Exam 2 Flashcards
purpose of IV therapy
maintain daily fluid and electrolyte imbalance; replace fluid and electrolyte losses; correct fluid and electrolyte imbalance; provide access to venous system for medication administration
IV Therapy
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
IV therapy used for
IV fluid, meds, blood products
Location of IV therapy (PIV)
superficial veins of the forearm and hand
most common way to run IV fluids
through a pump; gravity ran is much less common and used in emergency/trauma
larger gauge needed…
for more viscous fluids
magma catheter
14 gauge; used for trauma
gray catheter
16 gauge; used for major surgery, large volume infusions, unstable patients
green catheter
18 gauge; use for large volume infusions, multiple or rapid infusions
pink catheter
20 gauge; used for medications, hydration, and transfusions
blue catheter
22 gauge; used for small veins, common for short term access, usually cant administer blood (hemolyze blood)
yellow catheter
24 gauge; fragile small veins, pediatric population, last resort for adults
bevel up or down when inserting catheter
up
primary lines used for
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
IVAD
intermittent venous access devices aka saline lock
intermittent venous access devices use
used for intermittent infusion; use of extension tubing is recommended; flush 2-3mL q12 hours or per facility policy; flush in pulsatile method
when flushing be cautious for…
fluid restrictive patients; flush minimum required
when using PIV with IVAD be sure to flush…
before to ensure adequacy of line prior to administering meds; after to ensure all of medication is administered; pulsatile flushing med
when going about venipuncture
ensure comfortable position, dilate the vein, cleanse with chlorhexidine and allow to dry, stabilize the vein, keep bevel up
how to dilate vein
pump fist with hand lower than heart, stroke downward, friction from cleansing, use of tourniquet
cleansing with chlorhexidine
clean from center outward in circular motion
phlebitis
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
phlebitis score 0
no symptoms
phlebitis score 1
erythema (redness/warmth); possible pain
phlebitis score 2
erythema, edema, pain
phlebitis score 3
erythema, edema, pain, streak formation, palpable venous cord
phlebitis score 4
erythema, edema, pain, streak formation, palpable venous cord > 1inch, purulent drainahe
phlebitis treatment
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
infiltration
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
infiltration score 0
no symptoms
infiltration score 1
edema < 1in, cool to touch, pale
infiltration score 2
edema 1-6 in, cool to touch, pale
infiltration score 3
gross edema >6 in, cool, pale, pain, possible numbness
infiltration score 4
gross edema >6 in, pitting edema, skin tight, leaking, bruising, mod-severe pain; fluid could be escaping from insertion site
treatment of infiltration
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)
extravasation
worst complication of IV; leakage of a vesicant into surrounding tissue causing damage to vein and tissue
vesicant
any medication that can cause blistering, severe tissue injury, or necrosis
examples of vesicants
chemotherapeutic agents, catecholamines, dopamine, levophed, epinephrine, norepinephrine, gentamycin, mannitol
infiltration of any vesicant is considered…
extravasation
treatment of extravasation
stop the infusion, remove IV, clean site, notify physician, do no restart
sepsis
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
evaluating patient with PIV
pt IV remains patent, p does not experience complications, and if complications occur then recognize early
central lines placed into…
opening of the superior vena cava into the right atrium
types of peripherally inserted central line IV catheters
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
j-line IV
used in emergency situations, peripherally inserted into a large vein
tunneled vs non-tunneled
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
implanted port
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
huber needle
needle used to inject into implanted ports
CVAD considerations
typically inserted under ultrasound or radiography; require xray confirmation following insertion and prior to using if done at bedside
criteria for deciding which access device to use
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
complications associated with CVAD
CLABSI, air embolism, pneumothorax from insertion, migration, thrombosis (blood clots)
nursing assessment for CVAD
integrity of dressing, sutures intact?, s/s of infection?, tenderness upon palpation?, measure exposed catheter length, patentcy? (flushing well)
flushing a CVAD
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
bio-patch
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
blood transfusions pre-assessment
vitals, baseline information, done immediately before infusion
blood transfusion requirements
pre-assessment, patient identification (2 identifiers), equipment
blood transfusion equipment
y-set filtered tubing (prevent clots and filter particles), normal saline
nursing care with blood transufsions
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
considerations for blood transfusion
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)
vital sign monitoring for transfusion
q15min x 3, q30min x 2, q1hr until complete
s/s of transfusion allergic rxn
hives, itching, anaphylaxis
nursing intervention for transfusion allergic rxn
STOP transfusion immediately, keep vein open with N.S., notify provider immediately, admin antihistamine parenterally as needed
s/s of febrile rxn to blood transfusion
fever, chills, malaise, headache
nursing intervention for febrile rxn to blood transfusion
STOP transfusion immediately, keep vein open with N.S., notify provider, treat symptoms
s/s of hemolytic transfusion rxn to blood transfusion
immediate onset of facial flushing, fever, chills, headache, low back pain, shock
Nursing interventions for hemolytic rxn to blood transfusion
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
s/s of circulatory overload from blood transfusion
dyspnea, dry cough, pulmonary edema
nursing interventions for circulatory overload from blood transfusion
Stop or slow infusion, monitor vital signs, notify primary care provider, place in upright position with feet dependent
s/s of bacterial rxn from blood transfusions (bacteria present in blood)
fever, HTN, dry flushed skin, abdominal pain
nursing intervention for bacterial rxn from blood transfusion
STOP infusion immediately, obtain culture of pt blood and return blood bag to lab, monitor vitals, notify primary care provider, administer antibiotic as ordered
if any signs of infusion rxn are present
STOP the transfusion
3 types of chest tubes
dry suction with wet seal, wet suction with wet seal, dry suction with dry seal
reason for inserting chest tube
collapsed lung, pneumothorax, hemothorax, tension pneumothorax
nursing care with chest tube
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
continue checking _____ at bedside with chest tube
water seal chamber is “tidaling”, suction chamber is “bubbling” if it is to suction, suction set to 20cm and water seal at 2cm
necessities to keep at bedside with chest tube
1 vaseline gause, 1 occlusive dressing, new drainage system, sterile water
oropharyngeal airway
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
nasopharyngeal airway
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
endotracheal tube
advanced airway performed by advanced practitioners; inserted using laryngoscope; lung sounds auscultated to ensure proper positioning and then inflate cuff (CXR to confirm placement)
potential complications of endotracheal tube
long-term use can lead to pneumonia
tracheostomy tube
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
types of tracheostomy tubes
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
what is needed at the bedside with tracheostomy
obturator from current trach, same size trach, one size smaller trach, suction, O2, BVM
if trach is dislodged…
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
why use a tracheostomy sponge gauze pad instead of normal gauze?
trach gauze is much tighter weave and wont allow for pieces to come off and enter the incision site
dressing care for trach
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
components of cuffless trach
obturator (stiff plastic used to guide trach into place), cannula, outer tube with flange
components of cuffed trach
obturator, cannula, tube to inflate the cuff, outer tube
why keep one size smaller trach at bedside?
incase opening becomes inflamed
