DONESkills exam 1-powerpoints/ book Flashcards
QSEN & Monitoring IVs
always
do not
if you
Always follow a routine!
Do not trust anyone!
If you do not identify an error and allow it to occur, you are responsible as well.
intravenous therapy review
admisntered
fluids and medicines and can be admisntered through catheter
QSEN & Monitoring IVs
Check all parts in a sequential fashion from fluid bag to patient:
check
how much
check
how would
follow
when does
check the
inspect tubing
check iv site
inspect
is ??
Check fluid—is it correct?
How much is left in bag? (when will it need changing)
Check drip chamber—is it half-full?
How would you fix it if it is not?
Follow tubing to the pump
When does the tubing need changing?
Check the IV pump—correct rate set?
Inspect tubing for kinks, air, obstructions- follow tubing to iv site to male sure its running to patient
Check IV site- appropriate and infusing
Inspect insertion site for complications
Is the dressing intact?
Why is IV Therapy Ordered?
allows
meds
highly
used for
used to replace
Allows rapid fluid replacement
Medications bypass the GI tract
Highly potent medications can go through venous system
Used for nutritional support
Used to replace, maintain, or repair imbalances in fluids and electrolytes
hypertonic
Hyper-has higher concertation of solutes. Water will leave cell and shrink
hypotonic
Hypo-has low concentration of solutes.water will enter cell and expand
isotonic
normal saline remains
however
-normal saline remains in vascular compartment and increases blood volume.
However when administer rapidly this solution can cause acid base imbalances
isotonic d5w
used in
not to be
can cause
causing
Used in fluid loss, dehydration, hypernatremia,
not to be used with high volume deficient
can cause hyponatremia causing Brain swelling
isotonic .9% nacl
not typically used
can treat
USED IN
Not typically used as maintenance solution because it only provides Na and Cl in excessive amounts.
Can treat hypovolemia, metabolic alkalosis, hyponatremia and hypochloremia.
Used in Blood Transfusions
isotonic lactated ringers
contains
used in
used to
Contains electrolytes—about same as plasma,
used in hypovolemia, burns, and fluid loss for GI sources.
Used to treat Metabolic acidosis
hypotonic .33% Nacl
provides
allows
used
Provides Na, Cl and free water.
Allows kidney to select and retain needed amounts,
used in treating hypernatremia.
hypotonic .45% nacl
provides
used
often used
because
Provides Na, Cl and free water.
Used for maintenance.
Often used to treat hypernatremia.
Because it dilutes the plasma Na while not allowing it to drop too rapidly
hypertonic d5 0.45 nacl
used
Used to maintain fluid intake
hypertonic d10w
supplies
used in
Supplies 340 cal/L.
Used in peripheral parenteral nutrition (PPN)
hypertonic d5 0.9% nacl
used to treat
can temp be used
if
Used to treat SIADH (Syndrome of inappropriate Antidiuretic Hormone.
Can temporarily be used to treat hypovolemia
if plasma expander not available
18 gauge—
where used
allows
surgical and trauma patients—
allows rapid volume infusion
20 gauge—
most
minimal
most infusions and can use for blood,
20 gauge – minimal size needed for blood administration
22-24 gauge—
where used
why
fluids and medications
, use for older adults/ pediatric pts
Start low why w iv-
can/cant
due to
you can go back up but cant go down
because of potential leakage when going back in to body
Vein evaluation
apply
hold
compress
fist
choose
-apply tornequte to enlarge the vein.
Hold area depdendnt(drop arm to ground) to prmote blood return back to vein.
Warm compresses.
Open and close fist.
Choose a straight, firm and elastic vein.- want a vein that you can palpate and feels bouncy
Non-dominant side
why
- because most pateitns wipe themlseves with dominant hand and can lead to probelms
Site to avoid
antecubital area beucase the site will clot off easier due to usage
saline lock
average flush
injet slowly- what does it do
average flush is 2-5 ml even with srygne being 10 ml
inject slowly- push pause
This motion creates turbulence within the catheter lumen causing a swirling effect to move fibrin, lipids, medications and other adherents attached to the catheter lumen and prevents occlusions from occurring
Place tourniquet-
prep
allow
do not
do not
placed
skin prep with chlorhedixidine for 20 secinds.
Allow 30 secinds to dry
- do not fan area to dry.
Do not touch after prepping.
Placed 4-6inches above site that we are looking at going to
ensure patency in saline lock
do not
if there is
watch for
Do not force-if have to force, then iv is bad and will blow the vein
If there is burning/pain, then stop- means iv is bad and pt feels it
Watch for fluid leakage or swelling- is fluid coming out of catheter site and going underneath dressing, or at site is swelling occuring
Administering IV Medications presentation
check a
check ar
why am
check com
administer where
check I
adminster at
flush when
ALWAYS
prior
if continuous infusion
complete a
what type
teach
Check allergies
Check armband and have patient state name and birth date
Why am I giving this pt. this medication?
Check compatibility-might be giving 2-3 meds in iv site and meds to be compataible so they aren’t causing adverse reactions
Administer in the closest port to the IV insertion site….why??? Because we need medications to go in at the time frame that they need to go in. meds and saline flish are at same exact rate
Check IV patency
Administer at correct rate
Flush before and after (after at the same rate)
ALWAYS verify order with MAR
Prior to administering always check proper IV placement by flushing the IV if the IV is capped.
If the IV is a continuous infusion, ensure there is no infiltration
Complete a FOCUSED assessment related to the medication to be given. Remember to reassess AFTER medication is administered! If this is a new medication for the patient stay with them for a period of time to check for allergy reaction
What type of medications would require a focused assessment?
Teach your patient about the medication to be administered
Infusion Pumps
requirement
the pump
frequent
use
complications:
Requirement by Joint Commission that all fluids should be on a pump (per agency policies: i.e. clinics)
The pump is only as good as the operator
Frequent checks required
Use appropriate IV tubing
Complications of pumps: Occlusion Alarm, air in line alarm, malfunction Alarm
Decreased Fluid Volume cause
v
d
g s
s
I i
a
m e
e
Vomiting
Diarrhea
GI suctioning
Sweating
Inadequate intake
Ascites
Massive edema (burns)
Elderly (forget)
Decreased Fluid Volume symptoms
w l
poor
o
c u
d m m
postural __
–pulse
__Tension
hemoglobin
na
bun
Weight loss
Poor skin turgor
Oliguria
Concentrated urine
Dry mucous membranes
Postural hypotension
Weak/rapid pulse
Hypotension
Hemoglobin elevated
Na+ normal or increased
BUN elevated
Decreased Fluid Volume treatment
record
replace
remember
monitor
Intake and output
Replace fluids—isotonic
Remember H20 is hypo
Monitor weight
Excess Fluid Volume cause
chf
rf
lf
excess _ ingestion
over
excess __
Congestive heart failure
Renal failure
Liver failure
Excessive salt ingestion
Over-hydration
Excessive IV fluids
Excess Fluid Volume symptoms
p e
__/ __pulse
__bp
lungs
neck
d
c
d u
w g
na+
decreased
BUN
Peripheral edema
Increased// Bounding pulse
Elevated BP
Crackles lungs
Distended neck veins
Dyspnea
Confusion
Decreased urine SpG
Weight gain
Na+ decreased
Hgb/Hct decreased
BUN may be decreased
Excess Fluid Volume treatment
d
f r
m w
limit intake
Diuretics
Fluid restriction
Monitor weights
Limit sodium intake
Infiltration
what is it
how to treat
fluid is leaking out of vein and into tissue; area is swollen and cool to touch.
Stop infusion, remove catheter (physician order per agency)
Phlebitis—
what is it
how treat
vein is irritated due to injury or irritation; area is red, warm, possible swelling noted.
Stop infusion, remove catheter, apply warm compress
Fluid or blood leaking –
wear
check
change
Wear GLOVES!
Check all connections to make sure they are tight
Change dressing
extravasation of iv fluids s/s
Pain
Stinging
Burning
Redness
Swelling
Extravasation nursing considaerations and interventions
– stop immediately, take iv out, contact physician and pharmacy for orders and potential antidote.
difference between infiltration and extravasation
Infilatratiion is the leaking out of fluids
Extrvasation is the leaking of a vesicant or chemo drug- can cause tissue destruction or blistering// can lead to pain, loss of usage in infected extremetie or infection
differnece between iv bolus and push
IV “bolus” = an amount of medication or IV fluids given at one time. (Usually RAPID)
IV “push” = is a bolus, but SLOW administration
flush after meds
ensure length
Adminster flush after medication at same rate as medication
Ensure that length of tube and catheter are taken into account when flushing- longer tubing = more amount of flush
follow
ensure
green
Follow medication to pump to patient
Ensure pump is at ordered and correct rate for each medication
Green caps are used for open ports
Compatible iv push meds
if med is compatible
put
use
pinch
unpinch
restart
- If medication is compatible with IV fluids you need to turn the IV pump off (IV flow rate may be running faster than administration time of the med)
Put on gloves
Use the closest port to the patient
Pinch the tubing above and inject medication according to time
Unpinch tubing, may need to flush
Re-start IV pump
iv push meds
remember to
alchohol
use the
Remember to REASSESS as indicated
Alcohol wipes and saline flushes are sterile. Don’t set down, then pick up and use again!
Use the smallest syringe possible for the most accurate dose
iv push meds
if dose small
scrub the hub
If the dose is extremely small such as 0.2ml, dilute further to be able to administer in the appropriate time frame-usually 1mL as a minimum
Scrub the hub
15-30 seconds of a vigorous scrub is required on the port in order to decrease the risk of bacteria entering the port
PCA
enables-
doses-3
has what
Enables patients to self-administer analgesics
loading doses
continual dose (basal dose)
bolus dose
Has a lock out so patient is protected from overdosing themselves
advantages of pca
dose precision,
timeliness and convenience- pt isn’t waitng for nurse and can do it on own
disadvantages of PCA
care
potential
cost
: Nursing care for any IV line,
potential for infection
, cost of disposal of supplies
PCA
requires what
ensure what
Requires careful patient teaching and monitoring to patient and family
Ensure compatibility of PCA medication with any other medications to be administered in the IV Don’t forget about the PCA when you give IV Push medications
THINGS TO CHECK AHEAD OF blood TRANSFUSION
check / ask if
identify
explain/ask
check that/ and that
Check the physician’s orders and patient allergies –ask if they’ve ever had transfusions before
Identify patient using two identifiers
Explain procedure to patient and ask about any cultural needs/variations.
Check that type and crossmatch are complete and that blood is ready in the Blood Bank
things to check ahead of transfusion
perform
provide
review
assess
asses if
Perform basic physical assessment before initiating skill, including baseline set of vital signs - especially temperature
Provide Privacy
Review agency policy/protocol and procedure
Assess if patient has informed consent for transfusion
Assess if patient has established IV site, appropriate gauge catheter for administration of blood
administering blood — saline aspect
prepare
begin
close
spike
open
close
set
prepare supplies
begin infusion of sodium chloride
close clamps on y set tubing
spike bag of ns with 1 arm of y tubing
open clamp below tubing filter to prime main tubing
close main clamp when tubing is primed
set iv pump to run saline @ kvo rate
administering the product- blood
obtain
validate w/
pull/ to
spike w
open
administer
obtain blood from bank
validate name, blood, id number with another RN
pull back tabs on blood unit and expose port
spike blood bag with pre arm of y tubing
open clamp to blood
administer blood as ordered
Why must we monitor our patients so closely during any blood product administration?
Pts could have reactions from blood products
blood product
start __ for 15 minutes
stay with//take what
observe
regulate rate – complete in how long
Start blood infusion, administer slowly (15-30 ml blood) for initial 15 minutes (rate 60-120 ml/hr)
Stay with patient for first 15 minutes. Take vital signs within 5-15 minutes of initiating transfusion and at completion of transfusion or per agency policy.
Observe patient closely for adverse reactions; report as necessary or per agency policy
Regulate rate per health care provider orders; Complete transfusion within 4 hours so it doesn’t get warm and expire
post blood
obtain
place
document
Obtain post transfusion vital signs
Place transfusion related equipment in biohazard container as per agency policy
Document vital signs and patient’s tolerance to procedure on appropriate agency forms
Infusion Rate of blood
administer_ for first 15
if patient tolerates-> give how long
infuse at/// but care elderly
Administer slowly (15-30 ml blood) for initial 15 minutes (rate 60-120 ml/hr)
If the patient tolerates this “test dose”, the rate may be increased, the remainder of the unit is given over 2-3 hours. no more than 4 hours
Infuse at a rate patient tolerates, but care must be taken to avoid circulatory overload in elderly.
SYMPTOMS AND SIGNS OF TRANSFUSION REACTION
f
s o b
c
h
i
pain where
n
w
what at infusion site
facial what
c
what feeling
c
__tension
m
d
abnormal
u
edema where
o
r
j
Fever > 1°C/2°F
Shortness of Breath
Chills
Headache
Itching
Chest/back pain
Nausea
Wheezing
Heat at infusion site
Facial flushing
Coughing
Uneasy feeling
Cyanosis
Hypotension
Myalgia
Dyspnea
Abnormal bleeding
Urticaria (Hives)
Pulmonary edema
Oliguria/anuria
Rash
Jaundice
allergic reaction to blood
mild s/s
severe s/s
what do
Mild-: Hives/urticaria, itching
Severe: Coughing, wheezing, hypotension
Stop, new bag of saline, notify MD
febrile reaction to blood
s/s
do what
as ordered
Fever (1°C/2°F), chills
Stop, new bag of saline, notify MD
Pre-medicate, administer antipyretics as ordered
Circulatory overload reaction to blood
s/s
do what
Dyspnea, cough, edema
Slow/stop, elevate HOB, notify MD
Hemolytic reaction to blood
s/s
do what
clumped
Fever, chills, back pain, shock, burning@vein, tachycardia, hypotension
Stop, saline, notify MD – treat shock
Clumped rbc block vlow to organs- can cause renal failure
Infectious Disease Transmission/Bacterial reaction to blood
s/s
do what
Fever, hypotension, vomiting/diarrhea
Stop, notify MD, blood cultures, possible antibiotics
If any symptom of reaction occurs…
stop
keep iv
contact
notify
Stop Transfusion.
Keep intravenous (IV) line open with new saline. – not one in tubing
Contact treating physician for directions for patient care and administer supportive/definitive care.
Notify the transfusion service or lab
If any symptom of reaction occurs…
rule out_ by
complete
send _ to
defer_ until
Rule out clerical error by RECHECK of Unit, transfusion tag and patient identification.
Complete appropriate work-up/forms and send to laboratory.
Send actual unit to laboratory only when directed to do so.
Defer future transfusions until workup complete.
documentation of reaction to blood work
Complete all required information including:
times
recored all
pts
and
start, and stop times
,
record all vitals,
patients tolerance
any appropriate agency forms
DISPOSING OF BLOOD PRODUCT BAGS
discard
do not dispose if
Discard blood product container and IV tubing according to hospital policy for waste disposal.
Do not dispose of bags or tubing if transfusion reaction suspected.
blood compatibility
whole blood
unknown
o
a
b
ab
unknown- contraindicated
o o
a a
b b
ab ab
blood compatibility
red cells
unknown
o
a
b
ab
unknown-o
o-0
a- a or 0
b- b or 0
ab- any abo
blood compatibility
platlets
unknown
o
a
b
ab
unknown- any abo
o-any abo
a-any abo
b-any ano
ab- any abo
blood compatibility
FFP
unknown
o
a
b
ab
unknown –AB
o –any abo
a –a or ab
b –b or ab
ab –ab
Blood type and crossmatch-
types what
screening for
crossmatching
types pts abo antigen and rh factor//
screening for antibodies/
/ crossmatching serum and donor cells
Complete blood count-
evalautes
evaluates compotents of bloof including rbc and wbc
Arterial blood gas-
evalautes
presence of
evaluates oxygenation, acid-base balance,
and presence of metabolin or respiratory compensatory mechanisms
Blood alcohol Level
measures
alcohol does what
measues amount of alchohol in pts blood/
/ alchohol alters pts loc and repsone to pain
Urine drug screen-
drugs can do what
drugs can also alter loc and response
Pregnancy test
rules out
-rules out potential fot pregnancy/fetal injury
Focused assessment by sonography in trauma
evalautes
- evaluates identification of blood in cavities where its not suppoed to be
Focused assessment with sonography-
bedside
should be when
bedside ultrasouns that can detect blood in pericardial. Pritonieal or plueral spaces/
/ should be performed immedialy after primary survey
Computerized tomography (CT) scnas-
reveals
reveal injuries to brain, skull, spine, spinal cord, chest and abdomen
Magnetic ronasnce imagine scans-
reveals
reveal injures to brain/spinal cord
Blood componets/ crstalloids
when
replaces-
administered iv in treatment of shock–
replaces intravasluar volume
Inotropic and vasopressive meds-
given to
only administered when
meds
given to increase cardiac ouput and improve tissue perfusion/
/ only amdisnted after adequate fluid resoration/
/ dopamine. Dovuatmine, epinephrine, norepinephren, vasopressin, phenelphrin
Opiods-
admisntered how
treats
can alter
causes
admisterd bolus or continuous/
/treat pain asap/
/can alter response to injury,
cause hypotension and repository depression//closely monitored
Immunixations-
given when
what needs to be determined
given if pt has open wounds.
Tetanus status must be determained- if pt is unable to remember when last tetanus shot was given, unable to answer, ot has not received in 5 yers- give tetnaus
ringer lactate indications
restoration of
replacement of
Restoration of circulating volume
//Replacement of electrolyte deficits
ringer lactate advantages
readily
to use
cost
aids in
readily avaialbe,
safe to use,
low cost,
aids in buffering acidosis
ringer lactate disadvantages
rapid
leading
rapid movement from intrvascular to extravasdsluar,
leading to 3x or more requirements for replacement
advantages normal saline
a
cost
to use
avaialbe,
low cost,
safe to use
disadvantages whole blood
contains
greatest risk are for
risk of
contains few platelets,
greatest risk are for incompatilibty or circulatory overload,
risk of transmitting bloodborne pathpgens
disadvantages normal saline
what with prolonged use
hypercholermic acidosis associated with prolonged use of sodium solutions
indications whole blood
replaces
in what
replaced blood volume and oxygen carrying capacity
in hemorrhage and shock
indications packed rbc
restoration of
replacement of
restoration of intravascular volume,
replacement of oxygen carrying capacity
normal saline indications
restoration
vehicle
resortaion of circulating volume/
/ vehichle compatible with adminstation of blood
advantages. whole blood
contains
contains rbc, plasma, proteins, clotting factos and plasma
advantages packed rbc
one unit
in what
one unit should increase hemoglobin by approximetly 1 g
in absence of volume overload or blood loss
indications platelets
significant
continued
significant throimbocyopenia- >20000-50000/
continued hemorrhage
disadvantages packed rbc
requires
risk of
should be
contains
red cells require compatibility testing,
risk of transmitting bloodborne pathogens,
should be warmed to prevent hypothermia
, contains little to no clotting facotrs
disadvantages albumin
not
risk of
risk of
not a substitute for whole blood/
risk of hypersentaive reactions,
risk of trasmiting bloodborne pathofgens
indications albumin
expands
in
expands volume
in shock and truma
indications fresh frozen plasma
documented
restoration
supplies
documented coagulopathy,
resortation of clotting factors,
supplies plasma protens
disadvantages platelets
should be considered
risk of
postexposure prophalxis should be considered following rh+ transfusion in rh- women/
/ risl of transmitting bloodborne pathoegens
advantages platelets
testing
should
compatibility testing not required,
should raise adult platelets by 30,000 – 50,000
advantages albumin
good
good avlaiblity
disadvantages fresh frozen plasma
must be
should also
risk of
must be thawed in 37°C (98.6°F) water bath for approximately 30 min//
should be abo compatable,
risk of transmitting bloodborne pathogens
advantages fresh frozen plasma
not required
crossmatching and rh compatibility is not required
indications Cryoprecipitate
Coagulopathy w
restoration of
Coagulopathy with low fibrinogen/
Restoration of fibrinogen
advantages Cryoprecipitate
not important
rh
disadvantages Cryoprecipitate
risk of
contains
if large
risk of transmitting bloodborne pathogens/
/ contains hemagglutinins
, if large volumes of abo- are admisnted, hemolysis can occur
Blood group a
RBC Agglutinogens
Serum Agglutinogens
Compatible Donor Blood
Incompatible Donor Blood Groups
RBC Agglutinogens a
Serum Agglutinogens anti b
Compatible Donor Blood Group a,o
Incompatible Donor Blood Groups b, ab
Blood group b
RBC Agglutinogens
Serum Agglutinogens
Compatible Donor Blood
Incompatible Donor Blood Groups
RBC Agglutinogens b
Serum Agglutinogens anti a
Compatible Donor Blood Group b,o
Incompatible Donor Blood Groups a, ab
Blood group ab
RBC Agglutinogens
Serum Agglutinogens
Compatible Donor Blood
Incompatible Donor Blood Groups
RBC Agglutinogens a,b
Serum Agglutinogens none
Compatible Donor Blood Group a,b,ab,o
Incompatible Donor Blood Groups none
Blood group o
RBC Agglutinogens
Serum Agglutinogens
Compatible Donor Blood
Incompatible Donor Blood Groups
RBC Agglutinogens none
Serum Agglutinogens anti a and anti b
Compatible Donor Blood Group o
Incompatible Donor Blood Groups a,b,ab
