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Nursing Foundations 3 > Midterm: Modules 1-6 > Flashcards

Midterm: Modules 1-6 Flashcards

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1
Q

What are 2 goals of Intravenous Therapy?

A
  1. To maintain fluid, electrolyte and energy demands when patients are limited in their intake
  2. To prevent or correct fluid and electrolyte disturbance from excess losses
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2
Q

What is a crystalloid IV solution?

A

Solutions that contain small molecules that flow easily across semipermeable membranes.

Distinguished by relative tonicity to plasma:
Hypertonic- higher concentration of electrolytes compared to Extracellular fluid(ECF)
Isotonic- same concentration or tonicity compared to ECF
Hypotonic – lower concentration/tonicity compared to ECF

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3
Q

What is a common Isotonic crystalloid IV solution?

A

0.9% NaCl (NS, Normal Saline Solution)

Other examples:
Lactated Ringer’s Solution (LR, Ringer’s Lactate)
5% Dextrose in water (D5W)

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4
Q

What is a Colloid IV solution?

A

They contain protein or starch that does not cross semipermeable membranes, staying only in the intravascular space
They increase osmotic pressure, which then increases the vascular volume
Can be used for a profound bloodloss

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5
Q

What are natural colloids(IV solution) made from?

A

Blood products: Albumin and plasmanate

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6
Q

What are artificial colloids(IV solution) made from?

A

Dextran, Hespan

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7
Q

What are some nursing assessments for Parenteral Infusion Therapy

A

Vital signs, skin turgor, assessing the mucous membrane, daily weight, intake and output

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8
Q

What is Parenteral Nutrition(PN) ?

A

IV nutritional support

Can be a one-bag system(Total nutrient admixture TNA) or a two-bag system(TPN) (Amino acids/dextrose and lipid emulsion)

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9
Q

What are the indications for the two bag system (Parenteral Nutrition) ?

A

GI tract is not working

Burns

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10
Q

What are some things to monitor with TPN (Parenteral Nutrition)

A

Daily weights and fluid balance
Intake and output
Serum glucose levels
For signs and symptoms of infection - change in vital signs

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11
Q

What is TPN preferably administered through?

A

Central line catheter

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12
Q

What does the abbreviation TBA stand for?

A

To be absorbed

The amount of fluid left in the bag to be infused into the patient

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13
Q

What does the abbreviation TKVO stand for?

A

To keep vein open

The infusion is dripping very slowly (10-30mL/hr) depending on the type of access

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14
Q

What does the abbreviation SVI stand for?

A

Small volume infusion

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15
Q

What does the abbreviation SWI stand for?

A

Sterile water injection

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16
Q

What is a bolus?

A

A large volume of fluid infused over a short period of time

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17
Q

What can affect the flow rate?

A

Position of the patient/extremity
Size of the catheter in the vein
Position and patency of tubing and IV site
The viscosity of the infusion fluid
Adjustment of the roller clamp (gravity only)
Height of infusion bag in relation to insertion site (gravity only)

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18
Q

What are some things to asses the IV system/pump for?

A

Appropriate infusion at the appropriate rate
Air in the line
Rate alterations
Alterations in rate due to positioning
Medication precipitation or crystallization

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19
Q

How often should you monitor your patient with an IV?

A

Hourly or more, depending on the patients status

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20
Q

How often is the IV site changed?

A

Every 72-96 hours (every 3-4 days)

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21
Q

How long is an IV solution bag good for?

A

24 hours

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22
Q

What is Hypodermoclysis?

A

Long-term administration of medications through subcutaneous route
Used for patients with limited IV access, palliative care, mild dehydration

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23
Q

What are contraindications for Hypodermoclysis?

A

The acuity of the patient, existing fluid overload, marked edema, low platelet count

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24
Q

What are some IV therapy complications?

A

Infection, Infiltration, Phlebitis, Bruising, Air Emboli, Catheter Emboli, Fluid overload

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25
Q

What are signs and symptoms of an IV site infection?

A

Warmth, redness, swelling, drainage

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26
Q

What is Infiltration, and what are the signs and symptoms of it?

A

Occurs when intravenous fluids enter the surrounding space around the venipuncture site
Signs and Symptoms: Swelling, pallor, coolness, pain

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27
Q

What is Extravasation, and what are the signs and symptoms of it?

A

Leakage of certain irritating medications such as chemotherapy that can cause blistering and other severe tissue injuries including necrosis
Signs and Symptoms: Redness, pain, blistering, tissue damage

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28
Q

What is Phlebitis, and what are the signs and symptoms of it?

A

Inflammation of the vein, caused by chemical irritation, rate of medication administration, skill
Signs and symptoms: Pain, edema, erythema, warmth over the vein, redness tracking over the vein

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29
Q

What is an Air Emboli, and what are the signs and symptoms of it?

A

Air bolus entering venous circulation, caused by Ineffectively primed lines and flushes
Signs and Symptoms: Dyspnea, tachypnea, cyanosis, tachycardia, change in LOC, cough, nausea, gasp reflex, anxiety

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30
Q

How should a patient be positioned if an Air Emboli is suspected/present?

A

Left lateral trendelenberg

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31
Q

What is a catheter emboli (fragmentation)?

A

IV catheter fragments break off and are loose in the circulation
Can cause thrombosis, arrhythmias, infection, or endocardial/vascular perforation

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32
Q

Why would a nurse suspect there is a catheter emboli?

A

Because upon removal of the catheter, a piece could be missing from it. If suspected, immediately put pressure proximal to the site and call for help

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33
Q

What is fluid overload (pulmonary edema), and the signs and symptoms of it?

A

Excessive fluid in the alveoli
Increased risk with cardiac and renal patients, pediatric and elderly population
Signs and Symptoms: Crackles, distended neck veins, dyspnea, tachypnea, pink-frothy sputum, bounding tachycardic pulse, edema

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34
Q

What are some patient teachings for IV therapy?

A 
The rationale for IV therapy
To notify the nursing staff if:
The IV site is red and painful
There is leaking around the IV site
The solution is not dripping
There is air in the line
The solution bag is empty
The infusion pump alarm is sounding
The IV becomes dislodged
There is blood in the IV tubing
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35
Q

What is the difference between the drop factor vs. drop/drip rate vs. IV rate/flow rate?

A

Drop factor: gtt/mL
Drop/drip rate: gtt/minute
IV rate/flow rate: mL/hr(volume/time)

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36
Q

What are some reasons why medication is given IV rather than other routes?

A

Rapid effect of the medication is required
Patient is NPO
Provides constant, therapeutic levels
Less discomfort when compared to IM and SC injections
Patients are anticoagulated

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37
Q

What are high alert medications?

A

Medications that can cause increased harm when an error is made in medication administration
Extra precautions are put in place to help avoid errors Independent double checks are needed
Ex. Insulin

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38
Q

Why are IV bottles used?

A

Because the medication is not compatible with plastics.

IV bottles require vented tubing

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39
Q

What is an example of a medication that requires an IV bottle?

A

Albumin and Propofol

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40
Q

Where is the mini bag placed in relation to the primary bag?

A

The mini bag must be higher than the primary bag

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41
Q

What is considered the most dangerous method of medication administration?

A

Direct IV (push), it is injected directly into the IV line

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42
Q

What information can you find on the Parental Monograph?

A 
What the medication is and used for
Routes of administration
Safe doses
Admin instructions
Infusion rates
Nursing implications (monitoring requirements and side effects)
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43
Q

What is the medication calculation (dose to administer) ?

A

Desired Dose / Dose on hand x Vehicle = dose to administer

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44
Q

What is the 10% rule?

A

If adding 10% or more fluid volume of medication to your mini-bag then that amount must be removed from the mini-bag prior to instilling the medication

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45
Q

What is the range of gauge sizes for IV insertion?

A

14 to 24

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46
Q

What are some assessments prior to starting an IV?

A

Purpose of the IV
The skin integrity of the IV site
Size and age of the patient
Bleeding disorders
Allergies
Patients preferred site and their dominant side
The solution to be infused - quantity, viscosity

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47
Q

Where should you first begin to try the IV site?

A

start in the hand and work up the limb, selecting the most distal site

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48
Q

What are some areas to avoid putting an IV?

A 
Operative sites (surgery) 
Sites distal to the puncture site
Flexion points (wrist, AC) 
Ventral Surface of the wrist 
Antecubital fossa
Valves 
Bruised or traumatized areas 
Limbs with reduced blood flow or decreased sensation 
Areas below existing phlebitis 
Lower extremities especially in diabetics (need MD order)
49
Q

What are some tips for patients on anticoagulant therapy

A

Apply the tourniquet lightly.
Avoid excessive pressure when cleaning the skin.
When discontinuing the IV, apply direct pressure over the site and slight elevation to stop bleeding. Bleeding takes longer to stop.

50
Q

How long do you clean the IV site for with clorhexidine and alcohol?

A

Clorhexidine - for 30 seconds

70% Alcohol - requires 1 minute of friction rub

51
Q

What is the angle for insertion of an IV?

A

10-30 degree angle

52
Q

What is a Saline Lock, and what is it used for?

A

Covers and protects the end of the IV catheter. Keeps the system closed, thereby reducing the risk of infection to the patient.
Protects staff from exposure to blood during administration set
changes.
Provides access for intermittent IV drug therapy, blood administration, and tubing changes

53
Q

What is to be applied underneath transparent dressing for securing an IV?

A

sterile tape

54
Q

When do you stop an IV infusion?

A

If the doctor order says to
If the patient is able to drink fluids on their own
The patient is no longer needing the medications

55
Q

When is the saline lock flushed with normal saline? and how often should it be flushed?

A

It is flushed with 2-5mL of normal saline prior to and following the intermittent administration of an IV fluid/IV medication
Also must be flushed every 12 hours when not in use to ensure patency

56
Q

What are central venous catheters flushed with and why?

A

Flushed with diluted heparin solution after each use to keep clots from forming if non-valved

57
Q

What is a central line catheter?

A

Sterile vascular access device place in large veins in the central venous system
Tip dwells in the lower 1/3 of the superior vena cava

58
Q

What is the purpose(s) of a central line catheter?

A

Infuse fluids directly into the central venous circulation for:
Prolonged IV antibiotic treatment
Administration of parenteral nutrition
Extended and frequent chemotherapy/vesicant chemotherapeutic agents
Rapid infusion of blood and blood products
Administration of caustic fluids (i.e. potassium)
Allows for frequent blood draws without venipuncture

59
Q

What does the valve do on a valved central line catheter?

A

It minimizes the risk of blood reflux into the lumen of the catheter, and it makes it so that the catheter does not need to be clamped when not in use

60
Q

What is a direct percutaneous central line? and what are the indications for it?

A

A direct percutaneous central line is inserted directly into the external or internal jugular, subclavian or femoral vein and advanced into the superior or inferior vena cava

Indicated for: all infusions, blood withdrawl

61
Q

What is a tunneled(cuffed) central line?

A

The tunneled central line is inserted in to the subclavian and tunneled through the subcutaneous tissue exiting on the chest wall

A dacron cuff under the skin stabilizes the catheter and acts as a barrier to bacteria

62
Q

What is an implanted central venous catheter?

A

Soft silicone or polyurethane catheter attached to a reservoir which is covered by a self-sealing silicone septum
Reservoir inserted into a subcutaneous pocket in chest, arm or abdomen
The catheter segment is inserted into the subclavian vein

63
Q

What is a peripherally inserted central catheter (PICC)?

A

A PICC is inserted peripherally into the upper arm (basilica, cephalic, brachial) and tip advances to the superior vena cava
It must be stabilized with an external securement device

64
Q

What should not be done on the arm that a patient has a PICC line in on?

A

Blood pressure or venipuncture

65
Q

What is a midline catheter? and what is an indication for it?

A

Midline catheters are inserted into a peripheral vein
Midline catheters are NOT central venous catheters – tip is below or level of the axilla(armpit)
Indication: Use of midline catheters is an alternative in patients who don’t require a peripherally inserted central catheter but who need several days of IV therapy

66
Q

What are some assessments for Central line catheters?

A 
The condition of the catheter
The condition of the skin 
The securement devices (sutures, steristrips, dressing, etc.)
The leur lock condition
Assessing the skin for REEDA
Assessing the condition of the dressing
Assessing the catheter for any damage
Assessing the catheter for any change in external length
67
Q

Why is it important to flush and lock central lines?

A

To maintain patency

68
Q

What does S.A.S. stand for, and what does it mean?

A

S: Saline
A: Administration of medications or infusion
S: Saline
This is the recommended flushing and locking for valved lumens

69
Q

What does S.A.S.H stand for, and what does it mean?

A

S: Saline
A: Administration of medications and infusions
S: Saline
H: Heparin - low dose (10 - 100 units/mL)
This is the recommended flushing and locking for non valved lumens

70
Q

What must all catheters/ skin junctions of Central Venous Catheters be covered in?

A

Transparent or gauze dressing

71
Q

What tests should be ordered prior to inserting a central line?

A

Blood work:
INR, platelets (coagulation status)
CBC

72
Q

What are some nursing responsibilities while a central line is being inserted?

A

Cleaning all work surfaces
Making sure certain visitors and other activities are limited
Gathering the supplies
Educating the patient on the Valsalva maneuver (a breathing method to help slow down your heart when it is going too fast)
Monitoring the patient for any pain, and signs and symptoms of any complications

73
Q

How often should you be monitoring a central line catheter after insertion?

A

Every 4 hours for the first 24 hours after insertion

Every shift and as needed after the first 24 hours

74
Q

What are some complications of a Central Line Catheter?

A 
Local and systemic infections
Extravasation or infiltration
Occlusion
Migration of catheter
Embolism - air or catheter
Thrombosis
Nerve injury
75
Q

What are some signs of a local infection? Systemic?

A

Local: redness, warmth, swelling, tenderness, purulence, pain or tenderness
Systemic: fever, chills, diaphoresis(sweating), tachycardia, backache, nausea, and vomiting, headache, hypotension

76
Q

What is occlusion? What can it lead to?

A

The inability to infuse or inject fluid into a catheter, the inability to aspirate blood from a catheter or both
If left untreated can lead to venous thrombosis and infection

77
Q

What are signs and symptoms of Thrombosis?

A

pain in the chest, ear, jaw, shoulder
numbness or tingling of extremities
edema
difficulty flushing or aspirating from the catheter
leakage of infusion solution from the catheter/skin junction
tachycardia
shortness of breath

78
Q

What are signs and symptoms of a nerve injury?

A

Radiating electrical pain during insertion
Paresthesia, tingling, burning, prickly feeling, or numbness after insertion
Respiratory difficulty (with external jugular, internal jugular, or subclavian lines) after insertion due to phrenic nerve disruption
Horner’s syndrome – excessive pupillary constriction, eyelid droop, absence of sweating on affected side of the face, hypotension

79
Q

What are surgical procedures classified under?

A

Seriousness (Major or Minor), Urgency (Elective, Urgent, Emergency) and Purpose (Diagnostic, Palliative, Reconstructive, Constructive, Cosmetic etc.)

80
Q

What is an ablative surgery?

A

Removing a diseased part of a person, Ex. a tumor

81
Q

What is the preoperative nurses role?

A

Checking if the consent form has been signed
Ensuring that the patient understands the procedure
Notifying the surgeon if the patient is unsure, or hasn’t signed the consent form

82
Q

Who is responsible for explaining the surgical procedure and obtaining informed consent?

A

The surgeon

83
Q

What is the purpose of a pre-op assessment?

A

To establish the patient’s baseline preoperative function to assist in preventing and recognizing possible postoperative complications

84
Q

What information should you go over in a pre-op assessment?

A

Medical history, risk factors, previous surgeries, medication history, allergies, smoking, alcohol and substance abuse, family support, patient expectations, cultural considerations, etc.

85
Q

What are some surgical risk factors that can put a patient at risk for complications?

A 
Pre-existing medical conditions and medications such as cardiac problems, COPD, renal disease, diabetes, liver disease
Nutritional status - malnutrition 
Obesity
Age
Fluid and electrolyte imbalances
86
Q

What blood work tests should be ordered before a surgery?

A 
CBC - RBC, Hemoglobin, Hematocrit, WBC
Electrolytes - Na, K, Mg
Coagulation Studies - PTT/INR, platlets
Creatine clearance
Glucose
BUN - Blood urea nitrogen
87
Q

What are some patient teachings to do before a surgery?

A

The preparations needed - skin, medication, fasting
Drains and catheters - type, location, care, maintenance
Incision and Dressing care
Pain management
Progression of diet

88
Q

How long should a patient be NPO for before a surgery?

A

8-12 hours

89
Q

What are the 4 types of anesthesia and what are they used for?

A

General - total unconsciousness
Regional - loss of sensation in an area of a body (epidurals)
Local - Loss of sensation at the desired site (can be topical)
Procedural - Combination of opioids and anxiolytics to produce sedation

90
Q

What is the vital signs protocol for post op assessments?

A

Q 15 min x 4 (every 15 min for the first hour)
Q 30 min x 2 (every 30 min for the 2nd hour)
Q 1 hour x 4 (every hour for the next 4 hours)
Q 4 hour x until stable (every 4 hours until stable)
Q8h

91
Q

What is important to write down for post op documentation?

A 
Document the time of the arrival to the post-op unit
Initial assessments 
Vital signs
Systems assessments
Dressing assessment
IV info - what is the solution, the rate its running at
Any drains
What patient has said to you
92
Q

What are some post operative complications that can occur?

A 
Hemorrhage
Wound dehiscence, evisceration or infection
Post-op delirium
Urinary retention
Pneumonia
Pain
Pulmonary embolism
Thrombosis
Obstruction of the intestine due to paralysis (paralytic ileus)
93
Q

What are some things to include in discharge teaching and planning?

A

Follow up appointments ex. when staples will be removed
Teaching regarding a new prescription
Pain management
When to return to the hospital or seek immediate medical attention

94
Q

What is the purpose(s) of blood transfusions?

A

Increase circulating blood volume after surgery, trauma, hemorrhage
Increase the number of red blood cells and maintain hemoglobin levels with severe anemia
Replace selected cell components

95
Q

How long is type and screen blood work good for?

A

Valid for 96 hours(4 days) from the time of collection

96
Q

What are the three common types of transfusions?

A

Blood, plasma, platelets

97
Q

What does whole blood contain?

A

Red blood cells, White blood cells, platelets, plasma, cryoprecipitate
Whole blood is not routinely used for transfusions

98
Q

What are the indications to administer Red Blood Cells?

A

To replace blood loss due to hemorrhage, surgery, trauma
Not used unless hemoglobin is below 70
Needs to be transfused within 4 hours
Have a shelf life of 42 days

99
Q

What are the indications to administer Platelets?

A

For bleeding due to decreased platelet production or abnormal platelets
Prophylactically for invasive procedures, when platelet levels are low
Must be used within 4 hours of hanging
Have a shelf life of 5 days

100
Q

What are the indications to administer Plasma(FFP)

A

Replace clotting factors
Reverses the effects of warfarin and heparin
For a patient who is bleeding due to coagulopathy
Have a shelf life of 1 year

101
Q

What are plasma expanders?

A

They are composed of large molecules which draw or hold fluid in the bloodstream
Natural: made from blood products, sterile - no risk of viral transmission, ex. albumin
Synthetic: Contain no human antigens, Ex. Pentaspan

102
Q

What is irradiated blood and why is it used?

A

It is blood that is exposed to radiation to minimize bacteria
This blood is used for patients with poor immune systems
Reduces the risk of a reaction

103
Q

What emergency medications should be available on the unit for blood transfusion administration?

A

Epinephrine
Diphenhydramine (Benadryl)
Hydrocortisone

104
Q

What is the only fluid/solution that can infuse with blood?

A

Normal saline

105
Q

Can medications be given through a blood line?

A

NO!!! Never!!

106
Q

What should the rate of blood administration be for the first 10-15 minutes?

A

1-2mL per minute = 60-120mL/hr

107
Q

What should you teach the patient to immediately report when receiving a blood transfusion?

A

Fever, Shortness of breath, Itching, Chills, Feeling very unwell

108
Q

When is it more likely for an adverse reaction to occur when receiving a blood transfusion?

A

in the first 5 to 15 minutes

If an adverse reaction occurs, immediately stop the transfusion and do NOT flush the line

109
Q

How often should you be taking vital signs with a blood transfusion?

A

After the first 15 minutes, then every hour (at least) until the infusion is complete

110
Q

What information should be documented regarding a blood transfusion?

A 
Date and time of transfusion
Type of component used and its product number
Vital signs and the time they were taken
The ID of the person administering
The ID of the second person verifying the blood component and product number
Adverse events and the treatments given
Volume administered
Patient outcomes
111
Q

What infectious diseases can be transmitted through blood by asymptomatic donors?

A

HIV, Hep C, Hep B, bacterial sepsis

112
Q

What is the most common blood transfusion reaction?

A

Febrile, Non-Hemolytic

Antibodies against the donor WBC’s

113
Q

What causes a mild allergic reaction to a blood transfusion?

A

Antibodies against the donor plasma

114
Q

What is the most serious reaction to a blood transfusion?

A

Acute Hemolytic Transfusion (AHTR)
This results because of blood type incompatibility(as little as 10mL)
Occurs in the first 15 minutes

115
Q

What can an Acute Hemolytic Transfusion Reaction progress to?

A 
Vascular collapse
Bleeding
Acute renal failure
Shock
Cardiac arrest
Ultimately death
116
Q

What are some nursing actions if a blood transfusion reaction occurs?

A 
Stop the transfusion immediately
Provide emergency care for ABC's
Do not flush the IV line
Change IV set and start normal saline
Notify physician
Provide medications as ordered
Report to transfusion medicine and return unused blood and tubing
117
Q

What is a massive transfusion?

A

When a patients entire blood volume is given in 24 hours

10 units of RBCs

118
Q

How do you calculate flow rate?

A

( Total volume(mL) / Time(min) ) x drop factor(gtts/mL

= gtts/min (flow rate)

Nursing Foundations 3 (1 decks)

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