroke
  • cardiac arrest
  • death
  • Pulmonary edema
  • heart failure
Cause / mechanism

Infiltration

  • Local: non-vesicant fluid leaks into tissue

Extravasation

  • Local: vesicant drug leaks into tissue
Signs & symptoms

Infiltration

  • Cool, puffy, taut skin
  • Dull ache, tightness

Extravasation

  • Cool, puffy, taut skin
  • Burning, stinging at site
Assessment clues

Infiltration

  • Flow sluggish/stopped
  • cool, swollen, non-vesicant

Extravasation

  • Flow sluggish/stopped
  • vesicant infusing
Nursing priorities

Infiltration

  • Stop infusion
  • elevate extremity

Extravasation

  • Stop infusion
  • aspirate residual drug
  • DO NOT flush
  • notify provider
Management

Infiltration

  • Warm compress to site

Extravasation

  • Antidote per drug if available
Prevention

Infiltration

  • Secure site
  • report swelling or coolness

Extravasation

  • Give vesicants via patent central line
Red flags — escalate

Infiltration

  • Severe swelling, blanching, ↓ pulse

Extravasation

  • Blistering, necrosis then tissue loss
Complications

Infiltration

  • Compartment syndrome (large volume)

Extravasation

  • Tissue necrosis
  • loss of function

marks the fact that sets a column apart.

Clinical Pearl

Cool + swollen = infiltration. Warm + red streak = phlebitis. Vesicant running + swollen = extravasation — stop and aspirate.

Component Topics

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