POD1 Flashcards
arteries
high pressure & pulse can be palpated
veins
pressure low
blood moved back to heart by valves & muscle contraction
tunica intima
inner layer
smooth, elastic, endothelial lining, forms valves too
tunica media
middle layer consists of muscle & elastic
thick & comprises bulk of vein
tunica adventicia
outer layer
areolar connective tissue
orders for IV should consist of
solution, additives, rate/volume of infusion
what can we do with IVs
- provide hydration
- blood
- medications
- replace electrolytes
- provide nutrition
types of IVs
- peripheral venous catheter
- central venous catheter (CVC, PICC)
isotonic
expands body’s fluid volume without causing a fluid shift from one compartment to another
does isotonic have same osmolarity as blood
YES
when isotonic fluid infused it stays in
intravascular space & expands the intervascular volume
isotonic fluid often given as
maintenance infusions or increase BP
examples of isotonic fluids
- normal saline NS 0.9% sodium chloride
- ringers lactate RL
- D5W = dextrose 5% in water
- 2/3 1/3 = 3.3% dextrose, 0.3% sodium chloride
hypertonic (higher osmolarity than blood)
higher osmotic pressure = pull fluid from cells causing shrinking
fluid shifts from cells into vascular space = expanding circulating volume
hypertonic fluids can be used as
maintenance fluids & assist in decreasing edema
examples of hypertonic
- D5NS = dextrose 5% in 0.9% NCl
- D5 1/2NS = dextrose 5% in 0.45% NCl
- D10W = dextrose 10% in water
- D5RL = dextrose 5% in RL
hypotonic (lower osmolarity
less solutes than blood, cause water to move out of blood vessels & into cells & interstitial spaces (swell)
hypotonic fluids used for
treat cellular dehydration
not recommended for pt at risk for increased intracranial pressure
hypotonic examples
1/2NS = 0.45% NCl
1/3NS = 0.33% NCl
IV solution additives
potassium chloride
where can you find if a solution is hypo/hypertonic
on IV bag
nursing responsibilities for IV
- site assessment
- make sure IV solution & rate correct
- make sure bag not expired
- check tubing (96hrs)
- assess infiltration & phlebitis
common signs of infiltration
- cool skin @ site
- skin blanched, taut, feels “tight”
- edema at site
- discomfort/tenderness
- change in quality & flow of infusion
- frequent IV pump occlusion alarms
- IV fluid leaking from site
prevention of infiltration
- stabilization of catheter (dressings)
- proper admin techniques = patency of catheter & vein should be assessed frequently
- visually inspect & palpate site checking fro symptoms (edema, temperature, tenderness)
when should you change primary line
q96hr
when should you change secondary line
q24hr
blood products tubing changed
after 4 hours or 4 units
parenteral nutrition tube changed
containing amino acids/dextrose = q96
infusions containing lipid emulsion tubing changed
with each dose (q12)
gauge #18
green
uses: trauma pt, rapid infusions, high viscosity fluids
gauge #20
pink
pre-op pts, blood transfusions
gauge #22
blue
general infusions, blood infusions, children/elderly
gauge #24
yellow
fragile veins
Formula for calculating the flow rate gravity method
total hr volume (mL) / 60 min X drop factor
how full should drip chamber be when priming
1/3 to 1/2
Monitoring flow
- connect admin set to an IV infusion pump, if pump not available, prep “time tape” with volume of fluid to be infused over 1hr, attach tape next to solution container
- IV not running properly, need to check entire system to determine cause, sometimes problem can be corrected easily
- INFUSIONS RUN BY GRAVITY NEED TO BE HUNG 3 FT ABOVE HEART – IF POLE IS TOO LOW IV WILL NOT FLOW
- when evaluating patency, start at venipuncture site & work up to bag
what is infiltration
fluid no longer infused in vein but into tissues = interstitial
what do to if infiltrated
take out cannula, stop infusion, let physician know
how to treat infiltration
elevate limb, apply warm compression = increase circulation
phlebitis
inflammation of IV site & vein
phlebitis symptoms
pain, swelling, redness, heat, tenderness
air in tubing =
syringed out from port distal to bubbles with 10cc syringe
- Stop infusion.
- Clamp line below the Y-connector (port)
- Attach the syringe
- Recommence the infusion and draw fluid into the syringe until the air bubble is captured. When using a pump, you will usually not need do draw back on the syringe - it will push the fluid into it.
- Remove syringe & clamp and re-commence infusion.
drip chamber too full?
fluid can be pushed back into bag:
- remove bag from pole
- invert IV
- squeeze chamber pushing fluid back into bag
- check chamber = 1/3 to 1/2 full
- hang bag back on pole
if leaking at site . . .
- connection b/w cannula & saline lock loose (connection between cap & extension set is loose OR connection between cap & IV tubing loose)
- IV interstitial & needs to be removed
slow flow rate
- assess position of pt arm
- height of pole
- signs of infiltration
- recalculate drip rate with roller if gravity
why admin IV fluids?
- maintain fluid balance
- maintain electrolyte balance
- energy demands
- delivery of meds (NPO)
homeostasis
ability to maintain internal stability to compensate for environmental changes
goal of homeostasis
maintain a balance b/w intake & output
what goes into body = what comes out
fluid balance not achieved..
- negative balance
- positive balance
hypovolemia =
dehydration (negative)
hypervolemia =
fluid overload (positive)
hypovolemia (fluid loss) symptoms
headache, dizziness, decreased urinary output, dry mucus membranes, cool clammy skin, decreased BP, tacycardia, dyspnea, confusion
causes hypovolemia
dehydration (diarrhea, vomiting)
blood loss (internal/external)
plasma loss (burns)
treatment hypovolemia
bolus fluids
push oral fluids if NPO
hypervolemia (fluid overload) symptoms
edema, increased BP, bounding pulses, course crackles, dyspnea, increased weight, confusion
causes hypervolemia
heart failure, kidney failure, admin large volumes of IV fluids, cirrhosis
treatment hypervolemia
stop/slow infusion
monitor intake/output
monitor VS
admin O2
admin diuretics
water movement for hyper/hypotonic, isotonic
iso = water moves in/out of cell equally
hyper = water moves out of cell (shrink)
hypo = water moves into the cell (swell)
what can we do to prevent infection
- aseptic
- tourniquets & insertion equipment single use
- careful skin prep
- careful site management
- examine equipment for integrity & expiry date
- filter needle for prep of IV meds
- schedule change IV tubing & solutions
- ongoing assessment for infection
macrodrip
- big drops
- drop factor located in tear drop on tubing
- pump = 20gtt/mL
microdrip
- small drops
- often used for slow rates
- drop factor 60gtt/mL
priming tips
- gather supplies
- double check dates
- maintain sterility (spike set & leur lock end)
- clamp tubing prior to spiking IV bag
- fill drip chamber 13-1/2 full
- prime slowly
changing empty bag
- supplies & check what is ordered
- pause infusion
- hang new bag
- pull blue tag off new bag
- remove empty bag
- remove bag from spike set
- spike new bag & squeeze chamber
- reprogram pump
daily assessment of IV
- routinely assessed for redness, tenderness, swelling, & drainage
- visual, palpation, subjective info
- use phlebitis & infiltration scale
- tenderness = dressing removed to carefully assess site
troubleshooting occulsion
- assess clamps aren’t closed (must be open for flow)
- assess position of pt limb (IV in joints will occlude if bent)
- gravity = ensure IV pole 3 ft higher than heart
- flush site to assess cannula has not clotted or kinked
- assess that IV hasn’t gone interstitial
flushing IV
- gather equipment
- hand hygiene
- gloves
- 2 pt identifiers
- scrub saline lock w/ alcohol
- attach 5cc NS syringe, open clamp & flush (turbulent flush)
- clamp & attach curios cap
compartment syndrome
- pain, pallor, pressure, pulselessness, paresthesia, paralysis, poikilothermia
important information to gather from PACU
- VS
- LOC
- pain management
- medications
- when next doses of ABX due
- IV solution and rate
4 preventions of IV infiltration
- stabilize catheter
- proper administering techniques (check on patency of catheter & vein frequently)
- prior to each dose of meds, inspect and palpate site for s/s.
- warm and moist compress
Calculate infusion time for 1000mL of NS infusing at 75cc/hr
13 hr 20 minutes
IV flow rate
The number of gtt/min or mL/hr
IV Occlusion
obstruction in the flow of infusion:
- ensure clamp is open
- position of tubing (joint is bent)
- IV pole must be 3 ft above pt’s heart
- IV site must be flushed
- IV site must be patent (no infiltration)
Post-Op Assessment Priorities: respiratory
assess for respiratory depression: respiration can be altered by anesthesia and pain medications like opioids;
uncontrolled pain impacts ventilation;
pneumonia and atelectasis are common post-op complications - therefore provide deep breathing and coughing 10x/ hour;
splinting of incision during coughing decreases pain;
Post-Op Assessment Priorities: LOC
opioids;
pts w/kidney issues process inefficiently, leading to larger doses of meds circulating in body;
changes in LOC may be secondary to opioid overdose, hypoglycemia, hypovolemia, or neurological conditions such as TIA, stroke;
Post-Op Assessment Priorities: cardiovascular
BP
HR
CWMS
risk of hypovolemic shock due to hemorrhage;
- tachycardia (HR)
- anxiety
- cool and clammy skin
- decreased urine output
- dyspnea
BP can also decrease due to:
vasodilation secondary to opioids;
fluid loss during surgery;
pre-op dehydration
BP can increase due to uncontrolled pain and hypervolemia
interventions for urinary retention
- diagnosed with bladder scan
- mobilize
- position
- monitor intake and output
- catheterization
advantages of direct IV
rapidly achieve therapeutic levels;
given when other meds irritate tissues via other routes;
NPO or unconscious patients
less discomfort than IM
no absorption problems
disadvantages of direct IV
vein irritation;
fluid volume overload;
cautioned for pts w/ HF
requires IV access
fast adverse/ allergic reaction
infection
assessment needed for IV (secondary)
Assess peripheral IV for patency
IV line expiration
Allergy status
PDTM
- Compatibility
- Volume of bag to be used
- Specific period of time of infusion
- Rate of infusion
- Level of monitoring
Reconstitution
Process of turning a powdered form of medication into a liquid form for injection by adding a diluent
Diluent
Liquid used to mix powder in a vial, usually sterile water or NS
Displacement
Volume powder adds as it dissolves in the diluent to make a greater volume overall
equipment needed for reconstitution
PDTM, MAR, syringe, filter needle, mini-bag, reconstitution device, medication label, alcohol swab, diluent, medication, secondary line, tubing label
reconsititution drip rate formula
Mini-bag volume (mL) [diluted volume] / time (mins) X 60 mins / 1hr
Troubleshooting *** reconstitiution
Assess intermittent medication is dripping prior to leaving pt
Assess medication is infusing at correct infusion rate that was independently determined
Assess correct medication & dosage has be programmed into infusion pump
Assess for signs of infiltration & phlebitis
Ensure connections are tight
Ensure pump is dripping at prescribed rate
why iv direct
Quicker (over 1-5min)
Can be more irritating
Fluid restriction
Possible adverse effects
sutures & staples
Hold skin and underlying tissue together in wounds that heal by primary intention
type of wound closures: sutures
- Material used to sew tissues together
- Sutures used to attach tissues beneath the skin are often made of an absorbable material that dissolves over several days
- Are made of a variety of materials (silk, cotton, line wire, nylon)
- Can be used in various methods of suturing techniques
interrupted / intermittent sutures
each stitch is tied and knotted separately
continuous sutures
one thread runs continuously and is knotted at the top and bottom
retention sutures
- large gauge sutures used in addition to skin sutures for some incisions
- heavy reinforcing sutures placed deep within muslce of abdo wall to relieve tension on primary suture line
staples
do not fully encircle wound edges but form a trough keeping edges together
less time consuming than tying individual sutures
steri strips
sterile skin closure devices
used to secure, close, or support small cuts or wounds
applied post suture or staple removal
wound edges start to open up
Stop removing staples/ sutures immediately
Cover with sterile dressing
Notify the physician
document removal of staples…
Suture removal
Number of sutures/ staples removed
Appearance of incision
Application of steri-strips
Type of dressing applied
Patient tolerance
Patient teaching
principles of suture removal
cut as close to the skin as possible because suture material that is visible to the eye is in contact with resident bacteria of the skin and must not be pulled under the skin
- Suture material under the skin is considered free of bacteria
- Never leave any suture material under the skin as it acts as a foreign body and causes inflammation
- Inspect each suture upon removal
drain purpose
hasten/ accelerate the healing process by draining excessive exudates and prevent leakage of drainage around the incision site
drain inserted…
inserted into or near a wound after the surgical procedure is completed. One end of the tube or drain is placed near or in the incision when it is anticipated that fluid will collect in the closed area, delay healing and formation of granulation tissue
penrose drains
Acts by draining and fluid along its surfaces through the incision or stab wound adjacent to the main incision
It can be secured with either a suture to the skin or a safety pin to maintain its position
Is considered an open drain
hemovac and jackson pratt drains
Reduces possible entry of microorganisms into the wound through the drain
Are considered closed drains
Hastens the healing process by draining exudate and prevents leakage of drainage around incision site
Tubes have a built in reservoir that can be compressed to create constant low suction or left to gravity as per doctors orders
hemovac drains hold approx
350cc drainage
jackson pratt drains hold
90cc
Surgical Drains Nursing Responsibilities
- Maintain suction or leave to gravity as ordered
- Ensure drain is properly secured to the patients gown to prevent dislodgement
- Keep reservoir lower than insertion site to facilitate drainage
- Document colour, quantity of drainage throughout the shift
- Monitor for changes in colour, quantity, pain, redness, swelling at insertion site and accidental dislodgement
Surgical Drain Assessments
- type of drain
- type of drainage
- quantity of drainage
- presence of securement device
- tube patency
- odour
- dressing
emptying drain
- Empty drain when 1/2 to 2/3 full and at the end of the shift
- Use a separate container to empty drain to decrease transference of microorganisms
- Wash hands, put on clean gloves
- Open drainage port – avoid touching
- Drain contents into container and measure
- Compress the drain carefully, swab drainage port with alcohol swab and close to re-establish pressure
drain removal
- prn pain
- empty drain
- inspect
- sterile kit
- clean wound “clean to dirty”
- remove suture
- deep breath & pull drain out steady motion
- resistance = STOP STAT
- inspect tip for intactness
- dressing
- document
