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Advanced Assessment > Quiz 1 - Modules 1 & 2 > Flashcards

Quiz 1 - Modules 1 & 2 Flashcards

1
Q

Types of IV Solutions

A
  • isotonic
  • hypotonic
  • hypertonic
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2
Q

Isotonic

A

Remain in intravascular compartment without any net flow across the semipermeable membrane - same as blood
Helps treat hypovolemia
Two Types
* Saline 0.9%
* Lactated Ringers

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3
Q

Hypotonic

A

Less osmolarity than plasma, solution in intravascular space moves out and into ICF – cells swell and possibly burst
Helps treat hypernatremia
Types
* 0.33% normal saline
* 0.45% sodium
* D5W in the body

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4
Q

Hypertonic

A

Greater osmolarity than plasma, water moves out of the cell and is drawn into the intravascular compartment – cell shrinks
Types
* 5% dextrose in lactated ringers
* 5% dextrose in 0.9% normal saline
* TPN

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5
Q

Reasons for IV Therapy

A
  • Fluid administration: replace fluid and electrolyte losses or correct fluid and electrolytes
  • Med admin
  • Blood
  • IV contrast dye
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6
Q

Benefits of IV Therapy

A
  • Rapid administration of fluid into vascular compartment: bypasses GI tract for direct absorption
  • Maintain therapeutic med levels within the blood
  • Quicker absorption and onset of action for most meds
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7
Q

Crystalloids

A

isotonic, hypotonic, and hypertonic solutions

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8
Q

Colloids

A

Hypertonic solution with proteins
Pull fluid from interstitial and intracellular spaces by increasing intravascular colloid osmotic pressure
* blood and blood products, albumin, dextran

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9
Q

IV Patient Considerations

A
  • volume of fluid being infused
  • long/short term therapy
  • history of drug abuse
  • surgerys - mastectomy on that side
  • type of med
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10
Q

Peripheral IV

A
  • most common
  • short term therapy
  • placed in superficial veins of hand and forearm
  • uses: fluids, meds, blood products
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11
Q

Types of Peripheral IV Catheters

A
  • Automatic retraction: Reduce the risk of accidental needle sticks and possible exposure to blood-borne pathogens
  • Over the Needle catheters: most common, gauge and length determined by solution and vein condition
  • Winged: reduce risk of contamination, stable, needle is still there, no flexible placement
  • OSHA safety needles: active - user activated, passive - automatic retraction
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12
Q

Peripheral IV Considerations

A
  • Medical Hx, age, body size, condition of veins, duration of IV therapy, fluid/med being infused, level of activity
  • Can be used more than 6 days
  • Start as distal as possoble
  • Smallest gauge
  • Not appropriate for TPN, pH <5 or >9,
    osmolality >600 mOsm/L
  • Supine with head elevated, arms supported
    (risk for vasovagal if sitting up)
  • Apply tourniquet 5-6 in above site
  • Bevel up, 10-30 degree angle
  • Common sites: cephalic, basilic, metacarpal
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13
Q

Peripheral IV - What to Avoid

A
  • Wrist → close proximity to nerves
  • Legs/feet/ankles → lead to DVT
  • Veins below an area of phlebitis/sclerosed/thrombus
  • Skin inflammation/bruising/breakdown
  • AV shunt/fistula
  • Lymph nodes removed
  • Infection
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14
Q

Primary Lines

A
  • Continuous infusion - either pump ot gravity
  • Increasing height of IV increases flow rate when flow is by gravity
  • Vented or unvented - in the airspike
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15
Q

Intermittent Access Devices - Saline Locks

A
  • Replaced every 72-96 hrs
  • Intermittent Infusion
  • Saline lock: IV catheter and short piece of extension tubing
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16
Q

Flushing Guidelines

A
  • 2-3 mL saline q8 hr. or with each use
  • Pulsatile method (push-pause) - inhibits backflow of blood
  • Positive pressure method - Slide clamp closed as you instill last mL
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17
Q

How to Administer Venipuncture

A
  • Apply turnicate 5-6 in above intended venipuncture site
  • Dilate vein: Pump first with hand lower than heart, stroke downward, friction from cleaning, warm wrap
  • Cleanse with chlorohexidine
  • Pull skin taut to stabilize vein
  • Bevel up, 10-30 degree angle
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18
Q

Monitoring IV

A
  • every hour
  • look at tolerance to fluid volume, dressing integrity, and any complications
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19
Q

Complications

A

By location
* Local complication: at or near the insertion site or as a result of mechanical failure
* Systemic complications: occur within the vascular system, remote from IV site. Can be serious or life threatening.

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20
Q

Infection Control

A
  • Hand hygiene
  • change IV site every 72-96 hours
  • aseptic technique
  • change secondary tubing every 24 hours
  • change dressing q 24 hrs
  • Discontinue IV as soon as clinically indicated
  • Avoid writing on IV bags with pens/markers
  • Wipe all ports with antiseptic swab before using
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21
Q

Local Complication: Infiltration

A

Leakage of IV fluid into surrounding tissue
Caused by improper placement/dislodgement
S/S: edema, coolness, pain, burning, pale, decreased/stopped flow rate
* 0 = no symptoms
* 1 = edema <1”, cool, pale
* 2 = edema 1-6” cool, pale
* 3 = gross edema > 6” cool, pale, pain, possible numbness
* 4 = gross edema > 6”, pitting edema, skintight, leaking, bruised, mod/severe pain

Treatment:
* Removal/restart
* elevate, check cap refill
* Warm Compress for normal and basic pH (8-9)
* Cold Compress for acidic (5-6)

22
Q

Local Complication: Phlebitis

A

Inflammation of a vein associated with acidic/alkaline solutions with high osmolality
S/S
* wamth
* swelling

Scale
* 0: no symptoms
* 1: erythema, possible pain
* 2: erythema, edema, pain
* 3: same as 2 with streak formation (go up the vein), palpable venous cord
* 4: same as with palpable venous cord >1 cm, purulent drainage

Risk Factors
* Mechanical irritation: lumen of vein or inappropriate gauge
* Chemical irritation
* Bacterial contamination
* Prolonged use of site

Treatment
* remove cathete when redness/pain is there
* warm compress
* restart using larger vein or smaller device but not near phlebitis

23
Q

Local Complications: Extravasation

A

Leakage of vesicant in surrounding tissue
Vesicant: any medication that can cause blistering, severe tissue injury, or tissue necrosis
* chemotherapeutic agents, catecholamiens, digoxin

S/S
* blistering
* blanching
* swelling

Can Cause
* tissue damage/necrosis
* delayed healing
* infection
* loss of function
* possible amputation

Treatment
* immediately stop infustion
* aspirate med
* notify MD how much was infused
* elevate
* call pharmacy for antitote
* apply ice for 15-20 min x 48 hrs for all meds

24
Q

Systemic Complications: Fluid Overload

A

Dyspnea, high BP/HR/RR, crackles, JVD, edema

25
Q

Systemic Complications: Speed Shock

A

Reach toxic levels with medication when introduced too fast in places that are rich in blood
Dizziness, chest tightness, flushed, pounding headache, chills, back pain, dyspnea, apprehension

26
Q

Systemic Complications: Sepsis

A

Red, tender IV site, fever, malaise, VS changes

27
Q

Systemic Complications: Air Embolism

A

Air traps blood and goes into right ventricle
Resp distress, low HR, high BP, cyanosis, change in LOC, wheezes, cough

28
Q

Central Venous Access Device: CVAD

A

For extensive IV therapy, poor peripheral access, infusing vesicants, hypertonic solutions, and chemotherapy – high osmolarity or pH extremes
* Terminal line ends in Superior Vena Cava: need radiological confirmation of placement or use fluoroscopy
* Multiple lumens: to infuse multiple meds, TPN and blood have separate line
* Hemodynamic monitoring
* Frequent blood sampling

Short term: non-tunneled and PICC lines
Long term: tunneled and implantable port

29
Q

Non-Tunneled CVAD

A

Duration: short term (3-10 days)
Uses: patients who are unstable
Placement: inserted in jugular or subclavian, put patient in trendelenburg for sub, Sutured in place, no sedation for insertion
Indications: IV therapy, blood sampling, central venous monitoring
Disadvantage: High risk for central line associated bloodstream infection (CLABSI) and pneumothorax

30
Q

PICC Line

A

Duration: Short-term (6 weeks-6 months)
Uses: IV therapy at home & acute care settings
Placement: upper arm (antecubital fossa) to superior vena cava, secured with wound closure strips (not suture since this can create infection), need X-ray to confirm placement
Advantages: eliminates risk for pneumothorax, use for all ages, easier to ahve labs drawn, replace only as needed

31
Q

Implanted Port

A

Duration: Long-Term, permanent device
Placement: upper chest wall, antecubital area of arm
need radiology to confirm placement
Advantages: no visible external port/lines, minimal daily care, good for kids, low risk for infection, improved self-image
Disadvantages: discomfort when accessing, inserting needle into skin

32
Q

Tunneled CVAD

A

Duration: Long-Term
Placement: Jugular or subclavian vein, Sutured in place but stitches are removed after 7-14 days, Dacron → seal to prevent bacteria under the skin & prevent dislodgement - takes 3 weeks for catheter to heal
Advantages: lower risk for CLABSI, allows for ease of movement

33
Q

Assessing CVADs

A
  • integrity of dressings
  • infection
  • tenderness
  • measure length of exposed catheter
34
Q

Flushing CVADs

A
  • push-pause method
  • use 10mL or larger syringe - less pressure
  • 3-5mL of saline before and after
  • 3mL of heparin 100u for catheter patency
  • q7 days if not in use
35
Q

Dressing Changes for CVAD

A
  • sterile procedure with masks, gowns, and gloves
  • change every 24 hrs or when soiled
  • antimicrobial swab over site for 30 seconds, 2” radius
  • change caps
  • change tubing every 24 hours for TPN
36
Q

Complications for CVAD

A

Pneumothorax/hemothorax:
* Sudden onset of chest pain/SOB due to air accumulation in the lungs
* Give oxygen, monitor vitals, pressure on entry site, remove catheter

CLABSI
* Central line associated bloodstream infection & catheter related bloodstream infection
* If WBC low → will not see drainage or pus, will see fever/chills

Air Embolism

Thrombosis
* start IV somewhere else and give warm compress
* S/S: fullness in face, swelling

Catheter Migration
* Occurs when catheter moves from where it was placed
* Risks: physical activity, vomiting
* Signs: swelling of neck/chest during infusion, pain

37
Q

Primary Line: IV Med Admin

A
  • Primary IV bag (directly attached to patient)
    ○ Piggyback (medication is piggybacked on primary IV infusion)
    ○ IV push (through a primary line)
    ○ Syringe pump (either primary line or piggy backed onto primary line)
    ○ Volume controlled (primary line or piggybacked onto primary line)
38
Q

Saline Lock: IV Med Admin

A
  • intermittent infusion
  • IV push directly
39
Q

IV Push through Primary Line

A
  • infuses rate faster
  • clamp tubing above distal port, proximal to patinet
  • check for blood return
  • admin slowly
40
Q

Admin Meds Via Mini-Infusion Pump

A
  • controls the rate, can program the rate
  • infuse using distal port on primary line or saline lock
  • used for peds
41
Q

Volume Controlled Infusion

A

Purpose: for peds, small amount of controlled substance, diluted with IV solution, do not fluid overload

42
Q

IV Push via Lock

A
  • flush with 1-3mL saline before and after for patency
  • instill flush as same rate as med
43
Q

Physical Incompatability

A

One drug is MIXED with another drug/solution to produce a product UNSAFE for administration

44
Q

Chemical Incompatability

A

REACTION of drug with other drugs/solutions → ALTERATIONS in integrity and potency of active ingredient

45
Q

Therapeutic Incompatability

A

Undesirable effect occurring as a result of 2 or more drugs being given concurrently - Can have an increased or decreased therapeutic response

46
Q

Blood Transfusion: Assessment

A
  • Baseline vitals, taken periodically once transfusion starts based on protocol
  • Kidney function, cardiovascular, lung sounds
  • Evaluate IV site, gauge of needle - 18 gauge needle for rapid, 20 gauge for slow
  • Blood matches patient
  • Identify unit label of blood and patient by TWO nurses before hanging blood
  • Check for expiration by TWO nurses (both nurses must document that check occurred)
  • need Y set filters and normal saline
47
Q

Blood Transfusion: Guidelines

A
  • Pump can inform us of phlebitis, easier for 4 hour period
  • Infuse slowly: Large enough dose that can alert the nurse of a reaction but small enough that it can be successfully treated
  • If pt shows signs of an adverse reaction, transfusion is stopped IMMEDIATELY & hang NS alone in separate tubing
  • After 15 mins have passed safely, flow rate can be increased
  • RBCs should be infused within a 4 hour period
  • RBCs should be hung within 30 mins of obtaining from blood bank
48
Q

ABO Blood Grouping

A

Group A – Recipient Antigens A – Antibodies present – Anti B

Group B – Recipient Antigens B – Antibodies present - Anti A

Group AB – Recipient Antigens A&B – Antibodies none

Group O – Recipient Antigens none – Antibodies Anti A and B

49
Q

Mild Reaction

A

Within 1 hr
S/S: Urticaria, localized erythema, facial flushing, dyspnea, wheezing
Nursing Action: Pause transfusion, keep vein open, notify
provider, monitor vital signs, administer antihistamine orders (or benadryl 30 mins before)

50
Q

Severe Reaction (Anaphylaxis)

A

Within 1 hr
S/S: Anxiety, hypotension, shock, wheezing, urticaria
Nursing Actions: Discontinue transfusion, keep vein open with just NS, administer CPR, anticipate order for steroids, maintain BP; prevention using well washed RBCs where plasma has been extracted

51
Q

Febrile Reaction

A

Reactions to antibodies directed against leukocytes/platelets
Occurs immediately or 1-2 hours after transfusion is completed
PreventionL use leukocyte-reduced blood components
S/S: fever, chills, N/V/headache, tachycardia, nonproductive cough
Nursing Actions: Discontinue transfusion, Keep vein open with NS, notify provider, monitor vitals, administer antipyretic

52
Q

Acute Hemolytic Transfusion Reaction

A

Most life-threatening
Occurs after infusion of incompatable RBCs
Leads to activation of coagulation system and release of vasoactive enzymes that result in vasomotor instability, cardiorespiratory collapse, and DIC
Prevention: extreme care in identification process
S/S: fever, Lumbar, Flank, Chest Pain, flushing of face, tachycardia
Nursing Actions: stop transfusion, disconnect tubing, infuse saline, call provider, monitor need for dialysis

Advanced Assessment (4 decks)

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