Week 4 Nursing Flashcards

Question

Equipment – Fluid Order Chart

Answer 1

▪ Written order to indicate the type of fluid and the rate it should be infused (in 24 hours). ▪ As for any medication order it MUST include: – Patient Identifiers, prescriber signature

Answer 2

▪ Correct fluid is determined by the fluid order chart (8 rights apply) ▪ Safety and Quality checks of the fluid bag:- – Expiry date – Type and strength of fluid – Colour and clarity of IV fluid – Check bag for leaks by gentle squeeze (condensation from outer bag is ok). – Time label with time and initials may be attached (but must not obscure the details on the bag. Two nurses check fluid against fluid order and patient.

Answer 3

* Different gauges - attempt to use the smallest that can deliver the volume * Size 14 and 16 - large bore, used in high risk surgery - requires a large vein. · Size 18 - used in trauma, blood transfusions, CT with contrast · Size 20 - most commonly used. Ok for fluids and blood. · Size 22 and 24 - used for smaller veins. In elderly or paediatric patients.

Answer 4

▪ Giving sets are the tubes that deliver the fluid – they have an inline drip chamber. 1. Gravity sets 2. Infusion pump sets ▪ Blood/inotropes ▪ Macrodrip giving rates – Chamber 20 drops per ml ▪ Adults – Chamber 60 drops per ml ▪ Paediatrics/elderly

Answer 5

▪ Burette – A measured tube that goes ‘in-line’ between the giving set and the IV fluid. – The IV fluid is clamped at the top, so only fluid in the burette can be infused at one time. ▪ Infusion pumps – They regulate the rate of fluid to be infused in mls/hr. – Use specific giving sets that fit the infusion pump. – Pump alarms if air in line, if fluid has completed or if IV is blocked ▪ Syringe drivers – Deliver small volumes of fluid – 60 mls. – Used for paediatrics, or certain medications.

Answer 6

▪ Cleanser/disinfectant – Alchowipes, chlorhexidine, betadine (depending on facility policy) ▪ Gloves – Standard precautions ▪ Tourniquet – Reduce back flow of blood, distend veins to ease cannulation. ▪ Tape and Dressing – To anchor cannula. Depends on policy, but transparent dressing common ▪ Armboard – Only if required to stabilise joint to ease flow. ▪ Watch with second hand – Needed to time the infusion rate.

Answer 7

▪ Complication associated with IV fluid administration can be divided into two: 1. Systemic complications ▪ Occur less frequently, but often more serious 2. Local complications ▪ Occur at or near the IV insertion site

Answer 8

▪ Fluid Overload – Too much IVF leads to hypervoleamia and increased CVP ▪ Signs & Symptoms – Fine crackles, oedema, cough, restlessness, weight gain, dyspnoea, increased shallow RR, distended jugular veins. ▪ Cause – Rapid infusion of IVF, renal, or cardiac disease. – Can lead to acute pulmonary oedema (APO) – esp in elderly – circulatory overload

Answer 9

Patients at risk of Fluid Overload ▪ Paediatric patients ▪ Elderly patients ▪ Cardiac disease – When heart is not pumping effectively, fluid backs up into lungs. ▪ Renal disease – Kidneys are not functioning properly, cannot eliminate fluids at rate to match the infusion Nursing Management (as always, start with DRSABC) * Stop infusion, sit up (Fowlers), MET call if abnormal vital signs * Focused cardiac and resp assessment. Provide reassurance. * Apply oxygen and titrate to SpO2. Notify MO.

Answer 10

▪ Air Embolism – Air enters vascular system and displaces blood. Rare. ▪ Signs and Symptoms – Dyspnoea, cyanosis, hypotension, weak pulse, increased HR, LOC, chest/shoulder/low back pain. ▪ Cause – The rate of entry of air as well as the volume of air. Most likely in cannulation of central veins. ▪ Treatment – Clamp cannula, assess vitals, place on left side, head down position.

Answer 11

▪ Infection – Through IV solution or administration set. ▪ Signs and Symptoms – Sudden temperature rise, tachycardia, hypotension, tachypnoea, decreased urine output (signs of sepsis). ▪ Cause – Poor ANTT, contamination of IV fluids/medication. These increase if pt immunocompromised. – Sepsis has 10-20% mortality rate – Regarded as totally preventable ▪ Treatment – Symptomatic treatment. Cultures of IV tubing/solution.

Answer 12

▪ Inadvertent administration of solution/medication into surrounding tissue. ▪ Oedema, swelling, inflammation ▪ Can occur when IV cannula dislodged from vein. ▪ Treatment – Stop infusion – Remove IVC – Cold compress

Answer 13

▪ Inflammation of vein due to chemical or mechanical irritation. ▪ Warm IV site or along vein, pain, swelling. ▪ Treatment – Stop IV – Warm compress to site ▪ Prevention – Good ANTT – Appropriate size cannula for vein

Answer 14

▪ Inadvertent administration of irritant into surrounding tissue ▪ Blistering, inflammation, necrosis ▪ Treatment – Stop infusion – Notify Doctor – Follow extravasation protocol – Antidote may be given – Neurovascular observations

Answer 15

▪ Blood leaks into surrounding tissue. ▪ Due to needle slipping out of vein, or poor pressure when cannula removed. ▪ Bruise ▪ Treatment – Remove IVC – Pressure

Answer 16

▪ Blood clots from in IV tubing due to – Kinked IV tubing – Kink/bend in IVC – Slow infusion rate – not flushed regularly – Empty/neglected IV bag ▪ Indicated by stopped or reduced flow ▪ If clot in IV line – Stop infusion and start again with new set and line ▪ If clot in IVC – KVO (keep vein open) – maintenance fluids/regular flushes – Doctor may inject a thrombolytic agent

Answer 17

▪ Clot and inflammation in the vein. ▪ Pain, redness, warmth, swelling. Immobility of extremity, fever. ▪ Treatment – Stop IV – Apply cold compress (reduces flow) then warm compress and elevation. – Do not flush line - clots

Answer 18

▪ Hand hygiene before contact with set, fluids, patient. ▪ Check IV containers for cracks/leaks, fluid for cloudiness ▪ Good anchoring of IV to prevent movement (stay in vein) ▪ Daily inspection of IV site. ▪ 8/24 checking of patency – N/S Flush ▪ “Scrub the hub” before accessing bung ▪ Change IVC as per facility policy – often 72 hours – IVCs inserted in emergency/pre-hospital situations sooner. ▪ Replace fluid and giving set as per policy. ▪ IVC insertion sites should be rotated at least every 72-96 hours (depending on health service policy)

Answer 19

▪ Doctors prescribe the fluid and the rate that it should be given. – The rate is described as the number of hours it should run for – e.g. 4/24, 8/24,12/24 etc ▪ Nurses maintain the flow rate*. – Determined by the amount of solution to be infused over an hour – drip rate. – Drip rate is determined by the size of the lumen of the giving set. ▪ Various sizes, the most common being 20 or 60 drops per ml – Important to ensure fluid is at appropriate rate and will not affect the fluid balance. *Flow rate calculations will be covered in your workshop/lab this week.

Answer 20

▪ Giving set changes – Most facility policies state change every 72 hours – Giving sets used for TPN, blood and some medications will require more frequency – 24hrs ▪ Fluid changes – Occur at the end of an infusion – keep sterility of IV system ▪ Piggy-back infusions – Whilst IV infusion taking place, another IV solution or medication can be added onto the existing fluid via the port.

Answer 21

▪ Indications for giving blood – Volume loss (trauma, surgery, haemorrhage), clotting abnormalities, anaemia ▪ Blood cross matching – Patient must be cross matched to identify their blood group. – Patients receive their own blood group – except in emergencies where type O- can be used. – If patient is given the wrong blood – they may have a haemolytic reaction. ▪ Blood products – There are different blood products including – whole blood, packed red cells, plasma, platelets, serum albumen, cryopreciptate.

Answer 22

▪ Factors which may affect the flow rate include:- – The height of the fluid in relation to the person – The person’s position (inc limb position) – The patency of the IV system – line and cannula ▪ Blocks, knots, kinks, clamps – Blood pressure ▪ IV infusions should be checked hourly – Patient movement, medication administration, equipment changes can all affect the IV rate.

Answer 23

▪ Due to the risk of haemolytic (transfusion) reaction, patients receiving blood require close monitoring. ▪ Blood checking procedure – Blood must be given within 15 minutes of arrival on ward – 2 RNs must check patient (ID, blood type), blood pack (expiry date, unit ID number), prescription (fluid order, infusion rate, number of units). ▪ Blood administration – Baseline set of vital signs – Start infusion slowly – reactions occur in first 10-15 mins ▪ Blood monitoring – Vital signs every 15 mins in first hour, then every 30 minutes. – If changes in vital signs occur – stop infusion, advise NIC/MO *Facility policy may vary – check locally*

Answer 24

IV potassium must NEVER be given as a bolus (or push) - may cause potentially fatal cardiac arrhythmias. * Potassium should not be given at a rate faster than 10 mmol/L per hour * Separate ampules of potassium should not be used and should not be added to IV bags. * IV fluids with potassium have red writing on them as a warning.