IV therapy - exam 3 Flashcards
what is the goal of IV therapy?
- restore and maintain fluid and electrolyte balance
- provide med admin directly into the bloodstream
what are the risks of IV therapy?
- phlebitis/infection
- infiltration/extravasation
- Speed shock
- Fluid overload
- Allergic reaction
- Embolism
how often do IV sites need to be monitored? and what do we monitor for?
- Per institutional policy (q1 or q2)
- phlebitis/infection
- Infiltration
- Extravasation
- Intact dressing
Peripheral intravenous catheters (PIV)
- short term (mostly)
- measured in gauge
- typically IV
Peripherally inserted central catheters (PICC)
- Considered central line
- Inserted by specially trained nurses / providers
- Insertion and subsequent dressing changes considered sterile procedure and requires sterile environment
Central venous catheters (CVC) “central line”
- Same considerations as PICC but insertion performed by advanced provider
what are the nursing considerations for a central line?
- Period for long term IV therapy (eg. antibiotic) or oncologic circumstances (hickman line)
- Considered as an alternative when PIV instruction is contradicted, difficult to obtain, difficult to maintain, ect
- Risk for infection much greater w/ central lines
why is risk for infection in a central line greater?
-Patient safety requires adherence to aseptic technique an promote infection prevention
- Infections acquired by central lines associated w/ 12 - 25% mortality rate for adults
- easily infection into the blood stream
what is a CLASBI? how is it harmful?
- CLASBI = central line associated bloodstream infection
- Is an hospital associated (acquired) infection (HAI)
- Prevention and improved performance:
Incentrization by centers for Medicare and Medicaid services (so the hospital wouldn’t get reimbursed)
what are some key considerations for CLASBI prevention?
- Proper hand hygiene (minimize jewelry on hands/wrist)
- Docmaminating IV ports each time you instill/add medications (Ex: scrub the hub)
- Using chlorhexidine gluconate solution for skin preparation
how do nurses ensure sterile integrity of IV tubing?
- End caps maintained on female end of secondary bing between usage
- No iv tubing grazing or laying on the floor even if capped
- IV tubing changed per facility policy
- All Iv sites and dressings:
- Labeled with date/time/iitals
- Inspected regularly
- Changed as needed or per hospital policy
When in doubt throw it out (or change it)
why are I & O’s important?
- I & O provide a gauge in fluid balance & provides significant and valuable data about a patients health status
- May need access I/O more frequently based on patient condition
- Intake and output totals should be documented at last every 8 hours or per policy
what are examples of intake?
- Medications, Blood products, Drinking PO, IV meds, Fruits & veggies (watermelon, ect), Soup, Ice chips/popsicle, Coffee, soda, tube feeding, ect
what are examples of output?
- Vomiting, sweating, blood loss, urine, stool, mucus (if theres a lot), drainage from dressing change
define overt aspiration
- can see the pt is aspiration, coughing, puls ox lowering,
Pt at risk: stroke pt
define silent aspiration
- not coughing, not choking, may have lower oxygen stats, adventitious breath sounds, hear something in throat, no obvious signs
- Scary bc pt may still being fed, ect
what is the nursing assessment of Pt at risk for aspiration
- look at disease processes to help determine, breathing tube in could have issues due to swelling, swallow assessment, pt w/ GN tubes, pt w/ dementia
- Feeding assistance
what is an enteral feeding?
- Meet the long or short term nutrition requirement for one who cannot eat
how to verify the tube placement of an enteral feeding tube?
- w/ x - ray, & pH of gastric contents, verify frequently
- Always check bowel sounds
what are the nursing precautions for nursing
- If continues feeding, and the pt has taken out or pulled their tube, stop it asap
- Check placement often (4 hrs) or if they pull on their tubes
- Head of the bed needs to be 30 degrees at least
what are the C.M of a client asparating?
- Coughing, choking, low o2 sats, SOB
- Abdominal distension
what are the outcomes or goals to enteral feedings?
- Maintain or restore optimal nutritional status
- Prompt healthy nutritional practices
- Prevent complications associated with malnutrition
- Decreased weight or gained as needed
