Assessment Of IV Flashcards
Assessment of IV fluids
Verify what is ordered.
Verify correct solution.
Verify correct rate.
Pump vs. gravity
Bag & tubing dated and timed
What are you verifying on an infusion pump
- Hourly rate
- Alarms
- Plugged in or battery
What are you assessing on an IV site
Date of insertion
Condition of site: redness/swelling, pain
Dressing intact with date
How would you document D5 infusing on pump 100mL/h. IV has no problem and is in the left forearm
Date, Time
IV D5 NS infusing via infusion device at 100 ml/hr into left forearm, site clear, free of redness, swelling, or pain, date on dressing. Signature & title
Documentation of gravity flow of LR into right hand IV, 22g. No problems with IV
Date, time
IV LR infusing via gravity at 75 ml/hr into 22g right hand. Site free of redness, swelling, and pain. Date in dressing. Signature & title.
What are we looking for when we remove an IV?
Examine IV catheter, make sure it is intact.
What do we record on I&O sheet for IV
IV intake
Document 20g IV discontinued
IV 20g discontinued intact left forearm. Site is clear, free of redness, swelling, or pain. Patient educated to report any development of pain, redness, or swelling to nurse. Signature & title
Macro-drip
10-15 gtt/mL
Micro-drip
60 gtt/mL
How to prime tubing & avoid bubbles
-close roller clamp
-hang IV bag
-fill chamber 1/3 to half chamber before priming
-Prime, control flow, allow inversion of injection ports before fluid reaches the and tap as fluid fills them, minimize turbulence
Piggyback set up
secondary bag higher than primary, both lines are open, use primary clamp to adjust rate & secondary wide open, prime secondary by backflow, primary bag to flush secondary
How often should primary tubing for continuous infusions be changed
Change primary tubing for continuous infusions no more than q96 hours
How often should secondary tubing be changed
every 24 hours due to risk of contamination
When should IV be assessed
at beginning of shift and t/o
What are you assessing for management of IV
site, solution, tubing, flow rate
What are you looking for at IV site
redness, streaking, firmness, swelling, drainage, firmness, blanching, pain temperature change
How often is IV replaced
q 72-96 hours
what are complications of IV
infection, phlebitis, infiltration, circuatory overload
what are Sx of infection at IV site
redness, swelling, warmth, purulent drainage
Nursing intervention (NI) for infection of IV site
discontinue IV, express drainage, send catheter for Cx
Sx of phlebitis
pain, increased skin temp, redness along vein
NI for phlebitis
dc, apply moist & warm compress, monitor qh for redness & tenderness, document degree with 1-4 scale (no sx to severe)
what is infiltration of IV
leakage into extravascular tissue, occurs when IV dislodged
Sx of infiltration
edema, pallor, decreased temp, pain
NI of infiltration
discontinue, apply warm compress to help absorb fluid
what is extravasation
catheter dislodged and meds infuse into tissues, can damage tissue
Sx of extravasation
pain, stinging, burning, selling, redness
NI of extravasation
dc, apply cool compress, administer antidote, document
what is circulatory overload
excess fluid in circulatory system
Sx of circulatory overload
dyspnea, increased BP, edema, moist lung sounds
NI for circulatory overload
preventative measures: assess baseline and monitor for fluid excess t/o
Removal of IV NI
double check order to dc, inspect catheter tip
