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IV therapy
Nursing skills test 4
60
Nursing
Undergraduate 3
11/09/2010

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Cards

Term

IVP with saline lock

 

SAS

Definition
  1. insert syringe of saline
  2. unlock clamp (before or afer insertion)
  3. aspirate to check of blood if your protocol requries it
  4. push saline
  5. give med
  6. flush with saline
  7. lock clamp before removal of syringe
  8. SALINE, ADMINISTER MED, SALINE
Term

SASH

 

IVP with picc line

Definition
  1. insert syringe of saline
  2. unlock clamp
  3. push saline gently to determine if line is patent
  4. if patent, give medication
  5. flush with saline
  6. flush with heparin
  7. Lock clamp before each removal of syringe
  8. SALINE, ADMINISTER MED, SALINE, HEPARIN
Term
IVP for infusing IV
Definition
  1. select port
  2. scrub hub for 15 sec
  3. insert needleless syringe into port
  4. inject med at appropriate rate, occlude IV line by pinching tubing above port if nescessary
  5. release pinched tubing as necessary for med to flow into patient
  6. repeat as necessary until entire med is infused
  7. dispose of syringe
Term
Four main reasons that intravenous therapy is used
Definition
  1. to supply maintenance fluid and electrolyte requirement
  2. to provide replacement or corrective fluid
  3. to provide nutrients when a client is unable to absorb them from GI tract
  4. to provide a route for giving medications
Term

IV therapy

supply maintence fluid and electrolytes requirements

Definition

this maintains requirements refer to the amount of fluid and electrolytes that the body needs to function properly under normal conditions

  • client who is NPO
  • post-op client who is unable to take enough fluid orally
Term

IV therapy

provide replacement or corrective fliud

 

Definition

fluid is needed when the client has had abnormal fluid lossses

situations like:

  • diarrhea
  • loss of gastric fluid and electrolytes from vomiting
  • hypovolemia secondary to acute blood loss or burn
Term

IV therapy

provide nutrient when client is unable to absorb them

 

Definition
total parenteral nutrition or CPN involes infusion of concentrated solution of protein, glucose, minerals, electrolytes and vitamins
Term

IV therapy

provide a route for giving meds

Definition
only way some meds are effective, maintain high blood levels of meds, prevent the trauma of repeated intramuscluar injections.
Term
Dextrose solution
Definition

hypotonic, 10 and 50% are hypertonic

 

maintain water balance and correct imbalance. supplies calories as carbohydrates

provide "free" water

electrolyte free solutions may cause peripheral circulatory collapse and anuria in patients with sodium deficiency, may aggravate hypokalemia

dont administer with blood

Term
Saline solutions
Definition

Hypotonic (.45%), isotonic(.9%), hypertonic (3%)

 

indications: fluid replacement, dehydration, sodium depletion, low salt syndrom

Percautions: use sodium solution with caution in edematous patients with heart, renal or hepatic disease

administer 3% or 5% slowly.

Term
Dextrose with saline
Definition

Hypotonic (5% dextrose and .45% NaCl)

Isotonic (5% doxtrose and .9% NaCl)

 

Indication: fluid replacement, few calories, dehydration, sodium depletion

precautions: Check serum electrolytes: Na, Cl, K, dextrose 5% spares muscles breakdown in NPO status

Term

Lactated Ringers injection

 

Definition

Isotonic

 

Indications: replacement of surgical and GI loss, dehydration, sodium depletion, acidosis, diarrhea and burns

Precautions: Trauma fluid

Term
Dextrose solution
Definition
this is actually hypertonic solutions that are hypotonic in the body, glucose is metabolized and the remaining solution is hypotonic
Term
Types of IV solution
Definition
IV solution, electrolyes, blood volume expanders
Term
Blood volume expanders
Definition

These solutions are used to increase the volume of blood following severe loss, hemorrhage or burns, common blood volume expanders are:

1. dextran

2. plasmanate

3. Human serum albumin

Term
factors influencing fluid needs
Definition
age, weight, temperature, activity level, any known renal or cardiac problems, intake in past hours and days, urinary output, stool, hydration status
Term
Corrective fluid therapy
Definition
fluid losses and fluid excess
Term
Signs of dehydration
Definition

when this happens people show:

 

decrease urinary output, acute weight loss, lack of tears, poor skin turgor, sunken eyes, increase pulse

Term
Signs of overhydration
Definition

when people experience this they are:

 

increased urine output, acute weight gain, tears present, possible edema, full fontanel, pulmonary edema, increase pulse, decreased bp

Term
Calculating and maintaining intravenous
Definition

1. amount of fluid to be infused over a period of time is calculated

2. the order for intravenous fluid intake is written for number of liters per 24 hours or rate in mL per hour

Term
Factors that influcence rate of infusion
Definition
 pressure gradient, length of tubing, diameter of tubing, friction, vicosity, postion of needle in vein
Term

Frequent nursing observation of IV

 

Definition

1. patency of intravenous: every hour the entire iv set up needs to be checked.

2. Client tolerance of intravenous- note any changes in vitals, discomfort or pain at site, output, note any abnormal daily weight gains.

Term
pervention of infection
Definition

    1. change the IV tubing every 72 hours or according to hospital policy

2. prevernt air contamination with glass bottls by changing the bottles every 24 hours

3. be caertain that all conncections are secure to avodi their coming apart and becoming contaminated

4. IV site care

5. scrub the hub

6. hand hygiene before handling IV equipment

Term
Recording
Definition
  1. amount and type of fluid
  2. important with children, critically ill, elderly
  3. also provides safety check
Term
Complications
Definition
infiltration, phlebitis, circulatory overload, infection, infection, air embolism
Term
Infiltration
Definition

this refers to the accumulation of IV fluid in the extra vascular tissue "leaks"

 

occurs when needle becomes dislodged fromthe vein and the fluid infuses into tissue instead of the bloodstream. to large a volume of fluid is forced into a small vein

Term
Signs of infliltration
Definition

sign of this include:

pian at the site, swelling at the site or swelling in the dependent part of extremity, blanching or paleness at the site, skin cool to touch over site, IV flow may slow or stop

Term
Nursing actions for Infiltration
Definition

nursing actions for this include:

  1. to prevent, protect IV- taping IV securely, limiting movement
  2. Assessment- the goal of assessment is to detect an infliltration early stages when signs are subtle, observe IV site carefully and frequently
  3. check for blood return
Term
What to do when infilration occurs
Definition

when this occurs you should:

  • stop IV immediately
  • remove venipuncture device
  • use of warm packs to cause vasodilation to increase absorption of fluid
  • keep extremity elevated and immobilized
  • notify someone to restart IV
  • check extravasation policy
Term
infiltration reasons
Definition

reason for this would be:

 

  • catheter punctures wein wall
  • difficult IV start
  • catheter migrates out of vein due to movement of catheter by pt or staff
  • high pressure injection
  • chemical irritation
Term
Treatment of infilration
Definition

treatment:

  •  once you know it is no longer in the vein
  • or once it is causing tissue trauma
  • it needs to be removed
  • warm packs to area
  • elevate
  • restart IV in another site
Term
IV monitoring for shift
Definition

what to look for when on shift

 

  • what is hanging
  • what rate is running at?
  • are the connections secure?
  • is the tubing patent
  • is fluid running correct?
Term
Documentation for fluid
Definition
  • type of fluid hanging
  • rate of fluid
  • site inspection
  • document when a new IV bag is hung
  • chart amount of med given for IV meds not volume
Term
When IV stops running
Definition
  • start at the top of the set up and wrok toward the patient
  • IV pump battery/settings
  • pump set correctly
  • clamps open/no air/no tubing problem
  • IV site patency
  • height of fluid if gravity set up
Term
Phlebitis
Definition

this is inflammation of the vein, can develop any time during IV therapy, potassium is irritating to veins

 

due to: side of IV catheter, medication, rate of infusion

Term
signs and symptoms of phlebitis
Definition

Signs and symptoms of this:

 

edema, puffy, warm to the touch, redness at site of IV , possibly red along the vein the IV catheter, hardness along the path of vein, observe and palpate site to assess.

Term
Prevention of phlebitis
Definition

observation of site- change IV site, change IV tubing, do site care

Dilute medication appropriately, use smallest size catheter possible, Ice area to decrease inflammation followed by hot packs in a few hours, continue observations

Term
Infection
Definition
this is from orgainisms from the skin surface that are introduced during the IV start or during manipulation of the site
Term
Infection signs and symptoms
Definition

signs and symptoms of this;

  • Localized: inflammation, warm to touch, purulent drainage
  • entire blood stream: febrile, N/V, change in VS decrease bp tachycardia, site changes red, swelling, tender, abscess
Term
Prevention of infection
Definition

preventions;

  • aeseptic technique with all IV starts, changing IV, accessing the IV line
  • change IV tubing per routine
  • check sterility of any solution hung or pushed through IV
Term
Circulatory overload
Definition
this refers to excessive fluid intake in the intravascular compartment. may occur in a short period of time and with little warning with small children
Term
Signs and symptoms of Circulation overload
Definition

signs and symptoms are;

 

increased pulse, respiration and bp, pulmonary edema, peripheral edema, acute weight gain, increase urinary output, circulatory collapse

Term
Nursing pervention of overload
Definition

nursing prevention;

 

never have more than 2 hours worth of fluid in the soluset at one time, check IV frequently, monitor urine output, monitor vital signs, observe for edema, ausculate lungs for rales

Term
Air embolism
Definition
this refers to the entry of air into the blood stream, this may occure through use of faulty equipment or by impormper replacement of air with fluid when setting up the IV, or by allowing the fluid to run out so tht air enters the line
Term
Signs and symptoms of air embolism
Definition

signs and symptoms or this;

cyanosis, weakness, weak, rapid pulse, hypotension, unconsciousness

Term
Nursing actions for air embolism
Definition

nursing actions;

 

Make sure all connections from the needle to bottle fit snugly, infuse fluid completely through the tubing before attaching the needle, observe carefully for air bubbles, notify physician immediately

Term
Central Venous catheters
Definition
long term IV therapy, site of insertion is a peripheral vein usually the antecubital area or jugular or subclavian
Term
Names of CVC
Definition
Port of cath, hickmann, TCVC, quinton, PICC, IVAD, Triple lumen CVC, broviac are some names of this
Term
Broviac Catheter
Definition

1. Head

2. Heart

3. superior vana cava where CVC distal tip is to be located, could be a little closer to the heart but you do not want it to enter the Right atrium

Term
Type of device will determine what you can do with it
Definition

depending you could;

 

infuse medication that irritate veins, infuse blood, infuse hypertonic solutino, blood draws, may have one tow or three or four lumens

Term
Complications with CVC
Definition

complications include;

 

pneumothorax (collapse lung)- they would have trouble breathing

infection, catheter occulusion- clot, kink

air embolism, catheter displacement, venous thrombosis, catheter cracking

Term
Maintain catheter patency
Definition
Flush unused lumen with recommended solution: heparin saline, saline dose will vary according to type of catheter, flush used lumen well with saline/heparin
Term
CVC care maintenance
Definition

Nursing care is essential to the sucess of CVC therapy through:

 

knowledge of administration of meds, nutrition therapy, chemo, blood through this route

Knowledge of care maintenance of catheter to pervent and decrease risk of complications

Term
PIV
Definition
slower rate, average volume, isotonic solution non greater than D10, nonirritating meds, short term IV therapy, change site every 3 days, end point is peripheral
Term
CVC
Definition
higher rate, large volume, hypertonic solution, irritating meds, several meds at once, long term IV therapy, end point in the SVC, blood draw form it
Term
Complications with PIV
Definition
infection, phlebitis, infiltration, extravasation
Term
Complications of CVC
Definition
infection, thrombosis, thrombophlebitis, catheter occulsion, air embolus, pheumo with insertion
Term
Can you take a patient's b/p on an arm with a PICC
Definition
use other arem if you have a choice, you can take blood pressure on arms that have PICC line but would avoid repetitive, some physician will order no b/p on PICC arm
Term
why have a tunneled catheter
Definition
this could help with infection pervention: if the vein is not acessed immediately after the skin is broken, the microbes on the skin have to travel much futher before reaching the blood stream.
Term
What is a cuff on a CVC catheter
Definition

A larger part of the catheter that is designed to prevent the microbes from traveling any further up the catheter.

 

it looks like a tiny balloon under the skin but it is not something that has air injected into it like a foley catheter.

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