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27 Cards in this Set
- Front
- Back
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What are the three classes of phlebitis? |
Mechanical, chemical, bacterial (infectious) |
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What are the causes of mechanical phlebitis? |
Cannula too large Cannula inserted near a joint inadequate dressing and securement |
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How is mechanical phlebitis managed? |
Remove cannula Apply warm compress Use smallest cannula Discuss with doctor Re-secure or re-dress Document |
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What are the causes of Chemical phlebitis |
Infused alkaline solutions Acid solutions infusion of hyper/hypotonic solutions Speed and method of delivery |
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Define phlebitis |
An inflammation of one or more layers of the vein |
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What are the clinical signs of phlebitis? |
Localised redness, swelling, heat, tenderness and pain |
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What are the signs of grade 1 phlebitis? |
Possible signs: either slight redness or slight pain |
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What are the signs of grade 2 phlebitis? |
Early stage: Two of the following: Pale near IV site, Erythema, Swelling |
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What are the signs of grade 3 phlebitis? |
Medium stage: All of the following are evident: Pain along path of cannula, Erythema, Induration |
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What are the signs of grade 4 phlebitis? |
Advanced stage/ start ofthrombophlebitis: All of the following are evident and extensive: Pain along path of cannula, Erythema, Induration, Palpable venous cord |
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What are the signs of grade 5 phlebitis? |
Advanced stage of thrombophlebitis All of the following are evident and extensive: Pain along path of cannula, Erythema, Induration, Palpable venous cord, Pyrexia (fever) |
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Who is at higher risk for developing hypervolaemia with IV therapy? |
Elderly, children, Pt with cardiac or pulmonary disease, pt with renal disease/injury, pregnant women |
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What are the clinical signs of hypervolaemia? |
Deteriorating respiratory status- tachypnoea, dyspnoea, decreased o2 stats Tachycardia Hypertension Distended jugular vein Pulmonary oedema Weight increase |
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Define extravasation |
Vesicant (producing blisters) fluids leaking into the extravascular tissues |
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What are the clinical signs of extravasation? |
Swelling, burning or pain at insertion site, slowing of infusing rate, no blood return on aspiration |
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What is the treatment for extravasation? |
Aspirate drug from cannula, remove cannula after aspiration, notify medical staff |
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Define a flare reaction |
A transient venous irritation |
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What are the signs of a flare reaction? |
Local urticaria (a rash of round, red welts), stinging, oedema, inflammationalong vein track |
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What is the treatment for flare reactions? |
Flush the line, rest the vein for 30 mins, assess using phlebitis scoring, flush to check patency of line, recommence medication |
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What are the clinical signs of an air embolism? |
Abrubt onset of signs, loss of conciousness, focal seizures, complete collapse, loud heart murmur, death |
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What is the treatment of an air embolism? |
Stop the infuse, clamp the line, place pt in trundleberg position, administer O2 |
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Define cellulitis |
An inflammation of the tissues |
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What are the clinical signs of cellulitis? |
Erythema, pain, tenderness, swelling |
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What sign differentiates cellulitis from infection? |
Purulent discharge |
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Define anaphylaxis |
An acute allergic reaction to an antigen that the body has became sensitive to |
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What are the clinical symptoms of anaphylaxis? |
Bronchospasm, oedema, low bp, tachycardia, GI cramps and diarrhoea, flushed skin, swelling of the throat and mouth, |
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What is the treatment for anaphylaxis? |
Stabilize airway, breathing, circulation. Intramuscular adrenaline 0.3-0.5 mg. Given in the middle third of the thigh (vastus lateralis), 1000ml saline, administer adrenaline if symptoms persist after 5-10 mins |
