If a nurse notes coolness and blanching at an IV insertion site for a client receiving heparin, how should the infiltration be documented?

When documenting the infiltration of an IV insertion site, a scale often used is the infiltration scale, where various levels indicate the condition of the site. The scale typically ranges from one to four, with one being mild and four being severe.

In this case, the presence of coolness and blanching at the IV insertion site suggests that there is some degree of infiltration but not necessarily severe or extensive involvement of the surrounding tissues. Documentation of a level one infiltration reflects a mild case, indicating that there is no significant impairment and is likely limited to the initial symptoms of coolness and blanching without other distressing symptoms like swelling or pain typically associated with more severe infiltration.

Thus, documenting it as a one indicates that the situation is being monitored but is not critical, justifying the chosen answer. The other levels represent increasing severity and complications that are not indicated by the client's current symptoms. This approach allows caregivers to appropriately address the issue while keeping a clear and consistent record of the patient's IV site condition.