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95 Cards in this Set

  • Front
  • Back
What is infiltration?
-an inadvertent administration of a nonvesicant solution into surrounding tissues
What causes infiltration?
-faulty catheter insertion
-infusion device not secured properly
-high delivery rate
-high pressure from pump
-obstruction of blood flow through the catheter and phlebitis
What are the S/S of infiltration?
-infusion rate stopped or slowed
-coolness of skin around site
-taut skin
-pain may or may not be present
-absence of back flow or diluted blood return
What are the possible complications of infiltration?
-possible tissue necrosis
-compartment syndrome
-reflex sympathetic dystrophy syndrome
How can you as a nurse prevent infiltration?
-check IV site q 2 hours
-check placement of patients IV site
-checking for infiltration by applying pressure above the site to see if the flow stops or continues
What are the treatment options for a patient with IV infiltration?
-STOP IV flow
-use a cold or warm compress
-refer to IV manual or hopital policy
What is phlebitis?
Inflammation of a vein
What causes phlebitis?
-use of a large catheter in a small vein
-improper taping causing the catheter tip to rub against the vein wall and damage the endothelial cells
-improper dilution of medications
-rapid infusion
-presence or particulates in fluid
- vesicant solutions
-bacterial infection from improper aseptic technique
What are some preventative measures for phlebitis?
-use large veins and central line for hypotonic solution
-rotate IV site q 72-96 hours
-stabilize catheter
-use .22 micron filter on-line
-use smallest catheter appropriate for solution
What is the treatment for phlebitis?
-discontinue infusion
-apply warm or cold compress
-notify doctor
-notify infection control depending on hopitol policy
What is thrombosis in regaurds to IV therapy?
A blood clot which is the result of trauma to the vein causing red bloos cells to adhere to the vein wall.
How do you prevent thrombosis with IV therapy?
-use of IV pumps
-avoid placing IV catheter in areas of flexion and lower extremities
-if infusing by gravity at rates less than 50mL/hr use a micro drip tubing for more movement
What is the treatment of thrombosis with IV therapy?
-never flushing a catheter to remove an occlusion
-discontinue IV and move to another site
-assess the site for circulatory repairment
What is thrombophlebitis in regaurds to IV therapy?
It's two injuries in one. Thrombosis and phlebitis.
What are the S/S of thrombophlebitis during IV therapy?
-sluggish flow rate
-tender and cordlike vein
-site warm to touch
-red line above puncture site
-mottling and cyanosis of involved extremity
What preventative measures should be taken with prevention of thrombophlebitis?
-check IV site for redness, and swelling q 4 hours
-use veins in forearm rather than hands for infusing medication
-dont use veins in joint flexion areas
What is the treatment for thrombophlebitis associated with IV therapy?
-never flush catheter
-remove entire IV and restart in opposite extremity
-apply warm, moist compress
-notify doctor
-aspirate blood with 5cc syringe and discard clot
-try to start flow again and if does not work remove
What are some possible causes of thrombophlebitis?
-IV rate too slow to keep patency
-lock not being flushed regularly
-IV bag allowed to run dry
-precipates formed from incompatible medications
What is extravasation in regaurds to IV therapy?
An inadvertant administration of a vesicant solution into the surrounding tissues which results in the formation of blisters and subsequant sloughing of tissues due to necrosis.
What are the possible causes of extravasation?
-puncture of any portion of the vein wall during venupuncture
-mechanical friction from catheter while infusing vesicant solution
-dislodgement of catheter
-poorly secured infusion device
-high delivery or high pressure from infusion pump
-thrombus at catheter tip
What are the S/S of extravasation?
-slow or stopped infusion
-complaint of pain or burning
-swelling either proximal or distal of site
-puffiness or edema at site
-skin tightnesss
-blanching or coolness at site
-damp or wet dressing
**severity is determined by tyoe, concentration, and volume infused**
What are the methods of prevention used for extravasation?
-use of practioner knowledgable of the vesicant used
-verify present of good blood return
-use free flowing IV to push medication
-remove gauze or dressing to fully assess site
-note the condition of the patient
What is the treatments for extravasation?
-most effective treatment is prevention
-stop infusion
-leave catheter in place nad aspirate the medication and blood
-insert antidote immediately through catheter
-remove catheter
-apply cold compress
-notify doctor
-photograph area and fill out incident report per hospital policy
What is ecchymosis or a hematoma resulting for IV therapy?
The infiltration of the patients blood into the tissues at the puncture site.
What are the possible causes of a hematoma or bruising?
-nicking the vein in an unsuccessful puncture attempt
-discontinuing an IV cannula without sufficient pressure on site
-applying tourniquet too tight or longer than too mins or to soon before puncture
What is a vasospasm?
A sudden contracion of a vein resulting in a temporary cessation of blood flow.
What are the S/S of a vasospasm?
-include a sharp pain at the IV site that travels up the arm
-slowing of flow
What are the preventions for vasospasms?
-dilute the medication as recommended in IV drug book
-consider using a warmer fluid for rapid transfusion of cold agglutins
-wrap extremity with warm compress during infusion
What is the treatment for a vasospasm?
Decress flow rate until spasm subsides then restart and apply a warm compress to affected extremity
What are the causes of local infections?
-related to catheters left in place for more than 5 days
-field sticks not changed after 24 hours
-poor technique in placing the catheter
-poor technique in maintaining and monitoring the peripheral site
What are the S/S of a local infection with IV therapy?
-redness and swelling at the site
-exudates of purulent material
-elevated WBCs
What is the cause of septecemia related to IV therapy?
The presence of microorganisms or their toxic products in the blood stream.
What are the risk factors associated with septecemia?
-lack of hand washing
-break in sterile technique
-inexpierence in insertion of IV
-inadequately stabilized IV
-repeated manipulation of IV system
-Infusion factors such as: solution container, catheter material, insertion site, and duration of infusion
-Patient factors such as: age, underlying disease, immune status, presence of other infectious factors
What are the S/S of septecemia?
-cold sweat
-altered mental status
-abdominal pain
What are the preventative measures for septecemia?
-use only freashly opened solution
-albumin should be used as soon as it is opened
What is the treatments used for septecemia?
-determine if patient needs to be transferred to ICU
What is fluid overlaod and it's causes?
-caused by infusing excessive amount of isotonic or hypertonic solution rapidly
-failure to monitor IV infusion
-too rapid infusion in a patient compromised by cardiopulmonary or renal disease and elderly patients
**can lead to pulmonary edema**
What is the preventative measures for fluid volume overload?
-monitor fluid infusion
-maintain prescribed flow rate
-if behind schedule do not catch up
-monitor I&O
-know patients cardiac and renal history
What is the treatment for fluid volume overload?
-decrease teh flow rate
-position the patient in high fowlers
-monitor vital signs
-place on continuous O2 saturation
-administer O2 if stauration less than 95%
-call doctor
-keep patient warm
What is an air embolism and what causes it?
-rare but lethal complication especially involving vascular access device
-the air pocket causes an obstruction to the forward flow of the blood causing pulmonary hypoxia
-it then causes vasoconstricton in the lung tissue and reduces the blood flow out of the right heart which leads to decreased CO, shock and death
What are the causes of an air embolism?
-improper priming of the tubing with air still in the tubing
-superimposing a new IV bag to a line that has run dry without clearing the line of air
-loose connections that allow air to enter the system
-poor technique in tubing changes for central lines
-allowing solution in container to run dry
What are the S/S of an air embolism?
-pulmonary edema
-chest pain
-anxiety and confusion
-if untreated it can lead to hemiplegia, aphasia, coma and ardiac arrest
What are the preventative measures for an air embolism?
-instruct patient to valsalva maneuver when changing tubing
-remove air from administration set
-follow protocol for tubing changes of central line
-superimpose IV solution before the previous bag runs dry
-attach pig to the injection prt closest to drip chamber
-do not by pass IV pump
What is the treatment for an air embolism?
-call for help and call docor immediately
-position patient on left lateral decubitis with head down (will causer air to rise in the R atrium away from the pulmonic valve preventing from entering pulmonary artery)
-monitor vital signs and O2 sat
-administer 100% O2 (causes nitrogen in the air embolus to disolve and decrease the size of the bubble)
-large emboli require hybaric therapy and surgeon will try to remove air embolus by percutaneous aspiration through R ventricle
What is speed shock?
-occurs when medication is rapidly introdused into the circulation which allows the medication to reach toxic levels
What are the S/S of speed shock?
-facial flushing
-tightness in the chest
-irregular pulse
what is the preventative measures for speed shock?
-use an IV pump
-follow recommendation as to how slow or fast to administer IV medication
What are the treatments for speed shock?
-call for help
-give antidote or resuscitation medication as needed
What is a catheter embolism?
-a piece of the catheter breaks off and travels through the vascular system which may migrate to the R ventricle or pulmonary artery
What are the causes of a catherter embolism?
-reinsertion of the same catheter thaqt was used in an unsuccessful venipuncture
-pressure directly over the catheter during discontinuation
-placement of catheter in joint flexion
-removing a stylet and reinserting in thus sheraing off the tip
What are the S/S of a catheter embolism?
-sharp sudden pain at the catheter site
-minimal blood return
-rough or uneven catheter noted on removal
What are the preventative measures with a catheter embolism?
-never reinsert a needle in the catheter
-do not apply pressure to site when removing a catheter
-avoid inserting catheter over joint flexion when movement causes catheter to bend back and forth
-splint the arm if patient tends to bend at elbow
What is the treatment for a catheter embolism?
-have patient apply digital pressure on the vein above the insertion site
-apply a tourniquet above the elbow
-contact doctor
-start new IV line
-prepare patient for x ray
-keep catheter in a clean specimen container to facilitate measuring the remainder of the catheter tip
What is anaphylaxis?
a systematic and immediate hypersensitivity reaction caused by an immunoglobulin Ig-E mediated release of mediators fro the mast and basophils. It is often unpredictable.
What are the causes of anaphylaxis?
medications such as: antibiotics, muscle relaxants, radio-contrast media, anesthetics, non-steroidal anti-inflammatory drugs, latex materials, foods, stings, idiopathic causes
What are the S/S of anaphylaxis?
range from mild skin reactions to respiratory problems to cardiovascular collapse
What are the preventative measures for anaphylaxis?
-identify patients with known allergies
-ensure patients H&P and physical exam in performed
-inquire about adverse drug reactions with family
-ensure proper knowledge of the medication
What is tthe treatment for anaphylaxis?
-discontinue suspected medication
-monitor vital signs and O2 sat
-administer O2 and IV fluids and adrenaline as ordered or per hospital protocol
-get help
-activate emergency button
-maintain airway, breathing and circulation
-start CPR if pulse is not present
What are the local complications of IV therapy?
What are the systematic complications of IV therapy?
-Fluid overload
-speed shock
-air embolism
-catheter embolism
What commonly used IV solutions are isotonic?
-normal saline (0.9% sodium chloride)
-lactated ringers
-5% dextrose in water
What commonly used IV solutions are hypotonic?
-1/2 normal saline (0.45% sodium chloride)
What commonly used IV solutions are- hypertonic?
-D5 1/2NS
What are the purposes of IV therapy?
-administration of medication
-restore and maintain fluid and electrolyte balance
-transfusion of blood and blood products
-total parenteral nutritonal supplemntation delivery
-replacement therapy for present or continuing losses
monitors hemodynamic function
What are the various methods of of administering IV solutions?
-intravenous push
-KVO (keep vein open)
-intermittent/continuous dosing
What is a continuous infusion?
a set amount of IV solution delivered over an ordered time range
What is an intermittent infusion?
set amount of medication in a volume of mL to be delivered at a regular interval
What is an IV push?
administration of a prescribed concentration of medication by injecting through a Y port of primary tubing or through a salne lock
What is a KVO?
minimal volume of IV solution on continuous infusion to lessen the possibility of occlusion andmaintain IV access
What is intermittent/continuous dosing?
pateient self administers preset amount of PRN pain med-demand dose while pump may deliver a hourly fixed dose
What is an IV bolus?
a rapid delivery of an IV medication or solution
What is a hypotonic solution? What is its effect and indication?
also its cautionary uses
-below 240mOsm/L
-effect->shifts fluid out of the intravascular space into the interstitial and intracellular space
-indication->to correct cellular dehydration caused by hypergylcemia and excessive diuresis due to diuretics
-caution->can cause cellular edema, can worsen 3rd spacing, caution in patients with burns, liver disease, renal failure, trauma and can lower blood pressure
What is an isotonic solution? What is its effects?
-240-340 mOsm/L
-effect->expands intravascular volume
What is a hypertonic solution? What are its effects and indications? also its cationary uses
-above 340 mOsm/L
-effects->shifts fluid from intracellular and interstitial space into the intravascular space
-indications->may be used post operatively to stabilize BP, maintain urine output, reduce edema
-cautions->patients with heart and renal problems may not be able to handle the increased intravascular volume
What are the classifications of IV solutions?
-blood products
What is a crystalloid solution?
solution of sterile water with added electrolytes and non-electrolytes as glucose which diffuse across a semi-permeable membrane. It can be iso, hypo, or hyper
What is a colloid solution?
plasma expanders contain proteins or synthetic sugar/starch which remain in the intravascular space for several days
What is blood and blood product solutions?
whole blood, packed RBCs, fresh or frozen plasma, platelets, clotting factors, albumin 5% and 25%
What are lipid solutions?
fat emulsions made from soybean or safflower oil, eggyolk, phosolipids, and glycerol. Used in conjunction with total parenteral nutrition as a source of calories
T or F
An infusion of packed RBC increases hematocrit.
What is a saline lock and its purpose?
-an adapter fitted to an IV catheter with a resealable injectable port, used for peripheral venous access
-minimize restriction in ambulation, access for emergency medication, intermittent medication and has a limited IV intake
How do you flush a peripheral saline lock?
What are some important factors with a central IV access?
-patient consent for placement
-chest X ray needed for confimation of placement
-doctors order required
-tip is in superior vena cava
-may be sutured in place
-heparin may be use (MD order)
-can stay in place for days to months
-clear dressing change every 6 days
-gauze dressing change every 2 days and port to be changed every 6 days
How many ccs for a central line flush?
10 mL
How many ccs for a peripheral line flush?
T or F
Do not flush against resistance.
you may push a clot into circulation
What is done when flushing a central line?
-open clamp and clean port with alcohol for 30 sec
-and then SASH
-always open close open close a clamp
What are the 15 steps in venipuncture with the nurse roles?
-check MD order
-wash hands
-prepare equipment
-patient preparation
-site selection and vein dilatation
-needle selection
-site preparation
-vein entry
-catheter stabilization
-equipment disposal
-patient education
-rate calculation
-monitoring and documentation
What three things must the nurse attach a label to in regaurds to IV therapy?
-IV fluid- replaced every 24 hrs
-IV tubing- replaced every 72 hrs
-IV dressing- replaced every 72 hrs
What are the patient risk factors that lead to IV complications?
-underlying illness: cardiac renal, liver, immunocompromised
-duration of illness
-medications used: steroids, antineoplastics, anticoagulent
-presence of other infectious processes
-frequent movement associated with coughing, vomiting, restlessness, cognitive impairment
What are the nursing considerations when administering IV solution eith an additive?
-observe patients 5 rights in drug administration
-verify allergies
-read IV book about the drug to be administered
-implement sterile technique
-use electronic pump
-verify IV placement
What is parenteral adminstration and the gaols associated with it?
administration of nutrients by a route other than the GI tract.
-meet patients nutritional needs
-allow growth of tissues
-provide calories for resting energy
What should you as a nurse do with a KCl order?
-always dilute it, when not diluted it is fatal
-need to know the serum K level
-always obsereve the cardiac monitor
who has developed the infusion nursing standard of practice to protect patients and nurses who administer IV therapy?
Infusion Nurses Society
Guidlines for supporting client care have been developed by who?
OSHA-occupational safety and health administration
CDC-Centers for disease control