Intravenous Therapy 3 Flashcards
IV Discontinuation
have to have an order, there can be complications
IV Discontinuation Guidelines:
CDC; Facility policy; 72-96 hours/site & tubing; Tubing Exceptions-TPN, Blood, Lipids/24 hrs
IV Discontinuation Steps
- Explain to patient 2. Clamp tubing 3. Remove dressing & tape/stabilizing catheter 4. Inspect site 5. Using sterile gauze & light pressure 6. Pull catheter straight in line with insertion 7. Apply pressure 2-3 min (5-10 as indicated) 8. Inspect cannula 9. Document 10. Reassess site
Removing CVCs
Position patient with head as low as possible; Remove sutures and pull line with steady motion as patient holds breath or during expiration (have pt take deep breath and remove with exhale); Assure tip is present. For PICCs, see measurement obtained at time of insertion; Hold pressure until bleeding stops, apply dressing.
IV Complications -
- Occlusion 2. Bleeding 3. Infiltration 4. Phlebitis 5. Infection 6. Fluid Overload
Occlusion Causes -
Tubing clamped or kinked, Positional, Tape or dressing, Damaged cannula, Clot
Occlusion Assessment:
Tubing & site, Lower IV bag
Occlusion Intervention:
Correct any problem or discontinue site
downstream occlusion:
from pump to pt; tube clamped, pt postion
upstream occlusion:
from pump to bag
bleeding causes:
Anticoagulation therapy
• Low PLTs • Dislodged or disconnected
bleeding assessment:
Site- blood, hematoma or disconnection
bleeding intervention:
Small amount- change dressing & clean site; Discontinue site, apply pressure as needed
Infiltration causes:
Ruptured vessel • Dislodge cannula • Occlusion
Infiltration assessment:
Swelling, Blanched, Cool, Pain, Occlusion
Infiltration intervention:
Discontinue site; Elevate & Warm compress
with infiltration will not have what?
blood return
Infiltration Scale
Blanching & Cool plus-
1 Edema < 1”; With or without pain
2 Edema 1-6”; With or without pain
3 Gross Edema > 6”; Mild-Mod Pain; Possible numb
4 Gross Pitting Edema >6”; Skin tight; Leaking; Discolored; Circulation impaired; Mod-Severe Pain
OR any amount of blood, irritant or vesicant
Phlebitis causes:
Irritant solution • Dehydration • Infection
Phlebitis assessment:
Erythema, Warmth, Pain
Phlebitis intervention:
Discontinue site; Warm compress
Phlebitis site
warm to touch, “burned the vein”, can get blood return
Phlebitis Scale
1 Erythema; With or without pain
2 Erythema and/or edema; Pain
3 Erythema and/or edema: Pain; Streak, Palpable venous cord
4 Erythema and/or edema: Pain; Streak, Palpable venous cord >1” Drainage
infection causes:
Contamination at insertion • Migration of skin organism • Catheter hub or port contamination
infection assessment
Warmth, tenderness, redness, fever of unknown origin
infection intervention:
Discontinue site • Notify provider (because of if pt gets discharged)
Fluid Overload causes:
Rapid or large volume fluid administration, Compromised cardiac function
Fluid Overload assessment:
SOB & Crackles, Tachycardia, Agitation or anxiety
Fluid Overload interventions:
Slow infusion; Raise HOB (set up pt); Monitor VS ; Notify Provider
ways to get hemotomia
leave turnicate on, puncturing the back wall of a vessel
parental nutrition
pt failing to mature oral intake
Common Indications for PN
Patient has failed EN with appropriate tube placement
Severe acute pancreatitis Severe short bowel syndrome Mesenteric ischemia Paralytic ileus Small bowel obstruction
GI fistula unless enteral access can be placed distal to the fistula or where volume of output warrants trial of EN
Contraindications for PN
Functional and accessible GI tract
Patient is taking oral diet
Prognosis does not warrant aggressive nutrition support (terminally ill)
Risk exceeds benefit Patient expected to meet needs within 14 days
PN Central Access
May be delivered via femoral lines, internal jugular lines, and subclavian vein catheters in the hospital setting
Peripherally inserted central catheters (PICC) are inserted via the cephalic and basilic veins
Central access required for infusions that are toxic to small veins due to medication pH, osmolarity, and volume
last resort PN -
femoral lines
most common PN -
subq
peripheral can cause
plebitis
TPN -
Total Parenteral Nutrition, glucose, amino acids, vitamins & minerals; used for 7 days
PPN -
Peripheral Parenteral Nutrition; ph, amino acids
TNP -
Total Nutrient Admixture, glucose, amino acids, vitamins & minerals, & lipids
Monitoring Needs
(monitor every 4-6 hours) Glucose Monitoring Intake and Output Daily weight
Labs…CBC, BUN/CRE, Electrolytes (Mag, K+, Phosphate levels, Ca+), ABGs, Liver function test, PT/PTT, Urine osmolality, 24-hour urine collection.
Complications of TPN
Sepsis (because of glucose because mediator for bacteria ) Electrolyte Imbalance Hyperglycemia Hypoglycemia Hypervolemia Hepatic Dysfunction (lipids) Hypercapnea (CO2 in the blood) Lipid Intolerance
Prior to administration:
Obtain a complete health history including allergies, drug history, and possible
drug interactions.
■ Obtain a complete physical examination.
■ Assess for the presence or history of nutritional deficits such as inadequate oral intake, GI disease, and increased metabolic need.
■ Obtain the following laboratory studies: total protein/albumin levels, creatinine/ blood urea nitrogen (BUN), CBC electrolytes, lipid profile, and serum iron levels.
Ongoing Nursing Interventions
Use a pump to administer infusion of parenteral nutrition. Infusions should be started slowly to observe for untoward reactions. Check infusion rate at least every 2 hours.
If administration is interrupted, administer a 5% to 10% dextrose solution to prevent hypoglycemia, based on facility policy.
Check vital signs every 4 hours to monitor for the development of infection or sepsis. ; Monitor blood glucose levels every 6 hours. Use aseptic technique when changing solution, tubing,
filter or dressings according to agency policy.
Compare the client’s daily weights to fluid intake and output. Total weight gain should not be greater than 3 lb. per week. Weight gain greater than 1 lb. per day indicates fluid retention.
