NURS 311 FINAL Flashcards
Speed Shock
A sudden, toxic, adverse physiological reaction to IV medication or drugs that are administered too quickly
Symptoms of Speed Shock
Flushed face, headache, tight chest, irregular pulse, loss of consciousness, cardiac arrest
Infiltration
IV fluids enter the surrounding space instead of staying in the vasculature
Symptoms of Infiltration
Blanching, edema, coolness, pain, numbness
Extravasation
When interstitial medication causes damage to the surrounding tissues
Treatment of Extravasation
Stop IV infusion, elevate limb, notify MD
Thromophlebitis
Inflammation of the vein
Symptoms of Thrombophlebitis
Pain, edema, redness, warmth
Pneumothorax
Accumulation of air in the pleural cavity
Hemothorax
Accumulation of blood/fluid in pleural cavity
Placement of Chest Tube with a pneumothorax
placed anteriorly through the 2nd ICS
Placement of Chest Tube with a hemothorax
placed posteriorly through the 8th or 9th ICS
Dry Suction Water Seal System
1 - Suction Regulation
2 - Water seal Chamber
3 - Air leak monitor
4 - Collection chamber
5 - Suction monitor bellows
Nursing Care for Chest Tubes
- Ensure all connection is secured with waterproof tape or zip ties
- Chest tubes may be clamped to assess whether removal is possible
- Chest tubes may be clamped for < 1 minute (to change drainage unit, to locate an air leak, to assess bubbling and fluctuation of unclamped chest tube)
Patient assessment of a chest tube
Inspection (general, distressed, calm, SOB, cyanotic)
Vitals
Resp and O2 (auscultation, LOC, ABGs, SpO2, mucous membranes, resp effort)
Pain
Chest tube insertion site (D&I, occlude if air leak, excessive bleeding)
Encourage DB&C, ambulation
Complication r/t chest tubes
- chest tube placement
- infection at the insertion site
- pneumonia
- shoulder disuse
Central Venous Access Devices
More permanent IV cath
PICC
In basilic or cephalic vein into superior vena cava, securing device placed
Risks of PICCs
Phlebitis after insertion, more susceptible to kinks and damage, venous spasms
Pros of PICCs
Lower risk of infection and air embolism
Nontunneled Central Venous Catheter
Inserted internal jugular or subclavian vein
Risks of NCVC
Greater risk of complications at insertion, high risk of infection, not used outside of hospital
Tunnelled Catheter
For long term use when PICC is not appropriate
Implanted Port
silicone catheter attached to a metal or plastic reservoir (port) which has a self-sealing septum for needle access
Nurse management of CVC
Manage and assess site
Dressing changes and line/cap management
Administer meds
Withdraw blood
Site assessment of CVC
- Skin for redness, swelling, leakage, phlebitis
- infection
- security of dressing, sutures, or securing device
- damage to catheter or caps
Withdrawing Blood from CVC
- order is required
- blood may be taken from any lumen (except TPN line)
- withdraw blood before drawing specimen
- IV infusions turned off 1-2mins before
- lumens flushed after sampling
Removal of CVC or PICC
Check order, HH, remove dressings and sutures
Apply for 5 minutes and apply occlusive bandage
CVC removal
Remove on exhale, lie flat for 30 mins
PICC removal
Extend arm out at 90 degree angle and do not manipulate arm above site
Complications of CVADs
Infection, air embolism, VTE, catheter occlusion, displacement of catheter, pneumo/hemothorax, phlebitis, extravasation
Clinical Manifestations of Fractures
edema and swelling, pain and tenderness, muscle spasm, bone deformity, ecchymosis, loss of function, crepidation
Bone Healing Steps
1 - bleeding at broken ends of the bone with hematoma formation
2 - organization of hematoma into fibrous network
3 - invasion of osteoblasts and deposition of calcium
4 - callus formation
5 - remodelling
Nursing assessment of Fractures
History, physical assessment (S&S), neurovascular assessment, peripheral vascular assessment (color, temp, cap refill, peripheral pulses, edema), peripheral neurological assessment (sensation, motor function, pain), lab work (low HGB, increased WBC or ESR), diagnostic imaging, psychological assessment
Nursing diagnoses for fractures
- Acute pain due to fracture, edema, spasm and soft-tissue damage
- decreased mobility r/t acute pain
- potential NV compromise r/t altered perfusion
- infection r/t altered tissue integrity
Cast Care
Can cause neurovascular complications if too tight - frequent checks
Ice and elevation for 24-28hrs
Report breaks in cast
Traction Care
Pull ends of bone apart and reduce spasms
Compartment Syndrome
A condition in which increased pressure within a limited space compromises circulation, resulting in ischemia and necrosis of tissues
6 P’s of Compartment Syndrome
- Paresthesia
- Pain
- Pressure
- Pallor
- Paralysis
- Pulselessness
Compartment syndrome treatment
compare extremities, do not apply ice or elevate, remove/loosen bandage, reduce traction weight
