Unit 6: Circulation Flashcards
A vein has blood that has pooled, and not being circulated. This condition is refered to as:
Venous stasis
The patient has venous statis, is bed bound, and unable to move their legs. What circulatory complication should the nurse monitor the patient for?
Deep Vein Thrombosis (DVT)
The nurse educates the patient that elastic hosiery act by:
Promoting Venous Return-applying external pressure to decrease venous blood from pooling in the extremeties.
How does the nurse measure/fit a patient who has been ordered to wear below the knee elastic stockings?
Measure length from Achilles tendond to the popliteal fold.
Measure midcalf circumference.
Compare measurements to manufacturer’s chart to determine proper size.
How does the nurse measure/fit the patient who has been ordered to wear thigh high elastic stockings?
Measure midcalf and midthigh circumference.
Measure length from gluteal fold to bottom of heal.
Compare measurements to manufacturer’s chart to determine proper size.
The objective of elastic hosiery is to:
prevent venous stasis.
How often should elastic hosiery be remover? Rationale?
Remove stocking each shift for 30 minutes.
RAT: Check for skin integrity.
The patient has been ordered SCD’s. What does this stand for?
Sequential Compression Devices
What are the three components of the SCD?
Air pump
Tubing
Extremetie Sleeves
The patient is ordered SCD’s. When does the nurse assess the patients neurovascular status?
Before application, and each shift.
What specific body systems will the nurse assess in the patient who is receiving SCD treatment?
Neurovascular at the lower extremeties.
What may be present under the SCD? Why?
Elastic Hosiery, decrease irritation from the plastic and provide extra comfort.
The nurse performing venipuncture has selected a needle that is short, beveled, and has plastic tips/wings. What type of needle has the nurse selected? When are these needles typically used?
Wind tipped infusion needles. Shoft term therapy, or IV therapy for children/infants.
The nurse to perform venipuncture has selected a needle that has a sterile plastic catheter over the needle. What type of needle has the nurse selected?
Over the needle catheter (ONC)
The nurse has performed venipuncture with an ONC. The patient asks why the nurse removed the needle. How does the nurse respond?
The needle was used to puncture the skin, and a flexible catheter is now in place inside the vein to allow access to the venous system.
What type of devices are saline and heparin ‘hep’ locks?
Intermittent infusion devices.
When are intermittent infusion devices (saline locks) indicated?
Used with patients who are receiving solutions or medication intermittently.
How is flow rate adjusted in the patient who is receiving IV fluids by gravity?
Roller clamp adjusted to proper rate (GTT/MIN)
What factors affect gravity IV flow rates?
1) Height of solution chamber (IV BAG)
2) Position of extremity
3) Position of the IV access
4) Tubing obstruction
5) IV patency
What advantage do pumps offer compared to IV’s flowing by gravity?
Alarms warn of obstruction, infiltration, etc…
What flow rate is used for IV fluids being administered by pump?
ml/hr
What flor rate is used for IV fluids being administered by gravity?
gtt/min
How does the nurse assess the patient who is wearing SCD’s for proper fit?
Fit two fingers between patients leg and sleeve.
The patient is wearing SCD’s. What does the nurse monitor the tubing for?
Kinks or air leaks.
What does the nurse assess prior to applying SCD’s? Rationale?
Pedal Pulses Color Capillary Refill Temperature Sensation: Touch/Temperature
RAT: Obtain baseline
What must be present before applying elastic hosiery or SCD’s?
Dr’s Order
The patient is to receive IV therapy. What does the nurse assess the patient for prior to initiating the physicians order? Rationale?
Assess vital signs.
RAT: Baseline
Why must a Dr’s Order be present for IV therapy?
Considered a medication
What should the nurse inspect the IV solution for?
Color, Clarity, and Expiration Date
Angiocath is another name for what type of needle?
ONC (Over the Needle Catheter)
The nurse assessing the Iv site observes swelling and pallor around the infusion site that is cool to the touch, and pt c/o pain. The nurse identifies that _________ has occured
Infiltration
The pt’s IV has infiltrated, what would the nurse expect to see in regards to the IV flow rate? Rationale?
The IV flow rate would decrease.
RAT: Increased pressure withing the subcutaneous.
What must the nurse do when the IV infiltrates?
Remove the IV, and restart the IV in another site.
What comfort measure can the nurse take for the patient who has an infiltrated IV site? Rationale?
Warm soask can be used to decrease swelling.
The pt asks why their IV site is swollen, cool to touch, and painful. How does the nurse respond?
The IV site has likely infiltrated, meaning the catheter has slipped out of the vein, or fluids are leaking from the vein and are accumulating in the subcuataneous tissues.
Inflammation of a vein is referred to as:
Phlebitis
Inflammation of a vein and presence of a clot is referred to as:
Thrombophlebitis
What factors contribute to the development of phlebitis/thrombophlebitis?
Catheter gauge and material.
Length of time the catheter is in the vein.
Type and pH of solutions.
Use of small veins, where venous return is slow.
What does the nurse look for when assessing for phlebitis?
Complaints of discomfort and a vein that appears red and feels warm and hard. Slow IV infusion is also likely, especially in thrombophlebitis.
How does the nurse decrease the incidence of phlebitis?
Changing IV sites every 72 hours.
What steps must the nurse take once phlebitis has been identified?
Discontinue IV site, and restart in another location.
What comfort measure may be taken to promote pt comfort when experiencing phlebitis?
Warm soaks
The nurse identifies the IV is running slower than the precribed rate. In an effort to ‘catch up’ on the missed fluid the nurse increases the rate beyond the normal prescribed rate. This action can cause:
Fluid Overload
Fluid overload is most likely to occur in:
The very young or very old.
What does the nurse assess for in the patient suspected to have fluid overload?
Weight Gain, Decreased Urine output, Adventitious breath sounds.
The nurse identifies the pt has Fluid Overload after assessing the patient to have adventitious breath sounds, weight gain, and decreased urine out put. The pt is recieving IV fluids. What actions will the nurse take?
Place the pt in semi/high fowlers position, slow the IV infusion, call the Dr.
How does the nurse minimize the risk on infection for the pt recieving IV therapy?
Handwashing, site preparation, use of sterile technique during insertion and maintenance are essential to minimize risk of infection.
What would the nurse expect to see if the pt’s IV site has become infected?
Redness, warmth, purulent drainage.
The nurse identifies the pt IV site has become infected. What actions should the nurse perform next?
Discontinue the IV site and restart in another location. Save the catheter (may be needed for C&S) and call the Dr.
How does an air emolism occur?
Air in tubing, or loose IV connections
The nurse assessing the pt with and air embolism would expect to observe:
Pt chest, shoulder, back pain. Dyspnea Hypotension Cyanosis Thready pulse Loss of Consciousness.
What actions should the nurse take when the nurse suspects the pt to be suffering from and air embolism?
Place the patient on their left side in the Trendlenburg position. Notify the physician immediately.
Why does the nurse place the pt suspected of having and air embolism on their left side in Trendlenburg position?
To allow the air to rise into the right ventricle and allow the blood to pass into the lungs.
What causes speed shock?
Reaction the body has to a substance that is injected into the circulatory system too rapidly.
What does the nurse assess the patient for when looking for speed shock?
Pounding headache, fainting, rapid pulse rate, apprehension, chills, back pain, and dyspnea.
What veins are used for central venous access devices?
Subclavian, Jugular, Cephalic or Basilic
Where is the catheter tip of the CVC placed?
In the superior vena cava at the entrance of the right atrium.
What is the benefit of a multi-lumen CVC?
Multiple medications can be administered simultaneously without the risk of incompatability or solutions.
What high risk complications exist with CVCs?
- Pneumothorax with insertion.
- Air embolism because tip lies in the superior vena cava/right atrium.
- Infection
What position is the pt placed in during insertion of the CVC? Rationale?
Supine with head lower than body to prevent the risk of air embolism.
When are CVCs used? Not used?
Used for hospitalized patients.
Not used for pts recieving long term therapy.
What veins are used for PICCs?
Basilic and Cephalic in the antecubital.
Who can insert a PICC?
Physician or specially trained nurse.
Where is the tip of the PICC placed?
Superior Vena Cava
When are PICCs used? How long can they be left in place?
For pt receiving long term therapy. Left in place for months.
What must the nurse educate the patient with a PICC on when being discharged?
Care and maintenance. Complications and complication interventions.
What type of CVCs are more permanant? List the 3 types.
Tunneled CVCs.
- Hickman
- Groshong
- Broviac
How are tunneled CVCs placed? (Setting)
Surgically
What feature of tunneled CVCs anchor the catheter to the subcutaneous?
Dacron Cuff
