Download Intravenous Therapy: Principles, Solutions, Complications, and Nursing Assessments and more Exams Nursing in PDF only on Docsity!
NSE 221 WEEK 1 & 2 WITH COMPLETE SOLUTIONS
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Reasons for IV Therapy - ANSWER - Maintain or restore fluid vol.
- Replace or correct fluids & electrolytes
- Route for med. admin.
- Transfuse bld or bld components
- Nutritional support (TPN & lipids)
Common IV Solutions - ANSWER - Isotonic
- Hypertonic
- Hypotonic
- Plasma expander (colloids)
Isotonic Solutions - ANSWER - 'normal' osmolarity as serum & other body fluids
- Stays where its infused - intravascualr system
- Least irritating to endothelial lining of vein wall
- E.x. RL, NS, 5% Dextrose in water, 5% Albumin
Hypertonic Solutions - ANSWER - Osmolarity higher than serum
- Pulls fluids from interstitial & intracellular compartments
- Expand intravascular compartment (watch circulatory overload)
- Pull from cellular compartment
- May be used to cautiously to decr. edema
- Don't give pts w/ renal or cardiac impairment
- Incr. risk for vessel damage
- E.x. 5% dextrose in 0.45% saline or NS, D10W, 3% NS, 25% albumin
Hypotonic Solutions - ANSWER - Lower than serum osmolarity
- Fluid shifts into cells & interstitial spaces
- Hydrates cell but reduces fluid in circulatory system
- Cause shift of fluid from vascular into cells
- Caution: can incr. pressure ICP & intravascular hypovolemia (decr. circulatory vol.)
- E.x 0.45% saline
Plasma Expander - ANSWER - Colloids
- Larger molecules that cannot diffuse through capillary walls
- Stays in vascular system
- Solutions: dextran, pentastarch
- Bld & bld products (albumin, FFP)
IV Nursing Assessment - ANSWER Body weight changes
- Loss of 1 kg or more in 24h (ECV deficit)
- Gain on 1kg or more in 24h (ECV excess)
IV Clinical Markers - ANSWER - Vascular vol.
- Interstitial vol.
- Cardiac & resp. sign of electrolytes or acid-base imbalance
- Neuromuscular markers or electrolyte or acid-base imbalance
- GI signs of electrolyte imbalances
Peripheral IV Site - ANSWER - Stat at hand (distal) & for to antecubital
- Orders for feet (risk for DVT)
Hypodermoclysis Benefits - ANSWER - Simple procedure & safe
- Sc access
- May be done intermittently
Air in IV Tubing - ANSWER Causes:
- Container run dry
- Loose connections
- Air on syringe Possible Result:
- Air embolus can be fatal
- Higher risk in central Symptoms of Air Embolism:
- Cyanosis, loss of consciousness
- Weak, rapid pulse, drop in BP
- Resp. distress
Saline Lock - ANSWER - Short term access; for intermittent infusions or maintain access in case of emergency
- Flushing & locking required to maintain patency
- Turbulent flow (stop/start) technique
- Cather 'locked' or clamped a/f flushing
Complications W/ IV Administration - ANSWER - Fluid overload/deficit
- Pain
- Electrolyte abnormalities
IV Slow or Too Fast - ANSWER - Check height of IV fluids
- Kinks
- Position of catheter (client position)
- Check site for complications
- Check clamps
- Check rates
Recommended Dosage - ANSWER - aka safe dosage
- Expressed in mg/kg for 24h period
- May be stated safe dosage range: upper & lower limits of dosage
Total Daily Dosage - ANSWER - Multiply child's weight a/f converted in kg
Divided Dosage (aka Single Dose) - ANSWER - Amt child should receive each time med. admin.
- Total daily dosage divided equally & admin. q3,8,...
- Dosage over 24h divided by frequency
IV Assessment - ANSWER - Check site q1-2h; D&I, no pain; secure dressing
- Type: S/L or cont. infusion; peripheral of hypodermoclysis; gravity or pump
- Tubing: free lazy loops, date
- Check solution & rate
- At start & end of shift: amt already infused & amt tba
- Leaking clear or serous fluid from IV site
Infiltration Interventions - ANSWER - Stop transfusion, d/c IV
- Set up new system & restart IV
- Apply warm compress to facilitate absorption
- Elevate arm
- Notify HCP
- Document
Extravasation - ANSWER - Leaking of vesicant drugs into surrounding tissue
- Cause severe local tissue damage; delay healing, infection, tissue necrosis, disfigurement, loss of function, amputation S&S:
- Blanching, burning, discomfort at IV site
- Cool skin around site
- Swelling at or above site
- Blistering &/or sloughing
Extravasation Interventions - ANSWER - Stop infusion & d/c IV
- Estimate amt of extravasated solution & notify prescriber
- Set up new system & restart IV
- Follow pharmacy's recc. to apply cold or warm compress
- Elevate arm & perform frequent assessments of sensation, motor function,, & circulation/perfusion of affected extremity
- Admin. approp. antidote
Localized/Systemic Infection IV - ANSWER S&S:
- Localized at IV site, can spread to systemic circulation
- Redness & discharge at IV site
- Elevated temp.
- Painful
- Drainage
- Hyper or hypothermia
Infection Interventions - ANSWER - Stop infusion & d/c IV
- Notify prescriber
- Set up new system & restart IV
- Culture site & catheter as per order & agency policy
- Monitor temp. & vitals
- Admin. meds. as prescribed
- Document
Infection Prevention - ANSWER - HH, gloves, aeseptic technique
- Clean site w/ antiseptic b/f inserting IV
- Clean injection ports w/ alcohol swabs b/f each use
- Follow institutions policy for dressing changes
CVAD Definition - ANSWER - Flexible catheter inserted into large central vein w/ tip at anastomosis of superior vena cava or inferior vena cava & right atrium
- Other end exists through incision on chest, neck, leg, or arm
- Deliver fluid into SVC
CVAD - ANSWER Indicated for:
- Limited peripheral vascular access
- Long-term vascular access
- Dacron cuff inside body; supports growth of tissue, prevents dislodgment & provides barrier to infection
- Hickman; for longer residence & reduce incidence of infection by incr. distance b/w skin entry site & venotomy
Implanted Port - ANSWER - CVAD
- Long-erm, surgically implanted, self0sealing injection port connected to catheter
- Requires Huber needle
- Combo. of sc, injection port, & catheter
- Placed 1 in. below centre of right collarbone
- Sits underskin on chest. lets meds through, & seals itself shut
- Plastic catheter part is slende, allowing fluids & meds. (vesicant) into large veins
CVAD Nursing Assessments - ANSWER Pt:
- Vitals, chest assessment (cardiac, resp.), pain (chest, neck, arm, insertion site) Site:
- Location, type, dressing, date to be changed, length of catheter visible at exit site IV Tubing:
- Current date/date to be changed, no kinks, closed clamps, pinches, strain.pulling Fluids:
- Right fluid, right rate, VTBI
CVAD Signs of Complications - ANSWER Pt:
- Pain (chest, neck, arm, insertion site), vitals (fever/chills) Site:
- Pain/tenderness, redness, skin temp. hot, edema, misplacement or slippage, exudate Fluids/Tubing:
- Resistance w/ flushing or infusing, unable sample bld
CVAD Body Signs of Complications - ANSWER Resp.:
- Distress, dyspnea, decr. or absent breath sounds, unilateral chest expansion Cardiac:
- Pale, engorged veins or edema (neck or chest), irreg. HR, chest pain, hypotension, tachycardia Periph. Vasc.:
- Incr. or decr. external length of catheter, sluggish infusion or aspiration Other:
- Gurgling sound in ear
Management of PIV & CVAD Complications - ANSWER - Don't leave pt
- Get help
- Notify HCP
- Apply O2 (2lpm nasal prongs or prescriber order)
- Freq. assessments (caridac, resp, periph. vasc.)
- Freq. & complete vitals (q 5mins)
CVAD Complications Causes - ANSWER - Occlusion
- Embolism
- Infection
- Pneumothorax
- Migration
Nursing Management of Migration - ANSWER - Fluoroscopy to verify position
- Assistance w/ removal
- Insertion of new CVAD placement
