What should the nurse do first when a client's IV infusion has infiltrated and they are in pain?

When a client's IV infusion has infiltrated and they are experiencing pain, the highest priority is to assess the patient's condition to determine the extent of the infiltration. Measuring pulse volume and capillary refill is crucial because it helps to evaluate the circulation and perfusion of the affected area. This assessment can identify if there is significant tissue damage or if the infiltration has affected blood flow, which requires immediate intervention.

By checking pulse volume, the nurse can ascertain whether blood is still circulating adequately to the extremity. Similarly, capillary refill provides insight into tissue perfusion; a prolonged refill time could indicate compromised circulation due to the infiltration. These assessments guide the nurse in deciding the most appropriate actions to take, such as elevating the limb or applying a warm compress, and possibly notifying the healthcare provider for further evaluation.

Other considerations, such as checking for past history of drug abuse, evaluating ecchymosis, or compressing the infiltrated tissue, may be important but are secondary to ensuring that the patient is stable and that perfusion to the extremity is not compromised.