Final Exam Flashcards
Administering fluids, medications, or nutrition directly into a vein
Reason for IV
Maintain or prevent fluid and electrolyte imbalances
Administer medications
Replenish blood volume
Assist in pain management
Correct or maintain nutritional status
Goals of IV Therapy
Rapid Onset – good in an emergency
Can’t tolerate PO, can’t swallow, NPO
Large molecule drugs - chemo Rapid hydration
Precision to establish constant therapeutic blood levels
Meds that are irritating to muscle and SC (alkaline) – given IV and tolerated better
IV Advantages
No room for error (no ability to remove from body like PO)
High risk (infection, injury)
Incorrect application (i.e: pushing too fast) has serious implications
Challenges to stay in place, insert
Time-consuming (lots of equipment to handle, many meds require 2 nurse check)
IV Disadvantages
is short term treatment (days)
Peripherally inserted
Superficial veins
PVAD
Therapy > 7 days (weeks to months)
Catheter inserted into a large or peripheral vein of the chest or groin with the tip advanced to a central position, either the superior or inferior vena cava
Can have multiple lumens
Decreased trauma and physical anxiety for client
Pt vascular characteristics/age/comorbidities (poor venous access for example)
pH and osmolality
Large volumes
CVAD
Duration of treatment, type of solution Patient characteristics (vessel health, comorbidities)
Type of VAD depends on
Types:
Long PIVC
- Midline Catheter
- CVADs
- PICC
- Implanted Port
- Non Tunneled CVAD
- Tunneled, Cuffed Catheter
Types of VAD
Peripheral IV </= ___ days
5
Ultrasound guided PIV _____ days
6-14
Non Tunneled / Acute CVS _____ days
6-14
_______ preferred to PICC if proposed duration is </=14 days
Midline catheter
_______ preferred to midline if proposed duration >/=15 days
PICC
_______ preferred to tunneled catheter and ports for infusion 14-30 days
PICC
Tunneled & Port >/= ____ days
31
During IV insertion, dressing change, medication administration
Breaking sterility / contamination
Asepsis during insertion
Use site above previous insertion if failed
Reducing contamination
Our role:
Aid with placement
Care and maintain device
Administer solutions or medications
Assess site for s/s complications
CVAD
Notify of any complications.
Document catheter information.
Skin integrity, complications, external catheter length, mid-arm circumference (PICC)
Type of equipment, type of securement device
Dressing integrity – D&I
Document exit or port insertion site.
Document catheter removal.
Document blood draw.
Document unexpected outcomes, health care provider notification, interventions, and patient response.
Special equipment
Palpate
Edema, Pain And Tenderness
Inspect For
redness, swelling, discharge
kinks in tubing
presence of a securement device
ensure dressing is completely intact (change 5-7 days)
blanching of skin around insertion site or along vein path with infusions
assess chest and neck for engorged veins or difficulty with movement
Measure external length of CVAD
Flush and assess patency according to policy
Assess for signs of systemic infection (fever, chills, hypotension)
CVAD Nursing Responsibilities
Safety Guidelines:
1. Clinician competence is required for the use, placement, and management of VADs.
a. Knowledge + skills
b. Recognizing s/s of VAD-related complications
2. Know the indications for prescribed therapy prior to initiating IV therapy.
a. High risk = know your meds, know your calcs
b. Understand Flow Rate and Concentration
3. Prior to initiating IV therapy, assess the patency and functioning of the VAD.
a. Aspiration of blood return
b. Absence of resistance
c. Patient c/o pain when flushing
4. Reduce risk for administration set misconnections.
a. Trace path between IV connection and patient
b. Label admin sets (tubing)
c. Route different tubing in different directions
5. Maintain sterility of a patent IV system using Infusion Nurses Society (INS) standards.
6. Know standard precautions for infection control for bloodborne pathogens exposure.
safety guidelines for VAD
No blood return, can’t flush
Signs line is not patent
Scored 1-6
Phelbitis
Scored 0-4
Infiltration
Intravenous (IV) site appears healthy
Phelbitis Score 1
All of the following signs are evident and extensive:
Pain along path of cannula
Erythema
Induration
Palpable venous cord
Pyrexia
Phelbitis Score 6
Two of the following are evident:
Pain at the IV site
Erythema
Swelling
Phelbitis Score 3
No symptoms
Infiltration Score 0
Skin blanched, translucent
Skin tight, leaking
Skin discolored, bruised, swollen
Gross edema >15.2 cm (6 in) in any direction
Deep pitting tissue edema
Circulatory impairment
Moderate-to-severe pain
Infiltration of any amount of blood product, irritant, or vesicant
Infiltration Score 4
Select the most appropriate vein and location by visual inspection and palpation. Veins should feel soft and bouncy and be adequate size to accommodate selected gauge.
Use the most distal site above the wrist in forearm
Do not use areas of flexion
Avoid veins located in hands for short term use
Do not use a site below a failed insertion attempt unless completely healed
Skin must be intact/free of infection
Criteria: anticipated duration of tx, type of solution, pt characteristics (age, comorbidities, vessel health)
Select least invasive and smallest device allowed. Incollab with patient, for vessel health and preservation.
PVAD Site Selection
BEVEL UP!
Applying Tourniquet to dilate vein
Caution in older pts
Avoid arm hair (place over gown)
Vein Selection
Inspection + Palpation
No gloves necessary while selecting
Pt can clench and unclench fist to build pressure
Veins should be soft and bouncy
Big enough to accommodate chosen gauge
No areas of flexion (AC, wrist), avoid hands
Site most distal above the wrist
Do not use site below failed insertion attempt
Skin assessment
3 finger widths above wrist
Can use heat to vasodilate
Contraindications: fistula, extremity affected by CVA, lymphedema or lymph node removal
Remove the tourniquet after insertion - not longer than 60 seconds on arm
VAD Insertion
A single clinician should not make more than __ attempts at initiating a PIVC and should limit total attempts to no more than four.
2
Trauma, surgery, rapid blood transfusions, and rapid fluid replacement
Gauge 14, 16, 18
Continuous or intermittent infusions in adults; administration of blood transfusions in adults
Gauge 20
Continuous or intermittent blood products in adults, children, newborns, and older persons
Gauge 22
Continuous or intermittent infusions in adults, children, newborns and older persons; administration of blood or blood products in adults, children, newborns, or older persons
Gauge 24
_________ Infusion (IV you inserted is now connecting to a line and a bag)
Connect to primed tubing
Release clamp
Start pump
Continuous
_________ Infusion (We insert the IV and “lock” the short amount of tubing, saving it for later when meds will be given)
Preservative-free 0.9% NS to fill the extension set
Used to use Heparin to prevent clotting, now only for special situations (dialysis access, CVADs, certain types of equipment)
Attach syringe with NS to extension set and flush/lock with recommended amount
Intermittent
Maintenance:
Assessment
Monitoring site for complications
Monitoring for patency
Monitoring Dressing
Scheduled Tasks & Assessments
Assess site how often?
Change the needleless connector?
Change the entire system and insert a new VAD?
Change tubing per employer policy
~ every 72-96 hours
Daily if TPN (Total Parenteral Nutrition)
Assess patency qShift
Flush with 1-2 mL, gently aspirate for blood return
After confirmed blood return, push/pause flush (1 mL bolus)
Volume of flush tbd by VAD type and agency
IV Site Maintenance
Maintaining the System:
Keeping system sterile
Should you disconnect an IV line to change a patient gown? NO
Changing solutions, dressings Assisting patient with ADLs without disrupting system
Walking IV-poles
Tubing should never be disconnected because it becomes tangled
Extension tubing is possible but not recommended
Needle-free connector (purple leur-lock things) are better than caps
IV Site Maintenance
Check orders for discontinuation, understand the rationale
Pt education: keep extremity still; report bruising/edema/pain that develops after removal
Wear gloves
Close clamps on line
Remove tape first
Slide catheter out, holding gauze over insertion site with hub parallel to skin
Apply pressure for 30 seconds longer if on blood thinners (5-10 mins)
Inspect catheter to make sure it is intact
IV Removal
Assessment of site and VAD
Decision/rationale for removal
Care after removal (dressing)
Documenting Removal of IV
________ for Intermittent:
Can be given through saline lock
Some IVs have a “saline lock” which keeps the IV patent without having to maintain a constant drip
Locks save time by eliminating constant monitoring of IV line
Better mobility, safety, and comfort for patients (don’t need to be hooked up to a bag all the time)
After you administer bolus through IV, flush with saline to keep it patent
Flushes vary 1-5 mL
Saline Lock
Before:
Assess site
Assess patency + placement Flush if “saline locked” with 2-5 mL NS and pull back for blood return (patency)
IV Assessment
After:
Flush
Normal Saline for Peripheral Catheters 2-5 mL if “saline lock”; 10 mL if primary is not compatible with med
“Heparin lock” – only specific situations (dialysis)
Fluids and volumes you flushed with are documented
Usually small volumes of flushing fluid are in larger syringes (decrease pressure, decrease catheter damage)
Med Delivery:
Always assess compatibility
IV Assessment
Concentrated dose directly into systemic circulation
IV Push Bolus
Advantages:
No fluid overload risk (couple of mLs)
Fast onset in emergency
Doses of short-acting meds can be titrated by pt response
More accurate (no med left in IV bag/line)
Back in the day: some med hanging in a large bag (1 L) – not so common anymore; management of admin would carry from shift to shift – multiple people
No need to program pumps, no need to label bags
IV Push
Disadvantages:
Most dangerous, no time to correct or stop, med peaks quickly
Not all meds can be pushed
Requires precise calculation and timing
Could irritate BV lining (concentrated) – infiltration, phlebitis risk
IV Push
Use hourly rate to calculate minute flow rate (gtt/mL). Know calibration (drop factor), in drops per milliliter (gtt/mL), of infusion set used by employer
Infusion via gravity
Dextrose 5% in water (D5W)
Dextrose 10% in water (D10W)
Dextrose in Water Solutions
0.225% sodium chloride (quarter normal saline; ¼ NS; 0.225% NaCl)
0.45 sodium chloride (half normal saline; ½ NS; 0.45% NaCl)
0.9% sodium chloride (normal saline; NS; 0.9% NaCl)
Saline Solutions
Dextrose 5% in 0.45% NaCl sodium chloride (D5 ½ NS; D50.45% NaCl)
Dextrose 5% in 0.9% sodium chloride (D5NS; D50.9% NaCl)
Dextrose in Saline Solutions
Lactated Ringer’s (LR)
Dextrose 5% in lactated Ringer’s (D5LR)
Balanced Electrolyte Solutions
Isotonic
Isotonic when first enters vein; dextrose enters cells rapidly, leaving free water, which dilutes ECF; most of water then enters cells by osmosis.
Dextrose 5% in water (D5W)
Hypertonic
Hypertonic when first enters vein, dextrose enters cells rapidly, leaving free water, which dilutes ECF; most of water then enters cells by osmosis.
Dextrose 10% in water (D10W)
Hypotonic
Saline is sodium chloride in water.
Expands ECV (vascular and interstitial) and rehydrates cells.
0.225% sodium chloride (quarter normal saline; ¼ NS; 0.225% NaCl)
Hypotonic
Expands ECV (vascular and interstitial) and rehydrates cell
0.45 sodium chloride (half normal saline; ½ NS; 0.45% NaCl)
Hypertonic
Draws water from cells into ECF by osmosis
0.9% sodium chloride (normal saline; NS; 0.9% NaCl)
Hypertonic
Dextrose enters cells rapidly, leaving 0.45% sodium chloride
Dextrose 5% in 0.45% NaCl sodium chloride (D5 ½ NS; D50.45% NaCl)
Hypertonic
Dextrose enters cells rapidly, leaving 0.9% sodium chloride
Dextrose 5% in 0.9% sodium chloride (D5NS; D50.9% NaCl)
Isotonic
Contains Na+, K+, Ca2+, Cl − , and lactate, which liver metabolizes to HCO3 –. Expands ECV (vascular and interstitial); does not enter cells.
Lactated Ringer’s (LR)
Hypertonic
Dextrose enters cells rapidly, leaving lactated Ringer’s.
Dextrose 5% in lactated Ringer’s (D5LR)
In general, _____ fluids are used most commonly for extracellular volume replacement (e.g., FVD after prolonged vomiting).
isotonic
The decision to use a hypotonic or hypertonic solution is based on the specific fluid and ________
electrolyte imbalances
The patient with a hypertonic fluid imbalance will in general receive a ________ intravenous solution to dilute the ECF and rehydrate the cells.
hypotonic
All intravenous fluids should be given carefully, especially ________ solutions, because these pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that can lead to pulmonary edema, particularly in patients with heart or renal failure.
hypertonic
insertion site is jugular vein and subclavian veins (best inshort term needs in acute care setting. About 1-2 weeks.
Nontunnelled cvad
catheters are tunnelled from the entry site, subcut, to the preferred vein, where the cath is inserted and advanced into the SVC. synthetic cuff anchors catheter for decrease risk of infection. Surgeon places tunnelled cath. For pts requiring blood, dialysis (long term needs)
Tunnelled cuffed
2.5mm 10mL/min
Digital/metacarpal
6mm 45mL/min
Cephalic
16mm 300mL/min
Axillary
8mm 80mL/min
Basilic
19mm 800mL/min
Subclavian
20mm 2000mL & Turbid
Superior Vena Cava
Employer policy re: fever (e.g: present to emergency department for fever over 38); s/s fever
Should have a list of providers #s
Written instructions for dressing changes, flushing, tubing changes if discharging; also written list of suppliers of equipment
Kelly clamp (no teeth)
Patient and caregiver education: flushing, dressing changes, site care
How to dispose soiled dressings
CVAD Discharge
Protocols give the nurse more autonomy to determine the rate/amt of drug to administer
Similar to insulin SC sliding scale, nurse will titrate
Amount of Heparin given is based on latest aPTT
Amount of Insulin is based on blood glucose
IV Infusion Protocol
Fluid Balance:
Ins and Outs
Ins: PO liquids (drinks, soup, gelatin, ice); IV fluids (+ flushes), blood components, fluids provided with meds (including tube flush, etc)
Outs: urine, diarrhea, emesis, gastric suction, tube and wound drainage
Daily intake should equal output plus 500 mL
I&O Purpose
Disruption in the 1:20 ratio of _____ to ______
acid; base
a chemical system that prevents a radical change in fluid pH by dampening the change in hydrogen ion concentrations in the case of excess acid or base. Most commonly, the substance that absorbs the ions is either a weak acid, which takes up hydroxyl ions, or a weak base, which takes up hydrogen ions.
A buffer
Lungs adapt rapidly to an acid–base imbalance (Minutes)
Slower than the chemical buffers (seconds) but still rapid
Powerful regulator
Increased levels of hydrogen ions and carbon dioxide provide the stimulus for respiration.
Respiratory center (medulla)
Respiratory buffer
Kidneys
Longer - few hours to several days to regulate acid–base imbalance
Excreting Acids:
Excrete small amounts of free H+ (uses phosphate), weak acids Combine H+ with ammonia to form ammonium for excretion
Urine is acidic – body depends on excretion of some acid through urine (pH = 6)
Can speed up or slow down H+ excretion (pH 4 – 6) as part of compensation
Reabsorption of bicarb
Production of new bicarb
Kidney disease/injury will impact the ability to regulate
Metabolic buffer
_______: Respiration rate and depth ↑ to get rid of CO2
Hyperventilation
Acidosis Respiratory
________: Respiration rate and depth ↓ to preserve CO2
Hypoventilation
Lung disease/disorder = impairment of this system
Alkalosis Respiratory
Carbonic acid concentrations (comes from CO2)
Respiratory
H2CO3 (carbonic acid) → H+ (hydrogen ion) and HCO3- (bicarbonate which is a base)
The major source is _______ acid
carbonic
