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Block 2 > Exam 1: Perioperative nursing and IV therapy/venipuncture > Flashcards

Exam 1: Perioperative nursing and IV therapy/venipuncture Flashcards

1
Q

Nursing role for IV therapy

A

Venipuncture/insertion
Setting up equipment
Calculating infusion rate
Setting up pumps
Frequent observations
Determining site
Determining gauge
Determining when to remove IV and change sites if complications occur (phlebitis, infiltration, infection)
Patient education
Discontinuing

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2
Q

What should be assessed before IV therapy?

A

Medical dx
Has the patient had IVs before?
Hx of vasovagal reaction during previous venipuncture or seeing blood?
Activity level
Is the patient on anticoagulants?
Labs (Platelets, PT, INR)
Hx of fainting
Mastectomy

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3
Q

When should the RN ask the HCP for CVC or PICC?

A

Veins are poor or non-existent
Therapy is longer than 1-2 weeks
Therapy is irritant, vesicant, or hypertonic
Pt is going home on IVs for more than 1-2 weeks

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4
Q

How should the RN choose size of the IV device?

A

Expected duration of therapy
type of therapy
conditions of the patient’s veins
patient preference
RN/physician preference

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5
Q

Why would the RN choose a larger gauge (smaller number)?

A

If the solution is viscous
For rapid infusions during hemorrhage or shock

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6
Q

Why would the RN choose a smaller gauge (bigger number)?

A

Better blood flow around the catheter
Less discomfort
lower risk of phlebitis/thrombosis

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7
Q

How to choose the IV site

A

non-dominant extremity
round, stable, bouncy, straight vein
begin distal and work up

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8
Q

Veins to avoid

A

sclerosed or thrombosed veins (hard)
edema, inflammation, bruising
veins distal to previous IV infiltration, phlebitis, or scar
arm vein located on the same side as a mastectomy, CVA, or renal fistula
sites that interfere with surgery
joints and areas of flexion
impaired circulation

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9
Q

How to promote vein distention

A

tourniquet
BP cuff at 30 mm/Hg for fragile veins
warm moist compress for 10 minutes
gravity - hang arm below heart level
tap vein with fingers - do not slap
hydrated pt
multiple tourniquets
massage arm from proximal to distal end

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10
Q

What sites should the RN avoid sticking?

A

superficial antebrachial (near wrist) - sensitive and difficult to move around with
metacarpal veins (on hand) - last resort for elderly because their skin is fragile and it can result in bleeding and hematomas
feet - never use for diabetics and must have an order to use this site, can cause complications
digital veins - fragile veins, only can be used for isotonic solutions

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11
Q

how often should the RN rotate IV sites?

A

every 72h and prn

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12
Q

what gauge IV catheters are usually used for surgeries?

A

16-18 gauge

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13
Q

What size gauge is most commonly used?

A

20 gauge, 1-1.5 in

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14
Q

How should the IV site be prepared?

A

clip hair if needed, do NOT shave
chlorhexidine or alcohol and betadine scrubbed for 30 seconds (if allergic to both use alcohol x4 and keep skin wet for 1 minute)

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15
Q

What should the RN include on the IV site label?

A

date, time, initials, and gauge

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16
Q

What should the RN do if they are unable to access the vein or the vein blows?

A

release tourniquet
place gauze over the site and remove catheter
hold pressure for 1-3 min
assess the angiocatheter to ensure it is intact
tape gauze with pressure
try another site, if unable to do it again, have another RN do it
if starting in the same arm keep the other IV in place until the new one is started

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17
Q

How should the RN assess the IV?

A

check for pain, tenderness, redness, swelling, leaking
dressing is intact
tubing is taped securely
pt condition and response to therapy
IV is infusing properly
IV rate every time the RN enters the room
do not touch the bag while checking the volume of the bag
check F&E

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18
Q

what to do if a hematoma forms

A

release tourniquet immediately and remove the needle, apply firm pressure

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19
Q

What is phlebitis and what are the signs and symptoms?

A

vein inflammation
most common problem
causes: mechanical, chemical, bacterial, or post-infusion
s/sx: streak formation, palpable venous cord, vein may be thrombosed, IV flow may stop, might have purulent drainage

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20
Q

How can phlebitis be prevented?

A

rotating the IV site every 72-96 hours or at the first sign of phlebitis or infiltration

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21
Q

What should the RN do if they suspect phlebitis?

A

discontinue the IV
elevate the extremity and apply warm moist compress
notify physician

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22
Q

What is infiltration?

A

dislodgment of the cannula from the vein causes infusion into the subcutaneous tissue

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23
Q

signs and symptoms of infiltration

A

blanching
swelling
pallor
pain
during aspiration, blood may return with partial infiltrate or no blood may return

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24
Q

infiltration treatment

A

discontinue IV
elevate
apply warm moist compress or cold depending on what was infiltrated

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25
Q

extravasations

A

infiltration of a medication that may cause tissue injury or necrosis

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26
Q

what might cause extravasations?

A

chemotherapy
phenergan
dilantin
total parenteral nutrition

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27
Q

what should the RN do if they suspect an extravasation?

A

notify physician

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28
Q

IV infection s/sx and actions the RN should take

A

redness, warmth, tenderness, purulent drainage
replace IV, notify MD, culture drainage or catheter

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29
Q

venous spasm and actions the RN should take

A

pain along the vein track, can be caused by cold or irritating solution
assess for phlebitis, infiltration
apply warm moist compress to vein
slow the infusion prn

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30
Q

What should the RN do if a catheter embolism is suspected?

A

do not reinsert the needle
do not apply pressure
apply tourniquet above the site and send the pt to radiology with MD order

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31
Q

air embolism and s/sx

A

air gets into the venous system (50 ml over 3 sec) blocking pulmonary circulation
s/sx: chest pain, anxiousness, wheezing, tachypnea, hypotension

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32
Q

causes of air embolisms

A

loose connections - end open to air
air in IV line - did not prime tubing, glass bottle, vented tubing, dry plastic bag gravity infusion

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33
Q

air embolism treatment

A

call for help
clamp catheter
place on left side in trendelenburg
administer O2
aspirate air prn

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34
Q

general guidelines to prevent complications

A

hand washing and aseptic technique
prep skin well
rotate site q 72-96 h or at 1st sign of phlebitis or infiltrate
hang hydration bag for no longer than 24 h and change when some fluid is left to avoid running dry
secure catheter to prevent movement and contamination
assess site and pt q4h for adults and q2h for children and each time you enter the room
educate pt on s/sx of complications and when to call the nurse

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35
Q

what is the vein of choice for venipuncture?

A

median cubital vein
-it is more stationary than others, less painful to puncture, closer to the surface of the skin, and is not nestled among nerves and arteries

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36
Q

order of draw for blood cultures

A

red or tiger top
blue top
green top
lavender top
gray top

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37
Q

how much blood is collected from each site for a blood culture?

A

10-15 ml in a 20ml syringe

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38
Q

for anaerobic and aerobic cultures which should be inoculated first?

A

anaerobic bottle first

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39
Q

how should the blood culture be labeled?

A

at the bedside
pt name, date, time, and RN initials
send to the lab within 30 minutes

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40
Q

pt education after venipuncture

A

-do not bend arm - can cause bleeding in AC area compromising vessels and nerves
-keep arm straight and elevated while applying pressure
-keep dressing in place for a few hours

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41
Q

assessments and documentation after venipuncture

A

assess for bleeding or bruising
record:
-method used to obtain specimen, date and time collected, type of test, lab receiving specimen
-site after collection
-pt tolerance to procedure

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42
Q

geriatric considerations for venipuncture

A

use smaller needle (23g)
wmc

43
Q

What should the RN do if the pt continues to bleed at the venipuncture site?

A

apply pressure and a pressure dressing
continue to monitor

44
Q

what should the RN do if the pt develops a hematoma at the venipuncture site?

A

apply pressure to the site and document
continue to monitor

45
Q

What should the RN do if the collection is incomplete or no blood is obtained?

A

change the position of the needle/move it forward/move it backward/adjust the angle
loosen the tourniquet
try another tube - there might not be a vacuum
re-anchor the vein - it might have rolled

46
Q

what should the rn do if blood stops flowing into the tube?

A

vein might have collapsed -resecure the tourniquet to increase venous filling
remove needle, apply pressure to dressing, and redraw

47
Q

inpatient surgery

A

in the hospital
pt is admitted day of surgery or is already hospitalized

48
Q

what requirements must be met for a pt to have surgery in an outpatient setting?

A

surgery is less than 2 hours
requires less than 3-4 hour stay in PACU
low risk - no significant comorbidities, not an older adult or neonate, low risk of complications

49
Q

local anesthesia

A

loss of sensation without LOC

50
Q

regional anesthesia

A

loss of sensation to a body part without LOC
nerve blocks, epidurals

51
Q

What tasks does the RN complete during the pre op phase?

A

interview
assessment
diagnostic screening
informed consent
pre op teaching

52
Q

pre op interview

A

health hx - allergies, past surgeries, medications, alcohol, street drugs, smoking, advance directive
psychosocial assessment - anxiety, stress, spiritual beliefs, cultural beliefs
past experience with surgeries
concerns about surgery

53
Q

pre op assessment

A

physical exam done by MD
baseline assessment done by RN too
VS, nutrition, sleep pattern, activity, elimination, sensory/perceptual, ADLs, last menstrual period, medications and supplements, neurological, respiratory, cardiac, GI, GU, skin

54
Q

what factors can increase surgical risk?

A

hypovolemia
dehydration
F&E imbalance
nutritional deficits
extremes in age
extremes in weight
infection
hepatic and/or renal dysfunction
impaired immune
respiratory disease
cardiovascular disease
pregnancy
diabetes
endocrine disorders

55
Q

pre op diagnostic tests

A

CBC
electrolytes
UA
chest x ray if over 40 y/o
EKG depending on age and hx
type and cross match

56
Q

what is the RN’s role in informed consent?

A

witnessing the signature
the surgeon explains the procedure

57
Q

pre op checklist

A

RN completes the whole checklist before the pt goes into the surgical area

58
Q

pre op teaching

A

best done day before surgery and reinforced the morning of surgery
NPO instructions
incentive spirometer use, PCA use
involve the family to increase compliance
give rationale about why things are done
pain control - ask before pain is too bad
relaxation techniques
leg exercises to prevent blood clots
abdominal splitting with pillows
enemas - to cleanse bowels

59
Q

common pre op medications used

A

sedative and tranquilizers to reduce anxiety and induce sensation
narcotic analgesics/opioids - decrease amount of anesthesia needed and reduces discomfort during procedure
anticholinergics - decrease respiratory secretions, protects against aspiration, prevents bradycardia
antiemetics - decreases nausea and vomiting
prophylactic antibiotics - prevent infection

60
Q

pre op preparation

A

hair in cap, gown untied, dentures out, no jewelry
void/foley might be inserted
IV might be inserted
medicate if inpatient
patient is transferred to the OR suite

61
Q

Surgical environment - unrestricted area

A

Entry points for patients, holding area, staff locker rooms, nursing station

62
Q

Surgical environment - semirestricted area

A

only authorized personnel allowed
must wear surgical attire and cover head and facial hair

63
Q

Surgical environment - restricted area

A

masks, shoe coverings, surgical attire
OR suites, scrub sinks, clean core

64
Q

Holding area

A

Entrance to intra-op - ensure that check list and consent forms are completed at this point
Anesthetist meets with the patient
- asks about surgical and medical hx and administers medication to relax the patient
- discusses choices
- answers questions

65
Q

Circulating RN

A

non-sterile/not scrubbed in
assists with room prep
obtains needed items
identifies and assess pt, charts, and admits pt. to the OR
positions the pt, performs skin prep, records

66
Q

What is the main function of the circulator/circulating RN?

A

to protect the patient
- prevents wrong site, procedure, and/or surgery
- ensures that sterility is maintained

67
Q

How does the circulator protect patient positioning?

A

Allows accessibility of the operative site
Maintenance of the patient’s airway
Prevents injury to nerves caused by compression of tissues or poor blood flow
Provides correct skeletal alignment, adequate thoracic excursion, modesty
Prevents falls

68
Q

What are the dangers of improper positioning during surgery?

A

muscle strain, joint damage, pressure ulcers, nerve damage
ultimately can cause permanent disability

69
Q

Scrub RN, LPN, or tech

A

sterile
requires certification
assists with room prep
scrubs, gowns, and gloves self and others
prepare the instrument table and organizes the sterile equipment for use
assists with draping, passes instruments, counts instruments, monitors solutions used, reports amounts of local anesthesia and epinephrine used

70
Q

Anesthesia care provider

A

MD or CRNA
assesses pt pre operatively
prescribes pre op and adjunctive meds
monitors pt. cardiac status and VS during OR

71
Q

RN first assist

A

assists the surgeon and surgical team by
- handling tissues
- using instruments
- providing exposure
- assisting in hemostasis
- suturing
requires education and certification

72
Q

What combination of meds are usually used during surgery?

A

anesthesia - loses pain sensation
sedation - loss of consciousness
muscle relaxants

73
Q

general anesthesia

A

loss of sensation and loss of consciousness
skeletal muscles relax
ventilation and CV function might be impaired
administered by IV, inhalation, or rectally

74
Q

Phases of general anesthesia

A

Pre induction stage - conscious and ends with LOC, pre op meds given, IV access, application of monitors

Induction stage - LOC, dreams, hallucinations, intubation, position for surgery

Maintenance - during surgery, pt is monitored

Emergence - surgery done, dressings applied, reversal of anesthesia and neuromuscular blocking agents, airway removed

75
Q

Laryngeal mask airway

A

LMA
placed by anesthesia care provider after induction of anesthesia
reduces risk of aspiration

76
Q

monitored anesthesia care

A

low dose of benzodiazepines administered IV
analgesia, amnesia, reduced anxiety, no ventilation assistance needed, pt. remains responsive, regional or local anesthesia are often used as well
No inhaled agents are used
Pt. should have continuous pulse ox and reversal agents (Ramazicon) should be available

77
Q

Local anesthesia

A

loss of sensation without LOC
topically, IM, or SQ

78
Q

regional anesthetics

A

loss of sensation to a body region without LOC
specific nerve or group of nerves are blocked w/ administration of local anesthetic
sedating agents are also used to reduce anxiety

79
Q

risks of spinal anesthesia

A

respiratory depression
place on pulse ox

80
Q

Catastrophic events in the OR

A

Code - codes are run internally/without people from outside the surgical suite
Hemorrhage - pts are blood typed and crossed
Anaphylactic reaction - obtain a careful hx
Hypoxia - inadequate ventilation, poor intubation, aspiration of vomit, lack of respiratory excursion. Monitor with pulse ox
Unintentional hypothermia

81
Q

unintentional hypothermia

A

from cold surgical environment, infusion of cold fluids, cold irrigation solutions
at risk: pts. with advanced age and low body mass, long procedures, extensive blood loss
monitor core temps, use IV fluids slowly, keep warm blankets near

82
Q

Malignant hyperthermia

A

Genetic autosomal dominant disease
Causes hyper metabolic stat in skeletal muscle
S/x: tachycardia, tachypnea, fever, ventricular dysrhythmias
Treatment: Dantrium
Prevention: careful hx of surgical/anesthetic complications in patient and patient’s blood relative
Triggered by anesthetic agents
Usually occurs during anesthesia but may occur during recovery

83
Q

What information should the circulating nurse report to the PACU nurse?

A

Name
Age
Dx
Anesthesiologist
Surgeon
Surgical procedure
Pt. condition
Why surgery was done
Medical hx
Medication allergies
Current medications
Comorbidities

84
Q

What is a part of the immediate post op assessment?

A

ABCs
neuro
GU
surgical site
physiological needs (pain, N/V)

85
Q

What respiratory problems might present in the post op period?

A

atelectasis is most common
airway obstruction
pulmonary edema
hypoventilation
aspiration
atelectasis
pneumonia
hypoxemia

86
Q

atelectasis:
who is most at risk?
what causes it during surgery?

A

at risk: smokers, thoracic and abdominal surgeries, poor cough effort

what causes it: secretions obstructing bronchi, anesthesia and high levels of O2 administered during surgery

87
Q

What are potential neuro problems in the post op period?

A

pain
fever
delirium
hypothermia

88
Q

what are potential urinary problems during the post op period?

A

urinary retention
infection
acute renal failure (ARF)

89
Q

what are potential GI problems in the post op period?

A

n/v
distention
hiccups
delayed gastric emptying

90
Q

what are potential cardiovascular problems in the post op period?

A

hemorrhage
hypotension
shock
thrombosis
phlebitis
pulmonary embolism
postural hypotension

91
Q

what are potential fluid and electrolyte problems during the post op period?

A

fluid overload
fluid deficit
hypokalemia
acid-base disorders
hypo/hyperglycemia

92
Q

who is responsible for the patient until they are fully awake?

A

the anesthesiologist

93
Q

who is responsible for the surgical site and talking to the family?

A

the surgeon

94
Q

when can the patient be transferred or discharged?

A

transferred when they’re VS are stable
discharged when VS are stable, they have urinated, can keep down fluids, and pain is under control

95
Q

what should the PACU nurse include when giving report to the staff nurse when the patient is being transferred?

A

dx
type of surgery
age
pre op condition and VS
anesthetics and drugs used during OR and PACU
specimens sent to the lab
amount and type of fluids given
amount and type of pain/antiemetic meds administered in PACU
EBL, tubes, drains, cath

96
Q

once the patient is on the nursing floor, how often should the RN check VS?

A

every 15 min x4 or until stable
then every 30 min x2
then every hour x4
then every 4 hours
continuously check respiratory status, incision, color, circulation, motion, and sensation with each VS check

97
Q

how will the RN know how much drainage is coming out of a wound?

A

circling the drainage

98
Q

what nursing interventions should be done in the post op patient?

A

turning, deep breathing, and coughing
incentive spirometer
pain relief
relaxation
leg exercises
ambulate
increase fluids when allowed
monitor I&Os
monitor VS
intermittent compression devices

99
Q

what are complications during the post op phase?

A

n/v
sore throat
hiccups
paresthesia
pain
headache
gas
urinary retention (usually resolves in 48 hours)
shock
hemorrhage
DVT
pulmonary embolism, atelectasis, pneumonia
renal failure
dehiscence or evisceration
fistula
infection, sepsis
pressure ulcers

100
Q

what are risk factors for dehiscence/evisceration?

A

poor nutrition, advanced age

101
Q

what can help prevent dehiscence or evisceration?

A

splinting to prevent strain on wound edges

102
Q

who is in charge of making sure the 2nd verification of the procedure and surgical site takes place?

A

the circulating nurse

103
Q

when should the surgical site be marked?

A

prior to surgery with the surgeon and patient

Block 2 (4 decks)

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