NUR321 Final (UAB)

Fresh frozen plasma transfusion indications

Low plasma proteins/coagulation factors, critical conditions requiring expansion of plasma volume

Platelets - transfusion indications:

Low platelets, non functional platelets, treatment/prevention of bleeding in pts with previous issues

Why would we use IV for meds, rather than PO route?

Medicine or treatment can have a faster effect

indications for a trach: airway obstruction

ex. Tumors in the airway

TPN contamination

frothiness, cloudiness, precipitate, oily appearance

Increased WBC indicates

infection

phlebitis

inflammation of a vein

NPH insulin

intermediate acting, **will need to be gently rolled to suspend contents**, CLOUDY

phlebitis s/s

local, acute tenderness, redness, warmth and slight edema of the vein above the insertion site

Air emboli can occur when:

veins and arteries are exposed and pressure allows air to travel into them

A 22- to 24-gauge catheter is recommended for __________________ to minimize insertion-related trauma

neonates, pediatric patients, and older adults

Air embolism occurs when:

one or more air bubbles enter a vein or artery and block it

indications for a trach: airway protection

patients who cannot protect their airway or have an inefficient swallow or cough mechanism. Common in patients who have a high spinal cord injury, CVA or traumatic brain injury

Indications for a trach: ventilation

patients who need long term ventilator support due to chronic respiratory failure

indications for a trach: secretions

pts who cannot mobilize secretions

If administering a pressurized bolus, for hemodynamic instability or fluid challenge test, _________________________

remain with the patient until the infusion is complete to monitor for signs and symptoms of distress.

regular insulin

short acting, CLEAR, also called humulin R or novolin R

TPN admin

should always be infused through an IV pump

Inflation: s/s

swelling, pallor, coldness or pain around infusion site, significant decrease in flow rate

NG tube: intermittent

the set suction pressure will be applied for a few seconds, then released. So it will suction, suction, suction and then release. Any device that is on for a prolonged period of time

Typically, if you are feeding/giving meds

the tube will be smaller and more flexible, like the one below. The tube below is called a Dobhoff tube or a transpyloric (TP) tube. These even have weighted ends that will allow it to drift down (by gravity and peristalsis) into the duodenum, so that the tip of the tube: where meds, water, and feeding would come out, is placed just past the pyloric sphincter so all of that would bypass the stomach and empty out into the duodenum

speed shock causes

too rapid a rate of fluid infusion into circulation

packed red blood cells transfusion indications

low RBCs, Low H&H, symptomatic anemia in patients with previous conditions (tachycardia, excessive fatigue)

NG tubes are usually on __________

low intermittent suction

high range for suction

"full vac" should never be used in the GI tract- mucosa is far too fragile! High suction is used in the continuous mode mainly for yonker function.

A nurse is caring for an elderly client at his home. The client is incontinent of bladder and uses a condom catheter drainage system. Which of the following describes a condom catheter? a. A bag attached by adhesive backing to the skin around the genitals b. A urine drainage tube inserted but not left in place c. A urine drainage tube that is left indwelling over a period of time d. A flexible sheath that is rolled around the penis

- A flexible sheath that is rolled around the penis

Isotonic IV solutions

-0.9% NaCl (normal saline) -Not desirable as a routine maintenance solution because it only supplies Na and Cl, in excessive amounts -May be used to temporarily expand the extracellular compartment if circulatory insufficiency is a problem; also used to treat *hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia* -Used with administration of *blood transfusion*

The nurse is collecting equipment to administer a unit of packed red blood cells. Which IV fluid should be used to initiate the IV for this transfusion? a. 250 mL of normal saline b. 100 mL of 5% dextrose and 1/2 normal saline c. 500 mL of 5% dextrose and water d. 1,000 mL of lactated Ringer's solution

-250mL of normal saline -Blood and blood products should only be administered with normal saline. Other IV fluids may cause damage to the cells being administered.

Titrating High Risk Infusions: insulin- treatment of hypoglycemia

-<70 -Stop insulin, notify MD -If patient is awake/alert- give 25g dextrose IV -If patient is not awake- give 50g dextrose IV -Check Blood Glucose q 15 minutes until > 70mg/dl

A patient with a large infected wound needs negative-pressure wound therapy (NPWT) and asks the nurse how the technique works. Which statement by the nurse is most accurate? a. A skin protectant is coated lightly inside the wound. Several damp gauze pads with the prescribed solution are placed in the wound, and the vacuum device removes the fluid and heals the wound. b. Several pieces of foam pieces are packed firmly into the wound bed, solution is poured over the foam, and the pressure pushes the fluid into the wound to facilitate healing. c. A measured foam pad is placed over the open area along with an occulsive dressing. Negative pressure removes drainage and contracts the wound bed. d. The wound bed is flooded with solution, the foam is placed around the edges of the wound bed, and pressure is used to remove the solution and wound drainage.

-A measured foam pad is placed over the open area along with an occulsive dressing. Negative pressure removes drainage and contracts the wound bed. -The wound vac facilitates healing through contraction of the wound bed and removal of drainage.

Some considerations regarding site selection for an IV:

-Age- it is appropriate for infants to get IVs in their scalp or feet, but this is not true for adults -Length of time the infusion is to run- if it is short term you can use the hand or wrist, but if used continuously for many days suse forearm or antecubital area -Type of infusion to be used and condition of veins

Peripheral Short Catheters

-Also called an angiocatheter- plastic catheter fits over the needle -What we will be inserting -Butterfly needle -In peripheral vein -Short term use- less than a week

Titrating High Risk Infusions: heparin

-Anticoagulant- wont dissolve clots but keeps clot from getting bigger -Titrated based on lab values: either PTT or Anti Xa levels -Weight based! -Bleeding is biggest AE -In some people, exposure to heparin can cause immune system to make antibodies against and kills off their own platelets *heparin platelet antibodies leads to HIT* -Antidote is protamine sulfate

What is a tracheostomy?

-Artificial airway -A small hole that is made in the front of the neck into the windpipe -The hole is called a stoma -The trach tube is a small curved tube that fits into the stoma to keep the hole from closing -Placement can be temporary or permanent

The nurse has just inserted a nasogastric tube for gastric suction. What is the best initial test for assessing tube placement? a. Connect the tube to suction and observe the contents. b. Place the stethoscope over the stomach and listen while inserting water into the tube for a swishing sound. c. Aspirate stomach contents and check the acidity using a pH test strip. d. Place the stethoscope over the stomach and listen while inserting air into the tube for a swishing sound.

-Aspirate stomach contents and check the acidity using a pH test strip. -The initial and most reliable test to confirm gastric placement is to aspirate from the tube and check the pH of the contents pulled back

TPN NI

-Assess for S/S of hyperglycemia -Use very strict aseptic technique because the risk for infection is very high -Bacteria love sugar -Change tubing and bag every 24 hours -Incompatibility is a huge problem- check every medication to prevent it from forming precipitation -Taper off - rebound hypoglycemia can occur; never stop abruptly -Hypoglycemia is an issue after admin is stopped -Can infuse D10W to prevent hypoglycemia if TPN must be stopped abruptly

Unexpected situations and associated interventions: IV does not flush easily

-Assess insertion site. Infiltration and/or phlebitis may be present. -If present, remove the IV. -Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes. -Secure gauze with tape over the insertion site without applying pressure. -Assess the area distal to the venous access device for capillary refill, sensation and motor function. -Assess the need for continued venous access. restart the IV in a new location. -Estimate the volume of fluid that escaped into the tissue based on the rate of infusion and length of time since last assessment. -Notify the primary health care provider and use an appropriate method for clinical management of the infiltrate site, based on infused solution and facility guidelines. -Record site assessment and interventions, as well as the site for new venous access.

The nurse has been closely monitoring a patient who has recently had her indwelling urinary catheter removed. In the six hours since the catheter was removed, the patient has yet to void. How should the nurse first respond to this assessment finding? a. Obtain an order for an oral diuretic and administer this drug to the patient. b. Assess the patient's bladder by palpation and bedside ultrasound. c. Inform the physician and request blood work to assess the patient's renal function. d. Reinsert the patient's urinary catheter.

-Assess the patient's bladder by palpation and bedside ultrasound. -The nurse should adhere to the nursing process, with assessment preceding interventions such as reinserting the patient's catheter, even if a standing order exists to reinsert the catheter if needed. Similarly, a diuretic would not be the first course of action. A short-term lack of urine output, especially following the removal of a catheter, is not indicative of renal failure

What if there is an obstruction and little air is getting in?

-Asthma -Bronchial obstructions

Gastroccult Card

-Blue means blood -You can get acidic secretions from the lungs sometimes especially if the pt has GERD and it could reflex into their lungs

skin traction

-Can be applied by the nurse, but again specific training will be provided by nurses employed on units that will see traction therapy -Patients alignment should be straight in bed. Ok to adjust HOB

transfusion reactions

-Can range from mild to severe -Early S/S- flushing, hives, rash, itching, -Fever -Low back pain -Increased HR, RR, decreased BP -Distended neck veins -STOP blood transfusion, obtain vital signs and notify provider ASAP

infiltration NI

-Check infusion site every hour -discontinue the infusion if symptoms occur and restart the infusion at a different site -use site stabilization device

The nurse has delegated administration of tube feeding to a specially trained UAP. Before the UAP administers the tube feeding, what action should be taken by the nurse in regard to this delegation? a. Check tube for placement. b. Set up the equipment and mix the feeding. c. Regulate the rate of the feeding d. Order the equipment to give the feeding.

-Check tube for placement. -Checking the tube for placement is an assessment that must be performed by the nurse. Equipment may be ordered by anyone, including unit clerical staff. Setting up equipment and mixing feeding is part of administering the feed, and therefore something that the UAP will do, if trained to administer tube feeds. The rate of feeding will likewise be part of the actual administration by the UAP.

Negative pressure wound therapy can be used to treat _______ a. Wounds with necrotic tissue or eschar. b. Wounds that have been inadequately debrided. c. Chronic open wounds such as pressure ulcers. d. malignant wounds

-Chronic open wounds such as pressure ulcers. -NPWT is used in the management of chronic, complex wounds. Necrotic tissue and eschar will need to be debrided away before application of the wound vac device. Malignancy in the tissues is one of the contraindications for wound vac therapy.

Lactated Ringer's Solution

-Contains multiple electrolytes in about the same concentrations as found in plasma. (solution is lacking magnesium and phosphate) -Used in the *treatment of hypovolemia, burns, and fluid lost* from gastrointestinal sources. -Useful in *treating metabolic acidosis*

The nurse has completed closed irrigation of a client's indwelling catheter. What specific information should the nurse document about this procedure? a. Technique used to conduct the irrigation. b. Number of ml of solution used to inflate the catheter's balloon. c. Location of the draining bag and any dependant loops. d. Contents returning with the irrigant, such as blood clots, pus, or mucous shreds.

-Contents returning with the irrigant, such as blood clots, pus, or mucous shreds. -Documentation should include (Taylor, skill 12-9) baseline assessment of the patient, amount and type of irrigation solution used and the amount and characteristics of drainage returned after the procedure, the ease of irrigation and the patient's tolerance of the procedure, urine amount emptied from the drainage bag before the procedure and the amount of irrigant used on intake and output record

TPN (total parenteral nutrition)

-Delivering all pts nutritional requirements directly into the circulation by means of an IV -Thick, milky white substance -Special TPN tubing set that has a filter to allow the lipid based medication to flow through easier and not clot up the line -Requires 2 registered Nurses to verify before administration -Concentrated with dextrose

Venturi Ma

-Delivers a precise FiO2, dependent on the valve or diluter used -If you have an order to give your patient supplemental O2 at 40% this is the best noninvasive way to do it -On the valve it tells you what to set the flow meter to give the O2 prescribed

What size angiocatheter?

-Depends on vascular access needs -Prescribed therapy -Length of therapy -Vascular integrity -Size of vein

Unexpected situations and associated interventions: IV catheter is partially pulled out of insertion site (migrates externally)

-Do not reinsert the catheter. -Whether the IV is salvageable depends on how much of the catheter remains in the vein. -Assess for proper placement in the vein before further use. -If this catheter is not removed, monitor it closely for signs of infiltration and infection.

You patient has pin sites to secure Halo traction in her skull. What intervention would be a priority for this patient? a. Maintain bed rest with head of bed flat to ensure vertebral alignment. b. Document observation of scant serous drainage at pin sites. c. Vigorously clean pin sites every two hours with hydrogen peroxide. d. Adjust Halo traction for comfort by loosening the pins and arranging insertion sites.

-Document observation of scant serous drainage at pin sites. -There is no consensus on the frequency for pin-sit care, but when done should be done carefully and considerations are taken to maintain a relatively sterile, infection-free environment.

Trach care: Outer cannula

-Done according to the preference of the healthcare provider or facility -Most facilities change the outer cannula every 7-14 days after initial insertion

When opening a sterile pack, which action compromises the sterility of the contents? (SELECT ALL THAT APPLY) a. Dropping used swabs into a trash by gently reaching across the sterile field. b. Turning away from the opened sterile kit to start providing care to the patient c. Keeping the contents of the package away from the table's edge. d. Opening the package just before the procedure. e. Moving the box to the edge of the sterile drape after donning sterile gloves.

-Dropping used swabs into a trash by gently reaching across the sterile field. -Turning away from the opened sterile kit to start providing care to the patient -Moving the box to the edge of the sterile drape after donning sterile gloves.

Transducer set-up

-Ensure that air is removed first. Once the fluid has infused, air will be forced into the patient's vasculature -Do not prime with the pressure bag inflated. This can rupture the transducer -Ensure that vented caps are replaced with non-vented caps. Vented caps can leave the system open to air allowing air into the tubing and patient. -Vented caps also will increase the risk for infection.

Venous access device-related infection: causes s/s

-Erythema -edema -induration -drainage at insertion site -fever -malaise -chills -other vital sign changes

Applying an O2 delivery device when the patient's airway is obstructed is pretty useless

-For example Mucus -Pulmonary Hygiene: turn, cough, deep breathe, incentive spirometry -The nurse can implement incentive spirometry without an order -Make sure the incentive spirometer is near the bed, etc that way the patient may be more inclined to use it

Suprapubic Catheter

-For patients who have a completely obstructed urethra or for patients who need long term catheterization due to paralysis, trauma or other factors -Easier to keep clean -Not as hard to pull out

Non-rebreather mask

-Function based on a 1 way valve -Delivers highest concentration of O2 -Reservoir bag gangs from mask and must be inflated- it will take at least 10-15 L per minute

A student nurse is performing a urinary catheterization for the first time and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis for this procedure? a. Complete the procedure and then report what happened. b. Gather new sterile supplies and start over. c. Apologize to the client and complete the procedure. d. Nothing, because the client is on antibiotics.

-Gather new sterile supplies and start over. -When following surgical asepsis, areas are considered contaminated if they are touched by any object that is also not sterile. One of the most important aspects of medical and surgical asepsis is that the effectiveness of both depends on faithful and conscientious practice by those carrying them out.

Titrating High Risk Infusions: insulin

-Generally will be mixed 1:1 by pharmacist (1 unit/1mL) -Only regular insulin can be given IV -Will titrate based on labs: blood glucose and K levels -Add measured insulin into the flush and agitate it a bit to then push it

urine specimens

-If it is a culture- looking for infection -Must be collected sterility -Collected from sampling port

Central Access Device

-Implanted for long term use -Typicallly pts have chronic illnesses or damaged veins -Chemo, TPN, frequent blood draws -May have multiple lumens as well for multiple meds -Put in neck or chest -Can draw labs off the line

Humidification of O2 via nasal cannula

-Important if flow is > 2L a minute -Prevents drying/cracking of mucous membranes -The yellow part connects to the flow meter -When you turn on the flow meter, water will bubble -This bottle is not meant for flows > 6L a minute; pressure could build and the bottle could burst

In order to administer enema or medication to a patient who has a bowel management system (BMS), the nurse must: a. Inflate the stop-flow balloon to retain medication for the prescribed amount of time. b. Ensure that ostomy odor tablets are utilized in the collection bag. c. Flush the irrigation lumen with 20 ml of cold water d. Connect the IV pump to the clear connector port to administer the medication at an even rate

-Inflate the stop-flow balloon to retain medication for the prescribed amount of time. -In order to administer an enema or medication to a patient with a BMS, the nurse must inflate the stop-flow balloon with 25 ml of air, in order to keep the medication from coming out of the rectum.

Nursing interventions to prevent the occurrence of an air embolism

-Injection- remove all air from syringes prior to injection -Infusion- remove all air from IV fluid bags and tubing prior to gravity or pressurized infusion -Transducers-remove all air from IV fluid bag and transducer tubing prior to inducing

As the nasogastric tube is passed into the orpharynx, the client begins to gag. What is the correct nursing action? a. Remove the tube and attempt reinsertion. b. Have the client tilt the head back to open the passage. c. Use firm pressure to pass the tube through the glottis. d. Instruct the client to take a few sips of water.

-Instruct the client to take a few sips of water. -Retching and gagging are a common occurrence during NG tube insertion. Having the patient take sips of water can help engage swallowing muscles to ease the tube on down into the esophagus. Additionally, the nurse may hold the procedure to allow the patient to regain composure. When placing an NG, you want the patient to look downward, (chin to chest) to open esophagus and facilitate the correct position of the tube. Looking up or tilting head back will open airway and increase the risk of tracheal intubation. Firm pressure is not needed.

PICC- peripherally inserted central venous catheter

-Just above antecubital space of arm -Tip rests in superior vena cava- crucial for strict asepsis, dressings changed with sterile technique -Have 1-3 lumens so multiple meds can be given at one time -Long term access- weeks to months

negative pressure wound therapy: who benefits from its use?

-Many wounds can be supported, and outcomes are better when used earlier, not last resort acute/chronic wounds -Traumatic or dehisced wounds -Partial- thickness burns -Pressure ulcers -Diabetic ulcers -Grafts and flaps

contraindications for an IV

-Mastectomy or axillary node removal- sign will be placed above HOB -Cannot start in an upper extremity with arterial-venous fistulas or dialysis access -Avoid legs in adult pts- potential stagnation thrombophlebitis or ulceration -Lower extremity IV access requires an MD order -Try to avoid antecubital veins b/c patient will move arm around and pump will think it is occluded

Which nursing action is a priority for the care of a patient with a traction device? a. Provide pain medication frequently to prevent distress. b. Provide psycho-social support to prevent depression and isolation. c. Clean pin sites every four hours with hydrogen peroxide. d. Monitor circulation of the limb distal to the fracture.

-Monitor circulation of the limb distal to the fracture. -Although each of these interventions might be necessary depending on the patient's situation, the priority would be to assess circulation in the affected limb, checking pulses, color, skin temp, capillary refill.

after blood transfusion

-Monitor for one hour after transfusion after complete to observe for any adverse reactions -Document -Obtain another set of vital signs

hypotonic IV solution: 0.33%

-NaCl (1/3 strength of normal saline) -Provides Na, Cl and free water. The Na and Cl allow the kidneys to select and retain needed amounts. Free water is an aid to the kidneys to eliminate solutes. -*Used in treating hyponatremia*

Assess quality and characteristics of urine

-Normal urine should be light straw colored, clear and odorless -Note presence of any sediment

The client who has a nasogastric tube in place has been restless and pulling at the tube. How would the nurse assess if the tube is still in place? a. Assess the client's bowel sounds. b. Advance the tube. c. Obtain an order for a CXR. d. Auscultate for bilateral breath sounds.

-Obtain an order for a CXR. -The only test that can CONFIRM the placement of an NG tube is a CXR (or other imaging study).

You are observing your patient's use of an Incentive Spirometer (IS) to evaluate his understanding of teaching related to the use of this device. Which of the following behaviors indicate the need for further teaching? a. Patient's breathing is concentrated through the mouth, rather than breathing through his nose. b. Patient requests that the device be cleaned between uses with water. c. Patient relaxes between uses and takes several normal depth breaths. d. Patient inhales deeply then briskly blows into the device with lips sealed around the mouth piece.

-Patient inhales deeply then briskly blows into the device with lips sealed around the mouth piece. -The correct use of an incentive spirometer is for the patient to inhale through the device, not blow against it.

3 way catheter irrigation

-Patients who have a transurethral catheter sometimes need continuous irrigation to prevent blood from clotting in the urinary tract and impeding blood flow -Has a balloon inflation port and main port with a third built in irrigation port. -***Make sure the same amount of fluid going in is the same amount of fluid coming out***

Trach care: Inner cannula

-Periodic cleaning or replacement of the inner cannula prevents airway obstruction -Some inner cannulas are disposable -Inner cannulas should be inspected regularly, consider the volume and thickness of the patient's secretions -**Clients cannot receive ventilator support via a manual resuscitation or a mechanical ventilator when the inner cannula when it is not in place*** -Will need to wear sterile gloves when inserting a new inner cannula

Spiking Bag and Priming Line

-Prime the line to get rid of air- do not want air to go in the patient and cause an air embolism -Requires that you use *aseptic technique* -IV tubing that is used continuously and is *NOT for administration of blood, blood products, or fat emulsions* (TPN, lipids) should be changed no later than every 96 hours (most facilities follow 72 hours or even sooner -If IV tubing is used for administration of blood, blood products or fat emulsions, then the *tubing should be changed every 24 hours* -Label below drip chamber DO NOT touch the spike when cap is off it will contaminate it -Use roller clamp to turn tubing off to keep fluid from rushing out -Wear gloves when spiking bag -Hold IV bag in non-dominant hand and pull stopper off of the spike port. -Then twist and put the spike in the spike port -Then squeeze the drip chamber and open the roller clamp. All the fluid from the drip chamber will go through the line and let it drip through the ending -Double check for air in line

Client Education for trach

-Pt should know what to do in an emergency -The should be informed of the type, size and length of the traction tube -How and when to use suctioning -How to clean the stoma and the tube -How to change the ties -Indications of respiratory distress -S/S of infection and skin breakdown

TPN given to:

-Pts unable to take oral nutrition -Non functioning GI tract -Pts who need bowel rest: UC, bowel obstruction, pancreatitis -pt s with high caloric and nutritional needs d/t illness or injury

What if the catheter goes all the way through the vein?

-Pull the needle out of the infusion site, use a stabilization device, and start an IV in a new site. -Monitor for signs and symptoms

negative pressure wound therapy used to:

-Remove infectious materials -Remove any barriers to cell proliferating/migration, thereby promoting adherence -Provides a moist protected wound bed -Promotes tissues perfusion through enhancing angiogensis -Removes exudate from the wound -Reducing tissue edema by pulling away interstitial fluid

Programming an Alaris IV smart pump

-Remove the blue sheath to reveal a more delicate part of the line- this will go inside your pump -An IV pump consists of a brain and a module. -Lift the lever on the module and pop the blue cartridge in the system and pull on the tubing and stretch to where the blue part is above the channel and close channel door -Now attach to patient, clean hub and pull back for blood return and flush -Turn on pump and let it load -Asks if it is a new patient and respond accordingly -Then enter patient ID -Because you can have multiple channels connected to the brain, you have to let it know which channel you want to do what. So hit channel select and select appropriate channel -It will then give you three options: guard rails drugs, guardrails IV, or basic infusion. -Guard rails are programmed orders that are most used with correct mL and concentration- help keep from making a medication error -For normal saline, hit guardrail IV fluid- then choose your solution order-it will double check that this is correct- then enter rate for fluid infusion -VPVI- volume to be infused- put 950mL so that the pump will let you know when the bag is empty- bags usually have 1000 mL -Then press start

How do we know if the O2 the patient is getting is not enough?

-S/S of hypoxemia: Cyanosis (blue or gray skin tone around nose, ears, fingers or toes) -Associated symptoms are SOB, cough, sputum production. ***These do not mean a patient is hypoxic bnv but they could be** -A sign: usually a key finding, fairly specific to the issue at hand -Symptoms: if you have X symptom, it could be caused by Y problem

simple face mask

-Set on the flow meter, no less than 5L per minute; To keep any accumulated CO2 in the mask flushed out -Up to about 8-10 L- may get to about 60% -Better for mouth breathers or if sinuses/nose are clogged

Intermittent Infusions

-Shorter term infusions -These are typically doses of IV medications that need to be given slowly over an hour or more time. -These are also called"piggy-back" meds when they are set up as secondary infusions. -If there is no continuous infusion, and the patient just needs intermittent doses of IV medications, the pump will be turned off and on, and hooked up as needed.

Cleaning Stoma and Placing trach collar

-Stoma should be cleaned frequently -The skin should be inspected for signs of irritation or infection -Patients with copious secretions often require frequent dressing changes to keep the skin dry and prevent skin breakdown -Gloves should be worn for cleaning the stoma. Cotton tipped swabs or a gauze pad and saline are applied in semicircular motion; inward to outward -Trach ties should be replaced as needed, according to facility policy

Hypertonic IV solutions: 5% Dextrose in Lactated Ringer's solution

-Supplies fluid and calories to the body -Replaces electrolytes; shifts fluid from the intracellular compartment into the intravascular space, expanding vascular volume

A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra? a. Indwelling urethral catheter b. intermittent urethral catheter c. Straight Catheter d. Suprapubic catheter

-Suprapubic catheter -A suprapubic catheter is used for long-term continuous drainage and is inserted through a small incision above the pubic area. Suprapubic bladder drainage diverts urine from the urethra when injury, stricture, prostatic obstruction, or abdominal surgery has compromised the flow of urine through the urethra.

Assess patients overall condition:

-Temperature trends- fever may indicate infection -Reports of lower abd pain- Could be a UTI or bladder spasm -Mental Status- elderly show mental changes when having a UTI

Unexpected situations and associated interventions: IV does not flush easily cont.

-The catheter may be blocked or clotted due to a kinked catheter at the insertion site. -Aspirate and attempt to flush again. If resistance remains, do not force. -Forceful flushing can dislodge a clot at the end of the catheter. -Remove the IV. -Assess the need for continued venous access. -If a clinical need is present, restart the IV in a new location.

hypertonic IV solutions: 5% Dextrose in 0.9% NaCl

-Used to treat syndrome of inappropriate ADH (SIADH) -Can temporarily be used to treat hypovolemia if plasma expander is not available

A nurse is caring for both males and female clients with indwelling urinary catheters. Which consideration is important regarding common catheter-related health risks? a. The use of catheters in male patients increases the risk of future prostate cancers. b. Different innervation of the genital area means that males will experience more catheter related pain. d. Female bladder tissues are more easily irritated, increasing the risk of blood in the urine due to catheterization. d. The female urethra's shorter length increases the risk of bacterial infection.

-The female urethra's shorter length increases the risk of bacterial infection. -The anatomy of the urethra differs in males and females. The male urethra is about 5 to 6 inches (13.7 to 16.2 cm) long. The female urethra is about 1 to 2 inches (3.7 to 6.2 cm) long. This difference is important in terms of catheterization and risk of infection. The shorter length of the female urethra increases the risk of microbial infiltration and ultimately infection.

orthopedic traction

-The nurse does not apply initial weight to the traction- it will be placed by the provider or a specially trained orthopedic technician. -The nurse should, however, assess the equipment to ensure that weights haven't moved, ropes aren't frayed, ropes are properly on pulleys and weight is hanging freely. -Teach pts not to move around weights or equipment -Traction should never be interrupted, unless the provider orders the weights to be removed or it is intermittent traction -Be prepared to treat pain -Dramatically limits your patient's mobility; watch/assess for pressure spots -Redistribute weight without changing the angle of traction -Also consider other issues of mobility: atelectasis, pneumonia, blood clots, muscle atrophy, constipation, etc..) -Pin sites should be cleaned and dressed per hospital policy or providers orders

bowel management systems

-The purpose is to catch and contain liquid stool to keep it off of the skin and decrease risk of infection should the patient have wounds or skin break down -Stool must be liquid enough to go through the tube, otherwise it will push the balloon out -There is another balloon right inside the tube, and a red port can be put into it to stop the flow. The balloon is called a stop-flow or an occlusion balloon -Sometimes, a tube like this may be in place to allow fluid or medications to be instilled into the rectal vault and lower colon.

Trach Bedside Kit

-Trach tube of the same size and type -Trach tube 1 size smaller -Obturator -Suction catheters and functional suction system -Ambu bag and O2 -Disposable inner cannulas or cannula cleaning supplies -10mL syringe for cuff -Trach dressings and ties

Which of the following is true regarding traction? a. Patients with traction devices have decreased sensation and pulses in the limb distal to the fracture. b. Traction force enables the distal bone to remain in alignment with the proximal end. c. Patients with traction devices should be keep immobile. d. Traction pressure is used to keep bone fragments slightly apart.

-Traction force enables the distal bone to remain in alignment with the proximal end. -The purpose of traction is to align distal and proximal bone pieces in the case of bone fracture, not to keep the fragments apart. Patients with traction are somewhat immobile but are not meant to be kept immobile and range of motion should be allowed and promoted to unaffected joints. Patients with traction should not have diminished pulses in the affected extremity. This constitutes a problem which should be urgently evaluated.

How Can I Give an IV infusion if I don't have a pump?

-Tubing for "gravity drip" is classified by the size of the drops of fluid in the drip chamber. The pins at the top of the chamber are different sizes, allowing larger or smaller drops. -The "drop factor" is the number of drops that it takes in that tubing to dispense 1mL of fluid. This number will be given on the tubing package. -Using the roller clamp on the tubing, the nurse can control how fast the drops move.

The nurse notes that a tube-fed client has shallow breathing and dusky color. The continuous feeding is running at the prescribed rate. What is the nurse's priority action? a. Assess the client's bowel sounds. b. Assess the client's lung sounds. c. Place the client in high Fowler's position. d. Turn off the tube feeding.

-Turn off the tube feeding. -This scenario describes evidence of inadequate oxygenation, and given the placement of an NG tube and continuous feeding, there should be an immediate concern that the tube could be malpositioned and tube feeding is dripping into the lungs. Even if the client has a PEG, and not an NG, continuous feeding increases the risk for aspiration. While all of these interventions should happen rather quickly, the FIRST intervention is to turn off the tube feeding until you can investigate further. This prevents ongoing aspiration while you are assessing or repositioning this patient.

Implanted port

-Under skin and can be accessed as needed -Dressings are changed with sterile technique -If patient has this port- always determine if it is contrast compatible

negative pressure wound therapy: CI

-Untreated osteomeylitis -Necrotic tissue with eschar present, eschar removed first -Malignancy in wound -Exposed vasculature in wound -Unexplored fistulas or those with enteric bowel connection -If NPWT has to be interrupted, the nurse should remove the wound vac dressing and -Apply a wet to dry dressing

nasal cannula

-Up to 6L per minute -Needs to be humidified -Air inspired will contain around 40% (FiO2) -FiO2- Fraction of inspired oxygen -Not exact, little control -Order may read: Titrate FiO2 to keep sat at >92%

halo traction

-Used to immobilize the head/neck and protect the cervical spine r/t cervical trauma or surgery -Round "halo" around the patients head, attaches to a vest that distributes weight around the chest -A type of skeletal traction -There are pins that attach to the head around the halo -Provider will periodically need to retighten the bolts around the halo on the pins -Traction should not be interrupted, vests must be able to be unstrapped in case of CPR -To bathe pt, will need to loosen only bottom straps and reach underneath the vest to clean back/chest -Lined in sheepskin, changed as soiled by a professional trained nurse -An allen wrench should be left taped to the vest at all times -Patient may be able to get up and walk around with this traction -Watch for infected pins because it could lead to osteomyelitis; Hard to treat and could lead to sepsis

phlebitis causes

mechanical trauma from a needle or catheter; chemical trauma from a solution

How do I choose a site for an IV?

-Usually want to use an IV site of brachial vein, antecubital and back of hand usually become dislodged. -Also look at age- infants will have IV sites in the scalp and their feet. -Use distal veins first, non-dominant arm, feel for vein should be bouncy and give a little bit, soft and full -Forearm is best, make sure there are no contraindications such as lymph node removal, h/o breast cancer, burns, dialysis treatment -Don't use legs in adults- for thrombus formation and possible pooling of meds.

Select the oxygen delivery device that can promise the most precise measurement of oxygen (FIO2 - Fraction of inspired oxygen). a. Nasal cannula at 6 liters oxygen per minute b. Venturi Mask set to 50% oxygen c. Non-rebreather mask with 15 liters oxygen per minute d. open face mask (tent) set at 50% oxygen

-Venturi Mask set to 50% oxygen -A venturi mask is designed to deliver the most precise measurement of O2.

Salem sump tube

-Very rigid and big; the rigidity of the tube allows it to stay open when negative pressure is applied and if bigger chunks need to go through -For applying suction

A physician has ordered that a patient have their indwelling urinary catheter removed. Which step would be the initial priority for the nurse? a. Provide the patient with analgesic premedications to pre-treat the pain of catheter removal. b. Ask the client to take several deep breaths. c. Wash hands and don clean gloves d. Deflate the balloon by aspirating the fluid.

-Wash hands and don clean gloves

monitor labs: if getting diuretics

-Watch electrolytes like Na, K and Cl -Monitor Renal function tests: BUN, creatinine

A nurse is preparing to administer a unit of packed red blood cells to a patient. The nurse begins the transfusion on Tuesday at 2015. The nurse would ensure that the infusion is completed by what time? a. Tuesday at 2215 b. Wednesday at 0115 c. Wednesday at 0015 d. Tuesday at 2115

-Wednesday at 0015 -Once thawed, packed red blood cells expire after 4 hours, and must not be administered to a patient after that time. The nurse should ensure that the transfusion is complete within 4 hours, or by 00:15 (12:15 am) on Wednesday.

When is the 21% of oxygen in the air not enough?

-When the alveoli aren't working -COPD: alveoli get overinflated and destroyed -Pulmonary Edema: water in alveoli -Pleural Effusion: Pus in alveoli or alveolar walls and they get swollen or infected and consolidated (hard) -Atelectasis: Completely deflated alveoli- inside of alveoli are sticky and hard to pop back open

A nurse needs to administer medications to a client through an intravenous port. Which of the following actions should the nurse perform to ascertain that the IV catheter is in the vein? a. Pinch the tubing above the access port b. Aspirate and observe the tubing near the insertion device c. Instill a few tenths of a milliliter of medication d. Check the client's pulse rate near the port

-aspirate and observe the tubing near the insertion site -The nurse should observe for blood in the tubing near the catheter insertion site upon aspiration, as the presence of blood return validates that the catheter is in the vein.

before starting an IV

-assess vital signs -any allergies to tape, latex, or iodine -any meds like warfarin -diseases like hemophilia

The client complains of burning along the vein in which a medicated IV is infusing. Upon assessment, the nurse finds the IV site is slightly reddened, but not warmer than the surrounding skin, and without swelling. What action should be taken by the nurse? a. Discontinue the IV and place a warm pack on the area. b. Place a cool pack over the IV site and vein. c. Call the physician for direction. d. Slow the IV infusion and reassess the area in 15 minutes

-discontinue the IV and place a warm pack on the area -This assessment likely indicates the beginning of phlebitis. The nurse should discontinue the IV and place a warm pack on the area.

Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client complains of a headache. The nurse assesses that the client has slight shortness of breath and feels warm to the touch. What action by the nurse is priority? a. notify the client's physician b. prepare to resuscitate the client c. slow the rate of the transfusion d. discontinue the transfusion

-discontinue the transfusion -The priority intervention is to discontinue the transfusion. If this client is having a transfusion reaction, it will be better to limit the amount of blood transfused. The nurse would also contact the physician to collaborate on further treatment, but this action should be after the transfusion is discontinued.

When selecting a vein use the _________ of the arm first and subsequent IVs should be placed _______ to the previous site.

-distal veins -proximal

Venous access device-related infection: causes

-improper hand hygiene, frequent disconnection of tubing -access ports, or caps. -Poor insertion technique or multiple insertion attempts. -Multi lumen catheters -long term insertion -frequent dressing changes -An IV solution that becomes contaminated when solutions are changed, a medication is added, or the solution can infuse for too long a period.

A patient is receiving IV therapy with an isotonic solution. The nurse notes swelling and coolness at the site along with an absent blood return. Which of the following would the nurse suspect? a. phlebitis b. air embolism c. extravasation d. infiltration

-infiltration -When IV solutions, such as isotonic solutions, inadvertently leak into the subcutaneous tissues, it is called infiltration. The infiltrated site will be tender, but cool to the touch because the room-temperature fluid is under the skin. If the solution or medication is a vesicant or highly irritating, then it is called extravasation, local tissues will be more inflamed due to the chemical composition of the med and generally may seem more inflamed, especially if the extravasation has been ongoing for some time.

Nursing Responsibilities for IVs

-initiating, monitoring, and discontinuing the therapy -critically evaluating all patient orders prior to administration

16 gauge IV use

-large fluid volume -rapid infusion -trauma -high-risk surgery -requires a large vein

low range for suction

most common for those that are sitting in one spot (like an NG) for a prolonged period. The green area that goes up to -90mmHg

urinary output with a catheter

-normal output 30mL/hr -if getting IV fluids, output will be decreased -if haven't eaten in 3 days or have n/v/d, output will be decreased -pt on diuretic meds, produce more than normal output

Venous access device-related infection: NI

-perform hand hygiene before palpating -assess site routinely -notify provider is s/s of infection are present -use aseptic technique, consider use of 2% chlorhexidine wash for daily skin cleaning

A patient has been ordered to begin an insulin infusion. Other than glucose, what lab factor should the nurse pay particular attention to? a. Platelet count b. hematocrit c. potassium level d. sodium level

-potassium -Intravenous insulin administration also decreases potassium levels. The nurse must watch potassium levels closely and intervene as needed to prevent complications related to hypokalemia.

speed shock s/s

-pounding headache -fainting -rapid pulse rate -apprehension -chills -back pain -dyspnea

A nurse is preparing an intravenous infusion to be administered by gravity. Which part of the administration set would the nurse use to manually regulate the infusion rate? a. roller clamp b. slide clamp c. drip chamber d. spike

-roller clamp -When regulating the flow rate manually, the nurse would use the roller clamp on the administration set.

20 gauge IV use

-routine infusions and IV access -most commonly used

The nurse is reviewing laboratory data for a client who is receiving total parenteral nutrition. Which laboratory value should be immediately brought to the physician's attention? a. prealbumin of 15 b. BUN of 45 c. potassium of 3.5 d. serum glucose of 401

-serum glucose of 401 -The most important concern in this set of laboratory data is the increased serum glucose due to the risk of hyperglycemia and potential for severe complications.

24 gauge IV use

-slow flow rates -pediatric and elderly

22 gauge IV use

-small fragile veins -older adults -slower infusions

A patient with skeletal traction was noted to have purulent drainage around his distal fibular pin site. The drainage has been reported, cultured, and antibiotics have been ordered. What signs or assessment findings could most directly indicate that the patient's condition is getting worse? a. temperature 102.4 b. increased pain in the affected area c. Elevated white blood count d. impaired ability to sleep at night e. evidence of non-blanching skin over sacrum

-temperature of 102.4 -elevated white blood count -increased pain in the affected areas

18 gauge IV use

-trauma -surgery -viscous solutions -blood transfusions -requires a large vein

A physician has ordered 2L/NC be applied for your patient. What consideration is important for comfort and tissue integrity regarding the use of the oxygen? a. use of a humidification device attached to the tubing near the wall b. Ensure the prongs are placed in the nares pointing upward c. Encourage client to breath through their mouth to improve depth of respirations d. Apply a thick film of petroleum jelly along the nares to prevent the prongs from rubbing the nose

-use of a humidification device attached to the tubing near the wall -The use of humidification on NC supplemental O2 is important to prevent drying of mucous membranes and possible cracking, bleeding and discomfort for the patient.

speed shock NI

-use the proper IV tubing -carefully monitor the rate of fluid flow -check the rate frequently for accuracy

Which of the following is MOST IMPORTANT when administering an IV Push medication in order to prevent crystallization in the IV tubing? a. Explaining the purpose of the medication to the patient b. Patient privacy c. Y site compatabilty d. Scrubbing the hub prior to injection

-y site compatability -All of these are important tasks involved in administering an IV push medication. The only answer that addresses prevention of crystallization is Y site compatibility.

hypotonic IV solution: 0.45%

-½ the strength of normal saline -Provides Na, Cl and free water. -Used as a *basic fluid for maintenance needs* -Often used to *treat hyponatremia*

If the there is a problem with a machine, or the machine is turned off- the longest that the occlusive dressing may stay applied is __________. After that amount of time, the dressing needs to be removed and replaced with a wet to dry dressing until a new NPWT dressing can be reapplied

2 hours

The physician has ordered 50 mL of an IV solution to infuse over the next 20 minutes. In order to accurately infuse this solution, what rate should the nurse set the pump to deliver the medication?

20mL/hr

Indications for a trach

4 categories: Ventilation, Airway Obstruction, Airway Protection, Secretions

ph should be less than _____ if the tube is in the stomach

5

negative pressure wound therapy

A system by which vacuum (negative pressure) is applied to a wound to promote blood flow into the area, supporting granulation of the wound, ultimately leading to the wound healing from the inside out. It also pulls out and away fluid (so may reduce swelling) and bacteria (keeps it clean)

albumin transfusion indications

Albuminemia, hypovolemic shock, liver failure

Cryoprecipitate transfusion indications

Bleeding due to hemophilia or disseminated intravascular coagulation, low fibrinogen

A 20- to 24-gauge catheter is recommended for __________________

most infusions in adult patients

Which IV cath should I use?

Depends on type of therapy prescribed: -If TPN or chemo a peripheral vein cannot support it -Length of stay -Vascular integrity

How can I reduce bleeding?

Hold above catheter site to apply pressure, pop off tourniquet, activate safety mechanism on needle stylet, quickly remove protective cap from extension tubing and attach catheter hub and tighten the Leur lock.

How can I arrange my hands to keep the catheter still and tape it down at the same time?

Hold the hub in place with nondominant hand and grab tape with dominant hand

What problems are best treated with IV therapy?

Hypovolemia, hyponatremia, dehydration

Why does my patient need an IV?

If they are having problems with acid-base or fluid electrolyte imbalances. They could also be used for nutrition

Heparin infusions are titrated using which lab values? a. PT/INR and CBC b. fibrinogen and PTT c. d-dimer and anti-Xa d. PTT and anti-Xa

PTT and anti-Xa

is the catheter leaking on the bed?

See if if catheter is significantly smaller than urethra and consider using a larger french

Nontunneled Percutaneous Central Venous Catheter

a type of CVAD that has a short dwell time (3 to 10 days); may have double, triple, or quadruple lumens; are more than 8 cm, depending on patient size; introduced through the skin into the internal jugular, subclavian, or femoral veins and sutured into place; and are mainly used in critical care and emergency settings

speed shock

The body's reaction to a substance that is injected into the circulatory system too rapidly

bowel management systems: meds

The meds or fluids can be given through that irrigation port. If you put something in that needs to sit and not come right back out (like a retention enema), you inflate the stop-flow balloon to occlude the tube temporarily. Then, when the retention time is complete, you deflate that stop flow balloon and the fluid and associated content will come flowing out

medium range for suciton

The yellow area up to -120mmHg. Probably okay for intermittent use or if you need it for really viscous or chunky secretions. Check facility policy

NG tube: continuous suctioning

There will be a continuous suction applied against the device at whatever intensity (negative pressure) that is set. The more negative the number, the more intense the suction. On these devices, they say "full" meaning continuous.

Unexpected situations and associated interventions: Peripheral venous access site leaks fluid when flushed

To prevent infection and other complications, remove from site. Evaluate the need for continued access; if a clinical need is present, restart in another location.

How do I know if the catheter is in place?

Will see flashback in the needle, flashback chamber or hub

Autologous Transfusion

a blood transfusion donated by the patient in anticipation that he or she may need the transfusion during a hospital stay

Peripheral Venous Access Device

a short (less than 3 in) peripheral catheter placed in a peripheral vein for short-term therapy. This device is not appropriate for certain therapies, such as vesicant chemotherapy, drugs that are classified as irritants, or parenteral nutrition. ***one beside nurses can put in***

Peripherally Inserted Central Catheter (PICC)

a type of CVAD, more than 20 cm, depending on patient size, that can be introduced into a peripheral vein (usually the basilic, brachial, or cephalic vein), and advanced so the distal tip dwells in the lower one third of the superior vena cava to the junction of the superior vena cava and the right atrium

Tunneled Percutaneous Central Venous Catheter

a type of CVAD; intended for long-term use; implanted into the internal or external jugular or subclavian vein; length of this catheter is more than 8 cm (approximately 90 cm on average), depending on patient size; tunneled in subcutaneous tissue under the skin (usually the midchest area) for 3 to 6 in to its exit site

Implanted Port

a type of CVAD; subcutaneous injection port attached to a catheter; distal catheter tip dwells in the lower one third of the superior vena cava to the junction of the superior vena cava and the right atrium

Central Venous Access Device (CVAD)

a venous access device in which the tip of the catheter terminates in the central venous circulation, usually in the superior vena cava just above the right atrium

Air detecting IV pumps should be used with ____________

all intravenous infusions when possible

As a bedside nurse, we only insert _______________

angio short caths

Straight IV tubing

approximately 20mL of air

500 mL fluid bag

contains 60mL of air

1,000 mL fluid bag

contains up to 100mL of air

blockage of urine flow

could be clogged with sediment, flush it

Crossmatching

determining the compatibility of two blood specimens

If need to know if tube is clogged below nose:

disconnect from suction momentarily and push 10-20 mL of air into the tube and listen for a light hiss from the air vent in the salum sump- if air is escaping it is patent, if not it may be blocked.

phlebitis NI

discontinue infusion immediately and apply warm compress to the site, avoid further use of the vein, restart infusion in another vein

Infilration: cause

dislodged needle or perforated vessel

Infilration

escape of fluid into subcutaneous tissue