UNIT 2 CHAPTER 15 INFUSION THERAPY Flashcards
- A nurse is caring for a client who has just had a central venous access line inserted. What action will the nurse take next?
a. Begin the prescribed infusion via the new access.
b. Ensure that an x-ray is completed to confirm placement.
c. Check medication calculations with a second RN.
d. Make sure that the solution is appropriate for a central line.
ANS: B
A central venous access device, once placed, needs an x-ray confirmation of proper placement before it is used. The bedside nurse would be responsible for beginning the infusion once placement has been verified. Any IV solution can be given through a central line.
- A client receiving gentamycin intravenously reports that the peripheral IV insertion site has become painful and reddened. What is the priority nursing action?
A. Contact the primary health care provider
B. Document findings in the electronic health record
C. Change the IV site to a new location
D. Stop the infusion of the drug
D. Stop the infusion of the drug
IF IV SITE IS RED AND WARM CAN BE SIGN BE A OF PHLEBITIS - INFLAMMED VEIN
Which of the following sites is the last resort for elderly adults with poor skin turgor, and active patients receiving infusion therapy?
A. Dorsal surface of the hand
B. Femoral Vein
C. Cephanic vein
D. Basilic Vein
A. Dorsal surface of the hand
However, cannulation of veins on the hand is not appropriate for older patients with a loss of skin turgor and poor vein condition or for active patients receiving infusion therapy in an ambulatory care clinic or home care. Use of veins on the dorsal surface of the hands should be reserved as a last resort for short- term infusion of nonvesicant and nonirritant solutions in young patients.
- A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
a. Redness at the catheter insertion site
b. Report of headache and stiff neck
c. Temperature of 100.1° F (37.8° C)
d. Pain rating of 8 on a scale of 0-10
b. Report of headache and stiff neck
ANS: B
Complications of epidural therapy include infection, bleeding, leakage of cerebrospinal fluid, occlusion of the catheter lumen, and catheter migration. Headache, neck stiffness, and a temperature higher than 101° F (37.8° C) are signs of meningitis and would be reported to the primary health care provider immediately. The other findings are important but do not require immediate intervention.
- A nurse assesses a client’s peripheral IV site, and notices edema and tenderness above the site. What action will the nurse take next?
a. Apply cold compresses to the IV site.
b. Elevate the extremity on a pillow.
c. Flush the catheter with normal saline.
d. Stop the infusion of intravenous fluids.
d. Stop the infusion of intravenous fluids
ANS: D
Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of infiltration include edema and tenderness above the site. The nurse would stop the infusion and remove the catheter. Cold compresses and elevation of the extremity can be done after the catheter is discontinued to increase client comfort. Alternatively, warm compresses may be prescribed per institutional policy and may help speed circulation to the area.
When will you not select a specific IV SITE?
- For adults, choose a site for placement in the upper extremity. DO NOT USE THE WRIST.
- Choose the patient’s nondominant arm when possible.
- Choose a distal site and make all subsequent venipunctures proximal to previous sites.
- Do not use the arm on the side of a mastectomy, lymph node dissection, arteriovenous shunt or fistula, or paralysis.
- Avoid choosing a site in an area of joint flexion.
- Avoid choosing a site in a vein that feels hard or cordlike.
- Avoid choosing a site close to areas of cellulitis, dermatitis, or complications from previous catheter sites.
- Choose a vein of appropriate length and width to fit the size of the catheter required for infusion.
- Limit unsuccessful attempts to two per clinician and no more than four total (INS, 2016).
Short peripheral catheters are most often inserted into superficial veins of the forearm. In emergent situations, these catheters can also be used in the external jugular vein of the neck. Avoid the use of veins in the lower extremities of adults, if possible, because of an increased risk for deep vein thrombosis and infiltration.
Would you want to utilize a palmar vein for an IV site
A. Yes
B. No
B. No
Critical Rescue - CAUTION DO NOT USE
Avoid veins on the palmar side of the wrist because the median nerve is located close to veins in this area, making the venipuncture more painful and difficult to stabilize.
Most Appropriate Sites for Peripheral IV?
The most appropriate veins for peripheral catheter placement include the dorsal venous network (i.e., basilic, cephalic, and median veins and their branches) (Fig. 15.4). However, cannulation of veins on the hand is not appropriate for older patients with a loss of skin turgor and poor vein condition or for active patients receiving infusion therapy in an ambulatory care clinic or home care. Use of veins on the dorsal surface of the hands should be reserved as a last resort for short- term infusion of nonvesicant and nonirritant solutions in young patients.
Which of the following is the “prime site” for catheter insertion?
A. Femoral vein
B. Cephalic Vein
C. Carotid artery
D. Femoral artery
B. Cephalic Vein
The cephalic vein begins above the thumb and extends up the entire length of the arm. This vein is usually large and prominent, appearing as a prime site for catheter insertion. Reports of tingling, feeling “pins and needles” in the extremity, or numbness during the venipuncture procedure can indicate nerve
puncture. If any of these symptoms occur, stop the IV insertion procedure immediately, remove the catheter, and choose a new site.
Which IV site is commonly associated with Total Parental Nutrition (TPN)?
A. Midline
B. Cephalic Line
C. Basilic line
D. Central Line
D. Central Line
Safe and Effective Care Environment
A client had a 20-gauge short peripheral catheter (SPC) inserted for antibiotic administration 48 hours ago. Which nursing intervention is appropriate?
A. Discontinue the SPC.
B. Relocate the SPC for infection control.
C. Assess the SPC for redness, swelling, or pain.
D. Change the occlusive dressing covering the SPC.
C. Assess the SPC for redness, swelling, or pain.
Which technique is crucial for IV insertion?
A.Clean
B. Aseptic
C. Nonsterile
D. Clean contaminated
B. Aseptic
Aseptic skin preparation and technique before IV insertion are crucial.
H: Hygiene—Wash your hands and use gloves before inserting a peripheral catheter or drawing blood. Ensure that skin is clean. If visibly soiled, cleanse with soap and water.
A: Antisepsis—Prepare clean skin with a skin antiseptic (chlorhexidine 2% with 70% alcohol, 70% isopropyl alcohol, or povidone-iodine) with a back-and-forth motion for 30 seconds and allow the solution to dry before peripheral venous catheter insertion.
N: No-Touch Technique—Once the area has been prepped, do not touch the site.
D: Documentation—Document assessment of the site, dressing, and tubing. Ensure
that the date is clear for all infusion sites.
S: Scrub the Hub—Scrub the hub of the catheter site with an alcohol pad for at
least 15 seconds each time you access an infusion site.
CAUTION FOR PICC LINES
Teach patients with a PICC to perform usual ADLs; however, the patient should avoid excessive physical activity. Muscle contractions in the arm from physical activity such as heavy lifting can lead to catheter dislodgment and possible lumen occlusion. PICCs may be contraindicated in paraplegic patients who rely on their arms for mobility and in patients using crutches that provide support in the axilla.
Are Nontunneled Percutaneous Central Venous Catheters the catheter of choice for home use or ambulatory clinic settings?
A. Yes
B. No
B. No
here is no recommendation for optimal dwell time. However, these catheters are commonly used for short-term situations and are not the catheter of choice for home care or ambulatory clinic se ings.
Nontunneled CVCs are most commonly used for emergent or trauma situations, critical care, and surgery.
Changing Administration Sets and Needleless Connectors
- Placing the patient in a flat or Trendelenburg position to ensure that the catheter exit site is at or below the level of the heart
- Asking the patient to perform a Valsalva maneuver by holding his or her breath and bearing down
- Timing the IV set change to the expiratory cycle when the patient is spontaneously breathing
- Timing the IV set change to the inspiratory cycle when the patient is receiving positive-pressure mechanical ventilation
