201 IV therapy part 2 Flashcards
what does cyanosis look like in pigmented individuals?
-brown skin may appear yellow-brown
-very dark brown or black skin may appear ash gray
normally, should you be able to see jugular veins?
-no, normally they are not visible
-if they are, its called jugular vein distention distention, which is a sign of central venous pressure (CVP)
-CVP indicates how much blood is flowing back to your heart and how well your heart can move the blood into the lungs and the rest of your body
-JVD is a symptoms of several different cardiovascular problems, some can be life threathening
-nurses need to assess for JVD during a focused CVS assessment, especially in clients exhibiting s/s of HF
what does it mean if the jugular venous pulsation is higher in the neck?
-it means the jugular venous pressure is higher, and if the pressure is too great, jugular venous distention occurs
-if the blood pressure in the heart is normal, the blood only rises a little in the neck
-if the pressure is too high, the blood is pushed higher up in the neck
what is the normal JVD?
4 cm or less
in what circumstances, are JVD normally distended?
-when the person is laying flat
-so when measuring the vein, keep the HOB 45 degrees (30-90 degrees is okay)
what does bilateral pressure greater than 4 cm mean?
means there is an elevated jugular vein pressure, indicating the pressure in the right atrium is higher than normal, which can lead to right sided heart failure
what does it mean if only on jugular vein’s pressure is elevated?
usually obstruction
how can you measure JVD?
manually with rulers or using an ultrasound
S3?
-a ventricular gallop
-extra sound heart sound: heard early diastole
-lupa-dupa (“kentucky”)
-heard in left ventricle failure, volume overload, heart valve regurgitation
S4?
-atrial gallop
-extra heart sound: heard late diastole
-ta-lub-dup (“tennesse”)
-heard in left ventricular hyperthropy, aortic stenosis, and CAD
murmur?
-turbulent sounds occurring between normal heart sounds
-heard in cardiac valve disorders
pericardial friction rub?
-high-pitched, harsh, grating, scratchy or squeaking sound heard both systole and diastole
-heard in pericarditis
pleural friction rub?
-low pitched, grating, scrating or squeaky
-caused by pleuritis
-tell pt to stop breathing, if sound goes away it’s pleural friction rub, and if it continues even if the person isn’t breathing, it’s pericardial friction rub
what is dependent edema?
-edema in the lowermost parts of the body relative to the heart, affected by gravity and position
-more noticeable when a person is sitting or sitting for long periods, as gravity causes fluid to accumulate in the lower parts of the body
what is generalized edema?
-edema that is all over the body
-often caused by poor venous return
-not localized by the effects of gravity
whats the difference between pitting and non pitting edema?
-pitting: leaves a small depression or pt when a finger pressure is applied for atleast 10-30 secs
-eg. CHF, low protein levels, DVT, liver disease, kidney failure, and venous insuffiency
-nonpitting: edema in which pressure does not leave a depressioin in the tissue
-eg. lymphedema, thyroid problem
what is ascites?
fluid retention in the abdominal cavity
what is peripheral edema?
edema that affects the lower extremities (eg. in heart disease)
what is lymphedema?
localized swelling of the body caused by an abnormal accumulation of lymph
what is cerebral edema?
accumulation of fluid in brain (brain and skull) tissue
what is pulmonary edema?
diffuse extravascular accumulation of fluid in the tissues and air spaces of the lung (eg. left ventricular failure)
what do you assess for in an edema assessment?
-skin assessment
-vital signs
-in/out
-daily weights
-heart/lung sounds
-abdominal girth
what is edema?
-the presence of excess interstitial fluid
-tissues appear swollen
-skin is shiny, taut (skin looks stretched) and blanched
what are the 3 main mechanisms that cause edema?
-increased capillary hydrostatic pressure (which pushes fluid into the interstitial spaces), which can cause fluid overload/dependent edema
-decreased plasma oncotic pressure (low levels of plasma protein prevent fluid from being drawn into the capillaries from the interstital space) , this decrease in plasma proteins can be caused by malnutrition, liver or renal failure
-increased capillary permeability (fluid escapes from the capillaries into the interstitial spaces), common causes are in allergic reactions
what is hypovolemia, what are it’s causes, goal of treatment and treatment?
-what it is: decreased blood volume in the vascular space
-caused by: abnormal loss of body fluids (eg diarrhea, polyuria, and hemorrhage) , decreased intake, and plasma-to-interstital fluid shift
-goal of treatment: to correct underlying cause, to replace both water and electrolytes
-txt: isotonic IV fluids (RL, 0,9%NS,blood)
what is hypervolemia, what is it caused by, goal of treatment and txt?
-is excess blood volume in the vascular compartment
-caused by: excess intake of fluids, abnormal retention of fluids (eg. in HF and renal failure)
-goal: to identify cause and treat, to remove sodium and water (without producing abnormal changes in the electrolyte composition or osmolality of ECF, no IV fluids usually
-txt: diuretics, fluid restriciton (and possibly Na restriction), paracentesis/thoracentesis if necessary (medical procedures done to remove fluid, in this case, it can be done for ascites, pleural effusion)
what is the normal serum sodium?
135-145 mmol/L
what is hypoantremia, what its caused by, goal of treatment and txt?
-sodium serum level less than 135mmol/L
-caused by: loss of sodium (Gi fluid loss, sweating, diuretics), gain of water/water excess (water shifts into the cell, and can be caused by excessive drinking of water)
-goal: normal serum sodium
-txt: sodium containing solutions (eg. NS 0.9%) AND Hypertonic NS (3%NS) if seizures , fluid restriction (if water excess)
what is hyperantremia, what is caused by, goal of txt and txt?
-is it serum sodium greater than 145 mmol/L
-caused by: water loss or sodium gain (water leaves the cels causing cellular dehyration)
-goal: if there is water loss (to treat underlying cause, prevent continued water loss, provide water replacement) and if there is sodium gain (to reduce sodium serum levels gradually)
-txt: if there is water loss (D5W or hypotonic saline such as NS 0.45%) , or if there is sodium gain (salt free IV fluids like D5W, diuretics, Na restriction, oral fluids)
what is blood fluid osmolarity?
285 -295 mOsm/L
what is the osmolarity of 0.9NS? (isotonic)
308
what is the osmolarity of 0.45 NS? (hypotonic)
154
what is the osmolarity of 3% NS? (hypertonic)
1027
what is the osmolarity of D5/0.9% NS (iso in the body)
560
what is the osmolarity of D5/0.45 % (hypotonic)
406
what is the osmolarity of Lactated ringers (isotonic)
273
what is the osmolarity of D5LR
525
what is the normal serum potassium?
3.5-5.3 mmol/L
what is hypokalemia, what are the causes, goals of txt and txt?
-serum potassium is less than 3.5mmol/L
-cause: abnormal losses of potassium (shift into intracellular fluid) from kidney and the GI tract (from diarrhea, vomitting laxative, ileostomy drainage) and deficient in dietary potassium intake
-goals: normal serum potassium
-txt: potassium chloride supplements (PO or IV), if severe, 40 to 60 mmol KCL IV (10-20 mmol/hr max) , and increased dietary intake of potassium
what is hyperkalemia, causes, goals, and treatment?
-potassium serum levels less greater than 5.3mmol/L
-causes: massive intake of potassium, impaired renal excretion (renal failure) and shift of potassium from intracellular fluid to the extracellular fluid
-goals: normal serum potassium
-txt: stop PO and IV potassium intake, increase elimination of potassium (diuretics, dialysis, increase fluid intake, kayexalate), force fluid from the extracellular to the intracellular (eg. IV insulin), reverse the cell membrane effects of the elevated extracellular potassium (calcium gluconate IV)
what is osmolarity?
-refers to the number of solutes particles per 1 liter of solution (Osmol/L)
-normal osmolarity of body fluids is 285-295 mOsm/L
-increases when dehyrated and decreases when there is fluid build up
what is 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 increase, it triggers the body to release antidiuretic hormone (ADH), which causes the kidneys to reabsorb water
what electrolytes are HAM for elderly?
-potassium chloride
-because elderly are at increased risk for hyperkalemia
what drug interactions with potassium chloride?
-potassium sparing diuretics (eg spironolactone or triamterene) and ACE inhibitors can produce hyperkalemia
what is 1mmol K equal to?
1 mEQ of K
for adults, for infusion greater than 20 mmol k/hour, how often is ECG monitoring?
continuous monitoring
for pediatrics and neonate, how often do you monitor for intermittent and continuous rates greater than 15mmol K/hour?
continuous ECG monitoring
what is recommended to monitor if giving potassium?
-serum electrolytes, urea and creatine and glucose
-assess IV site for signs of extravasation (leaking)
what are adverse effects of hyperkalemia?
-paraesthesia (numbness and tingling) of extremities, flaccid paralysis (muscles lose tone and become weak, soft, floppy), mental confusion, weakness, hypotension, ventricular arrhythmias, heart block , ECG changes and cardiac arrest (esp in renal impairment if administered too rapidly)
-pain at injection site, phlebitis and extravasation
what is the normal daily requirements of potassium?
40-80 mmol/24 hours
how much of chloride potassium increase the serum potassium by 1mmol/L
40 mmol KCL
where should you document IV electrolyte solutions?
1) MAR (dose, and time hung)
2) input/output record (electrolyte solution, amount, time of bag change, and total amount of solution infused)
3) progress notes if concerns (eg low/high potassium, and s/s)
what is catheter occlusion, how to prevent, how to recognize/assess and how to manage?
-when there is an obstruction or blockage in the catheter
-how to prevent: flush IV saline lock every 24 hours, ensure IV at least 1 meter above pt (heart) while laying or ambulating
-recognize/assess: you’re unable to flush
-manage: disconnect IV
what is interstitial/infiltrated IV, prevent, recognize, manage?
-when the IV moves out of place and into the surrounding tissues, and the fluid infused is going into the surrounding tissues
-prevent: frequent monitoring of IV site, teach client to report
-recognize: cool to touch, pallor, swelling, or hardness
-manage: discontinuse, warm compress and elevate the limb
what is phlebitis/thrombophlebitis, how to prevent, recognize, manage?
-inflammation of the vein, inflammation of the vein that causes the formation of the clot in the vein
-prevent: avoid using acidic, alkaline or solutions with high osmolality (chemical), use of same vein (mechanical), movement of limb near IV site (mechanical) and change IV catheter per protocol (bacterial)
-recognize: warmth, redness, pain/tenderness, purulent drainage and red line moving up along vein or palpable venous cord
-manage: discontiue, warm compress, and elevate
leaking IV site?
-prevent: frequent monitoring, teach pt to report, sometimes cannot prevent
-recognize: fluid/blood leaking out around site but connections are secure
-manage: often need to discontinue IV
local infection/cellulitis prevention, recognize, manage?
-cellulitis: bacterial infection of the skin
-prevent: monitor IV site hourly, always use aseptic technique, and keep site dry/clean
-recognize: localized redness (may move up limb), warmth, swelling, purulent drainage
-manage: discontinue, warm compress, elevation of limb, and Iv antibiotics
hematoma prevention, recognize, manage
-prevent: avoid trauma to the IV site, may not be able to prevent
-recognize: bruising, swelling, bleeding at site
-manage: discontinue, warm compress, elevation
accidental removal prevent, recognize, manage?
-prevent: ensure IV securely taped, teach pt to avoid pulling on IV or tubing, check IV tubing is free before moving client
-recognize: catheter out and bleeding at site
-manage: firm pressure on the site until bleeding stops (at least 5 mins if on blood thinners)
fluid overload prevent, recognize, manage
-prevent: check for correct IV rate and monitor, monitor for breath sounds for crackles, monitor for edema
-recognize: crackles, edema, and extra heart sounds
-manage: elevate HOB, oxygen, chest xray, diuretics, usually decrease IV rate to TKVO or SL IV (per MD orders)
air embolism prevent, recognize, manage
-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, tredenlenburg/left side: feet up head down (air moves from right atrium to pulmonary artery), notify MD
catheter embolism prevent, recognize, manage
-prevent: remove needle from IV catheter correctly following insertion
-recognize: s/s depend on where catheter is lodged
-manage: report to MD, treat symptoms, may need cardiac catherization
extravasation (from vesicant drug) prevent, recognize, manage
-prevent: ensure IV catheter in vein before admin of solution/med
-recognize: localized pain, redness, blistering, tissue necrosis, ulceration at site
-manage: stop IV, remove catheter, report immediately, txt as order
anaphylaxis prevent, recognize and manage
-prevent: check for allergies
-recognize: local symptoms (rasj, hives, itching) and more severe (lip/tongue/throat/face swelling)
-manage: report immediately, txt as ordered
what is speed shock?
-a sudden, adverse physiological reaction to IV meds or drugs that are given resulting in toxic levels of meds in the plasma
-signs:flushed face, headache, tightness in the chest, irregular pulse, shock, syncope, loss of consciousness, cardiac arrest
-nursing interventions: notify physician immediately, ensure patent IV for fluids, may need reversal/antidote, have an emergency equipment available and monitor closely
