Week Fourteen Flashcards
What is a contagion check?
Information that is gathered at the time of admission about the client’s immunization history, recent exposure to communicable diseases, history of communicable diseases, and current signs of any illness
What is the rationale of a contagion check?
identify possible sources of contagious diseases so measures can be taken to prevent its spread, identify children/adults who require recommended immunizations
What are reasons for a transfer?
condition changing, treatments, need to go to a different floor or facility
Define Risk for Latex Allergy Response
At risk for allergic response to natural rubber latex products
Risks factors for Risk for Latex Allergy Response
children with three or more surgeries, professions with daily exposures to latex, hairdressers, janitors, allergies to bananas, apples, carrots, history or asthma, history of allergies
AMA Discharge
Against Medical Advice. Attempt to determine why client wants to leave, notify nursing supervisor and client’s MD, client signs appropriate forms (if they won’t sign, document and have witness), assist client to get ready and escort them to the door
What will the RN teach the client during the admission process?
facility processes/healthcare team members, condition or medication management, NUR care plan, possible discharge scenarios
Why should the RN pay attention to the client condition prior to initiating any admission procedures?
address basic needs according to maslow, establish nurse-client relationship, modifications, wellness, age, culture, database
What client information should be obtained during the admission process?
biographical data, chief complaint, history of present illness, past medical history, past surgical history, allergies, immunizations, medications, family history, support system, physical assessment, functional abilities, discharge needs
What does the RN need to do to complete the admission process?
orient client to routines and environment, client teaching, discharge planning, collect ordered specimens, initiate nursing care plan and nursing process, document and report
What is the RN’s responsibility in the transfer of a client?
facilitating interdisciplinary collaboration and ongoing communication, being a client advocate, identify and help the client to access resources necessary to support recovery or maintain health, reduce client and family stress by teaching them what to expect
Transferring within an agency
explain reason for transfer, don’t forget to transfer belongings, send original chart, make transportation arrangements
Transferring outside of agency
pack all belongings, send copy of chart, report
Receiving a transfer within an agency
obtain report, may need orientation to new unit, review chart, document time of arrival and condition of client
Receiving a transfer from outside agency
implement usual admission procedure, review information sent with the client
Receiving telephone report
document date/time of call, document name and credentials of caller, accurately document information reported, sign note with name and title, if you are receiving report, repeat the information back to send to ensure clarity
Giving telephone report
be concise and accurate with report, begin with name, title and relationship to client, include client name and medical diagnosis, report changes in nursing assessment, report current VS and baseline VS, report significant lab values, report TNI and client response, after giving telephone report, document date, time, and content of call, signature and title
When does discharge planning begin?
on admission
What is continuity of care?
the coordination of health care services by healthcare providers for clients moving from one healthcare setting to another and between and among healthcare professionals
What is the RN’s role in the continuity of care
initiate discharge planning upon admission, involve client and family or support persons, collaborate with healthcare professionals
What are the essential components of discharge planning?
review why client was admitted, maintain ongoing assessment of client, assess client and caregiver needs at time of discharge, determine interdisciplinary needs, encourage client and support person participation, review discharge teaching with client and/or support person, written discharge instructions given to client and/or support person
What should discharge instructions include?
list of all medications to be taken, treatments/procedures, dietary and activity order, health promotion strategies, referrals, when to call MD and proper phone number, follow-up appointment and dates
What should the RN’s checklist or discharge summary include?
description of client’s physical, mental, and emotional status, resolved health problems, unresolved or continuing health problems and needs, treatments to continue, medications, restrictions, functional abilities, comfort level, support networks, client education provided at time or discharge, discharge destination and who accompanied client, referral services, follow-up
Intravenous Therapy
Method of supplying fluids and electrolytes directly into the intravascular fluid compartment
How does IV therapy work?
A needle attached to a catheter of a specific gauge is inserted into a vein. The vein can be peripheral or central. The needle is removed and the catheter is attached to plastic tubing. The plastic tubing is attached to fluid and infuses based on the rate set by the provider.
What is an example of a peripheral vein?
antecubital
What is an example of a central vein?
jugular
What are 5 purposes for IV therapy?
Maintenance therapy for daily body fluid requirements, replacement therapy (fluids, electrolytes, blood, restoration therapy for loss due to decreased nutrition, route for IV drug administration, rapid access to circulatory system
What are the factors that influence the rate of flow of a gravity IV infusion?
gravity, pressure, space, viscosity
Gravity
Fluid flows from a higher area to a lower area
Pressure
Fluid flows from higher to lower pressure. Smaller gauge = more pressure
Space
Fluid can flow more quickly in a wide space
Viscosity
Fluids that are less vicious will flow more quickly
Intracellular Fluid
The fluid within the cells of the body. Present in cells through diffusion/osmosis across cell membrane
Extracellular fluid
Intravascular = fluid component in blood vessels. Extravascular = interstitial and transcellular fluid
Osmosis
Movement of water from an area with more water to an area with less water
Diffusion
Movement of solutes from an area of high concentration to an area of low concentration
Osmolarity
Concentration of solutes in a liter of solution
Tonicity
How the osmolarity will effect osmosis or diffusion on each side of the blood vessel membrane
Isotonic Solution
Same osmolarity as that of body fluids, no difference in concentration of solute between plasma and cells, fluid remains in the intravascular space, used to expand the intravascular compartment ** solution is the same as what is going on in the vein **
When would an isotonic solution be used?
surgery, or any time homeostasis should be maintained
What would you expect to happy if an IV has an isotonic solution?
nothing but maintenance. The solution is the same as what is going on in the vein so it will stay in the intravascular space
Hypotonic Solution
less solute in plasma than the intracellular fluid, plasma fluid level is greater than cells, fluid moves into the cells, used to treat cellular dehydration ** Moves fluid out of the intravascular space **
Is there more solute in the plasma or intracellular fluid?
The intracellular fluid
What would you expect to happen if an IV has a hypotonic solution?
The fluid will move out of the intravascular space and to the cells
When would a hypotonic solution be used?
To treat cellular dehydration
Hypertonic Solution
more solute in plasma than the intracellular fluid, plasma fluid level is less than cells, fluid move out of the cells to plasma
When would a hypertonic solution be used?
to decreased edema, expand blood volume, in instances of BP drop or blood loss
What would you expect to happen if an IV has a hypertonic solution?
IV fluid has more solute than the blood plasma, therefore the cells fluid will follow the solute and move out of the cells and into the vein
NS
normal saline 0.9%
DSW
5% dextrose in water
LR
lactated ringers
Lactated Ringers
A solution of several electrolytes, may be combined with either DSW or NS
How many grams of glucose and number of calories in one liter of D5W?
170 calories in 1 liter (17 calories in 100mL)
Dextrose is
glucose
1/2 NS
0.45% NaCl
Normal Saline is
NaCl
D5W
Isotonic
LR
Isotonic
NS
Isotonic
1/2NS
Hypotonic
LR Na+
130 mEq
LR Cl-
109mEq
NS Na+
154 mEq
NS Cl-
154 mEq
1/2NS Na +
77 mEq
1/2NS Cl-
77 mEq
Infiltration
Inadvertent administration of a non-vesicant solution into the surrounding tissues
Assessing Infiltration
swelling/blanching at site, decreased IV flow, pain
Phlebitis
Inflammation of vein, increased risk for bloodstream infection
Assessing Phlebitis
pain/warmth at site, linear pattern redness
Non-Vesicant
not going to cause tissue damage
Assessing Infection
drainage from IV site, warmth and redness of IV site, fever
Circulatory Overload
Fluids administered faster than circulatory system can transport, filter, and excrete
Assessing Circulatory Overload
peripheral edema, jugular vein distention, dyspnea, lung crackles, increased HR, elevated BP
What should a nurse assess about the IV solution?
correct solution, correct flow rate, date and time hung, patency of tubing (kinked?)
What should a nurse assess about the IV insertion site?
infection, infiltration, phlebitis, bleeding
What other things should a nurse do about IV therapy?
monitor lab values
Setting up or changing IV fluid/tubing
aseptic technique, maintain closed system - keep air out!
Patient Teaching IV
purpose of IV therapy, care for site/equipment, abnormalities to watch for, when to report them, and to whom
Interventions for Infiltration
change IV site, apply warm compresses
Interventions for Phlebitis
change IV site, apply warm compresses
Interventions for Infection
change IV site, culture the IV site (MD order), antibiotics (MD order)
Interventions for Circulatory Overload
Decrease IV rate “KVO,” interventions to improve oxygenation, anticipate an order for diuretics, and other interventions for fluid volume excess
What are common medications that can be given by IV infusion?
insulin, heparin, opioids, injectable potassium concentrates, neuromuscular blocking agents, chemotherapy drugs, oxytocic medications
Medications administered IV are deemed what?
High Alert
Best practices for medications administered IV
infuse only on an electronic infusion device, monitor blood levels of the medication, monitor specific lab values, monitor medications effects (intended and non-intended)
What lab values are important with Heparin administration IV?
clotting values
What lab values are important with insulin administration IV?
blood glucose
Nursing Responsibilities for Potassium infusion
dilute in an IV solution, never given with a syringe directly into a vein, mix throughly when adding to an IV bag, infuse and less than or equal to 10 mEq per hour through a peripheral IV, max dose is less than or equal to 60 mEq/L, monitor carefully for infiltration, monitor serum K+ levels, never add to an existing IV infusion
What is normal serum K+ levels
3.5-5.0 mL
What is the max does for potassium infusion
60 mEq/L
Documentation of IV therapy
site, client response to therapy, adverse reaction, type of fluid infusing with additives, flow rate in mL/hr, amount administered over a specific time period, type of infusion device
D5 1/4NS
Isotonic
D5LR
Hypertonic
D5 1/2NS
Hypertonic
D5NS
Hypertonic
Grams of dextrose/100mL in D5 1/4NS
5
Grams of dextrose/100mL in D5LR
5
Grams of dextrose/100mL in D5 1/2NS
5
Grams of dextrose/100mL in D5NS
5
Na + in D5 1/4 NS
34 mEq
Na + in D5LR
130 mEq
Na + in D5 1/2 NS
77 mEq
Na + in D5NS
154 mEq
Cl- in D5 1/4NS
34 mEq
Cl- in D5LR
109 mEq
Cl- in D5 1/2NS
77 mEq
Cl- in D5NS
154 mEq
How much fluid is in the body of a premature infant?
90%
How much fluid is in the body of an infant?
70-80%
Why are infants at increased risk for fluid overload and deficit?
A decreased ability to regulate their intake and output and small body mass
What IV equipment would you need for a pediatric client?
smaller gauge needle, sites different from adult: scalp veins, legs, insert IV in separate room from child’s “bedroom,” may use topical anesthetic, restraints, rubber band as tourniquet, never insist on parent assisting with restraining child, specialized devices for stabilizing site and preventing accidental dislodgment, use pump to regulate flow (very small amount of fluid are necessary compared to an adult)
Interventions for IV therapy Infant
explain IV to parents, encourage tactile and verbal soothing, minimize parental separation
Interventions of IV therapy Toddler
allow to express feelings, allow for mobility, encourage favorite toy/blanket for comfort, explain only shortly before procedure to child, minimize parental separation
Interventions of IV therapy Preschooler
encourage to express/play out feelings, encourage mobility, explain in simple terms, use doll to demonstrate, explain that procedure is not punishment but to make them healthy, prepare just before procedure, praise cooperation and provide rewards
Interventions of IV therapy School Age
encourage to express feelings, prepare in advance, explain in simple terms, involve child in procedure (tearing tape, holding tubing), diversional activities, peer contacts, give immediate praise for cooperation
Interventions of IV therapy Adolescent
explain procedure in advance using adult terms, give choices in site selection, privacy, encourage participation in self care, allow to express feelings, use coping and relaxation techniques
What happens to the blood vessels with age?
they become non-elastic
Total body fluids for an elderly client
45-50%
Why are elderly patients more at risk for fluid volume deficit and excess?
poor regulating systems, slower response to changes
IV equipment and needs for IV therapy elderly patient
veins are fragile and roll easily, may have had many previous venipunctures, skin is very thin and SC tissue is diminished, loss of elasticity of blood vessels and dermis, apply warm compress to area to help distend vein to improve success, BP cuff may be used to distend vein, if use tourniquet apply over sleeve to prevent bruising, generally smaller gauge cannula, use a pump for more accurate control of flow rate, areas for IV access should have adequate tissue and skeletal support, therefore hand veins may not be the best choice
Psychologic Support for IV Therapy Elderly
speak slowly, clearly, and directly to elderly patients with sensory deficits, address the patient by his or her proper name, explain the steps of the procedure to increase cooperation and decrease anxiety, do not use unfamiliar terminology, because of decreased dexterity, observe the elderly client who is to self administer infusion therapy to be sure they are proficient with all equipment
KVO
Keep Vein Open
Keep Vein Open
Very sow flow rate which must maintain IV site by preventing blood from clotting in the vein
Drop Factor
Number of drops in 1 mL delivered by tubing. Found on tubing package.
Mini/Micro Drop Tubing
60gtts/1 mL
Intermittent Infusion Device (Saline Lock)
Clamped IV used for intermittent for medication
Symptoms of circulatory overload
dyspnea, SOB, elevated blood pressure, dilated neck veins
What is a normal KVO rate?
30-50mL/hour
What is credit?
what is left in the bag
What is the IV fluid intake?
What the client has taken in, the empty portion of the bag, what is gone
Types of scalp vein needles
butterfly and wing tip needle
Advantages of Scalp Vein Needles
good for one time short-term therapy, sides (wings) allow for easy insertion and taping
Disadvantages of Scalp Vein Needles
Non flexible needle increases the risk of infiltration, could puncture self after discontinuing clients IV with contaminated needle
Uses of Scalp Vein Needles
infants/children, adults with small veins, those receiving short-term therapy
What are Scalp Vein needles made out of?
Stainless steel
What lengths do scalp vein needles come in?
1/2 to 1 and 1/4 inch
What is an over the needle catheter?
consists of a needle covered with a flexible catheter sheath. The point of the needle extends beyond the tip of the catheter. After the vein is punctured the needle is withdrawn and discarded leaving the flexible catheter in the vein.
Over the needle catheter length
3/4 to 2 inches long
Gauge of over the needle catheter
12-24
Another name for an over the needle catheter
angiocatheter
Advantages to angiocatheter
easy to insert, stable, allows for great patient mobility, patent longer, radiopaque (can see on x-ray), infiltration rate decreased
Disadvantages to angiocatheter
sometimes difficult to secure with tape, increased risk of phlebitis
Use of angiocatheter
long-term therapy, delivery of viscous fluids (blood hyperalimentation
Drop Factor
permits a predictable amount of fluid to be delivered, drops per milliliter
micro drop
usually required if the fluid is to be aministered at a rate of 50-70 mL/hour. delivers 60 drops/mL of solution
macro drip
delivers 10-15-20 drops per mL of solution. should be selected with large quantities of solution or fast rates are required
Intermittent infusion device
can be attached to an existing IV catheter to keep venous access available for admin of intermittent or emergency med when a continuous infusion is not required. hep or saline is usually injected periodically to keep blood from coagulating within the tubing
intake
what went in patient
credit
what is left in the bag
What portions of the tubing and container (IV) must be kept sterile?
spike, inside of tubing, cannula end of tubing, spike port on IV bag, IV solution
