Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

3323 Advanced Assessment > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

purpose of IV therapy

A

maintain daily fluid and electrolyte imbalance; replace fluid and electrolyte losses; correct fluid and electrolyte imbalance; provide access to venous system for medication administration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

IV Therapy

A

immediate absorption into bloodstream (rapid onset); medications have immediate physiological response (ex. change in vitals); Peripheral IV is most common; used for short-term therapy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

IV therapy used for

A

IV fluid, meds, blood products

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Location of IV therapy (PIV)

A

superficial veins of the forearm and hand

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

most common way to run IV fluids

A

through a pump; gravity ran is much less common and used in emergency/trauma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

larger gauge needed…

A

for more viscous fluids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

magma catheter

A

14 gauge; used for trauma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

gray catheter

A

16 gauge; used for major surgery, large volume infusions, unstable patients

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

green catheter

A

18 gauge; use for large volume infusions, multiple or rapid infusions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

pink catheter

A

20 gauge; used for medications, hydration, and transfusions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

blue catheter

A

22 gauge; used for small veins, common for short term access, usually cant administer blood (hemolyze blood)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

yellow catheter

A

24 gauge; fragile small veins, pediatric population, last resort for adults

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

bevel up or down when inserting catheter

A

up

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

primary lines used for

A

main line is usually used for meds or fluids; continuous primary infusion; bolus or intermittent of fluid; pump or gravity; additives run slowly over time (ex. electrolytes);primary lines may have intermittent secondary infusions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

IVAD

A

intermittent venous access devices aka saline lock

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

intermittent venous access devices use

A

used for intermittent infusion; use of extension tubing is recommended; flush 2-3mL q12 hours or per facility policy; flush in pulsatile method

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

when flushing be cautious for…

A

fluid restrictive patients; flush minimum required

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

when using PIV with IVAD be sure to flush…

A

before to ensure adequacy of line prior to administering meds; after to ensure all of medication is administered; pulsatile flushing med

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

when going about venipuncture

A

ensure comfortable position, dilate the vein, cleanse with chlorhexidine and allow to dry, stabilize the vein, keep bevel up

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

how to dilate vein

A

pump fist with hand lower than heart, stroke downward, friction from cleansing, use of tourniquet

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

cleansing with chlorhexidine

A

clean from center outward in circular motion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

phlebitis

A

complication from IV; inflammation and or clot of vein due to mechanical trauma from needle, chemical trauma from solution, or from contamination; scaled 0-4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

phlebitis score 0

A

no symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

phlebitis score 1

A

erythema (redness/warmth); possible pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

phlebitis score 2

A

erythema, edema, pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

phlebitis score 3

A

erythema, edema, pain, streak formation, palpable venous cord

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

phlebitis score 4

A

erythema, edema, pain, streak formation, palpable venous cord > 1inch, purulent drainahe

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

phlebitis treatment

A

remove catheter and restart away from site, warm compress to dilate vessels, document of phlebitis and treatment, monitor to ensure healing vs infection or tissue damage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

infiltration

A

complication from IV; fluid leaks out of catheter and gets into the extremity; could see coolness to touch due to fluid pooling; scaled 0-4; any vesicant or blood product infiltration is graded 4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

infiltration score 0

A

no symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

infiltration score 1

A

edema < 1in, cool to touch, pale

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

infiltration score 2

A

edema 1-6 in, cool to touch, pale

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

infiltration score 3

A

gross edema >6 in, cool, pale, pain, possible numbness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

infiltration score 4

A

gross edema >6 in, pitting edema, skin tight, leaking, bruising, mod-severe pain; fluid could be escaping from insertion site

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

treatment of infiltration

A

warm compress for hypotonic solution, cool compress for isotonic or hypertonic solution, elevate extremity, remove catheter and restart away from site, document infiltration and treatment (might need to call provider)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

extravasation

A

worst complication of IV; leakage of a vesicant into surrounding tissue causing damage to vein and tissue

37
Q

vesicant

A

any medication that can cause blistering, severe tissue injury, or necrosis

38
Q

examples of vesicants

A

chemotherapeutic agents, catecholamines, dopamine, levophed, epinephrine, norepinephrine, gentamycin, mannitol

39
Q

infiltration of any vesicant is considered…

A

extravasation

40
Q

treatment of extravasation

A

stop the infusion, remove IV, clean site, notify physician, do no restart

41
Q

sepsis

A

life threatening complication of an infection that occurs when chemicals are released into blood stream to fight infection but trigger inflammatory throughout entire body; symptoms include fever, diff. breathing, low BP, fast HR, mental confusion

42
Q

evaluating patient with PIV

A

pt IV remains patent, p does not experience complications, and if complications occur then recognize early

43
Q

central lines placed into…

A

opening of the superior vena cava into the right atrium

44
Q

types of peripherally inserted central line IV catheters

A

picc- long term use, long line, ends up in central venous system; midline catheter- not entered into central venous system, used long term but not as long as a picc

45
Q

j-line IV

A

used in emergency situations, peripherally inserted into a large vein

46
Q

tunneled vs non-tunneled

A

non-tunneled is not used in long term scenarios and usually sutured in place; tunneled are used more long term and tube is passed under the skin

47
Q

implanted port

A

aka port-a-cath; another central access system; used for long term therapy and for those with chronic illness; allows for freedom due to no long wires hanging; not good to use if pt needs daily infusions; CF patients commonly have ports

48
Q

huber needle

A

needle used to inject into implanted ports

49
Q

CVAD considerations

A

typically inserted under ultrasound or radiography; require xray confirmation following insertion and prior to using if done at bedside

50
Q

criteria for deciding which access device to use

A

emergent vs. non-emergent situations, type and length of treatment, quality of life, the medication to be administered, least risk of complications, pt/family ability and preference

51
Q

complications associated with CVAD

A

CLABSI, air embolism, pneumothorax from insertion, migration, thrombosis (blood clots)

52
Q

nursing assessment for CVAD

A

integrity of dressing, sutures intact?, s/s of infection?, tenderness upon palpation?, measure exposed catheter length, patentcy? (flushing well)

53
Q

flushing a CVAD

A

use 10mL or larger to flush entire line, know your agency policies, central lines should have brisk blood return, infusion/IV site to be checked atleast every hour or more

54
Q

bio-patch

A

goes around insertion of catheter into skin and is underneath dressing; infused with chlorhexidine, can be sutured in, change when you change dressing, place within 24 hours of IV placement

55
Q

blood transfusions pre-assessment

A

vitals, baseline information, done immediately before infusion

56
Q

blood transfusion requirements

A

pre-assessment, patient identification (2 identifiers), equipment

57
Q

blood transfusion equipment

A

y-set filtered tubing (prevent clots and filter particles), normal saline

58
Q

nursing care with blood transufsions

A

3 S’s: stay with pt for first 5-15 minutes to observe for signs of reaction, start transfusion slowly for first 15 minutes (2mL/minute), stop blood transfusion if uspect reaction

59
Q

considerations for blood transfusion

A

20 gauge PIV for adult (smaller causes destruction of RBC), return blood if not been used within 30 minutes of arrival from blood bank, unit of blood must be administered within 4 hours (must discontinue transfusion once past 4 hours)

60
Q

vital sign monitoring for transfusion

A

q15min x 3, q30min x 2, q1hr until complete

61
Q

s/s of transfusion allergic rxn

A

hives, itching, anaphylaxis

62
Q

nursing intervention for transfusion allergic rxn

A

STOP transfusion immediately, keep vein open with N.S., notify provider immediately, admin antihistamine parenterally as needed

63
Q

s/s of febrile rxn to blood transfusion

A

fever, chills, malaise, headache

64
Q

nursing intervention for febrile rxn to blood transfusion

A

STOP transfusion immediately, keep vein open with N.S., notify provider, treat symptoms

65
Q

s/s of hemolytic transfusion rxn to blood transfusion

A

immediate onset of facial flushing, fever, chills, headache, low back pain, shock

66
Q

Nursing interventions for hemolytic rxn to blood transfusion

A

STOP transfusion immediately, keep vein open with N.S., notify primary care provider immediately, obtain blood sample from site, obtain first voided urine, treat shock if present, send unit of blood/tubing/filter back to lab, draw blood for serological testing and send urine to lab

67
Q

s/s of circulatory overload from blood transfusion

A

dyspnea, dry cough, pulmonary edema

68
Q

nursing interventions for circulatory overload from blood transfusion

A

Stop or slow infusion, monitor vital signs, notify primary care provider, place in upright position with feet dependent

69
Q

s/s of bacterial rxn from blood transfusions (bacteria present in blood)

A

fever, HTN, dry flushed skin, abdominal pain

70
Q

nursing intervention for bacterial rxn from blood transfusion

A

STOP infusion immediately, obtain culture of pt blood and return blood bag to lab, monitor vitals, notify primary care provider, administer antibiotic as ordered

71
Q

if any signs of infusion rxn are present

A

STOP the transfusion

72
Q

3 types of chest tubes

A

dry suction with wet seal, wet suction with wet seal, dry suction with dry seal

73
Q

reason for inserting chest tube

A

collapsed lung, pneumothorax, hemothorax, tension pneumothorax

74
Q

nursing care with chest tube

A

resp assessment- monitor RR, lung sounds, O2 sat.; monitor/record type, color, and amount of drainage; vasoline gauze/occlusive dressing over insertion; all connections secured and taped; tubing free of kinks; monitor for s/s of infection; semi-fowlers position; cough, turn, deep breathing q2hours; incentive spirometer and chest splinting; chest drainage system needs to be below chest tube level for gravity drainage

75
Q

continue checking _____ at bedside with chest tube

A

water seal chamber is “tidaling”, suction chamber is “bubbling” if it is to suction, suction set to 20cm and water seal at 2cm

75
Q

necessities to keep at bedside with chest tube

A

1 vaseline gause, 1 occlusive dressing, new drainage system, sterile water

76
Q

oropharyngeal airway

A

airway adjunct to keep airway open and keep tongue from obstruction; insert upside down until resistance is met and then flip; should sit at teeth; measure from corner of mouth to angle of jaw

77
Q

nasopharyngeal airway

A

airway adjunct used to keep airway open and free from obstruction; measure from tip of nose to angle of jaw; use lube prior to inserting; bevel towards septum when inserting; contraindicated in facial trauma

78
Q

endotracheal tube

A

advanced airway performed by advanced practitioners; inserted using laryngoscope; lung sounds auscultated to ensure proper positioning and then inflate cuff (CXR to confirm placement)

79
Q

potential complications of endotracheal tube

A

long-term use can lead to pneumonia

80
Q

tracheostomy tube

A

tube surgically placed in between the 2nd and 3rd tracheal rings; usually done if upper airway is obstructed, trauma/spinal cord injuries, choking, anaphylaxis, or misformation of trachea

81
Q

types of tracheostomy tubes

A

cuffless or cuffed; cuffless used for long-term care and is used to ween off of a ventilator; cuffed used in more acute settings and not long-term

82
Q

what is needed at the bedside with tracheostomy

A

obturator from current trach, same size trach, one size smaller trach, suction, O2, BVM

83
Q

if trach is dislodged…

A

use anything to keep airway open; once it closes after the trach falls out the pt is at an immediate threat of losing their airway

84
Q

why use a tracheostomy sponge gauze pad instead of normal gauze?

A

trach gauze is much tighter weave and wont allow for pieces to come off and enter the incision site

85
Q

dressing care for trach

A

avoid getting gauze wet and moist to prevent infection and skin breakdown; keep clean dry and intact; strap around neck should be 1 finger breadth tight

86
Q

components of cuffless trach

A

obturator (stiff plastic used to guide trach into place), cannula, outer tube with flange

87
Q

components of cuffed trach

A

obturator, cannula, tube to inflate the cuff, outer tube

88
Q

why keep one size smaller trach at bedside?

A

incase opening becomes inflamed

3323 Advanced Assessment (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions