NMNC 4335 - IV Skills

how do you prepare your patient to have an IV placed?

- explain procedure & rationale - anesthetic - infiltration w lidocaine, emla cream - tell your pt before you insert needle

how do you change CVAD dressing changes?

- strict sterile technique - according to policy - transparent semipermeable dressing/gauze - chlorhexidine cleansing agent

The client's intravenous (IV) site is tender with erythema, warmth, and mild edema. Which action will the nurse take? 1) Irrigate the IV tubing. 2) Change the IV site. 3) Slow the rate of the infusion. 4) Obtain a prescription for an analgesic

2) Change the IV site.

What needs to be documented about IV sites?

- # attempts @ insertion - Precise description of insertion site - Date + time - Type of solution + additives infusing - Pt rxn - Cath gauge, type, length, brand - Rate + method of infusion (EX) gravity, name of EID - Purpose of infusion - When infusion was started - Evaluation of pt learning - Signature + credentials - Q shift - pt status, IV fluid infusing, amt infused, integrity + patency of system

what are CVAD's used for?

- frequent, continuous, rapid, or intermittent administration of fluids and drugs - drugs that are potentially vesicants - blood/blood products and parenteral nutrition - hemodynamic monitoring - pt w limited peripheral vascular access / who need long-term vascular access

Ten minutes after the initiation of a blood transfusion, a client reports chills and flank pain. Which nursing action would be performed first? 1) Stop the transfusion. 2) Obtain the vital signs. 3) Notify the health care provider. 4) Maintain the flow with normal saline

1) Stop the transfusion.

The IV team nurse just completed insertion of a PICC line into R.J.'s right basilic vein. What must you do before administering the IV antibiotic via the PICC line?

Do not use a newly placed CVAD until the tip position is verified with a chest x-ray

s/s infiltration

cool trouble flushing/administering meds swelling catheter must be removed apply warm pack unless contraindicated

is IV therapy a medication?

yes

How do you remove CVADs?

- done according to institution policy & nurse's scope of practice - nurses w demonstrated competency can remove PICCs & non-tunneled central venous catheters - remove any sutures & gently withdraw catheter while instructing patient to perform Valsalva maneuver as last 5-10cm of catheter is withdrawn - immediately apply pressure to site w sterile gauze to prevent air from entering & control bleeding - check cath tip to determine that it is intact - after bleeding stops, apply antiseptic ointment & sterile dressing to site

A 2-year-old toddler is to have intravenous (IV) antibiotic therapy. Which action will the nurse take to prevent the child from pulling out the IV line? 1) Keep the arms restrained. 2) Tell the child not to touch the IV site. 3) Cover the IV site with a protective device. 4) Have the parent hold the child continuously.

3) Cover the IV site with a protective device.

The lungs act as an acid-base buffer by a. increasing respiratory rate and depth when CO, levels in the blood are high, reducing acid load. b. increasing respiratory rate and depth when CO, levels in the blood are low, reducing base load. c. decreasing respiratory rate and depth when CO, levels in the blood are high, reducing acid load. d. decreasing respiratory rate and depth when CO, levels in the blood are low, increasing acid load.

a. increasing respiratory rate and depth when CO, levels in the blood are high, reducing acid load.

While the nurse is giving an IV infusion of a piggyback medication, the patient's IV site becomes cool, pale, and swollen. The nurse should take which action? A) Stop the current infusion and change to another site. B) Slow down the rate of the infusion. C) Flush the IV line with normal saline. D) Retape the IV catheter to decrease the pressure

A) Stop the current infusion and change to another site.

how do you perform a venipuncture?

Apply traction to vein Bevel up 20-30° angle Direct stick Puncture skin Lower angle Advance until blood flash back Advance another 2 mm Holding needle absolutely still, advance cannula Remove tourniquet Remove needle Attach saline lock

How often do you change IV tubing?

No more frequently than 72 hours (hospital policy) Exceptions - Blood - 2 units of blood - TPN, Lipids - Q 24 hours - Propofol - Q6 - 12 hours (often with every bottle or every other bottle) - Immunosuppressed patients

The nursing care for a patient with hyponatremia and fluid volume excess includes a. fluid restriction. b. administration of hypotonic IV fluids. c. administration of a cation-exchange resin. d. placement of an indwelling urinary catheter.

a. fluid restriction.

advantages + disadvantages of CVAD's

advantages - immediate access - reduced venipunctures - decreased risk of extravasation disadvantages - increased risk of systemic infection - invasive procedure

how do you d/c IV access?

supplies - clean gloves, 2X2, tape, alcohol wipes technique - remove tape & dressing - while applying pressure, remove angio - assess for intact catheter - apply dressing/bandaid

Which would the nurse do first if an allergic reaction to a blood transfusion occurs? 1) Shut off the infusion. 2) Slow the rate of flow. 3) Administer an antihistamine. 4) Call the health care provider (HCP).

1) Shut off the infusion.

List at least 4 sites that should be avoided when initiating (inserting) a peripheral IV catheter.

- Heavily scarred / burned tissue - Upper extremity on the side of a mastectomy - Appendage c a fistula/cannula - Edematous extremities

Identify signs and symptoms of IV infiltration and IV phlebitis:

- Infiltration - taut, blanched, cool to touch skin, edematous, painful, infusion may slow/stop - Phlebitis - redness, tenderness, pain, warmth along vein originating from access site, red streak/palpable cord along vein

In which order would the nurse complete these steps when administering a blood transfusion? 1. Ascertain that intravenous catheter size is 18 or 20 gauge. 2. Check primary health care provider's prescription. 3. Change main line solution to normal saline. 4. Check client identification before hanging unit of blood. 5. Obtain vital signs and history of transfusions.

2. Check primary health care provider's prescription. 5. Obtain vital signs and history of transfusions. 1. Ascertain that intravenous catheter size is 18 or 20 gauge. 3. Change main line solution to normal saline. 4. Check client identification before hanging unit of blood.

The IV team nurse just completed insertion of a PICC line into R.J.'s right basilic vein. For what complications will you monitor R.J.?

Monitor for occlusion, embolism, infection, and catheter migration. A pneumothorax could be a complication of a centrally inserted catheter, but not a PICC

An left-handed patient who had a right mastectomy several years ago has good veins in her right hand. Where should the nurse place the IV catheter? a) Right hand b) Left lower arm c) The patient's preferred location d) Right antecubital site

b) Left lower arm

what is extravasation?

when a vesicant drug (EX chemo) leaks outside the vein or into the skin, causing a reaction vesicants cause blistering and other tissue injury which may be severe and can lead to tissue necrosis treated by - stop push / infusion immediately if pt admits to burning sensation or c/o pain - catheter should not be immediately removed, in case they can be used to aspirate the leaked vesicant (3-5mL) - remove needle - elevate affected limb to minimize swelling & encourage lymphatic resorption of the drug - apply warm/cold compress as indicated

what is a CVAD catheter embolism and how do you manage them?

(EX) catheter breaking, dislodgment of thrombus, entry of air into circulation S/S - chest pain, resp distress (dyspnea, tachypnea, hypoxia, cyanosis), HoTN, tachycardia management - administer O2 - clamp catheter - place pt on L side with head down for air emboli - notify HCP

The nurse assesses pain and redness at a vascular access device (VAD) site. Which action is taken first? 1. Apply a warm, moist compress. 2. Aspirate the infusing fluid from the VAD. 3. Report the situation to the health care provider. 4. Discontinue the intravenous infusion.

4. Discontinue the intravenous infusion.

Central inserted catheters (type of CVAD)

· Subclavian / jugular · PLACED BY HCP · Reduces vesicant vascular damage · Short-term needs in acute care setting · Tunneling of cath through SQ tissue & synthetic cuff used to anchor cath provide stability & decrease infxn risk · Single/double/triple lumen - multilumen cath useful in critically ill pt bc each lumen can be used for different therapies

How would you assess for a transfusion reaction and how would you respond? LEWIS CH 30 pg 649)

- Temperature change, tachycardia, dyspnea - Swelling / erythema @ site - Flank pain, flushing - Irritability, decreased LOC - Rigor - chills, shivering followed by fever - Txt shock & DIC if present - Draw blood samples - Maintain BP - Insert indwelling urine cath - Antipyretics / antihistamine / corticosteroid / epinephrine / O2 as prescribed - Obtain blood culture + give abx for septicemia

what is a CVAD catheter pneumothorax and how do you manage them?

- perforation of visceral pleura during insertion S/S - decreased/absent breath sounds, respiratory distress, chest pain, distended unilateral chest Tx - O2 admin, semi-fowlers position, chest tube insertion

What assessments does a nurse make before hanging an intravenous (IV) fluid that contains potassium? SATA 1. Urine output 2. Arterial blood gases 3. Fullness of neck veins 4. Serum potassium laboratory value in EHR 5. Level of consciousness

1. Urine output 4. Serum potassium laboratory value in EHR

When a client's total parenteral nutrition (TPN) bag is empty, which action is appropriate for the nurse to take? 1) Perform a finger stick glucose test and call the primary health care provider with the results. 2) Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag. 3) Discontinue the infusion and flush the intravenous (IV) line with saline solution until the next TPN bag is ready. 4) Hang a bag of 5% dextrose at a keep-open rate and notify the nurse manager of the occurrence.

2) Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag.

The intravenous (IV) line infiltrates and needs restarting on a client diagnosed with acquired immunodeficiency syndrome (AIDS). Which precautions would the nurse take when restarting the IV? SATA 1) Mask 2) Gown 3) Gloves 4) Face shield 5) Hand hygiene

3) Gloves 5) Hand hygiene

Which action needs correction regarding insertion of an intravenous cannula for administration of fluids? 1) Washing hands with antibacterial soap before insertion of cannula 2) Using chlorhexidine at the selected site of insertion 3) Shaving the client's skin immediately around the insertion site 4) Applying skin protectant solutions at the site of insertion

3) Shaving the client's skin immediately around the insertion site

Which assessment does the nurse use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit? 1. Dryness of mucous membranes 2. Skin turgor 3. Fullness of neck veins when supine 4. Fullness of neck veins when upright

3. Fullness of neck veins when supine

A patient on anticoagulant therapy needs an IV catheter to be removed. What nursing intervention is most appropriate after the nurse removes the catheter? A) Apply pressure to the IV site for 5 minutes B) Leave the IV in place and attach a saline lock for 24 hours C) Elevate the extremity for 10 minutes D) Use a warm compress at the site for several minutes

A) Apply pressure to the IV site for 5 minutes

The nurse is getting ready to administer an IV push medication. What is the most important action for the nurse to take before administering the med? A. Assess the condition of the IV insertion site. B. Stop the maintenance of IV fluids. C. Dilute the medication to decrease irritation. D. Ensure that the correct-size filter needle is applied to the syringe.

A. Assess the condition of the IV insertion site.

How do you administer potassium via IV?

Always use a pump MAX - 10mEg/50ml peripherally over 1 hour - 20mEg/100ml centrally over 1 hour - NEVER BY ANY SOURCE MORE THAN 20mEq/HOUR!!! Never PUSH Potassium Never ADD to a bag May require cardiac monitoring Assess peripheral sites at least hourly - very irritating to the vein

A nurse notes blanching, coolness, and edema at a client's peripheral intravenous site. Which nursing action is most appropriate? A) Check for a blood return. B) Discontinue the intravenous line. C) Apply a warm compress. D) Measure the area of infiltration.

B) Discontinue the intravenous line.

During assessment of the IV site the nurse observes redness and tenderness on palpation. The nurse discontinues the IV and documents that the IV was discontinued and restarted because of which complication? A) Clotting of the IV catheter B) Infiltration C) Phlebitis D) Puncturing of the opposite side of the vein

C) Phlebitis

Which patient is at greatest risk for developing hypermagnesemia? a. 83-year-old man with lung cancer and hypertension b. 65-year-old woman with hypertension taking B-adrenergic blockers c. 42-year-old woman with systemic lupus erythematosus and renal failure d. 50-year-old man with benign prostatic hyperplasia and a urinary tract infection

C. 42-year-old woman with systemic lupus erythematosus and renal failure

what is a CVAD catheter occlusion and how do you manage them?

Causes - clamped or kinked catheter, tip against wall of vessel, thrombosis, precipitate buildup in lumen S/S - sluggish infusion or aspiration, unable to infuse or aspirate Management - instruct patient to change position, raise arm, and cough - assess for & alleviate clamping/kinking - flush w NS using 10-mL syringe - don't force! Fluoroscopy to determine cause + site Instillation of anticoagulant or thrombolytic agents

how do you start IVPB?

Piggyback goes above primary Connect above roller clamp Controlled by clamp on primary set PB clamp must be completely open Clamp secondary set when infusion complete Then reset drip rate of primary

when would you use a small vein versus a large vein for IV access?

small vein acceptable - routine intermittent meds, small-moderate volumes of fluid, non-irritating drug infusions (heparin) large vein necessary - fluid resuscitation, blood products, anticipated longevity of site

where do you ideally place an IV?

upper extremities over lower extremities hand over upper arm/wrist avoid joints avoid interfering w ADL's - use non dominant side place subsequent IV's proximally

s/s phlebitis

warm redness tender on palpation catheter must be removed prevent by securing well, using stat-lock, smallest reasonably sized catheter

An older-adult patient is receiving intravenous (IV) 0.9% NaCl. The nurse detects new onset of crackles in the lung bases. What is the priority action? 1. Notify a health care provider. 2. Decrease the IV flow rate. 3. Lower the head of the bed. 4. Discontinue the IV site.

2. Decrease the IV flow rate.

When delegating input and output (I&O) measurement to assistive personnel, the nurse instructs them to record what information for ice chips? 1. Two-thirds of the volume 2. One-half of the volume 3. One-quarter of the volume 4. Two times the volume

2. One-half of the volume

What can you do to maintain patency of the PICC?

- flush according to policy - typically 10mL NS Q4-8H + after each use. - pulsatile flush technique & appropriate clamping depending on type of pressure cap used - positive pressure cap - remove syringe before clamping - negative / neutral pressure cap - clamp syringe while maintaining positive pressure (EX) while instilling last mL of saline

how do you change an injection cap for a CVAD?

- have pt turn head away - vasalva if no clamp

what is CVAD catheter migration and how do you manage it?

- improper suturing - trauma, forceful flushing, spontaneous S/S - sluggish infusion/aspiration, chest/neck edema during infusion, c/o gurgling in ear, dysrhythmias, increased external cath length Tx - remove + replace CVAD

what is a CVAD catheter infection and how do you manage them?

- contamination during insertion/use - migration of organisms along cath - immunosuppressed pt - local - redness, tenderness, purulent drainage, warmth, edema, local drainage culture, warm moist compress, cath removal if indicated - systemic - fever, chills, malaise, blood cultures, abx therapy, antipyretic therapy, cath removal if indicated

How does the use of central venous access devices (CVADs) differ from peripheral IV therapy? (LEWIS 292)

- Access to a large central vein (EX) subclavian or jugular vein - Immediate access to central venous system - Frequent, continuous, rapid/intermittent admin of fluids + meds - Allow for admin of meds that are potential vesicants, blood/blood products, parenteral nutrition - Allow for hemodynamic monitoring & venous blood samples - Useful for pt who have limited peripheral vascular access/projected need for long-term vascular access - Can be used to inject radiopaque contrast media - Disadvantages - increased risk for systemic infxn, very invasive, risk for extravasation

What key assessments should you make when caring for a patient with an IV access? (P&P 1031)

- Check Q4H minimum · Correct type & amt of solution infusion · Check for leaking @ connection sites · Function, intactness, patency of IV system · IV-related complications - palpate skin around & above IV site through intact dressing - Evaluate response to therapy - lab values, I&O, wt, VS, postprocedural assessments - ECV excess, ECV deficit, S/S F&E imbalances - Bleeding after IV removal, redness, tenderness, drainage, swelling during later eval

What is the procedure & education that should be followed (step-by-step) when administering blood products to patients? Does a patient need to sign a consent? (LEWIS CH 30 pg 649)

- Complete baseline physical assessment of the patient as a basis to assess changes during and after the transfusion. - Ensure that the IV line has an appropriate needle, catheter, or cannula, and that it is patent. - Double-check patient identification and blood product identification data with another licensed nurse (consider state nurse practice act and agency policy). - Adjust infusion rate of transfusion according to patient needs, provider's order, and agency policy. - Assess patient for signs of transfusion reactions. - Delegate UAP to take vital signs as directed. - Evaluate for therapeutic effect of blood product (improvement in CBC, increased blood pressure, decreased bleeding). - Monitor for signs of circulatory overload (e.g., shortness of breath) if the transfusion is given rapidly

What are the primary complications associated with IV therapy?

- Local infxn - infection @ cath skin entry point during infusion/after cath removal - Vascular damage - Phlebitis - inflammation of inner layer of a vein - Vein infiltration - IV fluid entering SQ tissue around venipuncture site - Vein extravasation - vesicant (tissue damaging drug EX chemo) enters tissues - Air embolism - air in vein from unpurged syringe/tubing - sudden onset of dyspnea, coughing, chest pain, HoTN, tachycardia, decreased LOC, signs of stroke - Circulatory overload - solution infused too rapidly or too great an amt - Transfusion - immune response to transfused blood components

implanted infusion port

- central venous catheter connected to a surgically implanted single/double subcutaneous port - port is metal sheet w self-sealing silicone septum - drugs injected thru skin into port - good for long-term therapy, low infxn risk, cosmetic discretion - care requires regular flushing

PICC

- central venous catheter inserted into vein in arm - single / multimumen, non-tunneled - pt who need vascular access for 1wk-6mos - cannot use arm for BP/blood draw

how do you remove a PICC line?

- put on non-sterile gloves & remove dressing - don sterile gloves & mask, have patient turn head to other side - remove sutures if present - slowly & steadily withdraw catheter - STOP if resistance is me for - can apply warm compresses for 20min & retry If resistance continues, notify HCP - have patient perform Valsalva maneuver as last 5-10cm of the catheter is withdrawn - pressure should be immediately applied to site w sterile gauze to prevent air from entering & control bleeding - inspect catheter tip to determine that it is intact - after bleeding has stopped, apply antiseptic ointment & sterile dressing to site

centrally inserted catheter

- vein in neck/chest/groin w tip resting in distal end of superior vena cava - non-tunneled/tunneled - dacron cuff stabilizes cath & decreases incidence of infection (by impeding bac migration along Cath beyond cuff) - single, double, triple, or quad lumen - (EX) Hickman, Groshong

When a client who is receiving a potassium infusion via a peripheral intravenous (IV) site reports a burning sensation above the IV site, which action would the nurse take first? 1) Check the IV access for a blood return. 2) Apply warm compresses to the affected extremity. 3) Slow the IV infusion until the burning sensation is gone. 4) Request an oral supplement from the primary health care provider.

1) Check the IV access for a blood return.

A client is scheduled to receive total parenteral nutrition (TPN). To administer TPN, which piece of equipment is important for the nurse to obtain? 1) Infusion pump 2) Tall intravenous (IV) pole 3) Clamp that will be taped at the bedside 4) Infusion set that delivers 60 drops/mL

1) Infusion pump

A health care provider prescribes two units of blood for a client. Which nursing interventions are necessary before the blood transfusion is administered? SATA 1) Obtain the client's vital signs. 2) Monitor hemoglobin and hematocrit levels. 3) Allow the blood to reach room temperature. 4) Determine typing and crossmatching of blood. 5) Use a Y-type infusion set to initiate 0.9% normal saline.

1) Obtain the client's vital signs. 4) Determine typing and crossmatching of blood. 5) Use a Y-type infusion set to initiate 0.9% normal saline.

The provider prescribes one unit of packed red blood cells to be administered to a client. To ensure the client's safety, which action will the nurse take during administration of blood products? 1) Stay with client during first 15 minutes of infusion. 2) Flush packed red blood cells with 5% dextrose and 0.45% normal saline. 3) Remove the intravenous catheter if a blood transfusion reaction occurs. 4) Administer the red blood cells through a percutaneously inserted central catheter line with a 20-gauge needle.

1) Stay with client during first 15 minutes of infusion.

Which action would the nurse take first when a client who is receiving a blood transfusion develops fever, chills, and low back pain? 1) Stop the blood transfusion and infuse saline. 2) Administer the prescribed antipyretic. 3) Obtain a prescription for an antihistamine. 4) Notify the blood bank about the symptoms

1) Stop the blood transfusion and infuse saline.

A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions? (Select all that apply.) 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increased fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights

1. Fall prevention interventions 4. Monitoring for constipation

An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.) 1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 3. Roller clamp wide open 4. Tubing kinked in bedrails 5. Circulatory overload

1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 4. Tubing kinked in bedrails

During a blood transfusion a client develops chills and a headache. Which intervention is the priority nursing action? 1) Cover the client. 2) Stop the transfusion. 3) Take the client's vital signs. 4) Notify the health care provider

2) Stop the transfusion.

The nurse is to initiate an intravenous line and applies the tourniquet to the selected site. The nurse would release the tourniquet at which time? 1) After cleaning the insertion site 2) When the needle enters the vein 3) As soon as the needle pierces the skin 4) After the device is secured with tape

2) When the needle enters the vein

The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate does the nurse program into the infusion pump? 1. 100 mL/hr 2. 125 mL/hr 3. 167 mL/hr 4. 200 mL/hr

2. 125 mL/hr

A client is to receive a transfusion of packed red blood cells (PRBCs). Which solution would the nurse use to prime the blood intravenous (IV) tubing? 1) Lactated Ringer solution 2) 5% dextrose and water 3) 0.9% normal saline 4) 0.45% normal saline

3) 0.9% normal saline

A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26, PaCO2 55 mm Hg, PaO2 68 mm Hg, and HCO3 24. How does the nurse interpret these laboratory values? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3. Respiratory acidosis

Which nursing action would the nurse perform first if nerve damage is suspected during an intravenous catheter insertion? 1) Clean the exit site with alcohol. 2) Apply a warm compress. 3) Elevate the affected limb. 4) Immediately stop the insertion if the client reports extreme pain.

4) Immediately stop the insertion if the client reports extreme pain.

what are some possible complications of IV therapy?

Fluid & electrolyte imbalances Fluid volume overload Lung crackles, SOB, BP changes, JVD, edema, I>O Bruising/hematoma Infiltration (cool) Phlebitis (warm) Septicemia

what are field sticks?

IV's placed outside of the hospital restart ASAP - in accordance w agency policy

During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is a. osmosis. b. diffusion. c. active transport. d. facilitated diffusion.

a. osmosis.

The nurse expects the long-term treatment of a patient with hyperphosphatemia from renal failure will include a. fluid restriction. b. calcium supplements. c. magnesium supplements. d. increased intake of dairy products.

b. calcium supplements.

What are some special considerations for IV's with pediatrics and geriatrics?

peds - scalp, saphenous veins in babies - feet in children - 22-26g needles gero - fragile skin & veins - use smallest possible catheter - avoid back of hand - maybe no tourniquet - frequent assessment

A patient has the following arterial blood gas results: pH 7.52, PaCo, 30 mm Hg, HCO, 24 mEq/L. The nurse determines that these results indicate a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

d. respiratory alkalosis.

How would the nurse prepare an intravenous piggyback (IVPB) medication for administration to a client who has an established IV infusion? SATA 1) Wear clean gloves to assess the IV site. 2) Flush the IV insertion site with 2 mL saline. 3) Place the IVPB at a lower level than the existing IV. 4) Use a sterile technique when preparing the medication. 5) Establish the flow rate for infusion

1) Wear clean gloves to assess the IV site. 4) Use a sterile technique when preparing the medication. 5) Establish the flow rate for infusion Clean gloves should be worn to check the IV site because there is a risk of coming into contact with the client's blood. Because IV solutions enter the body's internal environment, all solutions and medications using this route must be sterile to prevent the introduction of microbes, and sterile technique should be used to avoid introducing microbes into the infusion system. It is important to establish the flow rate so that medications do not infuse too rapidly or too slowly. The insertion site does not have to be flushed with an infusing IV. The IVPB should be hung higher, not lower, than the existing bag.

When a norepinephrine intravenous infusion is prescribed for a client in septic shock, which intravenous line would the nurse choose for the infusion? 1) Implanted port 2) Midline catheter 3) 18-gauge peripheral venous catheter 4) Peripherally inserted central catheter (PICC) line

4) Peripherally inserted central catheter (PICC) line Norepinephrine is a vesicant and can cause tissue necrosis if it infiltrates into the intradermal or subcutaneous tissues. It is best infused through a central line, such as a PICC line. Implanted ports are also central lines, used mainly for chemotherapy, but require specialized needles and staff who are trained in accessing the port. Midline catheters are peripherally inserted in the antecubital area or upper arm and are not recommended for infusion of vesicants because large amounts of fluid may escape into the subcutaneous tissues before the infiltration is noted. Infiltration of fluids occurs more frequently when fluids are infused through the smaller and more fragile peripheral veins.

In which order would the nurse treat the infiltration of a nonvesicant intravenous (IV) solution leaking into the extravascular tissue? 1. Apply a sterile dressing. 2. Elevate the extremity. 3. Insert a new catheter in the opposite extremity. 4. Stop infusion and remove peripheral venous catheter. 5. Obtain a study to determine the cause of the problem. 6. Rate the infiltration using the INS Infiltration Scale and document the procedure. 7. Use warm or cold compresses according to the solution infiltrated.

4. Stop infusion and remove peripheral venous catheter. 1. Apply a sterile dressing. 2. Elevate the extremity. 7. Use warm or cold compresses according to the solution infiltrated. 3. Insert a new catheter in the opposite extremity. 5. Obtain a study to determine the cause of the problem. 6. Rate the infiltration using the INS Infiltration Scale and document the procedure.

Place the following steps for discontinuing intravenous (IV) access in the correct order: 1. Perform hand hygiene and apply gloves. 2. Explain procedure to patient. 3. Remove IV site dressing and tape. 4. Use two identifiers to ensure correct patient. 5. Stop the infusion and clamp the tubing. 6. Carefully check the health care provider's order. 7. Clean the site, withdraw the catheter, and apply pressure.

6. Carefully check the health care provider's order. 4. Use two identifiers to ensure correct patient. 2. Explain procedure to patient. 1. Perform hand hygiene and apply gloves. 5. Stop the infusion and clamp the tubing. 3. Remove IV site dressing and tape. 7. Clean the site, withdraw the catheter, and apply pressure.

what is a CVAD?

Central venous access devices - catheters placed in large blood vessels (EX) subclavian vein, jugular vein - pt who require frequent / special access to vascular system - 3 main types of CVADs - centrally inserted catheters, peripherally inserted central catheters (PICCs), implanted ports - physician can place any CVAD, a nurse w specialized training can insert PICCs

Explain the differences between TPN and PPN. How does administering TPN/PPN differ from any other IV infusion? What are key nursing considerations when caring for a patient on TPN/PPN? (P&P 1122)

TPN (AKA) total parenteral nutrition PPN (AKA) partial parenteral nutrition Enteral IND - cancer (head + neck, upper GI), critical illness/trauma, neurological & musc disorders (brain neoplasm, CVA, dementia, myopathy), Parkinson's, GI disorders (enterocutaneous fistula, IBD, mild pancreatitis), respiratory failure c prolonged intubation, inadequate oral intake (anorexia nervosa, difficulty chewing/swallowing), severe depression Parenteral IND - nonfunctional GI tract, massive small bowel resection/GI surgery/massive GI bleed, paralytic ileus, intestinal obstruction, trauma to abdomen, head, or neck, severe malabsorption, intolerance to enteral feeding (established by trial), chemotherapy, radiation therapy, bone marrow transplantation, extended bowel rest, enterocutaneous fistula, inflammatory bowel disease exacerbation, severe diarrhea, moderate-to-severe pancreatitis, preoperative total parenteral nutrition, preoperative bowel rest, treatment for co-morbid severe malnutrition in patients with nonfunctional GI tracts, severely catabolic patients when GI tract not usable for more than 4 to 5 days - Considerations for TPN/PPN - check vein patency, line patency, S/S extravasation (causes bac growth) - Filter required on line - Often blood products in TPN & PPN - admin & handle accordingly - Monitor effectiveness (VIA creatinine + BUN) - D/C or changing involves monitoring BGL - run D5 between TPN solutions to prevent hypoglycemia - Infuse bolus of formula over at least 20-30min via syringe/feeding container - Serious complication - aspiration of formula into tracheobronchial tree - irritates bronchial mucosa, resulting in decreased blood supply to affected pulmonary tissue

It is important for the nurse to assess for which manifestation(s) in a patient who has just undergone a total thyroidectomy (select all that apply)? a. Confusion b. Weight gain c. Depressed reflexes d. Circumoral numbness e. Positive Chvostek's sign

a. Confusion d. Circumoral numbness e. Positive Chvostek's sign

An older woman is admitted to the medical unit with GI bleeding. Assessment findings that indicate fluid volume deficit include (select all that apply) a. weight loss. b. dry oral mucosa. c. full bounding pulse. d. engorged neck veins. e. decreased central venous pressure.

a. weight loss. b. dry oral mucosa. e. decreased central venous pressure.

advantages + complications PICC

advantages - lower infxn rate - fewer insertion-related complications - decreased cost complications - cath occlusion - phlebitis

The nurse should be alert for which manifestations in a patient receiving a loop diuretic? a. Restlessness and agitation b. Paresthesias and irritability c. Weak, irregular pulse and poor muscle tone d. Increased blood pressure and muscle spasms

c. Weak, irregular pulse and poor muscle tone

The typical fluid replacement for the patient with a fluid volume deficit is a. dextran. b. 0.45% saline. c. lactated Ringer's solution. d. 5% dextrose in o.45% saline.

c. lactated Ringer's solution.

During the postoperative care of a 76-year-old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because a. older adults have an impaired thirst mechanism and need reminding to drink fluids. b. water accounts for a greater percentage of body weight in the older adult than in younger adults. c. older adults are more likely than younger adults to lose extracellular fluid during surgical procedures. d. small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adults.

d. small losses of fluid are significant because body fluids account for 45% to 50% of body weight in older adults.

Peripherally inserted central catheters (PICCs) (type of CVAD)

· Cephalic / basilic / median cubital / brachial on arm - basilic vein is best bc of its large diameter · Placed by RN/LPN/paramedic/EMT · Common, easily placed, less disruptive · Single/double/triple lumen - double lumen preferred bc they allow simultaneous uses · Pts who need vascular access 1wk-6mos or longer · Advantages over CVC - lower infxn rate, fewer insertion-related complications, decreased cost, ability to insert @ bedside/outpt area · Increased risk of DVT & phlebitis

Implanted ports (type of CVAD)

· Lie in surgically created SQ pocket on upper chest/arm · Implanted infusion port consists of surgically implanted CVC connected to reservoir/port · Port consists of titanium/plastic reservoir covered w selfsealing silicone septum · Accessed by using special noncoring needle w deflected tip - prevents damage to septum · Drugs placed in reservoir by direct injxn / injxn into established IV line, reservoir slowly releases medicine into bs · Long term therapy, low rf infxn, less maintenance than other CVADs, monitor for infiltration

what will you teach pt ab proper PICC line care?

• Proper technique for cleansing port prior to access • Proper flushing technique • How to administer antibiotic • S/S of occlusion and infection to monitor for • Who to call if symptoms of occlusion and infection • Importance of clamping catheter and keeping cap connection secure • What to do if catheter is inadvertently open to air