Preparing to administer IV Flashcards
What should be written on the label of any bag or bottle of IV liquid>
the type of solution hung, date, time, and nurse’s initials. Write only on the label, not the bag or bottle. Do not use a marker.
What should be included on the label on iv TUBING?
Apply a label to IV tubing that indicates either when tubing was hung or when tubing should be changed, per agency policy.
Avoid vein selection in…
Areas with tenderness, redness, rash, pain, or infection
An extremity affected by previous cerebrovascular accident (CVA), paralysis, dialysis shunt, or mastectomy
Any site distal to a previous venipuncture site, sclerosed or hardened veins, a site of infiltrate, areas of venous valves, or phlebitic vessels
Fragile dorsal hand veins in older adults
Signs of fluid volume deficiency
decreased urine output, dry mucous membranes, decreased capillary refill, a disparity in central and peripheral pulses, tachycardia, hypotension, shock
signs of fluid volume excess
crackles in the lungs, shortness of breath, edema
signs of electrolyte imbalance
abnormal serum electrolyte levels, changes in mental status, alterations in neuromuscular function, cardiac arrhythmias, changes in vital signs
signs of infiltration
swelling and pitting edema, pallor, coolness, pain at insertion site, decrease in flow rate
signs of phlebitis
pain, increased skin temperature, erythema along path of vein
signs of bloodstream infection
change in vital signs such as fever, positive blood cultures, elevated white blood cell counts
what should be documented after implementing venipuncture and starting an infusion?
date, time, site, gauge, method of infusion (gravity or electronic infusion device); type and rate of infusion; device identification number (if you are using an electronic infusion device); size, length, and brand of catheter; when the infusion began; infusion pump type, # of venipuncture attempts required, and the patient’s response to the insertion (including pain), RN signature. Use an infusion therapy flowsheet when available.
What should be reported to oncoming nurse for patients with IV therapy?
the type of fluid, flow rate, status of the vascular access device, amount of solution remaining in the infusion bag, expected time for completion of infusion and need to hang subsequent IV containers, and the patient’s condition.
In general, IV tubing is usually changed every ___ _____
7 days. Some agencies may require every 4 days.
Tubing used for blood, blood products, or fatty emulsions should be changed after __ _____.
24 hours after initiating infusion.
Central line tubing is usually changed every __ ____
every 4 days (96 hours)
Central line tubing used for TPN or lipids should be changed every __ ____.
every 24 hours.
IV site dressings should be changed when…
they become soiled, wet, or loose, or otherwise every 24-48hrs.
signs of phlebitis
PAIN & REDNESS ALONG VEIN
reduced flow rate
purulent discharge
PALPABLE CORD long vein
signs of infiltration (leakage of non-irritating solution)
edema surrounding insertion site, with coolness.
signs of extravasation (leakage of irritating solution)
pain and burning with edema and coolness surrounding iv site.
signs of septicemia
fluctuating fever, cold sweat, N/V/D, tachycardia, hypotension, elevated WBCs
signs of AIR EMBOLISM
weak rapid pulse cyanosis respiratory distress change in mental status loss of consciousness iv container has run dry or pump wheel is making loud churning sound.
signs of circulatory overload
increased weight edema intake much greater than output shortness of breath, crackles jugular vein distention
how often should you flush an IV/saline lock?
once per shift when not in use.
if in use, before and after each use.
