from coursepack continuing care of the IV site Flashcards
how often should nurse inspect he IV site (at minimum)
every hour
what should you ask pt re ther IV site
is it painful or tender
what do you look for at the iv site
redness, swelling, discharge
what is one way of det if IV is interstitial (not flushing)
if you manually occlude the vein just beyond the catheter tip and if it continues to infuse it may be interstitial
CDC recommends IV sites be rotated every
72-96hrs or if pt only needs one more day or so of treatment and the site is good they can have it a little longer
how often should sterile occlusive drsgs be changed
every72-96hrs
when should drsg be replaced
when IV catheter is changed, sites wet, the drsg loses adherence to the skin
considerations for cleansing/chaging drsg
keep IV stabilied the whole time when cleaning/changing drsg to prevent phlebitis
what should be avoided with clotted IV
irrigating it as it could form embolism
how to check if iv clotted d/t lack of Iv solution
disconnect IV tubing and attach 3ml syringe. Pull back gently. IF no blood returns remove IV
what do if pt has venous spasm
apply heat to cannulated arm
how can you expel air from IV admin set
close clamp blow the air and
- roll tubing around pen
- tap the tubing to force air into drip chamber
- use sterile blunt cannula to withdraw it
what would happen if you didnt cloe the Iv clamp when changing the IV solution bag
air would get stuck. remove it
what do if chemical irritation of infusing solution occurs
- inc dilution of drugs in the IV solution
- reduce rate of infusion
- flush vein w isotonic sol w no additives
- use an in line filter
- if pain persists, discontinue IV and apply warm compresses
T or F you should never pull back on an IV
F. if the catheter is inserted too far you can pull it back slightly and retape it
signs and symp of phlebitis
warmth tenderness or pain at site redness or reddened streak along vein path palpable cord vein area of induration (hardness) edema w thrombophlebitis
what to apply when theres pain or tenderness at IV site
warm, moist compress to affected arm
how should the catheter be taped.
in the directon the catheter is lying
what should you do if you are frequently changing or manipulating the IV tubing
may need to use extension sets
if pt is susceptible to developing infusion-related phlebitis you should
rotate the iv sites every 24h
if youre using irritating medications or solutions eg antibiotics how should you change your IV care
infuse into lg vein w good volume to maximise hemodilution
whats thrombophlebitis
when phlebitis progresses tot he point of vein occlusion and clot formation
infiltration=
accumulation of fluid in the tissues which occurs hen catheter has been dislodged out of the vein
what do if pt has pain, burning, itching, or unusual sensation at IV site
remove the IV and elevate the libm
hematoma=
an effusion of blood into the subcutaneous tissue
if there is discoloration d/t hematoma you should
remove Iv
if theres swelling d/t hematoma you should
rest affected limb??
if theres tenderness d/t hematoma you should
apply P over Ivs tie to prevent further bleeding
hwo should you treat Iv site after removal
apply firm pressure after removal. at least 1 minute. Elevate.
when the IV may have caused nerve, tendon or ligament damage when should you report to dr?
when theres loss of sensation or movement to an area
if theres inc pain or C/O numbness or tingling w insertion what do
remove
where should you use avoid to make sure not to damage nerve
wrist fold to avoid potential radial nerve damage
what do if purulent discharge
obtain a swab for C&S
if pt has pain d/t infection and you want to culture what do
either swab the discharge or remove catheter and using sterile scissors snip the catheter tip into sterile container
if pt has infection at site and fever how can you aid their healing
warm compress to affected limb. assess, inform dr, record
no notes on inadvertant arterial occlusion because we dont insert them
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