Exam 1 - Peripheral IV, Blood Glucose Testing, Blood Products Flashcards
reasons for peripheral IV therapy
- prevent or treat fluid or electrolyte imbalances
- give meds
- give blood products
- provide nutrition
what is max dextrose solution for peripheral IV nutrition
12.5% dextrose
what should you consider for peripheral IV
location and size
should you go small with your IV catheter so it’s easier
no, don’t go small because it may not last
always go _____ when picking IV site and move _____ if necessary
distal….proximal
common sites for peripheral IV in adults
- dorsum of hand
- forearm (intern’s vein)
- antecubital fossa (cephalic and basilica veins)
common site for peripheral IV in peds
- scalp veins
- feet and ankle veins
are the veins used for blood draws the same as ones used for peripheral IV and why
not necessarily because some veins are very positional and should be avoided for IV’s
what gauge peripheral IV catheters for adults
18 and 20
what gauge can be used for elderly or those with difficult peripheral access
22 gauge
what gauge can be used for teens
18-22 gauge
what gauge can be used for children
20-22 gauge
what gauge can be used for infants
22-24 gauge
clean or sterile gloves for inserting peripheral IV
clean gloves
at what angle for needle for peripheral IV insertion
shallow low angle
bevel up or down for peripheral IV needle
bevel up
once see flash of blood along the catheter what do you do with the needle
lower it to skin level and advance slowly
before retracting needle during IV insertion what do you do
release the tourniquet
when retracting needle during IV insertion what is important to do
hold pressure below the catheter tip to stop blood flow
should you ever reinsert the needle during IV insertion
never
when to assess IV site in adults
- beginning of shift
- prior to medication
- whenever accessed or flushed
- if pt complains of pain or discomfort at site
when to assess IV site in peds
- beginning of shift
- if infusing, hourly
- before meds
- whenever accessed/flushed
- pt or parent request
what is phlebitis
inflammation of vascular endothelial wall
inflammation of vascular endothelial wall is
phlebitis
if phlebitis is accompanied with a blood clot it is called
thrombophlebitis
factors that can contribute to phlebitis
- catheter gauge
- size of vein
- length of time catheter in place
- type and pH of solution
- use of small or lower extremity veins
what is required in order for lower extremity veins to be used for IV access
an order
infiltration is characterized by what symptoms
swelling
cool to touch
pale to pink
tender to touch
phlebitis is characterized by what symptoms
swelling warm to touch erythematous tender to touch "cord" like vein with reddened line proximally from site
infiltration would be ____ to touch
cool
phlebitis would be _____ to touch
warm
nursing actions for infiltration
- remove IV
- may insert more proximal
- replace IV in unaffected arm
- warm pack
nursing actions for phlebitis
- remove IV
- insert in unaffected arm
- avoid insertion in affected arm
- warm pack
complications of peripheral IV
- catheter occlusion
- fluid overload
- infection
- air embolism
what is the universal blood donor
O-
what is the universal blood recipient
AB+
Rh positive can receive _____
positive and negative blood
Rh negative can receive _______
only negative blood
what is included in whole blood (7)
- red cells
- white cells
- platelets
- electrolytes
- plasma
- antibodies
- added anticoagulant
what is whole blood indicated for
massive blood loss
is a filter needed for whole blood
yes
what is a normal volume for a unit of whole blood
500 mL
what is usual adult peds dose of whole blood
20mL/kg
what does packed red blood cells contain
- mainly red cells with plasma removed
- some white cells
what is a normal volume for unit of packed red blood cells
300 mL
what is packed red blood cells indicated for
raise hemoglobin or hematocrit when dangerously low
one unit of packed red blood cells raises hemoglobin by ___
1
one unit of packed red blood cells raises hematocrit by _____
3
is a filter needed for packed red blood cells
yes
what is a normal peds dose for packed red blood cells
10mL/kg
what are platelets made of
platelets separated from plasma
what is normal volume for one unit of platelets
50-70 mL of platelets
what are indications for platelets
to stop bleeding or when platelets low
one unit of platelets increases platelet count by how many
5000
is a filter needed for platelets
yes
what is fresh frozen plasma
plasma is separated from whole blood and then frozen
one unit of fresh frozen plasma is usually what volume
200-250 mL
what are indications for fresh frozen plasma
clotting deficiencies, DIC, liver disease, warfarin reversal
is a filter needed for fresh frozen plasma
no, but should be matched to pt blood type and Rh factor
what is cyroprecipitate
prepared from plasma, contains factor VIII, von Willebrand’s factor, factor XIII and fribrinogen
one unit of cryoprecipitate is usually what volume
5-20ml
what is cryoprecipitate indicated for
hemophilia A (factor VIII deficiency von Willebrand's disease and factor XIII deficiency
what is albumin
plasma derivative
does albumin need to be ABO or Rh matched
no
what two concentrations are there for albumin
5% and 25%
what are the indications for albumin
when crystalloid solutions are not adequate for volume expansion or when there is a capillary leak
what does albumin do in the vessels
it provides oncotic pressure to keep plasma fluid in the intravascular space
what blood product uses a filter to draw up, but not with administration
albumin
what other plasma derivatives are there
factor VIII, factor IX, and ISG (immune serum globulin)
when giving blood what must be obtained by the patient
consent
what does blood transfusion consent include
the advantages, disadvantages, risks, complications, and if alternative methods could be used
when is consent for blood transfusions delayed
in emergency situations, such as trauma
in pediatric pt’s who gives consent for blood transfusions
parent or legal guardian
who usually obtains blood transfusions
the patient’s provider
for patient’s who oppose blood and blood products for religious reasons what would be given instead
- increase crystalloid or some may agree to albumin in order to increase intravascular volume
do blood administration policy’s and guidelines vary by facility
yes
how long do you have before hanging blood to get vitals
30 mins
when is it best to send for blood
after taking vitals and checking IV patency
how long can blood last before it must be hung
it must be hung within 30 min, but preferred
if blood not hung before 30 mins what do you do with it
send it back to blood bank
can you put blood in the unit refrigerators
no
when administering blood use the _______ IV access you can
largest
what gauge do you use for blood administration
18g is preferred, but can use 20g
does blood transfusion tubing include a filter
yes
how long is blood tubing good for
24 hours
how many units of blood can be used per tubing
6 units
what personal protective equipment is required for blood admin
clean gloves and face shield if concerned for blood splashes
how many RNs need to check blood product
2 RNs
what gets checked by 2 RNs during blood transfusion
blood product type donor ID# donor blood type patient blood type any special prep
if any blood info does not match from blood compatibility tag and blood bag what do you do
send it back to blood bank
can the 2nd nurse checking the blood product be an LPN
yes
what type of tubing is used for most blood transfusions
Y tubing
what do you prime blood transfusion tubing with
normal saline
what would happen if you used lactated ringers or dextrose solution to prime blood transfusion tubing
it would hemolyze the red cells
can you use lactated ringers or dextrose to prime blood transfusion tubing
no
what is the only other product that can be infused or piggy backed to blood transfusion
only normal saline
can you ever add medications or piggyback anything following blood transfusion
no, only normal saline
how long is blood good for
4 hours
why is blood expired after 4 hours out of the blood bank
the risk for bacterial infection is greater and RBCs begin to die
at what rate do you first infuse blood and for how long
at 30ml for 15 minutes
why do you infuse blood slower at first
to see if there is any adverse reaction to the infusion
after 15 min with no reaction to blood transfusion what do you do
take vitals and increase the infusion to what is ordered
at what point are vitals taken at the end of the blood transfusion
within 15 minutes of the end of the transfusion
what do you do if patient is having a reaction to blood transfusion
stop the infusion immediately and if patient is stable take vitals
what documentation is included for blood transfusions
all vitals, product type, donor ID #, how long it infused, and how pt tolerated
what is frequently given with minor blood transfusion reactions
Benadryl and tylenol
if mild blood transfusion reaction occurred are they able to receive another unit of blood later
yes
evidence shows that most reactions to blood tranfusions occur within the first_____ minutes
15
4 most common types of blood transfusion reactions
- febrile non-hemolytic
- acute hemolytic
- allergic
- anaphylactic
of the 4 types of blood transfusion reactions which is the most common
febrile hemolytic
what happens with febrile hemolytic blood transfusion reaction
- happens within 6 hrs
- antigen-antibody response to donors WBC
- sudden chils, fever, headache, flushin, muscle pains, chest pain, dyspnea
what would be ordered for a febrile hemolytic reaction
antipyretics
what happens with allergic reaction to blood transfusion
during transfusion or within 1 hr after
- sensitivity to foreign plasma proteins
- flushin, itching, hives
what would be administered for allergic reaction to blood transfusion
antihistamines (Benadryl)
blood trans reaction: antigen-antibody response to donors WBCs
febrile hemolytic
blood trans reaction: sensitivity to foreign plasma proteins
allergic reactions
what happens with acute hemolytic blood trans reaction
ABO incompatibility, happens due to some sort of mislabeling
- occurs within 5-15 min
- chills, fever, low back pain, tachycardia, tachypnea, hypotension, renal failure, hemoglobinuria, cardiac arrest, death
nursing actions for acute hemolytic blood trans reaction
check vitals q 5 min and ABC support
blood trans reaction: ABO incompatibility
acute hemolytic
what happens in an anaphylactic reaction to blood transfusion
- infusion of IgA protein to IgA deficient recipient
- reaction happens immediately
- anxiety, wheezing, respiratory distress, nausea and vomiting, cramping, shock, cardiac arrest
nursing actions for anaphylactic reaction to blood transfusion
support ABC and admin epinephrine
what may be given to high risk pt’s such as though with CHF while receiving blood transfusions
Lasix to avoid fluid overload
blood trans reaction: infusion of IgA protein to IgA deficient recipient
anaphylactic reaction
lab testing procedures performed in an area where pt is located instead of traditional lab
point of care testing
what is the purpose of blood glucose testing
- test for hypo or hyperglycemia
- effectiveness of insulin or oral hypoglycemic meds
is a prescriber order required for blood glucose testing
yes
what type of blood is used for blood glucose testing
any type (capillary, venous or arterial)
how is blood glucose value reported
in milligram per deciliter (mg/dl)
what is normal glucose range
60 - 100
critical low value for BG
less than 40
critical high value for BG
more than 500
if BG high or low on first test what should you do
repeat the test
when are quality control tests done for glucometer testing
24 hrs prior to patient testing, usually done on nights
fight or flight response with increased adrenaline and glucagon are adrenergic signs and symptoms of what and why
hypoglycemia due to decline in plasma glucose
change in mental status from confusion and agitation to loss of consciousness are neuroglycopenic signs and symptoms of what and why
hypoglycemia due to shortage of glucose in brain
do the neuroglycopenic symptoms of hypoglycemia occur before or after the adrendergic symptoms
usually concurrently or after the adrenergic signs
what are the nurses response to hypoglycemia
- admin 25-50 grams of dextrose (D50)
- graham crackers, saltines, and juice
- glucagon
what are the classic signs and symptoms of hyperglycemia
three Ps = polydipsia, polyuria, polyphagia
aside from 3 P’s what are other signs of hyperglycemia
anorexia, nausea, vomiting, fatigue, rapid shallow respirs, loss of consciousness, dehydration, hypotension, tachycardia
what are kussmaul’s respirations
rapid shallow respirations that are compensating for metabolic acidosis by blowing off excess CO2
if a persons breath smells fruity and they are breathing quick shallow breaths what is it an indication of
hyperglycemia
what can the manifestations of hyperglycemia ultimately lead to
diabetic ketoacidosis (DKA)
how does symptoms of hyperglycemia lead to DKA
increased glucose levels cause body to use fat for energy which increases production of ketones
when increased glucose levels cause the body to use fat for energy it results in an increased production of what which is called
increased ketones and is called diabetic ketoacidosis
would you correct hyperglycemia quickly or slowly and why
slowly because if not it can lead to rebound hypoglycemia
treatment of hyperglycemia would be
- fluid resuscitation
- regular insulin
what is fluid resuscitation
bolus of normal saline (.9%)
