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cp 3 > POD1 > Flashcards

POD1 Flashcards

1
Q

arteries

A

high pressure & pulse can be palpated

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2
Q

veins

A

pressure low

blood moved back to heart by valves & muscle contraction

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3
Q

tunica intima

A

inner layer

smooth, elastic, endothelial lining, forms valves too

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4
Q

tunica media

A

middle layer consists of muscle & elastic

thick & comprises bulk of vein

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5
Q

tunica adventicia

A

outer layer

areolar connective tissue

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6
Q

orders for IV should consist of

A

solution, additives, rate/volume of infusion

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7
Q

what can we do with IVs

A
  • provide hydration
  • blood
  • medications
  • replace electrolytes
  • provide nutrition
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8
Q

types of IVs

A
  • peripheral venous catheter
  • central venous catheter (CVC, PICC)
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9
Q

isotonic

A

expands body’s fluid volume without causing a fluid shift from one compartment to another

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10
Q

does isotonic have same osmolarity as blood

A

YES

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11
Q

when isotonic fluid infused it stays in

A

intravascular space & expands the intervascular volume

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12
Q

isotonic fluid often given as

A

maintenance infusions or increase BP

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13
Q

examples of isotonic fluids

A
  • 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
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14
Q

hypertonic (higher osmolarity than blood)

A

higher osmotic pressure = pull fluid from cells causing shrinking

fluid shifts from cells into vascular space = expanding circulating volume

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15
Q

hypertonic fluids can be used as

A

maintenance fluids & assist in decreasing edema

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16
Q

examples of hypertonic

A
  • 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
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17
Q

hypotonic (lower osmolarity

A

less solutes than blood, cause water to move out of blood vessels & into cells & interstitial spaces (swell)

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18
Q

hypotonic fluids used for

A

treat cellular dehydration

not recommended for pt at risk for increased intracranial pressure

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19
Q

hypotonic examples

A

1/2NS = 0.45% NCl

1/3NS = 0.33% NCl

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20
Q

IV solution additives

A

potassium chloride

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21
Q

where can you find if a solution is hypo/hypertonic

A

on IV bag

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22
Q

nursing responsibilities for IV

A
  • site assessment
  • make sure IV solution & rate correct
  • make sure bag not expired
  • check tubing (96hrs)
  • assess infiltration & phlebitis
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23
Q

common signs of infiltration

A
  • 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
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24
Q

prevention of infiltration

A
  1. stabilization of catheter (dressings)
  2. proper admin techniques = patency of catheter & vein should be assessed frequently
  3. visually inspect & palpate site checking fro symptoms (edema, temperature, tenderness)
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25
Q

when should you change primary line

A

q96hr

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26
Q

when should you change secondary line

A

q24hr

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27
Q

blood products tubing changed

A

after 4 hours or 4 units

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28
Q

parenteral nutrition tube changed

A

containing amino acids/dextrose = q96

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29
Q

infusions containing lipid emulsion tubing changed

A

with each dose (q12)

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30
Q

gauge #18

A

green

uses: trauma pt, rapid infusions, high viscosity fluids

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31
Q

gauge #20

A

pink

pre-op pts, blood transfusions

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32
Q

gauge #22

A

blue

general infusions, blood infusions, children/elderly

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33
Q

gauge #24

A

yellow

fragile veins

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34
Q

Formula for calculating the flow rate gravity method

A

total hr volume (mL) / 60 min X drop factor

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35
Q

how full should drip chamber be when priming

A

1/3 to 1/2

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36
Q

Monitoring flow

A
  1. 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
  2. IV not running properly, need to check entire system to determine cause, sometimes problem can be corrected easily
  3. INFUSIONS RUN BY GRAVITY NEED TO BE HUNG 3 FT ABOVE HEART – IF POLE IS TOO LOW IV WILL NOT FLOW
  4. when evaluating patency, start at venipuncture site & work up to bag
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37
Q

what is infiltration

A

fluid no longer infused in vein but into tissues = interstitial

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38
Q

what do to if infiltrated

A

take out cannula, stop infusion, let physician know

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39
Q

how to treat infiltration

A

elevate limb, apply warm compression = increase circulation

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40
Q

phlebitis

A

inflammation of IV site & vein

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41
Q

phlebitis symptoms

A

pain, swelling, redness, heat, tenderness

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42
Q

air in tubing =

A

syringed out from port distal to bubbles with 10cc syringe

  1. Stop infusion.
  2. Clamp line below the Y-connector (port)
  3. Attach the syringe
  4. 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.
  5. Remove syringe & clamp and re-commence infusion.
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43
Q

drip chamber too full?

A

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

44
Q

if leaking at site . . .

A
  1. connection b/w cannula & saline lock loose (connection between cap & extension set is loose OR connection between cap & IV tubing loose)
  2. IV interstitial & needs to be removed
45
Q

slow flow rate

A
  • assess position of pt arm
  • height of pole
  • signs of infiltration
  • recalculate drip rate with roller if gravity
46
Q

why admin IV fluids?

A
  • maintain fluid balance
  • maintain electrolyte balance
  • energy demands
  • delivery of meds (NPO)
47
Q

homeostasis

A

ability to maintain internal stability to compensate for environmental changes

48
Q

goal of homeostasis

A

maintain a balance b/w intake & output

what goes into body = what comes out

49
Q

fluid balance not achieved..

A
  • negative balance
  • positive balance
50
Q

hypovolemia =

A

dehydration (negative)

51
Q

hypervolemia =

A

fluid overload (positive)

52
Q

hypovolemia (fluid loss) symptoms

A

headache, dizziness, decreased urinary output, dry mucus membranes, cool clammy skin, decreased BP, tacycardia, dyspnea, confusion

53
Q

causes hypovolemia

A

dehydration (diarrhea, vomiting)

blood loss (internal/external)

plasma loss (burns)

54
Q

treatment hypovolemia

A

bolus fluids

push oral fluids if NPO

55
Q

hypervolemia (fluid overload) symptoms

A

edema, increased BP, bounding pulses, course crackles, dyspnea, increased weight, confusion

56
Q

causes hypervolemia

A

heart failure, kidney failure, admin large volumes of IV fluids, cirrhosis

57
Q

treatment hypervolemia

A

stop/slow infusion

monitor intake/output

monitor VS

admin O2

admin diuretics

58
Q

water movement for hyper/hypotonic, isotonic

A

iso = water moves in/out of cell equally

hyper = water moves out of cell (shrink)

hypo = water moves into the cell (swell)

59
Q

what can we do to prevent infection

A
  • 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
60
Q

macrodrip

A
  • big drops
  • drop factor located in tear drop on tubing
  • pump = 20gtt/mL
61
Q

microdrip

A
  • small drops
  • often used for slow rates
  • drop factor 60gtt/mL
62
Q

priming tips

A
  • 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
63
Q

changing empty bag

A
  • 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
64
Q

daily assessment of IV

A
  • routinely assessed for redness, tenderness, swelling, & drainage
  • visual, palpation, subjective info
  • use phlebitis & infiltration scale
  • tenderness = dressing removed to carefully assess site
65
Q

troubleshooting occulsion

A
  • 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
66
Q

flushing IV

A
  • 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
67
Q

compartment syndrome

A
  • pain, pallor, pressure, pulselessness, paresthesia, paralysis, poikilothermia
68
Q

important information to gather from PACU

A
  • VS
  • LOC
  • pain management
  • medications
  • when next doses of ABX due
  • IV solution and rate
69
Q

4 preventions of IV infiltration

A
  1. stabilize catheter
  2. proper administering techniques (check on patency of catheter & vein frequently)
  3. prior to each dose of meds, inspect and palpate site for s/s.
  4. warm and moist compress
70
Q

Calculate infusion time for 1000mL of NS infusing at 75cc/hr

A

13 hr 20 minutes

71
Q

IV flow rate

A

The number of gtt/min or mL/hr

72
Q

IV Occlusion

A

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)

73
Q

Post-Op Assessment Priorities: respiratory

A

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;

74
Q

Post-Op Assessment Priorities: LOC

A

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;

75
Q

Post-Op Assessment Priorities: cardiovascular

A

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

76
Q

interventions for urinary retention

A
  1. diagnosed with bladder scan
  2. mobilize
  3. position
  4. monitor intake and output
  5. catheterization
77
Q

advantages of direct IV

A

rapidly achieve therapeutic levels;
given when other meds irritate tissues via other routes;
NPO or unconscious patients
less discomfort than IM
no absorption problems

78
Q

disadvantages of direct IV

A

vein irritation;
fluid volume overload;
cautioned for pts w/ HF
requires IV access
fast adverse/ allergic reaction
infection

79
Q

assessment needed for IV (secondary)

A

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
80
Q

Reconstitution

A

Process of turning a powdered form of medication into a liquid form for injection by adding a diluent

81
Q

Diluent

A

Liquid used to mix powder in a vial, usually sterile water or NS

82
Q

Displacement

A

Volume powder adds as it dissolves in the diluent to make a greater volume overall

83
Q

equipment needed for reconstitution

A

PDTM, MAR, syringe, filter needle, mini-bag, reconstitution device, medication label, alcohol swab, diluent, medication, secondary line, tubing label

84
Q

reconsititution drip rate formula

A

Mini-bag volume (mL) [diluted volume] / time (mins) X 60 mins / 1hr

85
Q

Troubleshooting *** reconstitiution

A

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

86
Q

why iv direct

A

Quicker (over 1-5min)

Can be more irritating

Fluid restriction

Possible adverse effects

87
Q

sutures & staples

A

Hold skin and underlying tissue together in wounds that heal by primary intention

88
Q

type of wound closures: sutures

A
  • 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
89
Q

interrupted / intermittent sutures

A

each stitch is tied and knotted separately

90
Q

continuous sutures

A

one thread runs continuously and is knotted at the top and bottom

91
Q

retention sutures

A
  • 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
92
Q

staples

A

do not fully encircle wound edges but form a trough keeping edges together

less time consuming than tying individual sutures

93
Q

steri strips

A

sterile skin closure devices

used to secure, close, or support small cuts or wounds

applied post suture or staple removal

94
Q

wound edges start to open up

A

Stop removing staples/ sutures immediately

Cover with sterile dressing

Notify the physician

95
Q

document removal of staples…

A

Suture removal

Number of sutures/ staples removed

Appearance of incision

Application of steri-strips

Type of dressing applied

Patient tolerance

Patient teaching

96
Q

principles of suture removal

A

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
97
Q

drain purpose

A

hasten/ accelerate the healing process by draining excessive exudates and prevent leakage of drainage around the incision site

98
Q

drain inserted…

A

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

99
Q

penrose drains

A

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

100
Q

hemovac and jackson pratt drains

A

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

101
Q

hemovac drains hold approx

A

350cc drainage

102
Q

jackson pratt drains hold

A

90cc

103
Q

Surgical Drains Nursing Responsibilities

A
  • 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
104
Q

Surgical Drain Assessments

A
  • type of drain
  • type of drainage
  • quantity of drainage
  • presence of securement device
  • tube patency
  • odour
  • dressing
105
Q

emptying drain

A
  • 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
106
Q

drain removal

A
  • 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

cp 3 (2 decks)

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