Shared Flashcard Set


ATI Fundamentals Chpt 48-52
ATI Fundamentals for Nursing test review
Undergraduate 2

Additional Nursing Flashcards




Fluid bolus
large amount of IV fluid given in a short period of time, usually less than an hour.

Given to rapidly replace fluid loss that could be caused by dehydration, shock, hemorrhage, burns or trauma

A large-gauge angiocatheter (18gauge or higher) is needed to maintain the rapid rate in an adult
Volume controlled infusions
Some meds such as antibiotics are given intermittently in a small about of solution through a continuous IV system or with saline or heparin lock systems.
The medications infuse for short periods on scheduled basis.
Infusions can be administered by secondary IV bag/bottle/tandem, volume-control set, or by a mini infusion pump
IV bolus administration
Small amounts of solution (concentrated or diluted) injected within 1-2 minutes.
Some are given directly into the peripheral IV/port
Watch for redness, burning, or increasing pain

Never give meds that cause adverse effects such as potassium chloride
Continuous IV infusion
mixed in a large volume of fluid (500-1000ml) and given continuously.

i.e. Potassium chloride
Special Considerations
for older adult clients, clients taking anticoagulants or clients with fragile veins:

Avoid tourniquets
Use BP cuff
Do not slap extremity to visualize vein

Edema in extremities:
Apply digital pressure over selected vein to displace edema
Apply pressure with alcohol pad
Cannulation must be quick

Anatomical landmarks may be needed for obese clients
Preventing IV infection
-standard precautions
-Change catheter: if any break in surgical asepsis is suspected, according to policy (72hrs)
-Avoid writing on bags with pen/marker; ink could contaminate; change tube if contamination
-use sterile needle/catheter each attempt
-fluid shouldnt hang over 24 hrs unless closed system
-wipe all ports with alcohol or antiseptic swap before connecting IV lines or syringe; dont leave exposed to air
-Never disconnect for convenience or to position client
Selecting vein for IV catheter
-First choose distal veins on nondominant hand
-nonpainful site without bruising and will not interfere with activity
-a resilient vein with a soft, bouncy feeling when palpated
-Avoid veins: varicosed, inner wrist with bifurcations, flexion areas, near valves, lower extremities, in antecubital fossa, sclerosed or hard, in an extremity with impaired sensitivity
-enhance access: gravity, fist clenching, friction with alcohol, heat, percussion with gentle tapping
IV catheter procedure (clean gloves)
-Apply tourniquet/BP cuff
-Select vein and untie it
-Cleanse the site using friction in a circular motion starting at the middle with alcohol, iodine or chlohexidine, allow 1-2 dry
-Remove catheter cover and grasp hub, checking for smooth edges and retie T/BP
-Anchor vein below site of insertion, pull the skin taut and hold
-Insert bevel up at 10-30d until flashback of blood
-Lower hub close to skin to prepare threading into vein 1/4in
-Loosen needle and advance catheter using thumb/index, release t/bp
-Apply pressure 3cm above and remove needle; activate safety
-apply dressing, set up rate by order
Discontinuing IV therapy
clean gloves; prescription

-Remove tape/dressing; stabilize and clamp tubing
-Apply sterile gauze pad over site with no pressure or alcohol
-With other hand withdraw by pulling straight back
-Elevate extremity and apply pressure for 2min
-Assess, apply tape over gauze or pressure pad if needed and document
IV Complications of Infiltration
-Pallor, local swelling, decreased skin temp at site, damp dressing, slow infusion
-Stop infusion, remove catheter
-Elevate extremity
-Apply warm compress 3-4 times/day
-Restart infusion proximal to site or in another extremity

Secure cather
IV Complications of Phlebitis/Thrombophlebitis
Edema; throbbing, burning or pain at site; increased skin temp; erythema (reddening); red line up arm with palpable band; slow infusion

-Promptly discontinue infusion and remove catheter
-Elevate extremity
-Apply warm compress 3-4 times/day
-Restart infusion proximal/other extremity
-Culture the site if drainage
-Rotate the site at least every 72 hours; Avoid lower extremities; use surgical asepsis
IV Complications of Hematoma
Ecchymosis at site (discoloration from bleeding underneath)

-Do not apply alcohol
-Apply pressure after IV catheter removal
-Use warm compress and elevation AFTER bleeding stops

-Minimize tourniquet time
-Remove T before starting IV infusion
-Maintain pressure after removal
IV Complications of Cellulitis
Pain; warmth; edema; induration; red streaking; fever, chills and malaise

-Promptly discontinue infusion/remove catheter
-Elevate extremity
-Apply warm compress 3-4 times/day
-Obtain a specimen for culture at the site and at catheter if drainage
-Administer as prescribed: Antibiotics, Analgesics, Antipyretics

-Rotate site at least every 72 hrs
-Avoid lower extremities
-Use surgical aseptic technique
IV Complications of Fluid Overload
Distended neck veins, increased BP, tachycardia, SOB, crackles in lungs, edema

-Stop infusion
-Raise head of the bed
-Assess vital signs
-As prescribed: adjust rate, administer diuretics

-Use infusion pump
-Monitor I&O
IV Complications of Catheter Embolus
Missing catheter tip when discontinued; sever pain at site with migration or no symptoms if no migration

-Place T high on extremity to limit venous flow
-Prepare for removal under xray or surgery
-Save catheter to determine cause

Do not reinsert the stylet into the catheter
Side/Adverse med effects on CNS
CNS stimulation: may be at risk for seizure
CNS depression: advise not to drive/participate in dangerous activities
Extrapyramidal symptoms EPS: involuntary fine motor tremors, rigidity, restlessness, spastic movements within hrs or months: often associated with meds affects CNS like mental health
Side/Adverse med effects of anticholinergics/cardiovascular
Anticholinergic: block muscarinic; effect mainly eye, smooth muscle, exocrine glands and heart: teach liquid use for dry mouth, sunglasses for photophobia; urinating before medicine to help urinary retention

Cardiovascular: Antihypertensives can cause orthostatic hypotension: teach signs of postural hypotension and sit or lie down/move slowly
Side/Adverse med effects of GI/Hematologic
GI: irritation of tract, vomiting can cause adverse effects; NSAIDs can cause this and should be taken with food

Hematologic: can be life threatening with some groups of beds: bone marrow depression/supression with anti cancer meds; hemorrhagic disorders with anticoagulants and thrombolytics.
-Educate on s.s. of bleeding (bruising, discolored urine/stool, bleeding gums)
Side/Adverse med effects of Hepatotoxicity/Nephrotoxicity
Hepatotoxicity: damage to liver cells impairs metabolism causing accumulation, producing adverse effects: 2 or more hepatotoxic increased liver damage risk, intitial and periodic liver tests

Nephrotoxicity: NSAIDs often cause; kidney damage causes accumlation due to lack of excretion: Aminoglycosides may cause renal damage; monitor serum creatinine and BUM levels
Side/Adverse med effects of toxicity/allergic reaction
Toxicity: excessive dose and sometimes at TL; liver damage with tylenol overdose or chronic alc use; antidote acetylcysteine (Mucomyst) may be used to minimuze liver damage

Allergic reaction: immune response; mild rashes/hives: benadryl; before administering any meds, obtain complete med history
Side/Adverse med effects of anaphylactic reaction and immunosuppression
Anaphylactic: life threatening immediate allergic reaction causing resp distress, severe bronchospasm, cardiovascular collapse: treat with epinephrine, bronchodilators and antihistamines; notify and prove resp support

Immunosuppression: decreased or absent immune response: glucocorticoids depress immune response and increase infection risk; monitor clients and check for s.s.
Medication-Food interactions
foods may alter med absorption

-Foods with tyramine should be avoided when taking MAOIs
-Consistent intake of VitK should be maintained when taking warfarim (coumadin)
-Tetracycline(Tetracyn) should not be taken within 2 hours of consuming dairy
-Grapefruit juice should be avoided if taking oral meds
Fetus Risk by US Food and Drug Administration
Category A: There is no evidence of risk to fetus during pregnancy
B: No evidence of risk to animal fetus based on studies in pregnant women
C: Adverse effects have been demonstrated on animal fetuses. No adequate and well controlled studies in preg women but use of med during preg may be warranted based on potential benefits
D: Adverse effects have been shown on human fetus from investigational/marketing experience, may be warranted on potential benefits
X: Adverse effects have been demonstrated on human and animal fetus based on studies and investigational or marketing experience. Use is contraindicated. Risks outweigh potential benefits.
Factors Affecting Med Dosages and Response
-body weight: higher body mass may need higher dose-absorbed/distributed in body tissue
-Age: children/older adults have lower kidney/liver function
-Gender: body fat/hormones
-Biorhythmic cycles: responses very by cycles of the body; hypnotic meds work better given at usual sleep time
-Tolerance: congenital or acquired
-Accumulation: decreased renal function is the major cause in older adults leading to toxicity
-Psychological: emotional state/expectations. Placebo effect: positive med effects from psych factors
-Medical Condition
Children med administration
Pediatric dosages are based off body weight or body surface area! BSA

1m-12m: immature liver/kidney, alkaline gastric juices, immature blood brain barrier, decreased serum protein binding sites

-Decreased gastric acid production and slower gastric emptying
-decreased first pass
-increased absorption of topical meds
-lower BP (more flow to liver/brain, less to kidneys)
-Higher body water content (dilutes water soluble)

Most meds arent tested on children and may require dilution, calculation, preperation and very small doses; limited IV sites
Pregnancy and Lactation
Pregnancy: meds are distributed to the fetus as well; all should be considered as potentially harmful; weight risks.
Meds common: nutritional supplements and nausea/vomiting/gastric acidity and mild discomfort treatment.
Chronic conditions like DM and hypertension must be managed with careful maternal fetal monitoring.
Live virus vaccines are contraindicated-teratogenic effects (MMR, polio, yellow fever)

Lactation: meds are secreted in breast milk; avoid drugs with extended half life and take meds immediately after breastfeeding if safe to minimize med concentration in feeding
Required abilities for self-monitoring blood glucose levels
-Alertness or the ability to comprehend and give a return demonstration
-Adequate finger dexterity
-Adequate visual acuity
Interpretation of blood glucose findings
Hyperglycemia: level above 250 mg/dL
Hypoglycemia: level below 70 mg/dL

Poor storage: false readings: vial at room temperature
Preprocedure Nursing Actions for blood glucose test
-Check clients record: frequency and type of test, norms and ranges, actions based on results
-Review med profile; note: anticoagulant usage, times/dose of hypoglycemic agents; use of steroids/meds that elevate levels
-Gather materials
-Review manufacturer instructions
-Check expiration dates
-Calibrate and test if new bottle
-Explain procedure
-Evaluate site for skin integrity and compromised circulation
-Don gloves/hand hygiene
Urinalysis procedure
Usually done at home to check for keytones which indicates uncontrolled glucose. Positive above 180 mg/dL

-Sterile urine sample bottle; assist if needed
-Dip reagent strip in sample
-Compare color change with ranges on container (1-5s)
Supporting users have an ad free experience!