Chapter 15: Fluid, Electrolyte and Acid-Base Balance

steps of inserting an intravenous catheter

-apply tourniquet 3 to 4 inches above the site -cleanse the site with chlorhexidine -place nondominant hand 1 to 2 inches below the site and pull the skin taut -insert the needle gently -release the tourniquet -stabilize the catheter

signs of infiltration in the tissue around the IV catheter

-swelling -pallor -coolness

steps for initiating a continuous intravenous infusion into a peripheral venous access device

1)remove the administration set from the package 2) close the roller clamp on the administration set 3) insert the administration set spike into the entry site of the IV container 4) hang the IV container on an IV pole 5) squeeze and then slowly release the drip chamber, filling it at least halkway 6) open the roller clamp and allow fluid to move through tubing until no air remains

autologous transfusion

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

peripheral venous access device

a short peripheral catheter placed in a peripheral vein for short-term therapy -device is not appropriate for certain therapies such as vesicant chemotherapy, drug that are classified as irritants or TPN

tunneled 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 depending on patients size -tunneled in subcutaneous tissue under the skin for 3-6 inches to its exit size

peripherally inserted central catheter (PICC)

a type of CVAD more than 20 cm depending on the patients size that can be introduced into a peripheral 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 -sterile procedure

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, and the proximal end or port is usually implanted in a subcutaneous pocket of the upper chest wall. -implanted ports placed in the antecubital area of the arm are referred to as peripheral access system ports

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 the patients 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

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 *implanted ports are accessed with a specially designed angled needle -> no need to attempt to straighten it or replace it

edema

accumulation of fluid in body tissues

phlebitis

an inflammation of a vein caused by mechanical trauma from a needle or catheter -characterized by local acute tenderness, redness, warmth and slight edema

blood typing

determining a persons blood type (A, B, O, AB)

crossmatching

determining the compatibility of two blood specimens

hypovolemia

fluid volume deficit -deficiency of isotonic fluid (water and sodium) from the extracellular space

hypervolemia

fluid volume excess -excess of isotonic fluid (water and sodium) in the extracellular space

hypertonic

having a greater concentration of solutes than the solution with which it is being compared

hypotonic

having a lesser concentration than the solution with which is being compared

isotonic

having about the same solute concentration as the solution with which it is being compared

every 72 to 96 hours

how often should the nurse change the IV administration for an adult client

heparin

medication used to prevent clotting *used before removal of an access needle -> does not prevent the needlestick site from oozing or prevent infection

apply a tourniquet to the client's upper arm

part of the catheter breaks off when removing the PICC line, what should the nurse do immediately?

remove the IV catheter and reinsert another IV catheter in a different location

the clients intravenous catheter has been almost completely pulled out of the insertion site which of the following actions is most appropriate?

dehydration

the loss or deprivation of water from the body or tissues

gauze dressing

the nurse finds that the site of the peripheral venous access dressing is bleeding and oozing, which type of dressing should the nurse use for this client?

remove the IV catheter and restart the venous access site in a new location

the nurse has just flushed a peripheral venous access site and notices fluid leaking from the insertion site, what is the following action a nurse should use?

-the type of IV solution -location of the IV catheter access -gauge and length of the IV catheter -rate of the IV solution -clients reaction to the procedure

the nurse has just successfully inserted an IV catheter and initiated IV fluids, a nurse should document which of the following

swab the medication port on the tubing below the air bubbles; attach a syringe and aspirate the air

the nurse is caring for a client who has a continuous IV infusion -> nurse changed the IV solution and there are several large air bubbles below the roller clamp

foot IV insertion site

used for neonates and infants *should not be used once a child can walk

10 to 15 degree angle

which angle relative to the client's skin should the catheter be inserted?

-D5W -0.9% NaCl -lactated ringer

which fluids are known as being isotonic

-name on the clients identification band -number on the client's identification band

while observing the information on the blood bag, it is essential to verify which of the following with ANOTHER NURSE?