WK 1-2 Ax + IVs
assessment finding of blood clotting
decreased flow rate blood back flow in to tubing
air embolism is
often associated with cannulation of central veins
Hypotonic Fluids
1. Replace cellular fluid 2. Provide free water for excretion of waste 3. Excessive infusion may lead to intravascular fluid depletion and increased ICP
Re-assessment of Pain
> after intervention > must be done every 30-60 min depending on intervention
assessment finidings of thrombophlebitis
> localized pain, redness, warmth, & swelling at insertion site or along vein > streaking red > immobility of the extremity > sluggish flow rate > fever, malaise & leukocytosis
if TPN clogs abruptly
> must run D10W > IV infusion cannot be cold turkeyed otherwise blood sugar will bottom out > blood glucose checks Q4 and Q6
Telemetry Recall documentation
@ 6:00, 14:00, 22:00
Intravenous Push (IVP)
A medication is administered directly into the vein with a syringe 100% Bioavailability Know compatibility with all running fluids/components some meds may require dilution to help push easier Know Rate to push
Which nursing intervention is the priority for the nurse preparing to administer an intravenous (IV) piggyback medication to a client who is receiving a continuous infusion of IV fluids? A. Get an additional IV infusion pump for the medication. B. Check the compatibility of the medication and the continuous IV solution. C. Disconnect the continuous IV solution while administering the piggyback medication. D. Flush the client's venous access device to ensure patency.
Compatibility of the prescribed IV medication and infusing IV solution needs to be verified to prevent harm to the client because incompatible solutions may increase, decrease, or neutralize effects of the medication. An additional IV infusion pump is not necessary because IV medication will be administered through a piggyback infusion. The nurse needs to stop IV fluids and disconnect the tubing only if the prescribed IV medication is not compatible with IV fluids and there is a prescription to hold the continuous infusion. The client has a continuous infusion of IV; therefore, patency of the IV access device is already determined
IV fluid to be avoided in renal failure or liver disease
Lactated Ringers Kidneys unable to excrete K+ Liver unable to metabolize lactate into bicarb
Braden Score Indicating Risk
Less than 18
CVC tips end up in
Superior Vena Cava (SVC) Inferior Vena Cava (IVC) Right Atrium
=> tubing must be changed with each new bag or ea 24hr if continuous => filter must be used with tubing
TPN IV
size of IV necessary for blood products
at least 22G, any smaller lysing occurs
patient assessment before blood transfusion
baseline VS physically trace all tubing before initiating any IV infusion must have order to transfuse any blood if patient's T is > 101F Dual verification of blood component ID
discard tubing and empty blood bag
biohazard trash > if biohazard trash unavailable return bag and tubing to blood bank
assessment findings of extravasation
blistering necrosis inflammation
TPN or Chemo
can only be given through a CVC
site selection for CVC
jugular vein subclavian vein femoral vein
blood clotting in IV line may occur if
kinked IV tubing slow infusion rate empty IV bag failure to flush IV after intermittent infusion
used as a rescucitating fluid in hypercalcemia, or hyponatremia
normal saline (0.9% NaCl)
patients at risk for circulatory overload
renal disease elderly CHF
AVOID in head injury or fluid resuscitation
- initially infused D5W is isotonic BUT when body consumes dextrose it becomes hypotonic > once hypotonic water will rush into cells and cause brain swelling
Blood Sampling from CVCs
- maintain universal precautions and asceptic technique - prevent air from entering line - stop all infusing fluids for 1 min - discard 5 ml before sampling - use proximal lumen - only use pigtail of dialysis catheter - do not use vacutainers can collapse catheter - after sample collected flush with NS - restart fluids when complete
PICC line nursing considerations
-antimicrobial dressings should be used - transparent dressing changed every 5-7 days - gauze dressing changed every 48 hours - blood draw follows CVC policy
phlebitis scale
0 = No symptoms 1 = Erythema at access site with or without pain 2 = Pain at access site with erythema and/or edema 3 = Pain at access site with erythema and/or edema, streak formation, palpable venous cord 4 = Pain at access site with erythema and/or edema, streak formation, palpable venous cord >1 inch in length, and purulent drainage
Blood must be infused within _____
4 hours
electrolyte
An ionic compound whose aqueous solution conducts an electric current
A nurse caring for a patient who is receiving an IV solution via a central vein suspects the complication of an air embolism. Which of the following are signs and symptoms consistent with diagnosis? A. Crackles B. Cyanosis C. HTN D. Shoulder pain E. Dyspnea
B, D, E
Examples of hypertonic solutions
D10W, 3%NS, 5%NS, D5LR, D5-1/2NS, D5NS, TPN, Albumin
IV fluid to be avoided in ICP or fluid resuscitation patients
D5W = because it becomes hypotonic, it can cause cellular swelling Hypotonic Fluids = 0.45% NaCl
isotonic fluid that becomes hypotonic once infused
D5W initially when infused is isotonic but as body consumes dextrose it becomes hypotonic
CVC must be confirmed by
XRAY
Prevention of infiltration
assess IV every 2 hours appropriate size catheter
midline catheter dressing
must be changed every 5-7 days or PRN stat lock changed with dressing
type and cross
must be done every 3 days
IVs and IV tubing routinely disconnected
should be changed every 24 hrs
patients on IV fluids
should be monitored for reaction
Hypertonic Fluids
1. osmolality greater than plasma 2. used to increase extra-cellular volume and decrease cellular swelling 3. used to treat hyponatremia 4. irritating to veins 5. to b administered slowly with an IV pump to prevent system overload
Goals of IV therapy
1. provide H2O, electrolytes, and nutrients to meet daily needs 2. replace water and correct electrolytes 3. admininster blood products and medications
If Pain/discomfort present
Type Location Management Interventions Select Pain Scale
Before sending for blood components for transfusion
1. informed consent verified 2. current green type & cross band 3. confirm order 4. VS obtained < than 1hr old 5. Adequate IV access
Braden scale categories
1. sensory perception 2. moisture 3. activity 4. mobility 5. nutrition 6. friction/shear
Actions if IV complication
1. stop infusion 2. discontinue IV 3. apply sterile dressing 4. avoid limb for further IV access 5. cold compress
Which colloid is expensive but rapidly expands plasma volume? A. Albumin B. Dextrose C. LR D. Hypertonic Saline
A. Albumin Requires human donors = expensive The albumin is a protein that does not pass out of the capillary and stays in the vascular space, fluid will move from the interstitial space into the vascular space towards the albumin
before sending for blood component
> informed consent verified > current type & cross band > transfusion order confirmed > less than 1 hr VS obtained > adequate IV access => greater than 22G
Transfusion and Blood
> infuse through an uniterrupted line > only 0.9% NS compatible > use standard Y Tube with filter > educate the patient on transfusion rx symptoms and to notify RN > RN to stay in room for initial 10 min > discontinue transfusion after 4 hours - clock begins when blood hits patient > after completion flush IV with 0.9 NS to clear
Systemic complications of IV therapy
circulatory overload sepsis air embolism
action needed for air embolism
clamp cannula place patient on left side Trendelenburg position obtain VS access breath sounds administer O2
Lactated Ringers
contains multiple electrolytes except Mg used for hypovolemia AVOID in renal failure or liver disease
Why is pure electrolyte free water never given?
> electorlyte free water enters RBCs and ruptures them thus any fluid infused in an IV must have an electrolyte component
if no blood return on CVC
> flush with saline > repostion patient > have patient take deep breath/ or cough
notify blood bank
> if and what part of unit not transfused
Patient Education re: IVs
> indication for IV access > reporting S/S of problems > sm bubbles are ok! > IMPT: patient should never manipulate pump
PICC Line Nursing Consideration
> antimicrobial dressing should be used unless otherwise contraindicated > dressing changed 5-7 days or PRN > preferable for assistance during change, not to lose PICC line
starting IV documentation
> D & T of insertion > # of attempts > Gauge + Lngth of catheter > Patient's response to insertion
when to obtain VS from transfusion patient
> RN continuously observes patient first 10 min and through out transfusion > complete VS 10 - 15 min after initiation > obtain VS 1 hr after completion
Tunneled catheter
> A catheter that is tunneled through the skin and subcutaneous tissue to a central vessel > the entrance point of the catheter is distant from the entrance to the vascular system > more permanent access > require XRAY confirmation for use
transfusion reaction
a serious, and potentially fatal, complication of a blood transfusion in which a severe immune response occurs because the patient's blood and the donated blood do not match
A client receiving intravenous fluids complains of pain at the insertion site, and the nurse notes erythema and edema. Based on the phlebitis scale, how would the nurse document the phlebitis? Grade 1 Grade 2 Grade 3 Grade 4
According to the phlebitis scale, grade 2 presents as pain at the access site with erythema or edema. Grade 1 presents as erythema with or without pain. Grade 3 presents as pain at the access site with erythema or edema, streak formation, and palpable cord. Grade 4 presents as pain at the access site with erythema or edema, streak formation, palpable cord more than 1 inch long, and purulent drainage.
A nurse working on a trauma unit is initiating IV fluids for a patient. For what condition would the nurse administer an isotonic solution? A. Renal impairment B. Pulmonary edema C. Burns D. Hearth Failure
C. Burns A, B, D you do not want to expand the volume
A family member of a client who is prescribed a blood transfusion mentions that blood transfusions are not permitted in their faith. A. Which would the nurse do to handle the situation? B. Wait for the court's order to give blood to the client. C. Proceed with the transfusion to save the client's life. D. Inform the primary health care provider and not give blood to the client. E. Explain to the family member that the client needs this transfusion.
C. The client or the client's family member has the right to refuse treatment and the nurse would value their beliefs and traditions. The nurse would inform the primary health care provider and not perform the blood transfusion. The nurse would not wait for a court's order or try to convince the family member to change his or her mind. The nurse would not proceed with the treatment because this may cause severe legal implications.
extravasation
Extravasation is a vesicant fluid medication that leaks into surrounding tissues.
Hydrochlorothiazide should be used with caution in which of the following? Patients with AIDS AA Pregnancy and Breastfeeding Children Alcoholics Asian Females
Hydrochlorothiazide should not be given to breastfeeding or pregnant women because medication is excreted into breast milk. HCTZ and other diuretics may reduce overall circulating volume and reduce blood flow to placenta leading to defects.
0.45% NaCl
Hypotonic Provides only sodium, chloride, and free water Can be mixed with D5W Used in hypertonic dehydration, Na & Cl depletion and gastric fluid loss
Local complications of IV therapy
Infiltration Extravasation Phlebitis and post-infusion phlebitis Thrombosis Thrombophlebitis Ecchymosis and hematoma Site infection Venous spasm Nerve damage
What mechanism of action or pharmacological action is best associated with hydrochlorothiazide? Osmotic Diuresis Absorbs Calcium and Phosphorus Inhibits Na, K, Cl Inhibits Reabsorption of NaCl and H2O
Inhibits Reabsorption of NaCl and H2O HCTZ promotes urine production by blocking the reabsorption of NaCl in the early segment of the distal convoluted tubule. Since water follows salt, water reabsorption is also inhibited
A client with diabetes mellitus is scheduled to receive an intravenous (IV) administration of 25 units of insulin in 250 mL normal saline. Which type of insulin would the nurse recognize as compatible with IV solutions? A. NPH insulin B. Insulin lispro C. Insulin detemir D. Insulin glargine
Insulin lispro is compatible with IV solutions; it is a rapid-acting insulin. Insulin glargine is not compatible with IV solutions; it is a long-acting insulin. NPH insulin is not compatible with IV solutions; it is an intermediate-acting insulin.
used for hypovolemia, burns, fluids lost as bile or diarrhea, acute blood loss, and surgical patients
LR due to cellular nutrition and fluid resuscitation
reason LR can not be used in patients with liver disease
Lactate gets metabolized into bicarb in normal liver But in in liver disease lactate ends becoming Lactic Acid as it builds up and is not excreted
examples of tunneled catheters
Power Line, Hickman, Broviac
Colloid solutions
Solutions that contain molecules (usually proteins) that are too large to pass out of the capillary membranes and, therefore, remain in the vascular compartment.
In which order would the nurse treat the infiltration of a nonvesicant intravenous (IV) solution leaking into the extravascular tissue?
To stop infiltration via peripheral venous catheter, the first step of the nurse will involve stopping the infusion and removing the central venous catheter after the identification of the problem. The next step would involve application of sterile dressing if weeping from the tissue occurs. The third step for the nurse is to elevate the extremity. Next, the nurse would use warm or cold compresses according to the solution infiltrated and the organization policy. The fifth step is to insert the new catheter in the opposite extremity. The nurse would then obtain the study to determine the problem causing the infiltration. The final step of the procedure would involve the nurse rating the infiltration using the INS Infiltration Scale and document the procedure.
Starting an IV documentation
date & time number & location of attempts gauge & length of catheter patient response to insertion
action needed for circulatory overload
decrease fluid rate obtain VS High Fowler's position
Prevention of Extravasation
do not use veins that have had venipunctures turn pt carefully choose smallest IV catheter stabilize catheter avoid flexion points,
assessment findings for air embolism
dyspnea cyanosis hypotension weak and rapid pulse loss of conscioussness chest, shoulder, and low back pain
Assessment findings for infiltration
edema at insertion site leaking of fluid discomfort/coolness decrease in flow rate
how often should an IV and IV site be monitored
every 2 hours
bedside nurse may not
remove tunneled catheters
reason LR can not be used in patients with renal failure
unable to excrete K
before placing type & cross band on patient
use 2 identifiers verbally and visually confirm patient's full name legibly write D/T and collection person'ssignature on band
Which nursing intervention is the priority when the nurse notices that the client receiving a blood transfusion is having an acute hemolytic reaction? A. Stop the blood transfusion immediately. B. Report to the primary health care provider. C. Recheck identifying tags and numbers on the client. D. Maintain a patent intravenous (IV) line with saline solution
An incompatible blood transfusion can result in an acute hemolytic reaction in the client. During acute hemolytic reactions, the nurse would stop a blood transfusion as a priority nursing intervention. After stopping the blood transfusion, the nurse would report it to the primary health care provider. The nurse can then recheck the client's identifying tags and numbers and maintain a patent IV line with saline solution.
mediport/powerport
a catheter connects the port to a vein placed under the skin discrete the port has a septum through which drugs can be injected and blood samples can be drawn many times ports are used mostly to treat hematology and oncology patients ** may not be accessed for 24 hours after placement**
5% Dextrose in H2O
becomes a *hypotonic* solution when infused! 1. provides glucose for energy production (protein sparing effect) 2. provides free H2O 3. treats hypernatremia AVOID: in head injury or fluid resuscitation because it becomes hypotonic, it can cause cellular swelling. do not give to patients who have intercranial pressure (ICP) ex: cerebral edema (brain trauma) patients
if PICC line removed
requires pressure dressing
Dual verification of blood component ID
2 combo of RN, LPN, MD > compare cross match tag to green ID band
how often should a IV rate/dose be verified
every 4 hours
midline catheter
- not a central line - indicated for IV therapy > 6 days - starts above AC but catheter tip terminates before axilla - should never be used for continuous vesicant therapy or TPN - must remain clamped at all times - NOT POWER INJECTABLE
Selecting an IV site
-Choose distal to proximal - type of fluid in IV - condition of veing -Medical Hx i.e lymphdedema -Try to avoid their dominant arm -Avoid placing near joints -Select a Straight Vein -Want to Feel a bounce over just Seeing a vessel
Prevention of Air Embolism
-inspect bag and tubing for defects -make sure all connections fit tightly -have Pt perform valsalva when changing tubing on a central line - Luer-lock adapters on all devices - air detection via IV infusion pump
isotonic fluids
1. expand the extracellular fluid 2. replace fluid losses 3. used with caution in HTN and HF patients because amt of water into cell equals the amt of water out thus fluid overload can occur
To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse would change the administration set how often? A. Every 4 to 8 hours B. Every 12 to 24 hours C. Every 24 to 48 hours D. Every 72 to 96 hours
Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96 hours after initiation of use in clients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48 hours is not a cost-effective practice.
Hydrochlorothiazide (HCTZ) is most likely indicated for which of the following? Polydipsia Polyuria Wide pulse pressure Oliguria Edema Hypokalemia
Edema - thiazides can be used in moderated HF patients to decrease excess fluid in the system. The patient needs proper renal function for medication to work
During your assessment of a patient taking hydrochlorthiazide which of the following side effects is most likely to be seen?(SATA) Hyperchloremia Gout Hyponatremia Hypokalemia Hyperglycemia Hypovolemia
Gout Thiazide medications can elevate a variety of compounds in the blood. LDL, total cholesterol, triglycerides, and uric acid can be affected. Elevated uric acid (hyperuricemia) is typically asymptomatic can cause gouty arthritis in patients that are predisposed. Thiazide medications also elevate plasma glucose by inhibiting insulin release. Patients with diabetes or that are predisposed should be closely monitored. Hypokalemia because potassium is excreted by kidneys through the urine, hypokalemia is an adverse effect of thiazides. Hyponatremia hydrochlorthiazide decreases ability to reabsorb sodium or chloride making patients at risk for electrolyte imbalance. HCTZ also is a loop diuretic that interferes with water reabsorption so edema would be less likely to be seen Hyponatremia and hypochloremia can occur and should be monitored. Hypovolemia in severe cases. HCTZ inhibits reabsorption of NaCl and H2O which can lead to Daily weights should be performed to determine water loss or gain and be alert for dry mouth, unusual thirst and oliguria.
The nurse assesses a client who has an intravenous (IV) infusion of normal saline. Which assessment finding is the nurse's priority concern? There is bleeding at the infusion site. The client feels short of breath and is orthopneic. The IV limits client mobility. Infiltration has occurred at the catheter insertion site.
Hypervolemia may precipitate pulmonary edema, which produces shortness of breath and orthopnea; because it presents the greatest risk to the client, it is the priority concern. The other concerns are not as serious and can be easily remedied. Although bleeding at the infusion site may occur, it is not the most serious complication. Limited mobility is a concern that can be addressed with client teaching. Although infiltration at the catheter insertion site may occur, it is not the most serious complication because normal saline does not cause serious tissue damage.
Which of the following considerations is most important when administering hydrochlorothiazide? Avoid use in cardiac patients Avoid Antacids Hx of Thyroid Disease Sulfa Allergy
Sulfa Allergy Thiazide is sulfa-based which can cause allergic rxn in susceptible patients
Which action would the nurse take when a client reports pain and burning at a peripheral intravenous (IV) site after the nurse has flushed the saline lock with normal saline? A. Remove the IV catheter and restart the saline lock in another site. B. Document the findings per protocol and reassess the site in 8 hours. C. Flush the IV catheter and saline lock again vigorously with normal saline. D. Change the dressing and apply a new clean dressing per IV care protocol
The client's report of pain and burning at the site indicates that the tip of the catheter is no longer in the vein and the client needs removal of the current catheter and a new IV access site. Documenting the findings and then reassessing the site in 8 hours would leave the client with no IV access. Flushing vigorously will lead to more pain as more saline is pushed into the infiltrated site. Changing the dressing would leave the client without a patent IV access.
Which is the priority nursing intervention for a client with leakage of a vesicant intravenous solution into extravascular tissue via a short peripheral catheter after the nurse has stopped the infusion and disconnected administration set? A. Photograph the site. B. Administer the antidote. C. Aspirate the medication from a short peripheral catheter. D. Apply cold compresses for all medications except vinca alkaloids and epipodophyllotoxins.
The most important step after the nurse has stopped the infusion and disconnected the administration set is to aspirate the medication from the short peripheral catheter. The nurse would photograph the site after applying cold compress. The next most important step after the stopping the infusion process is administration of the antidote. After the administration of the antidote, apply a cold compress. The nurse would use a cold compress for all medications except vinca alkaloids and epipodophyllotoxins.
actions to take if blood clotting
catheter should not be forcibly flushed if unable to flush discontinue IV replace tubing with new IV tPA following protocols
examples of vessicants
chemotherapy vancomycin
crystolloid solutions
contain: water electrolytes sugar
assessment findings of circulatory overload
crackles edema weight gain
complications of circulatory overload
heart failure and pulmonary edema
vancomycin antidote in case of extravasation
hyaloronidase
CVC indications
i) Measurement - Invasive haemodynamic monitoring (CVP) ii) Infusion - Fluid & drugs iii) Accessing heart - pacing iv) Difficult peripheral access v) Long term venous access - Chemotherapy / TPN vi) Special procedures - Renal Replacement Therapy
how often should IV tubing be changed
if continuously running every 96 hrs
phlebitis
inflammation of a vein pain or tenderness at insertion site or along vein swelling
thrombophlebitis
inflammation of a vein + a clot formation
Infiltration
is a non vesicant fluid medication that leaks into surrounding tissues.
IV fluid to be used with caution/avoided in HTN and HF patients
isotonic fluids because amt of water into cell equals the amt of water out thus fluid overload can occur
total parenteral nutrition (TPN)
nutritional therapy that bypasses the gastrointestinal tract for patients who are unable to take food orally; meets the patient's nutritional needs with a highly concentrated, hypertonic nutrient solution administered intravenously through a central vein
0.9% Sodium Chloride
only solution compatible with blood products used in hypovolemia AVOID with fluid excess states no nutrition
PICC
peripherally inserted central catheter - needs order - tip confirmation by X-ray - RNs may remove PICCs
complications of air embolism
shock and death
Dyalisis & Pharesis catheters are
specialized large bore tunneled catheters
actions to take for thrombophlebitis
stop IV infusion apply cold compress followed by warm compress discontinue IV line culture if indicated
actions to take if extravasation occurs
stop infusion notify provider aspirate med from short peripheral catheter avoid cannulation of extremity
vesicant
substance that can cause tissue necrosis and damage substance that can produce blistering on direct blistering on direct contact with skin or mucous membrane