Fundamentals of Nursing Q 404
All of the following are common signs and symptoms of phlebitis except:
A. Pain or discomfort at the IV insertion site
B. Edema and warmth at the IV insertion site
C. A red streak exiting the IV insertion site
D. Frank bleeding at the insertion site
Correct Answer: D. Frank bleeding at the insertion site
Phlebitis, the inflammation of a vein, can be caused by chemical irritants (I.V. solutions or medications), mechanical irritants (the needle or catheter used during venipuncture or cannulation), or a localized allergic reaction to the needle or catheter. It usually affects lower limbs, particularly the great saphenous vein (60% to 80%) or the small/short saphenous vein (10% to 20%). However, it can occur at other sites (10% to 20%) and may occur bilaterally (5% to 10%).
Option A: When there is venous turbulence or stasis, vessel wall injuries, abnormal coagulability, or vessel wall injuries, microthrombi could propagate and then form macroscopic thrombi. Vascular endothelial injury reliably results in thrombus formation by triggering an inflammatory response that results in immediate platelet adhesion. Platelet aggregation is mediated by thrombin and thromboxane A2.
Option B: Patients with superficial thrombophlebitis typically present with a reddened, warm, inflamed, tender area overlying the track of a superficial vein. There is often a palpable cord. Some surrounding edema or associated pruritus may occur. Significant swelling of the limb is more commonly associated with DVT and should only be attributed to SVT after DVT has been excluded.
Option C: Signs and symptoms of phlebitis include pain or discomfort, edema and heat at the I.V. insertion site, and a red streak going up the arm or leg from the I.V. insertion site. Patients should be educated on the likelihood and significance of the propagation of disease and recurrence based on their risk factors. They should be advised of the need for further evaluation in the presence of migratory thrombophlebitis or if they are more than 40 years old at the time of their initial presentation and are without other risk factors for venous thromboembolic disease.