23.4 Sample Documentation
Open Resources for Nursing (Open RN)
Sample Documentation of Expected Findings
Initiated IV infusion of normal saline at 125 mL/hr using existing 22 gauge IV catheter located in the right hand. The IV site is free from pain, coolness, redness, or swelling.
Sample Documentation of Unexpected Findings
Attempted to initiate IV infusion in right hand using existing 22 gauge IV catheter. The IV site was free from pain, redness, or signs of infiltration. It infused freely with the normal saline flush. IV fluids were connected to run the normal saline infusion at 200 mL/hr. The infusion was started, but immediate leaking around the infusion site was noted. Swelling was noted superior to the infusion site and the fluids were immediately stopped.