201 Final Flashcards
1
Q
Risk factors for decreased tissue oxygenation
A
- genetic predispositions
- aging -> chest wall becomes rigid and lungs are less elastic and more air is retained in the lungs, less air is exchanged
- environment -> altitude, hear, cold, air pollution
- lifestyle -> diet, excursive, fitness level, muscle mass
2
Q
Hypoxemia
A
low oxygen in the blood
S+S: tachycardia, tachypnea, restlessness, light-headed, agitation, confusion, increased WOB, chest pain, cyanosis
hypoxemia usually leads to hypoxia
3
Q
Hypoxia
A
low oxygen in tissues and organs
S+S: depend on where the body isn’t receiving oxygen
anemic pts and pts with CO poisoning can have high SpO2 readings and still be hypoxic
O2 therapy prevents hypoxia
4
Q
Oxygen therapy
A
required for pts
- who have difficulty ventilating all areas of their lungs
- with impaired gas exchange
- with heart failure
5
Q
Ways to monitor oxygen within the body
A
- pulse oximetry -> does NOT replace clinical presentation
- ABGs -> the most reliable
6
Q
Infection control with oxygen therapy
A
all O2 equipment is single pt use
tubing, masks, and cannula are pt specific
label with date and pts name
change when visibly soiled
change nebulizer tubing and mask weekly and PRN
7
Q
O2 and CO2 levels
A
SpO2 for COPD pts = 88% to 90%
SpO2 = >95%
SaO2 = 95% to 100%
PaCO2 = 35 to 45 mmHg
PaO2 = 80 to 100mmHg
healthy adult’s peak inspiratory flow rate = 35 to 40 L/min
8
Q
Nursing care for oxygen therapy
A
can administer O2 without a doctors order in the event of hypoxeima -> ongoing O2 therapy requires an order
DO NOT use vaseline for dry nostrils -> oil based, very flammable
provide education NO SMOKING
9
Q
precautions with O2 therapy for COPD pts
A
pts with chronically elevated PaCO2, ventilatory depression may occur is the PaO2 is increased to >60 mmHg -> hypoxic drive may be impacted
for COPD pts: trying to normalize the CO2 levels and pH by withholding or providing inadequate oxygen is questionable practice because is could lead to hypoxia
hypoexemia can be fatal and high PaCO2 levels are generally less harmful
10
Q
low flow oxygen
A
includes nasal prongs/nasal cannula, simple mask , non-rebreather mask, O2 tents
the flow rate from the “low flow” system is less than the pts peak inspiratory flow rate
- therefore air is also inhaled along with the supplemental O2, so the FiO2 will vary depending on the RR, tidal volume, and L flow
when documenting low flow O2 document in L/min as we can’t say with certainty what the % of O2 that the pt is receiving
11
Q
% of O2 in room air
A
21%
12
Q
FiO2 increases by _ for each litre of O2 delivered
A
the FiO2 increased about 3-4% for every L of O2 delivered
1 - 2L/ min = 24-28% O2
3 - 4L/ min - 32-36% O2
5 - 6L/min = 40-44% O2
13
Q
Nasal prongs/nasal cannula
A
can deliver up to 6 L/min flow
22 to 44% O2
- humidity is not required
most commonly used
assess nares
14
Q
Simple mask
A
5 - 10 L/min flow
40 -60% O2
can cause drying of mucous membranes in upper airways
- for short term use, several hours only
15
Q
Non-rebreather mask
A
10 -15 L/min flow
60 - 100% O2
rapidly causes drying of mucous membranes in the airways, used for less than 1 hour
is similar to the SM however it has a reservoir bag -> must remain inflated during inspiration
-> also has one way valves
16
Q
oxymask
A
1 - 15L/min flow
24 - 90% O2
17
Q
bi-flow mask
A
covers the nose instead of going into the nasal passages like NP
1 - 12L/min flow rate
not well suited for mouth breathers
comfort for the pt
ideal for higher flow of O2 when needed during eating
18
Q
face tent
A
15 L/min flow, imprecise FiO2
should not be used on pts requiring high O2 levels
designed for use with pts that have facial burns/trauma that cannot wear or tolerate other systems
less claustrophobic than an aerosol mask
can also be used for humidity only
19
Q
titration fo oxygen algorithm
A
used if there is an improvement of deterioration in a pts condition
all deteriorations in respiratory status requiring change in O2 requirements must be communicated to the physician
if SpO2 is less than 92% reassess and encourage deep breathing -> if it doesn’t increase adjust O2 delivery by
- increase flow rate by 1-2 L/min
- change O2 delivery device
- change to high flow system
- increase FiO2 by 5-10% if on high flow system
- if increasing to greater than 40% or 8L/min call RT or MD
if SpO2 is greater or equal to 92%
- wean O2 to lowest level (1-2L/min at a time or 5-10% if on high flow system) to maintain level at 92% or higher
reassess pt condition and SpO2 5 mins after making a change to O2 therapy
20
Q
ways to improve oxygenation
A
encourage deep breathing and coughing -> COPD pts are told to exhale through pursed lips and exhale with a huff to prevent high expiratory pressures that may collapse their airways
hydration
humidification
nebulization
medications -> bronchodilators and anti-inflammatories
incentive spirometers
21
Q
bronchodilators and steroids
A
always give the bronchodilator first before the steroid
22
Q
skin function
A
provides a protective interface between the environment and the internal organs
skins the largest organ in the body
skin can be influenced by intrinsic (age, genetics, general health, nutrition, medications) and extrinsic factors (incontinence/hygiene, living conditions, mechanical forces)
23
Q
factors affecting wound healing
A
- impaired blood perfusion
- local edema
- nutritional status
- metabolic control
- alcohol, smoking, drug use
- systemic infection
- incontinence
- co-morbidities
- medications
- age
24
Q
braden scale
A
used to assess the level of risk for developing skin breakdown
completed in the acute care setting on admission
if score is 18 or less then reassess every 2 days and post operatively
25
intentional wounds
planned as a result of therapy -> surgery
incisions
puncture
26
unintentional wounds
- contusion
-abrasion
- puncture
- laceration
- penetrating wound
- pressure injury -> closed or open
- ulcers
- skin tear
27
skin tears
wound caused by shear, friction, or blunt force
layers of skin separate
usually preventable
very likely to become complex chronic if not managed properly
28
partial thickness skin tear
separation of the epidermis from the dermis
29
full thickness skin tear
separation of the epidermis/dermis from underlying structures
30
ISTAP skin tear classification
type 1 = no skin loss, flap is attached and can be repositioned
type 2 = partial flap loss, flap cannot be repositioned to fully cover the wound bed
type 3 = total flap loss, entire wound bed is exposed
31
acute wound
cause = often trauma or surgery
occurs quickly and heals quickly within an expected time from once cause is removed
dressings are typically less complex
tissue integrity is restored
32
chronic wounds
cause = vascular compromise, chronic inflammation, repetitive insult to tissue
cause of wound may impede healing
fails to heal in a timely manner
may require more complex dressings
wound unhealed for longer than 6 weeks are considered chronic
33
clean wounds
primarily closed wounds
uninfected
minimal inflammation
respiratory, GI, GU tracts are not entered
34
clean-contaminated wounds
surgical wounds
respiratory, GI, GU tracts have been entered under a controlled environment
no evidence of infection
35
contaminated wounds
include open, fresh, accidental, and surgical wounds
break in sterile technique or have been in contact with gross spillage
non-purulent inflammation's visible
36
infected wounds
old traumatic wounds with retained dead tissue
involve existing clinical infection of perforated viscera
37
primary intention
tissue surfaces have been approximated
minimal or no tissue loss
results in less scaring
ex. surgical incisions
38
secondary intention
where the edges of the wound cannot or should not be approximated because of:
- increase risk of infection, longer healing time
- increased scarring
39
tertiary intention
also known as delayed primary healing
wounds that are left open for 3-5 days and then closed with sutures, staples, adhesive skin closures
40
partial thickness wound repair
heals by regeneration
1. hemostasis
2. inflammatory response
3. epithelial proliferation and migration
4. re-establishment of the epithelial layers
41
full thickness wound repair
heals by scar formation
1. hemostasis
2. inflammatory phase
3. proliferative phase
4. remodelling/maturation phase
42
hemostasis
begins immediately after injury
vasoconstriction to stop bleeding
platelets aggregate (scab is formed)
fibrin clot is formed by deposits
wound edges start to pull in
43
inflammatory phase
begins immediately after injury once bleeding is controlled
last 3-4 days
phagocytosis -> after about 24 hours macrophage, neutrophils, and lymphocytes engulf microorganisms, cellular debris, bacteria, and damaged tissue
macrophages secrete an angiogenesis factor which stimulates the formation of epithelial buds
causes increased erythema, heat, pain, and induration (thickening and hardening of soft tissues -> skin)
44
proliferative phase
day 3-4 to day 21-24
fibroblasts that began in the inflammatory phase now begin to synthesize collagen and proteoglycan around day 5
- increases the strength of the wound
- if the wound is sutured this usually results in a raised ridge that appears along the incision
capillaries grow across the wound to increase blood supply, oxygen, and nutrients, while fibroblasts continue to deposit fibrin which results in granulation tissue which is fragile and bleeds easily
if the wound does not close by epithelialization that area becomes covered with dried plasma protein and dead cells called eschar
45
remodelling (maturation) phase
starts after wound closure and can take up to 2 years after the injury occurs
fibroblasts continue to synthesize collagen
collagen begins to reorganize in a more structured fashion
the scare becomes stronger but only approximately 80% as strong as uninjured tissue
46
wound assessment
includes:
location
pain
dimensions - measure
closure devices - sutures, staples -> how many are there?
approximation
redness -> not normal if the area is hot, har, red, painful, and pt has increased temp
wound bed
exudate
wound edges
odour - assess after the wound is cleaned
periwound skin
ecchymosis - bleeding into subcutaneous tissue (bruising)
47
demarcated wound edge
a demarcated wound edge is a wound with clearly defined edges that can be distinguished from the wound bed
if it is poorly demarcated, it may be difficult to determine the wound margins
48
exudate
aka drainage
note the colour, amount, odour, and consistency of any wound drainage
assess if it is an appropriate or expected amount of exudate -> depends on location and size of wound
49
serous
clear or slightly yellow
thin, watery
50
sanguineous
fresh blood
bright red or pink
syrupy texture
51
serosanguinous
thin watery fluid that is pink in colour
small presence of red blood cells
52
purulent
pus
thick, milky drainage
53
retention sutures
very large sutures used in addition to skin sutures for some incisions
attach underlying tissues of fat and muscle as well as skin
54
non-absorbable sutures
attach skin edges together
silk, cotton, linen, wire, nylon, dacron
staples
steri-strips
55
absorbable sutures
attach tissues beneath the skin the disappear in several days
animal or synthetic products
56
dehiscence
the partial or total rupturing of a sutured wound
usually involves an abdominal wound
57
evisceration
is the protrusion of internal viscera through the incision
apply saline soaked sterile dressing to wound and notify surgeon
58
contributing factors to dehiscence and evisceration
obesity, smoking, poor nutrition, failure of suturing, excessive coughing or sneezing, vomiting, dehydration
more likely to occur 4 -5 days post op
increased flow of serosanguinous drainage can indicate an impending wound dehiscence
is dehiscence or evisceration occurs apply saline soaked sterile dressing and place client in bed with knees bent, and notify surgeon
59
hemorrhage
is greatest in the first 48 hours after surgery
MEDICAL EMERGENCY
internal bleeding = increased swelling of the area
external bleeding = blood escaping through the wound site
hematoma = localized collection of blood under the skin
60
S+S of infection in wounds
- increasing pain
- fever
- localized erythema (redness), edema, induration, inflammation of wound edges, warmth in surrounding tissue
- unexplained increase in WBC
- purulent exudate
- malaise
- foul odour
- crepitance (crackly sensation, air trapped under the skin)
- abscess
- delayed healing
61
wound infection continuum
1. contamination = low levels of microbes, healing is not impacted
2. colonization = wound has proliferating microorganisms (limited amount), no host reaction
3. local infection = microorganisms invade wound tissue, host response evoked, subtle S+S of infection
4. spreading infection = microorganisms invade wound leading to classic S+S of infection, microorganisms spread beyond wound border, deep tissue, fascia, organs, or body cavities become involved
5. systemic infection = microorganisms invade the body, spread through vascular/lymphatic system, may lead to systemic inflammation, sepsis, organ dysfunction, and death
62
NERDS
for superficial infections
N= non healing wound
E = exudative wound
R = red and bleeding
D = debris
S = smell from wound
63
STONEES
for deep infections
S = size of wound is increasing
T = temperature is increased
O = Os-probes to bone or bone is visible
N = new areas of breakdown
E = erythema/edema
E = exudate
S = smell
64
how nurses can support wound healing
maintain moist wound bed
provide nutrition and fluids
prevent infection
consider pt positioning
pt education
65
sterile glove technique
uses sterile close, a sterile field, sterile dressing tray, sterile instruments, sterile solution, and sterile dressings
only sterile gloved hands or instruments are used for direct contact with the wound
66
no touch clean clove technique
uses clean gloves, sterile field, sterile tray, sterile instruments, sterile solution, and sterile dressings or dressings appropriately saved using no-touch technique
only sterile instruments are used for direct contact with the wound
67
clean technique
uses clean gloves, clean field, clean or sterile dressing tray, clean instruments, clean solution, clean dressings or dressing appropriately saved using clean technique
all supplies are single use or single client use
clean gloved hands or instruments are used for direct contact with wound -> NOT used in the hospital setting
68
when to change a dressing
typically guided by the type of wound, wound plan, and the products used
surgical dressings are usually left in place for the first 48 hours after surgery
superficial wounds are usually changed every 5-7 days or PRN
69
documenting a dressing change in the narrative notes
include:
- location
- wound assessment
- drainage -> amount, colour, type
- interventions
- type of cleanser, dressing used
- pt tolerance during procedure
for more complex wounds use the wound assessment and treatment flowsheet instead
70
macule
flat, non-elevated change in colour
1mm-1cm
circumscribed -> defined edges
71
patch
macule larger than 1 cm
72
papule
circumscribed, solid elevation of skin
less than 1 cm in size
73
plaque
superficial, solid, elevated lesion, greater than 1cm in size
74
vesicle
circumscribed, thin, translucent mass filled with serous fluid
75
bulla/bullae
versicles larger than 0.5 cm
76
pustule
a vesicle or bulla filled with pus
77
wheal
reddened, localized collection of edema fluid, irregular in shape
78
nodule
elevated, solid mass arising from the subcutaneous tissue or dermis
79
tumour
nodules larger than 2 cm, may have irregular borders
80
petechiae
minute, pinpoint, no-raise, perfectly round, purplish-red spot
81
erythemic rash
redness of the skin caused by congestion of the capillaries in the lower layer of the skin
82
surgical drains
are considered simple wounds
goal = to decompress or drain either fluid or air from the area of surgery
closed drainage systems:
- Jackson-pratt
-hemovac
open drainage system:
- Penrose drain
other:
- wound drainage bad may be used for a chronic wound with copious amounts of drainage
- percutaneous drain secured with stat-lock securement device
83
hemovac drain
portable self-contained unit
places into a vascular cavity where blood drainage is expected after surgery
consists of perforated tubing connected to a portable vacuum unit
total volume around 400 mL/24 hours
is usually empties when half full or per facility policy
84
Jackson pratt drain
portable self-contained unit
consists of a perforated round or flat tube connected to a negative pressure collection device
shaped like a bulb
small volume up to 100 mL/24 hours
usually emptied when 25 - 50 mL or per policy
85
Penrose drain
open drainage system
a soft rubber tube
no suction
held in place with a safety pin
usually pulled out in staged ( using sterile technique and sterile safety pin)
86
percutaneous drain
requires weekly dressing changes and PRN
attached to drainage bag
often to drain an abscess
87
showering for clients with open post op wounds/drains
a drain that is in-situ short-term should not get wet
client with a Penrose drain should not shower till drain it out
those with long term G-tubes can shower
with hemovac and JP drains that are expected to be removed in 3-4 days once they drainage has slowed, may not need to shower -> if they do shower they should keep the dressing dry
88
pressure ulcers
the result of localized ischemia
located over bony prominences
shallow or deep, may go to the bone
wound base may be covered with slough or eschar
no drainage to large amount of serous or purulent depending on stage
89
Braden risk and skin assessment schedule
must be completed with:
- 8 hours of admission and upon return from OR
- if at risk, every shift
- if less ask, at least daily
90
treatment for pressure ulcers
stage 1:
- relieve pressure
- apply barrier creams
- prevent from becoming worse
stage 2:
- relieve pressure
- usually no dressing (barrier cream), but sometimes a dressing to absorb drainage
- debride slough if present
- protect
Stage 3 and 4:
- relieve pressure
- debride slough/eschar if present
- pack deep wounds and sinus tracts/undermining if present
- dressing to absorb drainage
- decrease bacterial colonization
- protect
91
treatment of unstageable pressure wounds
surgical debridement to remove eschar
if non-surgical keep dry, protect, and prevent infection
use iodine swab, iodasorb ointment, inadine (antimicrobial gauze)
92
treatment of deep tissue injury
depends on presentation and when/if wound becomes open
may become stage III or IV ulcer
air-fluidized therapy -> causes finely divided particles to acquire the characteristics of fluid
non-contact low frequency ultrasound therapy -> promotes wound healing
93
venous ulcer
81% of leg ulcers are venous
develop as a result of skin and tissue changes caused by chronic venous insufficiency and the associated ambulatory venous hypertension
shallow, superficial, irregular shape
appear distal medial 1/3 of the lower leg and ankle
moderate to large serous drainage
peri wound skin often edematous with weeping dermatitis
peripheral pulses palpable
cap refill normal
94
treatment of venous ulcers
cleanse, irrigate PRN
use autolytic debridement if indicated
absorbent dressings to maintain moisture balance but keep periwound skin dry
elevate legs to minimize edema, improve circulation, decrease pain
use compression stocking if not contraindicated
analgesics PRN
95
compression therapy for Venus ulcers
used in conjunction with wound treatment for venous ulcers
can be specific compression wrap or purchased stockings
clients need education on care of and application of compression stockings
need to replaced every 6 months if worn daily
96
arterial ulcer
occurs as a result of severe tissue ischemia
shallow or deep, pale pink or yellow base, necrotic tissue and eschar common
punched out appearance, round
commonly on the toes, metatarsal heads, lateral malleolus, heels
little or no drainage
periwound skin thin, dry, shiny, with hair loss soon lower extremities
thickened nails and callouses
severe pain, relieved by lowering leg -> dangle off the bed
peripheral pulses diminished or absent, delayed cap refill
skin temp cold
97
treatment for arterial ulcers
if healable:
- for dry ulcers -> keep dry, maintain dry eschar, use antiseptic and dry dressing PRN
- for wet ulcers -> support moist wound healing, use autolytic (aqua cell AG) debridement if indicated
if non-healable:
- for dry ulcers -> keep dry, maintain dry eschar, use antiseptic and dry dressing PRN
- for wet ulcers -> dry and protect the wound with antiseptic and dry dressing
DO NOT DEBRIDE WET OR DRY WOUNDS IF NON-HEALABLE
analgesic PRN
position for comfort
good foot care
98
diabetic ulcer
shallow or deep, may probe to bone
may be necrotic, pink or pale
usually on the bottom of the feet at the pressure points
small to moderate drainage, dry or wet gangrene may be present
may have undermining or sinus tracts
usually painless
peripheral pulses papable
99
treatment of diabetic ulcers
cleanse, irrigate
use autolytic debridement if indicated
maintain moisture balance
keep peri-wound skin dry
protect wound
analgesics PRN
monitor and control blood sugar
regular feet inspection, appropriate foot and nail care
100
factors affecting wound healing
- wound temp -> cooled with saline
- frequency of dressing changes
- moisture -> to wet or dry
- yellow slough or necrotic tissue inhibiting granulation tissue growth
- packed to tight, causes tissue damage
- dead space not filled
- infection
-pressure on wound
101
principles of wound care
1. assess and treat the underlying cause
2. debride necrotic tissue
3. maintain a moist environment
4. assess and protect peri-wound skin
5. promote and support granulation tissue
6. fill dead space
7. stop infection and trauma
102
types of debridement
autolytic -> gels
enzymatic -> use of an enzyme
mechanical -> irrigation, shower, whirlpool, dressing removal
surgical/sharp
natural -> maggots, leeches
103
natural debridement therapy: maggots
will only eat necrotic tissue
secrete calcium carbonate and ammonia which disinfect wounds
provide warmth which may stimulate tissue growth
increase fibroblast growth which promotes granulation tissue
104
natural debridement therapy: leeches
leeches have unique saliva
causes blood flow to increase
contains natural anticoagulant properties that prevent clotting
once full of blood a leech detaches from the body
indications:
reduces severe and dangerous venous engorgement post-surgery in fingers, toes, ear, and scalp reattachments
limb transplants
skin flap surgery
breast reconstruction
105
maintaining a moist environment in wound healing
promotes angiogenesis, tissue growth, and cell migration
if wound is dry -> apply a product to add moisture
if wound is wet -> apply a product to absorb moisture
if the dressing becomes saturated, change the dressing
106
assessing peri-wound skin
assess for maceration (softening and breakdown of skin due to excess moisture)
- need either a more absorbent dressing or change the dressing more often
assess for redness, irritation, or skin breakdown
- surrounding skin may need a barrier -> cream or skin prep
107
promoting granulation tissue
- encourage good nutrition
- avoid frequent dressing changes
- cleanse with each wound change
- be gentle when cleansing fragile tissue
- use non-adherent dressing if dressing sticking
108
filling dead space
wounds heal from the bottom, up, important to fill open wounds with loose fluffy packing material
fluff don't stuff
damp packing, not wet
use one piece of gauze/packing if possible or ensure all pieces can be easily removed
109
diagnosing and treating infection
culture and sensitivity swab
systemic antibiotics (PO/IV) if needed
wick drainage to prevent pocketing (abscess formation) is warranted
change dressing more frequently to remove contaminated drainage
observe closely for deterioration -> locally or systemically
110
what to do if wound infection is suspected
obtain a C+S swab of the wound if 2 or more S+S of local or systemic infection is present (NERDS or STONEES)
diagnosis of infection is usually made by assessment not culture results
may start PO or IV antibiotics, order may be made before or after culture results are back
use anti-microbial wound care products
111
how to obtain a C+S swab from wound bed
1. throughly cleanse wound with 60 - 100mL of sterile saline
2. swab granulation tissue only
3. rotate swab over 1 cm square area of wound for 5 full seconds (Levine's technique)
4. label specimen with client ID info, swab source site, current antibiotic therapy and any pertinent info
5. refrigerate swab and transport to lab within 12 hours
112
wound care product selection
wet wounds to dry wounds (continuum)
- foam (allevyn)
- hydrofibre (aquacel)
- alginate
- hydrocolloid
- gel
113
how often to change dressing on chronic wounds
if wound dressing is appropriate and no issues Q3-5 days is common
114
cleaning an open surgical incision
clean to dirty
always move away from the opening
115
cleansing a surgical incisions and drain site
if there is both, cleanse the incision first (clean) and then drain site(dirty)
cleanse from the drain site and outwards
116
showering with a chronic wound
no reason why someone can't shower with a chronic wound
showering may help a dressing to loosen from the wound bed with less mechanical trauma
117
pt teaching for wound care
- S+S of infection (NERDS and STONEES) and when to seek help
- healing time
- importance of good nutrition-> protein, vitamin C, B, D, iron, zinc, calories
- importance of fluids -> 2500+mL/day
-hand hygiene before dressing changes
- positioning
- portable tap water may be used to clean wounds
118
documentation for closed incisions and minor superficial wounds
24 hour record
narrative notes
119
documentation for drains
24 hour record
in/out record
narrative notes
120
documentation for suture/staple removal
24 hour record
narrative notes
121
documentation for open wounds
wound assessment and treatment flow sheet
checkmark on 24 hour record
narrative notes if concerns
122
IV equipment for peripheral access
1. iv catheter
2. iv dressing
3. extension tubing
4. saline lock
5. iv tubing
6. iv bag
7. iv pump
123
types of IV catheters
1. angiocatheter -> new IH nexiva
2. butterfly (wing-tipped) IV needle
- metal needle with tubing
- short term (less than 24 hours)
- infants
3. arrow midline catheter
- some, flexible catheter referred to as a long cannula
- between 10 -25cm, inserted into the upper arm
- used in pts that require IV meds for 7 days up to 4-6 weeks
- same care as a PVAD
- inserted by the IV team
the smaller the catheter size the larger then lumen
124
yellow catheter
24 g
babies, happy, little
smallest size
125
blue catheter
22g
got the blues after all the fun you had in your 20s
126
pink catheter
20g
pinks a party
127
green catheter
18g
green means go, legal age
128
black catheter
16g
drive a car, gas is black
129
red/orange catheter
14g
the big O, biggest catheter
130
needless connected (blue cap, with foam thing)
may have positive, negative, or neutral fluid displacement
with a positive displacement device -> 0.19mL of fluid will remain in the cap when fluid is pushed through
should be clamped after finishing the flush and disconnecting the syringe
helps prevent IV infections
provides little to no blood reflux
change cap per facility policy
131
secondary tubing
used for medication
132
micro drip (mini drip)
is used for slower rates <100 mL/hour (60 gtt = 1mL)
usually used for peds
drip chamber has a small opening at the top
133
macro drip (maxi drip)
used for faster rates >100mL/hr (10 gtt = 1 mL)
most commonly used
drip chamber has a larger opening at the top
134
less than 20 mL/hr
used for continuous medication administration
135
20 - 50mL/hr
TKVO for PRN or intermittent medication administration
136
75 mL/hr
elderly
history if heart failure
137
100 - 125 mL/hr
to maintain fluid/electrolyte balance
pts that are NPO
138
150 mL/hr
to hydrate and replace fluid losses
139
250 -500mL/hr
fluid bolus infusion
rapid fluid replacement
140
IV site assessment
assess the insertion site, track of vein, and surrounding tissues
look for redness, swelling, inflammation, tenderness, exudate, leakage
once per shift and PRN
141
how often to monitor IV site during continuous infusions and intermittent infusions
Q1hr for continuous
Q shift for intermittent
142
when to change IV sites
if clinically indicated
pain, erythema, blanching, edema, induration, fluid leak, purulent drainage
143
phlebitis scale
if scale doesn't equal 0 than the PVAD should be removed
0 = no symptoms
1 = erythema at access site with or without pain
2 = pain at access site with erythema or edema
3 = pain at access site with erythema or edema, streak formation, palpable venous cord
4 = pain at access site with erythema or edema, streak formation, palpable venous cord, purulent drainage
144
IV infiltration
if IV is infiltrated, the catheter needs to be removed immediately
skin may be cool to touch, pallor, swelling, hardness
145
IV dressing assessment
assess with each site assessment
change dressing when blood, exudate, moisture is seen at site, edges lifted
use chlorhexidine swab to clean site
146
chlorhexidine
to be used for all VAD dressing/site care
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pt teaching for an IV
- report any S+S of infiltration, phlebitis, inflammation or any S+S pf catheter/flow occlusion
- numbness, tingling, discolouration, change in temp, or pain in limb
- blood on dressing or in tubing
- insecure or wet dressing
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when to assess VAD potency and flush
for new continuous infusions and intermittent infusion:
- before and after all meds
- before converting from a saline lock to a running IV
- after converting from a running IV to a saline lock
- with all IV tubing, extension set, or needless cap changes
- if VAD occlusion suspected
- if blood seen in lumen or IV tubing
For saline locks not in use (no regular scheduled meds)
- at least every 24hrs
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patency assessment and flush procedure
1. clean needless end-cap with alcohol swap for 30secs and dry
2. attach a 10mL NS syringe or larger
3. if appropriate to aspirate IV catheter for blood, do so by gently pulling back on syringe until blood is seen in the lumen-> don't do on fragile or small veins
4. if no blood gets pulled back, flush 1 -2mL into the vein and then try again
5. once patency is established completed flush using a start-stop technique with a min of 3 mL of NS
6. to SL the VAD after the final flush, hold pressure on the syringe plunger as the syringe is disconnected from the end cap and once syringe is removed close the clamp
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alcohol swabs
needleless end caps and IV ports need to be swabbed with 70% alcohol swabs before each access
when giving an IV med: the end cap is cleaned before the patencey assessment, clean before connected medication syringe, and cleaned before connecting the post-med flush syringe
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when to change IV tubing
for open system continuous infusion or closed system continuous infusion
-> change every 96 hours (4 days)
for intermittent or secondary infusion
-> change every 24 hours
always label tubing with date/time/initial when tubing is changed
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when to change IV bags
continuous IV solution without meds
-> can be used for 96 hours
intermittent IV solution without meds
-> can be used for 24 hours
IV solution with meds
-> can be used for 24 hours
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IV rate orders
TKVO and KVO are NOT acceptable abbreviation
a specific rate in mL/hr must be ordered
infusion rate must be documented in the client's chart on in/out record
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keeping ends of tubing and syringes sterile
always be aware of the ends are if you have to take the caps off, try to keep caps on until absolutely necessary to take off
you may use a blue cap, blunt fill needle, or white cap from saline flush to cover an IV port if temporarily disconnecting
155
osmolarity
is concentration of the solution
solute/volume
Osmoses/Liter (OsM)
mOsomoles/Liter (mOsM)
body fluid osmolarity is 285-295 mOsM/L
156
tonicity
describes behaviour of the solution, what it does to cell volume
has no units
is determined by osmolarity and by whether solutes in the solution can enter the cell
hypertonic, isotonic, hypotonic
157
crystalloids
contain small molecules that flow easily across cell membranes
ex. NS, LR, D5NS
158
isotonic solutions
- 0.9% NS
- lactated ringers (LR)
- dextrose 5% in 0.9%NS (D5NS) -> acts isotonic in the body after dextrose is metabolized
- D5LR -> acts isotonic in the body after dextrose is metabolized
osmolarity similar to serum
same osmolarity as the fluid inside the cell
no net movement, stays in intravascular space
expands intravascular volume
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indications for isotonic solutions
fluid and sodium loss -> hemorrhage, severe vomiting and diarrhea
hypovolemic shock
mild hyponatremia (low sodium)
160
hypotonic solutions
- 1/2NS (0.45% NS)
- D5W (dextrose 5% in water) -> acts hypotonic in the body after glucose metabolizes, water dilutes the plasma
- D51/2NS -> acts hypotonic in the body after glucose is metabolized
has an osmolarity lower than serum
has a lower osmolarity than the fluid inside the cell
shifts fluid out of the intravascular space
hydrate the cells and interstitial compartments -> cells swell
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indications for hypotonic solutions
conditions causing intracellular dehydration
hypernatremia
diabetic ketoacidosis
hyperosmolar hyperglycaemic state (very high blood sugar levels for a prolonged period of time)
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contraindications for hypotonic solutions
increased ICP, cerebral edema
liver disease -> worsen ascites and already may have issues with osmotic balance
trauma, burns -> want to maintain blood pressure
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hypertonic solutions
- 3%NS
-D10W
- high electrolyte concentrations
-TPN
has an osmolarity high than serum
has a higher osmolarity than the fluid inside the cell, causes cells to shrink
expands vascular volume
164
indications for hypertonic solutions
hypovolemia
severe critical symptomatic hyponatremia (3%NS)
cerebral edema (3%NS)
clinically significant hypoglycemia (D10W)
165
contraindication for hypertonic solution
fluid volume overload
pulmonary edema
166
colloid solutions
plasma volume expanders that draw fluid into the vascular space
contain large molecules that can't pass through cell membranes
- albumin (protein)
- dextran (glucose)
remain in the intravascular space
always hypertonic
increase osmotic pressure
draw fluid into vascular space
167
indications for colloid solutions
used to expand intravascular volume
168
contraindications for colloid solutions
hypervolemia
fluid volume overload
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The doctor orders NS 1000 mL to run over 8 hrs. Calculate the
IV rate
125 mL/h
170
The doctor orders IV 1000 ml at 75 mL/h. There are no IV pumps
available. What would be the drip rate using 10 gtt/mL tubing?
13 gtt/min
171
How many hours will an IV 1000 ml bag last running at
125 ml/h?
8 hours
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At what time would an IV bag need to be changed if a
1000 mL bag was hung at 0700 and running at 75
mL/hour? (Round to the nearest 1/2 hour and record as a
numeric answer with the unit of measurement)
2000 h
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monitoring fluid balance
fluid output should equal fluid intake
if output>intake, pt is at risk for fluid volume deficit
if intake>output, pt is a risk for fluid volume excess
daily input = daily output + 500mL to cover for insensible losses
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advanced cardiovascular assessment
- cyanosis assessment
- jugular vein distention (JVD)
- abnormal heart sounds
- edema assessment
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JVD
jugular vein distention
is a sign of increased central venous pressure (CVP)
CVP indicates how much blood is flowing back into your heart and how well your heart can move blood to your lungs and body
JVD is a symptom of several different cardiovascular problems including heart failure
176
JVD assessment
normal JVD = 4cm or less
measurement is usually done with the HOB at 45 degrees as jugular veins can normally be distended while laying down
bilateral pressures greater than 4cm are considered elevated -> indicates right-sided heart failure
one-sided pressure elevation is usually due to obstruction
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S1
first heart sound
lubb
tricuspid and mitral valves closing due to the contraction of the ventricles (systole)
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S2
second heart sound
dubb
the pulmonary and aortic valves closing due to diastole (ventricle relaxing)
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S3
this heart sound is heard in children and young adults
happens right after the S2 at the beginning of diastole
is the sound of blood entering the ventricle
1...23
1...23
Kentucky
ventricular gallop
heard in left ventricle failure, volume overload, heart valve regurgitation
180
S4
atrial gallop
happens late in diastole right before systole
heard right before S1
heard in left ventricular hypertrophy (stiffer ventricle), aortic stenosis, coronary artery disease
41...2
41...2
Tennessee
181
murmur
turbulent sounds occurring between normal heart sounds
heard in cardiac valve disorders -> valve regurgitation
182
pericardial friction rub
high-pitched, harsh, grating, scratchy, or squeaking sound
heard both in systole and diastole
heard in pericarditis
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edema
excess interstitial fluid
tissues appear swollen and skin is shiny, taut, and blanched
3 main mechanisms:
1. increased capillary hydrostatic pressure -> fluid overload pushes fluid out of vascular space
2. decreased plasma oncotic pressure -> low levels of plasma proteins prevent fluid from being drawn into the capillaries
3.increased capillary permeability ->fluid escapes from capillaries
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dependent edema
edema of the lowermost parts of the body relative to the heart
effected by gravity and positioning
will move around
185
generalized edema
often caused by poor venous return, not localized by the effects of gravity
186
edema assessment
skin assessment
vital signs
daily weights
intake/output
heart/lung sounds
abdominal girth
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hypovolemia
isotonic extracellular volume deficit
cause:
- abnormal loss of body fluids -> diarrhea, polyuria, hemorrhage
- decreased intake
- plasma-to interstitial fluid shift
goal of tx:
- correct underlying cause
-replace water and electrolytes
tx:
- isotonic IV fluids (RL, 0.9NS, blood)
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hypervolemia
extracellular volume excess
cause:
- excess intake of fluids
- abnormal retention of fluid -> heart failure, renal failure
goal of tx:
- to identify cause and treat
- remove sodium and water without producing abnormal changes in the electrolyte composition or osmolality of ECF
- no IV fluid usually
tx:
- diuretics
- fluid restriction, possibly Na restriction
- paracentesis/thoracentesis if necessary -> drains fluid from abdomen or lungs
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normal serum Na
135 - 145 mmol/L
190
hyponatremia
<135 mmol/L
cause:
- loss of sodium -> GI fluid loss, sweating, diuretic use
- gain of water/water excess -> water shifts into the cells
goal of tx:
- normal serum sodium
tx:
- sodium-containing solutions -> 0.9%NS
-> 3%NS if seizures
-> fluid restriction is water excess
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hypernatremia
>145mmol/L
causes:
- water loss or sodium gain -> water shifts out of the cells which leads to cellular dehydration
ex. diarrhea, excessive salt intake
goal of tx:
water loss:
-> treat underlying cause
-> prevent continued water loss
-> provide water replacement
sodium gain:
- to reduce sodium serum levels gradually
tx:
water loss:
- D5W of hypotonic saline
sodium gain:
- salt free IV fluids (D5W)
- diuretics
- Na restriction
- Oral fluids
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normal serum potassium
3.5-5.3 mmol/L
193
hypokalemia
<3.5 mmol/L
causes:
- abnormal losses of potassium -> shift from extracellular fluid to intracellular fluid
may be from the kidneys (potassium excretion) or GI tract (vomiting, diarrhea, laxative abuse)
goals of tx:
- normal serum potassium
tx:
- potassium chloride supplements (PO or IV)
- if severe, 40-60 mmol KCl IV (10-20 mmol/hr max)
- increase dietary intake of potassium
194
hyperkalemia
>5.3 mmol/L
causes:
- massive intake of potassium
- impaired renal excretion
- shift of potassium from intercellular fluid to the extracellular fluid
goals of tx:
- normal serum potassium
tx:
- stop PO and IV potassium intake
- increase elimination of potassium -> diuretics, dialysis, kayexalate, increased fluid intake
- force fluid from extracellular fluid to intracellular fluid -> IV insulin
- reverse the cell membrane effects of the elevated extracellular potassium with calcium gluconate IV
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osmolarity
refers to the number of solute particles per 1 litre of solution
Osmol/L
normal osmolarity of body fluids is 285-295 mOsm/L
increases when dehydrated and decreases when there is a fluid buildup
196
osmolality
the number of solute particles per 1 kg of solvent
Osmol/kg
serum osmolality measures how much water is in the blood compared to how many solutes are in the blood
when serum osmolality increases, it triggers the body to release ADH which causes the kidneys to reabsorb water
197
IV solutions containing potassium
1. Lactated Ringers (isotonic)
- 4 mmol/L potassium
2. solutions with potassium added
-NS 1000 mL with potassium added, both 20 and 40 mmol/L per bag is hypertonic
- 100mL NS mini bag -> can add 10 - 40 mmol, 10 mmol will by hypotonic, the rest will be hypotonic
198
Continuous IV infusion of potassium steps
1. check MAR
2. Check the IV policy, the IH parenteral manual to make sure it is appropriate to give
3. give med by hanging bag and sign MAR
199
documenting electrolyte IV infusions
must be documented on:
- MAR
- intake/output record
- progress notes if concerns
200
phlebitis/thrombophlebitis
to prevent:
- avoid infusing acidic, alkaline, or solutions with high osmolality
- avoid prolonged use of the same vein
- avoid movement of limb near IV site
- change IV catheter per hospital policy
recognize:
- warmth, redness, pain, purulent drainage
- red line moving up along vein or palpable venous cord
manage:
- discontinue IV
-warm compress
-elevation of limb
201
local infection/cellulitis from an IV
to prevent:
- monitor IV site hourly
- always use aseptic technique
- keep site clean/dry
recognize:
- localized redness, warmth, swelling, purulent drainage
manage:
- discontinue IV
- war compress
- elevation of limb
- IV antibiotics
202
how long to provide pressure to iv site after removal if on blood thinners
5 mins
203
fluid volume excess (FVE)
how to prevent:
- check for correct IV rate and monitor
- monitor breath sounds for crackles
- monitor for edema
recognize:
- crackles
- edema
-extra heart sound
manage:
- elevate HOB
- oxygen
- usually decrease IV rate to TKVO or SL IV -> per MD orders
- chest xray
- diuretics
204
air embolism
to prevent:
- check connections are secure
- prevent air from entering IV system
- prevent air from entering catheter on insertion/removal
recognize:
- sudden vascular collapse
manage:
- emergency procedures/oxygen
- trendelenburg/left side -> air entry moves from right atrium to pulmonary artery
-notify MD
205
catheter embolism
catheter enters the vascular system
prevent:
- remove needle from IV catheter correctly following insertion
recognize:
- symptoms depend on where catheter is lodged
manage:
- report to MD
-treat symptoms
- may need cardiac catheterization
206
extravasation from vesicant drug
vesicant drugs can cause necrotic tissue damage and blisters
prevent:
- ensure IV catheter in vein before administration of solution/med
recognize:
- localized pain
- redness, blistering, tissue necrosis, ulceration at site
manage:
- stop IV, remove catheter
- report immediately
- treatment as ordered
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