lab

what are some important nursing management for parenteral nutrition (CVAD)

1. USE STRICT ASEPTIC TECHNIQUE when handling TPN (prevent infection) 2. change bag and tubing at same time daily 3. ensure dressing is clean/dry/intact 4. ensure dedicated access for PN administration

what are three s/s, values you should monitor as the nurse

1. blood glucose q6 if NPO 2. monitor electrolyte values 3. s/s of fluid volume overload (heart/breath sounds)

what should the nurse observe after doing a NG tube placement

1. observe pt response to tube placement especially if tube is in respiratory tract 2. confirm x ray results with HCP 3. remove stylet after placement 4. routinely check condition of nares, loc of tube marking, color and pH of fluid aspirated from tube 5. assess LOC of pt after removal 6. ask pt how to communicate w NG tube placement

match the order of the blood therapy steps ensured blood type matches transfusion record and blood bag matched transfusion record number and patient's ID number checked unit number on blood bag with blood bank, checked expiration date and time checked expiration date and time on unit of blood checked the blood type and Rh type are compatible with donors checked pt ID info w blood unit label

2. matched transfusion record number and patient's ID number 4. checked unit number on blood bag with blood bank, checked expiration date and time 5. ensured blood type matches transfusion record and blood bag 6. checked the blood type and Rh type are compatible with donors 7. checked expiration date and time on unit of blood 8. checked pt ID info w blood unit label

Discuss different types of enteral tubes

Dobhoff or EnteraFlo (polyurethane or silicone rubber)

s/s of infection of enteral tube feeding include

Elevated blood glucose level, decreased urinary output, sudden weight gain, and periorbital or dependent edema Signs of dehydration (dry mucous membranes, thirst, decreased urine output)

what should the nurse record after NG tube placement

Recorded type and size of tube placed, location of distal tip of tube, patient's tolerance of procedure, condition of naris, and confirmation of tube position.

review CC policies for care of patient receiving enteral feeding: the tube is irrigated w water after every feeding and medication delievery and every ____ to ____ hrs during continous feeding what type of hygiene care is impt for enteral tube feeding? what should the nurse inspect (area of the body) and what should be changed every ___ days?

To maintain patency, the tube is irrigated with water after every feeding and medication delivery and every 4 to 6 hours during continuous feedings, or if the tube is set to gravity drainage or suction. Regular, conscientious oral and nasal hygiene is a vital part of patient care because the tube may cause discomfort and pressure, and may be in place for an extended length of time. The nose is inspected daily for skin irritation, and the nasal tape is changed every 3 days and as neede

after maintaining asepsis, the nurse should attach the primary tubing to patient's __________; CONNECTED THE PRIMED _______________________ to the patient's VAD

VAD; blood administration tubing

what are the 3 types of IV access

blood draws, central, and peripheral (most common)

catheter becomes _____________ and vesicant med infuses into tissues s/s:

dislodged; extravasation ; burning

when choosing an IV access, you want to start with _______ veins and work proximinally (upwards)

distal (lowest veins first)

_______________ nutrition is preferred over PN

enteral

vesicant leakage into tissue is what type of complication i.e: antibiotics, vasopressors ; describe what it may look like; what is tmt

extravasation; looks like bruising whole arm and hand swelling tmt: administer antidote

identify evidence-based techniques for assessing placement of enteral tubes: what can occur with these tubes bc the tube is pilabie a enteral feed tube should never be inserted into a pt with ___________________ fractures

feeding solution is given thru tube regulated by infusion pump, syringe, or gastric drip nasoenteric tube (nose through stomach) or oroenteric tube (mouth thru small intestine) is two techniques may kink bc tube is piliable especially when stylet is inserted; risk for tissue puncture or placement error should never be inserted with pt with basillar skull fractures

why might someone need an IV access

fluid adminstration, medication, electrolyte replacement, blood transfusion, blood draws

The nurse needs to do what every 4 hours with continuous feedings?

flush 30 mL of water with this enteral feeding tube

what type of lab values must be assessed before giving blood therapy (4)

hematocrit, coagulation values, platelet count, and potassium

what are the main two complications of pn

infection and blood clots

leakage of IV fluid/nonvesicant leakage into tissue ex: IV fluids is what type of complication; describe what it may look like, s/s, what are treatment

infiltration; complication and what it may look like: swelling primarily in fingers, not in the hands; cool skin temp is one s/s tmt: elevate extremity

what are the following steps that the nurse should do if there is an adverse reaction to blood therapy

maintain patient's VAD line with normal saline obtain VS don't leave pt, notify HCP, blood bank monitor VS frequently adminster prescribed medications initiate cardiac res if needed and send voided urine to lab

orange (14G) is used for

massive trauma sit

22G blue is used for

most chemo infusions; pt with small veins, elderly, or pediatric

when doing an enteral tube feed, the nurse should check for GRV (gastric residual volume) because increases may mean the patient will experience

nausea, abdominal cramping, possible sepsis

the task of administering PPN through a peripheral IV line can be delegated to NAP

no, the nurse can direct NAP to report complication, pump alarms, moist IV site dressing, change in vs, or SOB

why is it impt to gain pretransfusion VS, before blood therapy

notify HCP if pt was febrile (s/s of fever)

IV nutrition used to prevent malnutrition in those who are unable to tolerate oral or enteral routes

parenteral nutrition

when administering blood therapy, the nurse must verify that the IV cannula is __________ without complications, and administer blood components using appropriate _______________ catherer

patent and peripheral catheter

what are 3 things to verify when getting the blood bag (3)

patient, blood product, and type w another qualified person before initiating transfusion

describe the process of administration of the transfusion with blood therapy

perform hand hygiene, apply gloves, open Y tubing set, and set all clamps off, spike IV bag, prime tubing, open upper lamp on saline side and squeeze drip chamber prepare blood component with blood unit bag, spike unit with other Y connection, prime tubing w blood

wwhat is inflammation of the vein; what type of appearanace can it have ; s/s?

phlebitis; red streaking along vein, warm skin temp

what is most important for care of pt with traction; what should the nurse do

pt education maintain continous traction and counter traction inspect ropes, pulleys; ensure free hanging wts, and body alignment complications of immobility, skin care, neurovascular checks

discuss nursing interventions to prevent complications of enteral feeding

since pt is suspectible to problems like fluid volume deficit, pulmonary and tube irritation, the nurse should assess for FV deficit, dry skin, decreased urine output, lightheadness, hypotension - should assess i/o - feeding tubes placed beyond the pylorus can decrease freq of feeding regurgitation and aspiration - pt should be semi fowlers (30-45 deg) at least 1hr after intermittent tube feeding or whenever possible for patients receiving continuous tube feedings.

what types of tubes are better tolerated for enteral tube feeding (small vs large bores)

small bore tube are better tolerated, however they require freq monitoring and flushing, large bore can be uncomfortable

IVs are classified by gauge size, the larger the number, the ___________ the catherer

smaller

when detecting GRV, what should the nurse do

stop feeding immediately; notify HCP, discard aspirate check GRV q4h

what should the nurse do if there are adverse complications and reactions to the transfusion of blood therapy

stop transfusion immediately; remove blood component and tubing and replace it with normal saline and new tubing with ANTIHISTAMINE

advance the ng tube, every time the patient

swallows sips of water

what does a GRV between 250-500 mL mean in the past? how about now?

thought to indicate feeding intolerance, but doesn't indicate vomiting, aspiration, or pneumonia

before retrieving blood, the nurse must check that the pt had completed and signed _______________ consent

transfusion

16G gray is used for

trauma, surgeries, multi large volume infusions

yellow (24G) is used for

v fragile veins, elderly/pediatric