During peripheral IV administration of vincristine, the client reports burning and the nurse observes swelling at the site. Which action should the nurse take first?
1Increase the infusion rate to move the vesicant beyond the swollen tissue.
2Remove the catheter immediately and massage the area with firm pressure.
3Slow the infusion, apply a cold compress, and reassess after the dose finishes.
4Stop the infusion, keep the catheter for aspiration, and activate the extravasation protocol.✓ Correct answer
Explanation
Burning and swelling during vincristine administration indicate suspected extravasation. The nurse should stop the infusion immediately, leave the catheter in place initially for aspiration and protocol-directed management, notify the treatment team, and prepare prescribed local hyaluronidase and moderate warmth. The remaining dose is administered through a different verified vein if directed. Flushing, increasing or continuing the infusion, applying cold, or massaging can worsen tissue exposure.
Clinical reasoning Vincristine is a vesicant. Leakage into tissue can cause marked irritation and injury, so further drug delivery through the affected access must stop at once.
Decision rule For suspected vinca-alkaloid extravasation, stop infusion, preserve access for aspiration and antidote protocol, notify the treatment team, elevate the limb, and use prescribed hyaluronidase with moderate warmth.
Scenario Adult receiving vincristine IV via peripheral line; reports burning, swelling and absent blood return.
Vincristine extravasation — Unintended leakage of the vesicant vincristine from a vein into surrounding tissue, creating a risk of local injury.
Hyaluronidase — A locally administered enzyme used with moderate warmth under protocol to disperse vinca-alkaloid extravasation.
Vincristine fatal IT error — Never administer intrathecally — fatal; ISMP recommends mini-bag not syringe.