Before We Start
IV access basics — what you're putting in and why it matters
An intravenous (IV) line is a catheter inserted into a vein to deliver fluids, medications, and blood products directly into the bloodstream. It bypasses the digestive system entirely — which makes it the fastest route for drug delivery but also the route with the most serious complications when things go wrong.
Every IV site must be assessed at the start of every shift, before every medication administration, and any time the patient reports discomfort at the site. A complication caught at Stage 1 requires simple intervention. A complication missed until Stage 3 or 4 can require surgery.
💡 Assess the IV Site Every Time
Before administering any IV medication:
1. Flush the line with normal saline — assess for resistance and patient comfort
2. Look at the site — redness, swelling, streaking along the vein
3. Feel the site — warmth, coolness, hardness, tenderness
4. Ask the patient — "Does this site bother you? Any pain or burning?"
If anything is wrong — stop. Do not infuse through a compromised site.
The Three Major Complications
Infiltration · Phlebitis · Extravasation
Infiltration
Non-vesicant fluid leaking into surrounding tissue
Infiltration occurs when IV fluid (not a vesicant — tissue-damaging drug) leaks out of the vein into the surrounding subcutaneous tissue. The catheter tip has moved out of the vein, or the vein wall has been perforated.
Signs and symptoms:
• Swelling and puffiness around the site (most common sign)
• Skin cool to the touch (IV fluid is room temperature)
• Skin taut and shiny
• Pallor (paleness) at the site
• Decreased or absent blood return when aspirating
• Infusion slows or stops running
• Patient reports discomfort or pressure (may be painless)
What to do immediately:
1. STOP the infusion immediately
2. Discontinue (remove) the IV catheter
3. Elevate the extremity
4. Apply warm compress (promotes reabsorption of fluid)
5. Document the infiltration grade (1–4 scale), site assessment, time, and interventions
6. Start a new IV at a different site (opposite extremity if possible)
💊 Swelling + cool skin + pallor at IV site = infiltration. STOP infusion immediately. Do not push through it hoping it will clear — you're pushing fluid into the tissue, not the vein.
Phlebitis
Inflammation of the vein wall — the most common IV complication
Phlebitis is inflammation of the vein wall. Unlike infiltration, the IV is still in the vein — but the vein itself is becoming irritated and inflamed. This can progress to thrombophlebitis (clot formation) if not treated.
Three types:
• Mechanical: IV catheter moving inside the vein (patient with frequent arm movement, catheter too large for vein)
• Chemical: Irritating medications or solutions (potassium, vancomycin, many antibiotics, hypertonic solutions)
• Bacterial: Contamination during insertion or maintenance
Signs and symptoms — the classic triad:
• Redness (erythema) along the vein
• Warmth at and around the site
• Pain along the path of the vein
• Palpable cord (the vein feels like a hard cord under the skin as it becomes inflamed)
• Swelling may or may not be present
What to do immediately:
1. STOP the infusion
2. Remove the IV catheter
3. Apply warm compress
4. Elevate the extremity
5. Document and notify provider
6. Start new IV at a different site — rotate sites
💊 Red streak running up the arm along the vein + warmth + pain = phlebitis. Remove the IV — do not leave it in and hope it improves. A retained infected IV catheter can cause sepsis.
Extravasation
Vesicant leaking into tissue — the most serious IV complication
Extravasation is the accidental leaking of a vesicant (tissue-damaging medication) into surrounding tissue. This is a medical emergency. Vesicants cause progressive tissue necrosis — the tissue literally dies. In severe cases, extravasation requires surgical debridement and skin grafting.
Common vesicants:
• Chemotherapy agents (most notorious — vincristine, doxorubicin)
• Concentrated potassium chloride
• Calcium chloride
• Hypertonic solutions
• Vasopressors (dopamine, norepinephrine) — cause severe vasoconstriction and ischemia
• Vancomycin (high concentration)
• Phenytoin (Dilantin)
Signs — appear earlier and are more severe than infiltration:
• Burning, stinging pain at the site (more intense than infiltration)
• Redness and swelling
• Blistering and skin changes (may take hours to appear)
• Tissue discoloration (progresses to necrosis)
Critical difference in management from infiltration:
1. STOP the infusion immediately
2. DO NOT remove the catheter yet — leave it in place to aspirate as much medication as possible
3. Aspirate residual medication through the catheter
4. Notify provider and pharmacy IMMEDIATELY
5. Administer antidote per protocol (specific to the vesicant)
6. THEN remove the catheter
7. Apply antidote topically or inject per protocol
8. Apply cold or warm compress depending on the specific vesicant
9. Document with photographs if possible
10. Monitor and reassess every hour
💊 Extravasation = STOP, ASPIRATE (don't remove catheter yet), CALL provider immediately, then antidote. The sequence matters — removing the catheter before aspirating loses your chance to remove medication from the tissue.
Quick Comparison
Infiltration vs Phlebitis vs Extravasation at a glance
Infiltration
Fluid in tissue · Cool skin · Swelling · Pallor · Usually painless or mild discomfort
Cause: catheter out of vein or vein perforated
Treatment: stop, remove IV, warm compress, elevate
Phlebitis
Vein inflammation · Redness + warmth + pain along vein · Palpable cord · IV still in vein
Cause: mechanical, chemical, or bacterial irritation
Treatment: stop, remove IV, warm compress, new site
Extravasation
Vesicant in tissue · Burning pain · Blistering · Tissue damage/necrosis
Cause: vesicant medication escaped the vein
Treatment: stop, ASPIRATE FIRST, notify provider, antidote, then remove catheter
Prevention
How to prevent IV complications before they start
Site selection and catheter choice
Choose veins appropriate for the infusion: forearm veins for most infusions, antecubital for short-term use or blood draws, avoid hand and wrist veins for vesicants. Use the smallest catheter that meets the patient's needs — larger catheters cause more mechanical phlebitis. Avoid lower extremities when possible (higher infection and DVT risk).
Site rotation and dwell time
Change peripheral IV sites every 72–96 hours per facility policy, or sooner if complications develop. Rotate sites — don't use the same vein continuously. Document insertion date and time on the dressing.
Assess before every infusion
Flush with normal saline, observe for swelling or resistance, assess for pain — before every medication administration and at the start of every shift. A site that is fine at 7am may have infiltrated by noon.
Vesicants via central access
Chemotherapy and other high-risk vesicants should be administered via central venous access (PICC, port, central line) whenever possible — central veins have higher blood flow that dilutes the medication and reduces vessel irritation.
🏥 Clinical Scenario — Identifying the Complication
Three patients. Three different IV findings. What is each complication and what do you do?
Pt 1
Mrs. Park — receiving normal saline at 125 mL/hr. Site: left forearm. You note puffiness around the catheter site, skin is cool and taut, slightly pale. Patient says "it feels tight." Blood return absent on aspiration. IV running slower than ordered. → Infiltration. Stop infusion. Remove catheter. Warm compress. Elevate arm. New IV site.
Pt 2
Mr. Jackson — receiving vancomycin IVPB. Site: right forearm, day 3 of infusion. You notice a red streak running 4cm up his arm from the insertion site. The skin along the streak is warm. He says it's been "sore for the past few hours." A firm cord is palpable along the vein. → Phlebitis (chemical). Stop vancomycin. Remove catheter. Warm compress. New IV. Document. Notify provider — may need central access for continued vancomycin.
Pt 3
Ms. Thomas — receiving IV chemotherapy (vincristine). She calls out: "It's burning really badly — worse than before." You see subtle swelling and redness around the site. She rates the burning pain 7/10. → Extravasation. Stop infusion immediately. LEAVE catheter in. Aspirate through catheter. Call provider and oncology pharmacist STAT. Cold compress (for vincristine). Antidote per protocol. Document. Photograph site. Hourly monitoring.
📌 NCLEX Application
IV complication questions test recognition and correct initial action.
The most tested distinction: Infiltration vs Extravasation — both involve fluid leaking into tissue, but extravasation involves a vesicant and requires a different management sequence (aspirate before removing catheter).
Key NCLEX rules:
• Always STOP the infusion first — for ALL three complications
• Infiltration = warm compress (promotes reabsorption)
• Phlebitis = warm compress + remove catheter + rotate site
• Extravasation = stop → aspirate → call provider → antidote → then remove
• Vesicants should go via central access whenever possible
• Document IV site assessment BEFORE and AFTER every medication administration
⚠️ The Trap — Pushing Through a Questionable IV Site
The most dangerous IV habit: infusing medication through a site that "seems okay" because the nurse doesn't want to start a new IV. This is how infiltrations become extravasations, and how phlebitis becomes septic thrombophlebitis.
When in doubt about an IV site — remove it and start a new one. It takes 5–10 minutes. The alternative could be an emergency.
If a patient reports burning during an infusion of a vesicant — STOP immediately. Do not slow the rate and continue. Do not tell the patient "that's normal." Stop, assess, and treat as extravasation until proven otherwise.
✓ Quick Self-Test
Answer each question:
1. What is the key difference between infiltration and extravasation?
2. A patient's IV site shows redness, warmth, and a palpable cord along the vein — what is this?
3. During vancomycin infusion the patient reports burning pain — what do you do FIRST?
4. Why do you NOT remove the catheter immediately in extravasation?
5. What type of compress is used for infiltration and phlebitis?
Answers:
1. Extravasation involves a vesicant (tissue-damaging drug); infiltration involves non-vesicant fluid
2. Phlebitis — inflammation of the vein
3. Stop the infusion immediately — assess for extravasation
4. Leaving it in allows aspiration of residual vesicant from the tissue before it causes more damage
5. Warm compress for both infiltration and phlebitis