Definition

Question 1

IV Therapy

Answer 1

Assessment – renal/cardiac function
Monitor patient status (Wt, I/O, lab studies)
Doctor’s orders - rate and solution
Patient Safety
Be aware of “high alert” drugs (KCL)
Smart pump
Computerized physician order entry

Question 2

Flow rates via Gravity (without pump)

Answer 2

Patency of cannula
Venous spasms
Size of cannula
Blood in tubing
Present of local complications
The higher you hang a bag, the faster it will go
Patency – there should be nothing obstructing it (blood clot will cause drip rate to slow down or just blood in the tubing)
If you suspect blood in tubing, you can try and flush, but if there is a clot, DO NOT force it back into the body
Spasms – can slow flow; caused by cold temp (constricting vessels), cold temp of IVs/IV meds that are in the refrigerator

Question 3

Peripherally Inserted 
Central Catheters (PICC)

Answer 3

Placed in the antecubital fossa
Tip resides in SVC
Low complication rates and less expensive
No BP/blood draws in this extremity 
Fluid comes out in superior vena cava and can handle more meds because it is bigger than a vessel
Nurses need to protect PICC lines
BP cuff could collapse/destroy
Do not draw blood

Question 4

Multi-Lumen Catheter

Answer 4

Can deliver two or more solutions at same time via separate pathways
Necessary for patients who are getting multiple meds, especially blood because blood can only be given with saline
By the time they mix in the blood, all of the meds are well diluted

Question 5

Implanted Ports

Answer 5

No part of catheter is visible
Venous system most common placement
Accessed with a needle through the skin
Helpful for kids because they will not grab at it like they would with the lines
In the SVC
Can be accessed when needed, but okay to stay there without use as well (small lump)
Can stay in for months-years
Common for chemo patients so they can administer it at home
There may be a small incision over the top of the port from where it was inserted

Question 6

Indications for Central Venous Access Device (CVAD)

Answer 6

Medication Administration
Nutrition
Blood samples/transfusions
Conditions (renal failure, burns etc.)

Question 7

Intraosseous Route

Answer 7

High infusion rates are possible
Pain meds may be required
Good for severely dehydrated or during cardio/resp. emergencies
Proximal humerus, proximal and distal tibia
Instills meds directly into the bone
Severe dehydration and cant get a line or in the middle of a code
Used more in ER during traumas

Question 8

Central Line Care

Answer 8

X-Ray before starting fluids
Sterile dressing change
Observe site for S/S infection
Observe for IV systemic complications
Care depends on complication assessed
Cannot start anything until we know for sure that the tip is inserted in the correct area (SVC)

Question 9

Complications of Central Venous Access Devices (CVADs)

Answer 9

Catheter Occlusion
Embolism
Infection
Pneumothorax
Catheter Migration

Question 10

What is the nurse’s role in IV therapy?

Answer 10

Assessment and listen to the patients

Always investigate if there seems to be a problem

Question 11

Local Complications: Infiltration/Extravasation

Answer 11

Infiltration/Extravasation: Skin is pulled away – fluid going into interstitial space
Edema
Pain
Cool temperature
Red
When assessing IVs, you need to look at site at least every hour (fluid build up, red, open, etc)
Compare to other area (hand v. hand, etc)
Pull the IV out if you suspect something is wrong
Make sure you think about what to do next (what med/saline was going in and why?) – what needs to be done next to keep patient safe and stable

Question 12

Local Complications: Nerve Damage

Answer 12

Nerve damage is a big concern
Fluid compresses nerves
Tingling
Numbness in fingers (Emergent situation)
Fluid can be reversed, but nerve damage may not
Prioritize what needs attention

Question 13

Hematomas/Ecchymosis

Answer 13

Hold pressure after removal to avoid hematomas

Question 14

Phlebitis

Answer 14

Phlebitis is warm feeling – take catheter out of the arm to avoid more harm

Question 15

Thrombophlebitis

Answer 15

Thrombophlebitis = clot (this warrants a call to physician, do not press on clot b/c you could dislodge it)

Question 16

Site infection

Answer 16

Redness
Swelling
Possible fever

Question 17

Catheter Related Infection

Answer 17

Caused by poor sterile technique/contamination
Pay attention to ABCs
BP stable
Call RR
Abrupt rise in temp, severe chills, shaking, increase HR, RR, headache

Question 18

Circulatory Overload

Answer 18

Patient got too much fluids and body couldn’t handle it
Increase head of bed
Give O2
Turn to KVO rate (keep vein open) – slow down so your don’t do more harm to patient
If bad, call RR
If you catch it early, call physician – they will likely order Lasix to get rid of fluid excess quicker
Increase BP, distended neck veins, Shortness of breath

Question 19

Pneumothorax

Answer 19

Generally occurs when they are putting a central line in
Intervention with chest tube
Decreased or absent breath sounds, respiratory distress, distended unilateral chest

Question 20

Air embolism

Answer 20

BP is low unlike circulatory overload where it increases
Occurs when you change a central line – if you don’t cap it correctly
Prime line incorrectly
Intervene by positioning in left lateral modified Trendelenburg (head slightly down, feet slightly up, left side) – traps air in right atrium and it gets pulled out
Chest pain, SOB, decrease BP, increase HR, cyanosis, anxiety, confusion

Question 21

IV Push

Answer 21

Always flush before and after to make sure all meds are in patient
We don’t want to mix meds if there is some left over from previous push
Push slowly
Not all drugs can be pushed
Faster reaction from patients
If they do have a reaction, the nurse will be there to intervene quickly
Disadvantage: cant take back and cant slow down, adverse reaction could be more severe and quicker

Question 22

IV Piggyback

Answer 22

Assess patients and teach them meds
Goes into primary line with drip rate (over longer course of time)
Make sure it is diluted in the correct type of solution***
Advantage: Don’t have to be in the room the whole time, less risk of adverse rxn because it is diluted, if there is a rxn majority of med will still be in bag so we can stop it
Disadvantage: Not in the room the whole time to see reaction when it occurs

Question 23

PCA Pumps

Answer 23

Enables the patient to self administer medication on prn. basis
Programmed according to medical orders (dosage, time intervals between doses, and lock-out intervals)
Can record the amount of medications received and the number of requests by the patient

Question 24

Perfusion

Answer 24

refers to the flow of blood through arteries and capillaries, delivering nutrients and oxygen to cells.

Question 25

Central Perfusion

Answer 25

Force of blood movement generated by cardiac output Requires adequate cardiac function, blood pressure, and blood volume Cardiac output (CO) = Stroke volume × heart rate Central perfusion is cardiac output – need blood volume to maintain perfusion If the heart is not pumping, you will see signs all over the body

Question 26

Peripheral Tissue or Local Perfusion

Answer 26

Volume of blood that flows to target tissue Pressure generated from each myocardial contraction supplies blood to peripheral vascular system Valve in each vein keeps blood flowing in direction toward heart Local perfusion or tissue perfusion is a local effect (ex. Blood not flowing to feet) Local manifestations Most of the effects stay local, although it could create a chain reaction and become systemic

Question 27

Impaired Tissue (Local) Perfusion

Answer 27

Impairment of tissue perfusion is associated with loss of vessel patency or permeability, or inadequate central perfusion Results in impaired blood flow to the affected body tissue (localized effect) Leads to ischemia and, ultimately, cell death if uncorrected

Question 28

Atherosclerosis

Answer 28

Begins when waxy cholesterol (atheromas) becomes deposited on the intima of the major arteries Atheromas interfere with the absorption of nutrients by the endothelial cells that compose the vessel lining and obstruct blood flow Build up of plaque in the artery Lumen narrows and interferes with blood flow Blood flow does not get into vessel itself and can cause destruction is fatty substances within the walls of the arteries

Question 29

Arteriosclerosis

Answer 29

a thickening and loss of elasticity and hardening of the arterial walls

Question 30

Impaired Central Perfusion

Answer 30

Impairment of central perfusion occurs when cardiac output is inadequate. Reduced cardiac output results in a reduction of oxygenated blood reaching the body tissues (systemic effect). If severe, associated with shock If untreated, leads to ischemia, cell injury, and cell death Centers around cardiac output You may see shock (major organ damage), stroke (not enough O2 to brain, kidney failure (not enough blood to kidney), etc.

Question 31

Cardiac Output (CO)

Answer 31

CO = Stroke Volume X Heart Rate Stroke Volume = amount of blood ejected from the left ventricle with each heartbeat Heart Rate = Beats/minute If you change one of these factors, you change CO When blood volume drops, HR increases Hypoxia = increased HR If you increase the heart rate, you increase CO

Question 32

Stroke Volume

Answer 32

Influenced by Preload | & Afterload

Question 33

Preload

Answer 33

refers to amount of blood in left ventricle at the end of diastole The greater the preload the greater the “stretch” or contractility of the heart muscle resulting in a greater stroke volume (Starling’s Law)

Question 34

Starlings Law

Answer 34

when I stretch the fibers of the ventricle, it will cause a greater output If you overwork the muscles, they will die ex rubberband

Question 35

Afterload

Answer 35

reflects the amount of resistance the ventricles have to contract against (also know as systemic vascular resistance – SVR) influenced by diameter of blood vessels and blood volume An increase in afterload results in a decrease in stroke volume resistance; what the heart has to pump against to get the blood out When we decrease the afterload, we decrease how hard the heart has to work

Question 36

Perfusion: Modifiable Risk Factors

Answer 36

risk factor is one in which an individual may exercise control by changing a lifestyle or personal habit Weight Cholesterol Blood sugar

Question 37

Perfusion: Non-Modifiable Risk Factors

Answer 37

risk factor is a consequence of genetics over which an individual has no control Age Gender Family history

Question 38

Perfusion: Baseline History

Answer 38

family history, smoking, diet (cholesterol and sodium), exercise, occupation, sleeping (sleep apnea), stress, history of hypertension, medications (specifically BP meds, cholesterol, asthma, diuretics, blood thinners, OTCs (psudofed increases BP and HR, potassium supplements, calcium supplements like Tums))

Question 39

Perfusion: Focused History

Answer 39

Chest pain Edema – excessive fluid is a sign of heart failure Dizziness – blood flow to brain is perfusion issue Extremities are local perfusions Pain Dyspnea Edema Dizziness (altered mental status) Extremity changes (temp, skin, color etc.)

Question 40

Common Diagnostic Tests

Answer 40

``` Doppler Studies Ankle-brachial index (ABI) Laboratory tests Creatine kinase, natriuretic peptides, troponin, homocysteine, C-reactive protein, serum lipids, platelets, prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR) Electrocardiogram (ECG) Cardiac stress tests Exercise or pharmacological test Radiographic studies Chest x-ray, ultrasound, arteriogram, Cardiac Catheterization ```

Question 41

Biomarkers

Answer 41

``` Creatine Kinase (CK) BB – brain MM – skeletal muscle MB – cardiac muscles CK-MB Rise & fall over 2-4 days Onset about 3-6 hrs. Peak within 10-24 hrs. ```

Question 42

Troponin

Answer 42

complex of three regulatory proteins integral for muscle contraction Troponin I used for myocardial damage Released after myocardial injury Levels are usually so low, cannot be detected The higher the troponin, the greater the damage Start to rise within hours after infarct (most within 6 hours after attack) If levels are normal within 12 hours - infarction unlikely Levels detectable for 10-14 days Levels drawn upon arrival to ER and repeated twice within a 12-16 hour window This test does things CK-MB did not do Shows results within an hour or so – patients already release Troponin when they are having a heart attack Troponin can last up to 2 weeks – if a patient comes in days later, there is no CK-MB, but there will be Troponin Troponin correlates with injury – the more severe a heart attack, the more Troponin will be there Physicians will do a second test if the first comes back inconclusive

Question 43

hs-CRP (high sensitivity C-reactive Protein)

Answer 43

Reflective of endothelial inflammation Treatment to lower levels include aspirin, smoking cessation, exercise lipid lowering agents, Omega-3, Patients with rheumatoid arthritis – looks at inflammation

Question 44

Homocysteine

Answer 44

Amino acid result breakdown of dietary protein When levels are elevated, blood clotting may increase and the vascular endothelium may be damaged Treat with folic acid/B vitamin complex (supplements/diet)

Question 45

Serum lipids

Answer 45

-Triglycerides (<150 mg/dl) - HDL (high density) (40-60 mg/dl) - LDL (low density) (<100) - TC (total cholesterol) (<200) (Risk factors = smoking, low HDL, family history of premature CHD and age) HDL is good, LDL is bad It is okay if HDL is high because it is cardio protective – may negate another risk factor If you are diabetic, LDL needs to be less than 70

Question 46

Electrocardiogram (EKG)

Answer 46

PQRST wave forms to assess cardiac function | Deviations from normal sinus rhythm can indicate heart abnormalities

Question 47

Holter Monitoring

Answer 47

Recording of ECG rhythm for 24-48 hours to assess arrhythmias Normal patient activity during recording Recorder stores information Information analyzed Patient needs to keep diary of activities/any symptoms No bath or shower during monitoring Skin irritation may develop from electrodes Can pick up potassium imbalances The patient will keep a diary while wearing EKG electrodes so that if an abnormality occurs or if the patient feels something, they will know what they are doing when it occurs Steps Eat Sleep Rest vs. active

Question 48

Echocardiogram

Answer 48

Uses ultrasound waves Can measure heart structures and size, blood flow and ejection fraction Ejection fraction (EF) = percentage of blood volume that is ejected during systole Normal EF is > 55% Provides information about the left ventricle’s function The ability of a person’s heart to maintain cardiac output If it falls below 50%, that could be an early sign of heart failure Patients needs to lay on their side

Question 49

Transesophageal Echocardiography (TEE)

Answer 49

Provides more precise information about the heart Flexible endoscope with an ultrasound transducer Used in inpatient and outpatient Contraindicated in patient with esophageal disorders Require conscious sedation Behind the heart Put tube down esophagus and see the heart from the back side If there is an issue that is not getting resolved, this may be an option Patient is under monitored sedation Gag reflux has to be numbed – don’t let the patient go until the gag reflux comes back (ABCs) NPO for at least 4 hours prior

Question 50

Exercise Stress Test

Answer 50

Involves walking on treadmill ECG & BP recording included before during and after exercise Patient instructed to report any chest pain, SOB etc. immediately during procedure Wear comfortable shoes Light meal or NPO 2 hours prior No caffeine Avoid smoking prior to the test Some medications may be held Chest pain is a lack of O2 to the heart Most of the time, heart attack is already ruled out at this point, but they need to figure out what is wrong No caffeine or smoking before this

Question 51

Stress Echo

Answer 51

Same as exercise stress, but Includes echo ultrasound before and immediately after walking Pt. needs to get back on table as soon as exercises ceases so post exercise images can be obtained Outpatient test – they can drive after Get a baseline with EKG Put patient on table and do an echo As long as the patient seems okay to do so, they will slowly start treadmill walking Cardiologist will slowly increase rate of treadmill to put some stress on heart If the patient has chest pain, SOB, etc, the test is stopped immediately – if this happens, it is a failed test and they will go for further testing After testing, they have 30 seconds to get back on the table to redo the echo

Question 52

Nuclear Stress Test

Answer 52

Studies involve injection of radioactive isotopes Uptake is measured by a scan Provides info regarding contractility, perfusion and cell injury Patient lays still on back with arms extended overhead for 20 minutes; newer scans have seats Involves exercise on treadmill or medication to simulate activity for patients with ambulation issues Scans are repeated before & after exercise for comparison of images Sometimes the patient is on the treadmill, sometimes there will be a die injection This test is used more commonly on elderly patients to simulate walking on the treadmill Concern is allergy to die

Question 53

Cardiac Catheterization

Answer 53

Right-sided: vein Left-sided: artery Views heart, chambers, O2 status and chamber pressures Involves insertion of a catheter & injection of contrast media & possible placement of stent Coronary angiogram – dye injected into coronary arteries to evaluate condition/blood flow Test to view chambers Can see how blocked coronary arteries are With kids, we are looking at holes in the heart and other congenital issues Cath is threaded into heart and inserted with dye

Question 54

Primary Prevention

Answer 54

Smoking and nicotine cessation Diet Exercise Weight control Monitor BP, Cholesterol levels, Blood glucose They need to STOP smoking all together (not just cut down) Prevents further destruction of the area

Question 55

Secondary Prevention (screening)

Answer 55

Identify High Risk patients and screen Blood pressure screen Lipid Screening

Question 56

Altered Peripheral (Tissue)Perfusion

Answer 56

Arterial Disorders Issue: poor perfusion and oxygenation Atherosclerosis is the leading cause in majority of cases Causes narrowing of the lumen, obstruction by thrombosis, plaque ulceration, aneurysm, rupture Local perfusion Arterial – carries oxygenated blood away from the heart (blood isn’t getting to where it needs) Legs and arms Big component is plaque build up

Question 57

Altered Peripheral Perfusion Manifestations

Answer 57

Intermittent Claudication Thin, shiny, taut skin Loss of hair on the lower legs Diminished or absent pulses Skin changes related to color or temperature “Dependent rubor” “Elevation pallor” Ulcers (usually on toes or near toes, +pain, neurologic deficits present) Pain at rest Occurs in the foot or toes Aggravated by limb elevation The pt will experience intermittent claudication (pain with walking that is relieved with rest) When the pain is occurring at rest, there is a severity increase (red flag) Changes in skin because there is a lack of nutrients to the area Diminished you can live with, but absent is severe Ulcers tend to be near or on toes because of lack of nutrients and O2 to area – arterial disorder Pain deficits or lack of sensation

Question 58

Carotid Artery Disease

Answer 58

Risk of stroke Manifestations: depending on size of obstruction Diagnostic: Carotid duplex ultrasound, MRI, CT (with contrast)

Question 59

Carotid Endarterectomy (CEA)

Answer 59

Opening the carotid artery and removing the obstructing plaque Nursing Care: Monitor vital signs, neuro status, pulses, bleeding

Question 60

Peripheral arterial bypass

Answer 60

Operation with autogenous vein to carry blood around the lesion or occlusion Nursing care Important to assess for occlusion (pulses, temp cap. refill, etc.) Report of pain (type of pain) Bedrest for 18-24 hours Check blood pressure Notify surgeon immediately of abnormal findings

Question 61

Raynaud’s Phenomenon

Answer 61

Extreme sensitivity to cold aggravated by nicotine, emotion, chilling, limited to hands and feet Treatment and education related to preventing vasoconstriction Stress Smoking Painful Goal is to treat patient how to prevent this - (ex if they go into freezer to get something, wear warm gloves) Give them something to reverse the constrictions (vasodilator) – be careful because this decreases BP though (MONITOR)

Question 62

Thromboangiitis Obliterans or Buerger’s Disease

Answer 62

Non-athrosclerotic, recurrent inflammatory vaso-occlusive disorder resulting in microscopic occlusion (thrombi) of distal vessels of upper and lower extremities Caused by history of tobacco/marijuana use Directly related to smoking With the increased use of marijuana, there is also an increase in bureger’s Autoimmune response Lost arms/legs Causes inflammation process and occludes vessels and clots Pt needs to stop smoking – this will slow down inflammation and prevent further worsening

Question 63

Virchow’s triad

Answer 63

Venous stasis Damage of endothelium Hypercoagulability of blood Pain, warmth, redness, and edema

Question 64

Venous thrombosis

Answer 64

formation of a thrombus in association with inflammation of the vein Superficial vein thrombosis (SVT) Formation of thrombus in superficial vein Generally benign disorder Deep vein thrombosis (DVT) Formation of thrombosis in deep vein Most commonly iliac and femoral veins involved

Question 65

Venous thromboembolism (VTE)

Answer 65

Spectrum of pathology from DVT to PE Watch for signs of pulmonary embolus If they think the pt has a clot, they will immediately be put on heparin

Question 66

Venous Insufficiency Disorders

Answer 66

Results of prolonged venous hypertension that stretches the vein and damages the valves Difficulty eliminating waste Builds up in the tissues resulting in stasis, ulcers, edema, cellulitis, brownish “brawny” appearance Prominence of superficial veins Ulcers Usually ankle area, +pulses, no claudication, no neurologic deficits Walking around helps move fluid and get it back to the heart Deoxygenated blood and waste moving back to heart This is a problems of the waste products are not going away There is pain and sensation in the area – very painful Location is key – tells you if it is arterial or venous Who is at risk – Diabetics Smokers Standing in one place Heart disease Immobile Hypertension Obesity Hormone therapy patients Tests ordered – Ultra sound/doppler to see circulation leaving the area Blood test (INR) Cholesterol levels Dye to find what they are looking for

Question 67

Venous Insufficiency Disorders: Care & Patient Teaching

Answer 67

``` Avoid sitting/standing for long periods Avoid trauma to limbs Elevate legs above level of heart to reduce edema Compression therapy Proper nutrition Exercise Collaborate with Wound Care specialist Varicose veins VNUS procedure Laser Adhesive (FDA approved in 2015) ```