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92 Cards in this Set

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the inadvertent administration of a nonvesicant solution into surrounding tissues; occurs from the dislodgement of the catheter from the lumen of the vein
What are 7 causes of infiltration?
1. faulty catheter insertion
2. infusion device not secured properly
3. high delivery rate
4. high pressure from an electric pump
5. overmanipulation of an IV device
6. obstruction of blood flow through the catheter
7. phlebitis
What are 6 signs and symptoms of infiltration?
1. infusion slows or stops
2. coolness of skin around IV site
3. taut skin
4. edema
5. absence of back flow or diluted blood return
6. pain (depending on degree of infiltration)
What are 3 advanced complications from infiltration?
1. ulceration and possible tissue necrosis
2. compartment syndrome (change in pressure leads to arterial compression, which leads to vascular spasm, pain, and muscle necrosis)
3. Reflex sympathetic dystrophy syndrome- chronic and exaggerated inflammatory process which leads to limited function of the area
How quickly can muscular changes occur with compartment syndrome? nerve damage?
muscular changes= 4-12 hours
nerve damage= 24 hours
How can you prevent infiltration?
check iv site every 2 hours (or more); check that iv isn't caught underneath patient when turning
How can you check for infiltration?
place pressure 3 inches above catheter site in front of tip and apply pressure either digitally or with a tourniquet; if IV slows or stops, placement is proper. If IV continues to run, suspect infiltration.
How do you treat infiltration?
- stop infusion; use warm or cold compress (depending on hospital policy)
- possible to aspirate infused medication; stop infusion but do not remove catheter and attempt to aspirate surrounding fluid

inflammation of a vein
Phlebitis may lead to ________ if the patient isn't treated early.

Phlebitis may lead to thrombophlebitis
Mechanical phlebitis can be caused by what?
the use of a large catheter in a small vein and improper taping
Chemical phlebitis could occur with what 4 situations?
1. irritating or vesicant solutions are infused
2. improperly diluted medication
3. rapid infusion
4. presence of particulate matter in a solution
Bacterial phlebitis may occur in what 7 situations?
1. poor aseptic technique
2. breaks in the integrity of the equipment
3. poor insertion technique
4. inadequately taped catheter
5. condition of the patient
6. vein condition
7. failure to do a site assessment
What two skills are essential to preventing bacterial phlebitis?
1. handwashing
2. careful and proper site preparation
What are 5 measures to prevent phlebitis?
1. use large veins and central lines for hypertonic solutions
2. rotate IV site ever 72-96 hours (or per hospital policy)
3. stabilize the catheter
4. use a 0.22 micron filter
5. choose the smallest catheter possible

You should d/c infusion within 24 hours of the first sign of phlebitis.
False- you should d/c immediately
What are 4 steps/treatments for phlebitis?
1. d/c infusion
2. apply warm/cold compress
3. notify MD
4. notify infection control (depends on hospital policy)

a blood clot that results from trauma to a vein

An IV site may appear healthy when a thrombosis is present.
Should you ever force fluid into an IV site that is resistant? Why or why not?
No, b/c a thrombosis could be present and become dislodged with pressure
Can a thrombosis ever become infected?
yes, bacteria and other particles may become trapped in the clot leading to thrombophlebitis
Thrombosis along with thrombophlebitis can lead to what?
What are 3 methods to prevent thrombosis?
1. use an IV pump
2. when infusing by gravity @ rates lower than 50 ml/hr, select microdrip tubing
3. avoid IV placement in areas of flexion and the lower extremities
What is the treatment method for a thrombosis?
1. d/c and restart a new catheter
2. assess the site for circulatory impairment

(never flush a catheter to remove an occlusion)
What are the signs/symptoms of thrombophlebitis?(6)
1. sluggish flow rate
2. edema
3. tender/cordlike vein
4. site warm to touch
5. red line above site
6. mottling/cyanosis of the involved extremity
What is the treatment for thrombophlebitis?
- Remove entire IV set up and restart in opposite upper extremity using ALL new equipment
- follow treatment measures for thrombosis and phlebitis
Clotting at the tip of the cannula that results in sluggish or absent flow is caused by what 4 things?
1. IV rate too slow
2. saline/heparin lock not flushed regularly
3. IV bag allowed to run dry
4. precipitates from incompatible medications
How can you prevent clotting at the tip of the cannula?
1. monitor flow rate regularly
2. use microdrip if flow rate is less than 50ml/hr
3. flush saline/heparin lock every shift and before/after medications
What steps do you take if you suspect a clot at the tip of a cannula?
- aspirate blood with a 5cc syringe and discard blood (do not irrigate)
- restart IV infusion and observe if flow resumes and observe site
- if flow does not infuse, remove IV and restart in another suitable site
What is the result when the patient's own blood infiltrates the tissues at the venipuncture site?
What causes an ecchymosis/hematoma at the IV site? (3)
1. nicking the vein during an unsuccessful venipuncture attempt
2. d/c of an IV cannula without sufficient pressure held over the site
3. applying a tourniquet too tightly, too long, or too soon above a previously attempted venipuncture site
What are 5 recommendations to reducing the likelihood of hematoma development at the IV site?
1. apply tourniquet just before venipuncture (no longer than 2 minutes)
2. use a 20-22 gauge for patients with paper-thin skin
3. be gentle
4. use a dry, sterile gauze when removing cannula
5. be alert to coagulation problems
What are 3 treatment measures for hematomas?
1. after removal apply direct, firm pressure for 2-3 minutes using dry, sterile gauze (5-10 if patient is on anticoagulants)
2. elevate on a pillow
3. use ice to prevent the hematoma from enlarging

the inadvertent administration of a vesicant solution into the surrounding tissues which results in the formation of blisters and subsequent sloughing of tissues due to necrosis
What are examples of vesicant solutions?
- antineoplastic drugs
- electrolyte solutions
- certain antibiotics
- vasopressors
- radiocontrast media
- hypertonic dextrose solutions
- misc. IV drugs (phenergan, ativan, dilantin)
What are 6 causes of extravasation?
1. puncture of the vein wall during venipuncture or by mechanical friction from the catheter
2. dislodgement of the catheter
3. poorly secured infusion device
4. high delivery rate/high pressure
5. overmanipulation of the infusion device
6. thrombus at catheter tip
What are the signs/symptoms of extravasation? (7)
- slow or stopped infusion
- complaint of pain or burning
- swelling proximal or distal to IV site
- puffiness in the dependent part of the extremity
- skin tightness at the IV site
- blanching or coolness of the skin
- damp or wet dressing
What determines the severity of damage due to extravasation?
- type, concentration and volume of fluid
What are 4 ways to prevent extravasation?
1. use a skilled practitioner for infusion
2. verify good blood return
3. use free-flowing IV solution for push medications
4. remove gauze dressing fully to visualize site during administration
If extravasation is suspected, what should you do? (list steps in order) (9)
1. stop infusion
2. leave catheter in place
3. aspirate medication and blood
4. instill antidote immediately through catheter
5. remove catheter
6. apply cold compress for 24-72 hours for all extravasation except those of the vinka alkaloids (antineoplastics)
7. notify MD
8. photograph area
9. document an incident report

a spasm of a vein resulting in temporary cessation of blood flow
Vasospasms can be caused by what? (4)
1. administering cold solution
2. administering an irritating solution
3. too rapid infusion
4. administering a viscous solution
What are 2 signs/symptoms of vasospasm?
1. sharp pain at the IV site that travels up the arm
2. slowing of the flow
What techniques are used to prevent vasospasm?
1. dilute meds as recommended in IV book
2. keep solution at room temperature
3. consider using a fluid warmer for rapid infusions of cold agglutins
4. wrap extremity with warm compress during infusion
What is the treatment method for vasospasms?
- decrease the flow rate until the spasm subsides and restart
- apply warm compress to the affected extremity
Local infections of the vein (such as intravascular thrombus) are one of the most serious catheter related infections. What are 4 causes attributed to this type of infection?
1. catheters left in place longer than 5 days
2. field sticks not changed within 24 hours
3. poor technique in placing catheter
4. poor technique in maintaining and monitoring the peripheral site
What are 4 signs/symptoms of a local infection (such as thrombophlebitis)?
1. redness and swelling at the site
2. exudates of purulent material
3. elevated WBC
4. fever
How do we prevent local infections (such as thrombophlebitis)? (5)
- inspect all solution containers
- change solution every 24 hours
- adequate skin prep
- thorough hand washing
- maintaining asepsis at all times
What are the steps (in order) for treating a local infection? (6)
- notify MD
- remove catheter and send for culture without contaminating it
- obtain a swab from the insertion site for culture
- prepare for 2 blood cultures before antibiotic therapy is started
- apply sterile dressing
- monitor IV site
What are 6 systemic complications related to IV therapy?
1. septicemia
2. circulatory overload
3. pulmonary edema
4. air embolus
5. speed shock
6. catheter embolus

the presence of microorganisms or their toxic products in the bloodstream
What are the 2 most common microorganisms involved in catheter-related HAIs?
1. coagulase-negative staphylococcus
2. enterococci
What are examples of practitioner-related factors for the development of septicemia (in regards to IVs)? (6)
- lack of handwashing
- break in sterile technique
- lack of experience inserting IVs
- inadequately prepared skin over insertion site
- inadequately stabilized and maintained IV access
- repeated manipulation of IV system
What are 4 infusion related factors linked to the development of septicemia?
1. problems with the solution container
2. problems with the catheter material
3. error at the insertion site
4. duration of the infusion
Often times, the development of septicemia if related to patient risk factors. What are examples of this? (4)
- age
- underlying disease
- immune status
- presence of other infectious processes
What are 10 signs/symptoms of septicemia?
- fever
- cold sweat
- tachycardia
- hyperventilation
- hypotension
- altered mental status
- nausea
- vomiting
- diarrhea
- abdominal pain

To prevent septicemia, you should follow the same techniques of prevention as used to prevent local infections, phlebitis, and infiltration.

Solutions of albumin should be used within 1 hour of opening.
False- albumin should be used as soon as the seal is broken.
When treating septicemia, the regimen is similar to that of local infections, phlebitis, and infiltration. Supportive treatment may also be indicated for what 2 additional systemic problems?
1. cardiovascular collapse
2. respiratory compromise
What are 3 causes of fluid overload?
1. excessive amounts of isotonic or hypertonic solutions rapidly
2. failure to monitor IV infusion
3. too rapid infusion in a compromised patient (renal/cardiopulmonary/elderly)
Fluid overload can lead to what?
pulmonary edema
What are the signs/symptoms associated with fluid volume overload? (12)
- irritated cough, SOB, or crackles, wheezing
- drop in O2 sat.
- pulmonary edema
- distended neck vein
- tachycardia
- increased BP/ bounding pulse
- polyuria
- urine SG less than 1.01
- moist, taut skin
- headache, confusion, lethargy
- weight gain in a short time
- decreased sodium, BUN, hct.
If fluid volume overload is not corrected, what can result? (4)
- pulmonary edema
- shock
- congestive heart failure
- cardiac arrest
How can fluid volume excess be prevented? (4)
1. monitor the infusion and know the solution's physiologic effect on the circulatory system
2. maintain prescribed rate (never try to "catch" up)
3. monitor intake/output
4. know the patients renal/cardio history
What are the treatment measure you should implement for fluid volume overload? (7)
1. decrease flow rate
2. position patient in high fowlers
3. monitor vital signs
4. place on continuous O2 saturation
5. administer O2 if less than 95%
6. Call MD
7. Keep patient warm

an air pocket that causes obstruction to the forward flow of blood
air embolism
What are the chain of events following the obstruction of blood flow due to an air pocket?
air pocket causes pulmonary hypoxia ----> results in vasoconstriction of lung tissue ----> reduces blood flow out of the heart ----> leads to decreased cardiac output, shock, and finally death
What are 5 causes of an air embolism?
1. improper priming of tubing with air still in the tubing
2. superimposing a new IV bag to a line that has run dry without clearing the line
3. loose connections that allow air to enter the system
4. poor technique in tube changing for central lines
5. allowing the solution container to run dry
What are the "initial" signs/symptoms of an air embolism? (12)
- palpitations
- lightheadedness
- weakness
- cough
- dyspnea
- cyanosis
- pulmonary edema
- tachycardia
- chest pain
- hypotension
- jugular vein distention
- anxiety, confusion, seizure
If an air embolism is left untreated, the condition leads to what 4 signs/symptoms?
1. hemiplegia
2. aphasia
3. coma
4. cardiac arrest
As a nurse, you should implement what 6 measures to prevent an air embolism?
1. instruct patient to do the valsalva maneuver when changing the tubing
2. remove air from the administration set
3. follow protocol for tubing changes of central lines
4. superimpose IV solution before the previous bag runs dry
5. attach piggyback to the injection port closest to the drip chamber
6. do not bypass the IV pump
If an air embolism is suspected, you should immediately begin treatment. What 4 things should you do (in order)?
1. have someone call MD
2. position patient on left lateral decubitus with the head down
3. monitor vitals and O2 sat.
4. administer 100% O2
When treating an air embolism, what is the rationale for placing the patient on his left lateral side with the head down?
this will cause the air to rise in the right atrium away from the pulmonic valve, preventing it from entering the pulmonary artery
When treating an air embolism, what is the rationale for administering 100% O2?
this causes nitrogen in the air embolus to dissolve in the blood and the bubble to decrease in size
What type of therapy is indicated for a large air emboli?
hyperbaric therapy
Describe the surgical procedure that may be indicated for an air embolus.
percutaneous aspiration of the air through the right ventricle

medication is rapidly introduced into circulation which allows it to reach toxic proportions
speed shock
What are the signs/symptoms of speed shock? (7)
- dizziness
- facial flushing
- headache
- tightness in the chest
- hypotension
- irregular pulse
- shock
What are 2 preventative measures of speed shock?
1. follow manufacturer's recommendation re: rate of administration
2. use an IV pump
What is the treatment for speed shock?
Call MD and give the antidote or resuscitation medication as needed

a piece of catheter breaks off and travels through the vascular system
catheter embolism
What are the causes of catheter embolism? (4)
- reinsertion of the same catheter that was used in an unsuccessful venipuncture attempt
- pressure directly over the catheter during d/c of therapy
- placement of catheter in joint flexion
- removing a stylet and reinserting it thus shearing off the catheter tip
What are the signs/symptoms of a catheter emboli? (4)
- sharp, sudden pain at the IV site
- minimal blood return
- rough/uneven catheter noted on removal
- additional s&s same as an air emboli
How can a catheter embolism be prevented?
- never reinsert a needle in a catheter
- do NOT apply pressure over the site when removing catheter
- avoid inserting over a joint flexion
- splint arm if flexion must be used
What is the treatment for a catheter embolism?
1. have patient apply digital pressure on vein above catheter site
2. apply a tourniquet above the elbow
3. call MD
4. start a new IV line
5. prep patient for xray
6. keep catheter in a clear specimen container to facilitate measuring the remaining tip

systemic and immediate hypersensitivity reaction caused by an immunoglobulin Ig-E mediate release fro mast cells and basofils

Anaphylaxis is often unpredictable.
What causes anaphylaxis? (5)
- meds such as antibiotics, muscle relaxants, radio-contrast media, anesthetics, non-steroidal anti-inflammatory drugs
- latex
- food
- stings
- idiopathic causes
What are the signs/symptoms of anaphylaxis? (3)
- mild skin reactions
- respiratory problems
- cardiovascular collapse
What measures should be taken to prevent anaphylaxis? (5)
- identify known allergies
- take patient history
- perform physical exam
- inquire about and adverse drug reactions among family
- have thorough knowledge of the medications
What is the treatment for anaphylaxis? (7)
- d/c suspect med.
- monitor vitals and O2 saturation
- administer O2, IV fluids and adrenaline as ordered or per hospital policy
- activate ERT
- maintaing ABCs
- start CPR if pulse is absent