Postoperative Day 3: A Slowing IV and a Reddened Sacrum
Kenji M, 64 years old, is on postoperative day 3 after a right hemicolectomy. He is 172 cm tall and weighs 96 kg (BMI 32.4), has type 2 diabetes (HbA1c 8.1%), and smokes. He has an epidural catheter for analgesia, a urinary catheter, a nasogastric tube on low suction, and a 22-gauge peripheral IV in the dorsum of the right hand infusing 5% glucose 500 mL every 6 hours. At 14:00 the nurse finds the dorsum of the right hand swollen and tense, the skin cool and pale, capillary refill 4 seconds, and he rates a burning pain at 4/10. The infusion has slowed to 20 mL/hour against a prescribed 83 mL/hour. Blood pressure is 138/76, heart rate 92, SpO2 96% on room air, temperature 37.4 degrees C. He has stayed semi-recumbent since 09:00 because of wound pain and refuses to turn. The sacral area shows a 3 cm x 2 cm patch of non-blanchable erythema.
1. Interpret the findings at the IV site and state the first four actions in priority order, with the reasoning for that order.
Read the worked answer
Interpretation. Swelling, tautness, coolness and pain around the cannula with a falling flow rate point to infiltration - fluid tracking into tissue because the tip has left the vein. The discriminators matter: phlebitis would give warmth, erythema along the vein, and a palpable cord; extravasation implies a vesicant (chemo, calcium, high-concentration potassium, vasopressors) and needs antidotes. 5% glucose is non-vesicant but hypotonic, so it irritates tissue without causing necrosis. Capillary refill of 4 seconds and a burning pain are the warning signs to watch, because severe infiltration can progress to compartment syndrome - pain on passive stretch, pallor, pulselessness and paraesthesia are late, not early, findings.
Actions, in order:
- Stop the infusion and do not flush the line. Flushing forces more fluid into tissue.
- Disconnect and withdraw the cannula, applying gentle pressure with gauze; do not massage the area.
- Elevate the hand above heart level to aid reabsorption, and apply a warm compress (cold is used for vesicant extravasation, not for this).
- Mark the border of the swelling with a pen, note the time, check distal pulse, sensation and capillary refill, and notify the physician; re-site the line in the opposite arm because this arm is now unavailable.
Document the site, volume infused, findings and actions, and reassess at least hourly until the swelling resolves.
2. He refuses to turn because of wound pain. Prioritise the pressure-injury measures for the next 24 hours and justify each in terms of the risk factors you can identify.
Read the worked answer
Risk profile. Non-blanchable erythema over the sacrum is already stage 1 pressure injury (JPU: erythema that does not blanch). Contributing factors are visible in the scenario: immobility from epidural analgesia and pain, moisture (urinary catheter, possible faecal soiling), reduced activity, obesity with friction and shear on a semi-recumbent backrest, and hyperglycaemia impairing tissue repair.
What to do first (24 hours):
- Offload the sacrum now with a 30-degree lateral tilt, and set a written turning schedule every 2 hours. Give analgesia before turning and explain why it matters, otherwise the plan fails at the next shift. Do not drag him - use a slide sheet to cut shear.
- Lower the head of the bed to 30 degrees or less whenever epidural level and respiration allow; higher angles concentrate pressure on the sacrum and coccyx.
- Request a pressure-redistributing mattress, not a standard foam one, for a patient of this weight who cannot reposition himself.
- Manage moisture: check for urine leakage and faecal soiling each turn, clean and dry the skin, and use a barrier product - do not massage the reddened area.
- Inspect and document the sacrum, heels and occiput at every turn; measure the lesion and photograph per facility policy.
- Refer to the dietitian and the wound/ostomy nurse; adequate protein and glycaemic control support healing.
Justification: the measures that will fail fastest are turning and moisture control, so they need a schedule, analgesia cover and a named person per shift rather than a general instruction.
3. Write the SBAR handover and state which two findings you would insist the physician addresses the same day.
Read the worked answer
Situation: Mr M, 64, day 3 after right hemicolectomy, has an infiltrated IV in the right hand and a new stage 1 pressure injury over the sacrum.
Background: BMI 32.4, type 2 diabetes, epidural analgesia, urinary catheter, NG tube. Semi-recumbent since 09:00 because of wound pain; declining to turn.
Assessment: Right hand swollen, tense, cool, capillary refill 4 s, pain 4/10; infusion running at 20 mL/h against 83 mL/h. Sacrum: 3 x 2 cm non-blanchable erythema. Vital signs stable (BP 138/76, HR 92, SpO2 96%, 37.4 degrees C).
Recommendation: Please review for (1) re-siting vascular access and analgesia that permits turning; (2) pressure-injury care and a pressure-redistributing mattress. I have stopped and removed the IV, elevated the hand and marked the swelling.
The two findings I would insist on same-day physician attention:
- Analgesia that lets him turn. Without it every prevention measure is theoretical, and he is already at stage 1.
- The vascular access plan. He still needs IV therapy for a patient who is obese, diabetic and immobile - leaving no working line risks missed doses.
I would not use SBAR to report only the redness; the reportable judgement is that pain and immobility are driving the injury and need prescribing decisions, not just nursing effort.