Care Plan for IV infiltration help please!!

[NG KIU HO]

Here is the case. A 48 years old woman who just had abdominal surgery. And she is having an IV infusion of 5% dextrose running at 500mL in 6hours. The IV stopped running and her infusion site is swelling and pallor. She is also complaining about the IV is hurting her. She is feeling pain, discomfort and general malaise. She has hypertension and intermittent episodes of gout in her past health history. Here are her vital signs.

BP 148/62, Pulse:62, Temperature:36.5, Respiratory rate:26, SpO2 % in room air.

What are the significance and importance in this case? What should the care plan be? like an actual problem and potential problem? Impaired tissue integrity?

Online teaching has limited my study nowadays. May anyone please give me some help?

[Wuzzie]

Nope. Not an excuse. Do you have a NANDA book? Have you written one before? Have you googled IV infiltration? You need to do some work first then we’ll help you tweak it.

[NG KIU HO]

Of course I have done many researches for the IV infiltration. But except infiltration, I can’t find any others problem that is needed to be concerned or I don’t know that they are related. I am wondering whether if I have missed anything or another actual problem except impaired tissue integrity. What will be the potential problem.

Online teaching has limited my study because teachers seldom reply our questions.

Thank you

[Wuzzie]

Okay, then start with that. Give it a go and we’ll help you fine tune it.

[Wuzzie]

Show us your work. Write the first nursing diagnosis and interventions. We won’t laugh at it. We’ll help you but we aren’t going to write it for you. Do you have a NANDA book?

[Rosalie Blythe, BSN, RN]

I will give you some hints, do you remember what is the normal range of respiratory range for adult?

Given that she has a history of hypertension and with the set of vital signs that are given, do you think its normal?

What type of systems you should focus on when you are conducting a head-to-toe assessment on her? Why is she hospitalized at the first place, what is her patient history suggesting that you might want to do further investigation?

How do you help the patient to relieve her pain and swelling at the IV infusion site?

[NG KIU HO]

The respiratory range for an adult should be 12-20 per minute. But she is having 26 breaths per minute which might because of the pain from her insertion site?

With a history of hypertension, I think it is reasonable for her of having 148/62.

For relieving her pain, I should apply a warm compressor on the infusion site?

That's help a lot. thx!

[Rosalie Blythe, BSN, RN]

On 3/15/2020 at 11:02 AM, roseblythe1995 said:

What type of systems you should focus on when you are conducting a head-to-toe assessment on her? Why is she hospitalized at the first place, what is her patient history suggesting that you might want to do further investigation?

NG KIU HO did you consider this question too?

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She is feeling pain, discomfort and general malaise.

What does this piece of information gave you...other than her pain in related to the IV infiltration? She just had an abdominal surgery. I want you to consider that.

[Rosalie Blythe, BSN, RN]

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NG KIU HO

The respiratory range for an adult should be 12-20 per minute. But she is having 26 breaths per minute which might because of the pain from her insertion site?

What else would the the source of pain, other than the IV site? You are having a tunnel version, not looking at the whole picture. You need to assess this patient considering the whole body system.

[Rosalie Blythe, BSN, RN]

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NG KIU HO

She has hypertension and intermittent episodes of gout in her past health history.

Do you know what are the S & S of gout? Do you think her having gout in her history plays a role in her current complaint?

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May anyone suggest another actual problem that is caused by IV infiltration?

Any source of foreign medical instruments that goes into the body, including drains, IVs, foley could be potential sources of what?

I have already done half of your homework.

[Rosalie Blythe, BSN, RN]

Now, based on all the hints that I gave you, What are the significance and importance in this case? What should the care plan be?? I think you can answer that, if you know the answers to all the questions I have asked you.

[Rosalie Blythe, BSN, RN]

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NG KIU HO

For relieving her pain, I should apply a warm compressor on the infusion site?

What about the swelling?