A nurse is observing the IV catheter insertion site of a client who is receiving continuous IV therapy. Which of the following manifestations should the nurse identify as an indication that the client has developed phlebitis?

Choice A rationale Pallor at the IV insertion site is not a manifestation of phlebitis; rather, it is a characteristic sign of IV infiltration. Infiltration occurs when the IV fluid or medication leaks into the surrounding subcutaneous tissue, causing the skin to appear blanched, pale, and stretched. Phlebitis is an inflammatory process of the vein wall itself, which triggers vasodilation and increased blood flow to the area, resulting in redness rather than the paleness associated with fluid accumulation and vasoconstriction. Choice B rationale Drainage or purulent discharge at the IV site is an indication of a localized infection or cellulitis rather than simple phlebitis. While phlebitis is inflammation of the vein, it is often mechanical or chemical in nature and does not necessarily involve an infectious process with exudate. If drainage is present, it suggests that bacteria have colonized the catheter tract. Phlebitis typically presents with systemic-like inflammatory signs localized to the vein path without the presence of pus or leakage. Choice C rationale Erythema, or redness, along the path of the vein is a classic sign of phlebitis. Phlebitis is the inflammation of the tunica intima of the vein, caused by mechanical irritation from the catheter, chemical irritation from medications, or infection. This inflammatory response leads to localized vasodilation and warmth. The nurse may also observe a red streak following the vein's course and the vein may feel hard or cord-like upon palpation. Erythema confirms the presence of an active inflammatory process. Choice D rationale Coolness of the skin around the IV insertion site is a hallmark sign of infiltration or extravasation, not phlebitis. When IV fluids, which are typically at room temperature, escape into the subcutaneous tissue, they lower the local skin temperature. In contrast, phlebitis involves an inflammatory reaction that generates heat. Therefore, the affected area in phlebitis will feel warm or hot to the touch due to increased capillary blood flow, making coolness a negative finding for a diagnosis of phlebitis.