1-6 Flashcards
(134 cards)
1
Q
What tonicity is D5W?
A
Isotonic
2
Q
What tonicity is NaCl (0.9% sodium chloride)?
A
Isotonic
3
Q
What tonicity is Lactated Ringers?
A
Isotonic
4
Q
What tonicity is 0.40 sodium chloride (1/2 NaCl)?
A
Hypotonic
5
Q
What tonicity is Dextrose 5% in normal saline?
A
Hypertonic
6
Q
What tonicity is Dextrose 5% in 1/2 normal saline?
A
Hypertonic
7
Q
What tonicity is Dextrose 10% in water?
A
Hypertonic
8
Q
What are Crystalloids?
A
Solutions that contain small molecules which flow easily across semipermable membranes
9
Q
What does Hypertonic mean?
A
Higher concentration of electrolytes compared to ECF. Cell shrivel and die.
10
Q
What does Isotonic mean?
A
Same concentration compared to ECF. Cell stays the same.
11
Q
What does Hypotonic mean?
A
Lower concentration compared to ECF. Cell swell and burst.
12
Q
What are Colloids?
A
Solution containing starch or protein that does not cross semipermable membranes and stay in the vascular space. Increases osmotic rsesure and increase vascular volume.
13
Q
Example of natural colloids? Example of Artificial colloids?
A
Natural: Albumin, plasmanate
Artificial: Dextran, Hespan
14
Q
How often will you monitor a patient with an IV?
A
Every hour
15
Q
What is a Hypodermoclysis used for? Who is it often used for? What are the contraindications?
A
Long-term administration of medications through subcutaneous route. Used for patients with limited IV access, palliative care or mild dehydration. Only one medication per site.
16
Q
What are the S/S for infection at IV site? Treatment for local infection? Treatment for systemic infection?
A
REED. Local infection is treated with ……………. Systemic is treated with antibiotics.
17
Q
What is Infiltration? S/S?
A
Occurs when IV fluid enters the surrounding space around the venipuncture site. S/S are swelling, pallor, coolness and pain.
18
Q
What is the treatment for Infiltration?
A
Remove IV, elevate affected limb and apply warmth. Asses type of fluid present. Vesicant fluid may cause extravasation.
19
Q
What is Extravasation? S/S?
A
Leakage of irritating medications such as chemotherapy that can cause blistering and other severe tissue injury including necrosis. S/S: Redness, pain, blistering, and tissue damage.
20
Q
What is the treatment for extravasation?
A
Remove IV, follow agency policy for specific drug.
21
Q
What is Phlebitis? S/S? Treatment?
A
Inflammation of the vein caused by chemical irritation, rate of medication administration and skill of nurse. S/S: Pain, edema, erythema, warmth over vein, redness tracking over the vein. Treatment: Remove PVAD, apply warm moist compress.
22
Q
What is an Air Emboli? S/S?
A
Air bubble entering venous circulation due to ineffectively primed lines and flushes. S/S: Dyspnea, tachypnea, cyanosis, tachycardia, change in LOC, cough, nausea, gasp reflex and anxiety.
23
Q
What actions do you take for an Air Emboli?
A
Clamp IV line, position patient in left lateral trendelenberg, administer oxygen, perform VS and notify physician.
24
Q
What is Fragmentation? What can it cause? What are nursing actions?
A
Catheter emboli, IV catheter fragments break off and are loose in circulation. Can cause thrombosis, arrhythmias, infection, or endocardial/vascular perforation. Nursing actions: nurse should remove catheter and inspect for intactness, put pressure proximal to site, call for help and notify MD.
25
What is Fluid Overload? S/S?
Excessive fluid in the alveoli. S/S: Crackles, distended neck veins, dyspnea, tachypnea, pink-frothy sputum, bounding tachycardia pulse, and edema.
26
What is treatment and nursing action for Fluid Overload?
Assess fluid status, respiratory and circulatory status. Slow or discontinue IV rate, elevate HOB, oxygen support if needed, notify MD, document, administer diuretic if ordered.
27
Who is at increased risk for fluid overload?
Those with cardiac and renal problems, pediatric and elderly population.
28
What Diagnostic testing can be done for electrolytes and fluid?
Vital signs, skin turgor/mucous membranes, daily weight, I/O including sensible and insensible losses. Lab tests including serum electrolytes, creatinine, hematocrit, BUN, ABG and urine tests.
29
Why do we administer medication via IV route?
Rapid effect of medication, patient is NPO, provide constant therapeutic levels, less discomfort vs IM and subcutaneous.
30
Why would we use a glass IV bottle and what type of tubing does it require?
When medication are not compatible with plastic. Requires vented tubing.
31
What is Direct IV push?
Injected directly into IV line. Very dangerous due to how quick the entire med is administered.
32
What are some differences between veins and arteries?
Veins have valves, arteries do not. Veins may collapse, arteries do not. Arteries pulsate, veins do not. Veins are superficial, arteries lie deep.
33
When initiating IV therapy why do we take into consideration the condition of the vein?
Large diameter veins have greater blood flow and can handle a large amount of fluid rapidly. Avoid veins that are cord-like, tortuous, scarred, or inflamed.
34
When initiating IV therapy why do we take into consideration the duration of therapy?
Initial infusion therapy should be started distally. Alternate arms. Choose IV site proximal to the last site.
35
Is a size 14 needle smaller or bigger than a size 24?
Bigger
36
What do we consider when choosing size of gauge?
The indication for administration, location and size of vein, type of fluid to be administered and the rate
37
What are the 3 most appropriate sites for IV access (in order)?
Arm, Hand, and Foot.
38
What do we need to take into consideration when choosing a spot for IV access?
Certain procedures may require specific sites to be used, try to use non-dominant hand, select most distal site and work your way up, consider patient activity, comfort and preference.
39
What are some considerations when initiating IV access to older adults?
The vessels are more mobile, more fragile and often more tortuous and thrombosed. The dermal layers become thinner and there is less subcutaneous tissue to support the blood vessels. The veins of older people are often easier to see because of the reduction in subcutaneous tissue. Medication such as anticoagulants and steroids make the tissue more fragile.
40
What should we consider when initiating IV access on a patient who is on Anticoagulants?
Use of tourniquet may result in bleeding and use careful and special care to avoid bleeding and bruising. Apply tourniquet lightly, avoid excessive pressure when cleansing skin and when discontinuing the IV, apply direct pressure over the site and slight elevation to stop bleeding.
41
What can be done to promote blood flow to a specific area?
Tourniquet, hang arm at sides, warm blanket or compress, hydration, make fist open close open close.
42
What is the preference when choosing an IV catheter?
Smallest gauge to achieve desired therapy. Ensure the vein used is larger than the catheter so that there is adequate blood flow and hemodilation around the catheter. Larger catheters will cause mechanical phlebitis sooner than smaller sizes.
43
How do we cleanse an IV site?
Using alcohol swab/chlorahexidine cleanse for 30 seconds in concentric circles 5-7.5 cm from insertion site and allow to dry completely.
44
How do we insert an IV catheter?
Anchor the vein, bevel up, insert catheter at a 10-30 degree angle.
45
At what angle to we insert the IV catheter?
10-30 degree
46
What is a saline lock?
Covers and protects the end of an IV catheter to keep the system closed, thereby reducing the risk of infection to the patient. Also protect staff from exposure to blood, provides access for intermittent IV drug therapy, blood admin and tubing changes.
47
How do we secure the IV site?
Tegaderm, only sterile tape is to be applied underneath a transparent dressing.
48
How often does a saline lock need to be flushed when not in use to ensure patency?
Every 12 hours.
49
How much NS do we flush with prior to and following an intermittent IV?
2-5mls
50
Where does a Central Venous Access Device lie once inserted?
Tip dwells in the lower 1/3 of the superior vena cava.
51
What is the purpose of a CVAD?
Infuse fluids directly into the central venous circulation for: prolonged IV antibiotic treatment, administration of parenteral nutrition, extended and frequent chemotherapy, rapid infusion of blood, and allows for frequent blood flows.
52
What may be happening if your patient with a CVAD is experiencing chest pain and AFib?
The tip of their CVAD may have passed the superior vena cava into the right atrium.
53
What is a Non-Valved Catheter?
Open-ended tip, no valve, IN-LINE CLAMP.
54
How do we flush a Non-Valved Catheter?
SASH; Saline, administration of meds/infusions, Saline, Heparin lock
55
How much Heparin do we lock the non-valved catheter with?
10-100 units/mL
56
What is a valved catheter?
No clamps, pressure to infuse allows fluid to enter, aspirating for blood opens valve inward to allow for withdrawal. Remains closed when not in use.
57
What is a Direct Percutaneous line?
Inserted directly into the external or internal jugular, subclavian or femoral vein and advanced into the superior or inferior vena cava. Non-valved. Must be sutured to skin. Use: days to weeks.
58
What is a Tunneled (cuffed) CVAD?
Inserted into the subclavian and tunneled through the subcutaneous tissue exiting the chest wall. Dacron cuff under skin stabilizes catheter and acts as a barrier to bacteria. Valved or non-valved. Can be uses weeks to years.
59
What type of needle is required for an Implanted CVC?
Non-coring needle
60
What is an implanted CVC?
Soft silicone catheter attached to a reservoir which is covered by a self-sealing silicone septum. Reservoir inserted into subcutaneous pocket in chest, arm or abdomen. Catheter segment inserted into vein.
61
What is a PICC?
Peripherally inserted catheter; Inserted into the upper arm and advances into the superior vena cava; must be stabilized by external securement device such as securacath; valved or non valved.
62
What do we need to know when inserting a PICC?
No BP or venipuncture on the PICC arm; external length must be documented every shift.
63
Post insertion of PICC how often do we apply hot pack?
Q4H x 48 hours
64
What is a Midline Catheter?
Inserted into a peripheral vein tip is below or level of the axilla. NOT a CVC. Remain in place for 1 to 4 weeks. Is an alternative in pt who don't require a PICC but need several days of IV therapy.
65
What do we assess PICCS and CVCs for every shift?
Condition of catheter/skin junction, securement, external length, redness, edema, drainage, pain, damage.
66
What is the purpose of needleless connector changes?
To ensure integrity and reduce chances of them being a potential source of bacteria. Primed with NS prior to application to decrease the risk of introducing air into the vascular system.
67
How often do we change a needleless connector when CVC is not in use?
Every 4 to 7 days.
68
When flushing lumens how much NS do we flush with?
10mL for each lumen; flush with 20mL NS after lipids, blood products, collection of blood or meds known to crystalize or precipitate.
69
How do we flush and lock Valved Lumens?
SAS; Saline, administration of medications/infusions, Saline.
70
What is a Type & Screen?
When blood is testing for antigens present on RBC membrane.
71
How long is a Type & Screen valid for?
96 hours or 4 days from time of collection
72
What is a Cross-Match?
Blood from donor & recipient are mixed in the lab and incubated about 1 hour to check for any reaction
73
What is the Universal Blood Donor?
O-
74
What is the Universal Blood Recipient?
AB
75
What is RH Factor?
RH Antigen is a protein found on the surface of RBC. If you blood has the protein than you are Rh Positive.
76
What is an Autologous transfusion?
Donation of ones own blood up to 5 weeks before a planned surgery. Safest form of transfusion.
77
When is whole blood used?
Usually in emergency settings due to inadequate blood supply in the bank.
78
What are indications for PRBC?
Blood loss due to hemorrhage, surgery and trauma.
79
What is the self life for RBCs?
42 days after collection.
80
What does your patients hemoglobin have to be before transfusion?
<70
81
How long do you have to finish your blood transfusion?
<4 hours
82
How soon do we being blood transfusion?
Within 30 minutes
83
What are indications for Plateters?
Bleeding disorder such thrombocytopenia.
84
What is the shelf life for platelets?
5 days
85
What are indications for Plasma?
Clotting factors, reverse affect of warfarin & heparin or patient who is bleeding due to coagulopathy.
86
What is the shelf life of Plasma?
1 year
87
What are plasma expanders?
Blood product; Colloid; Large molecules which draw or hold fluid in the bloodstream.
88
What is Rho(D) Immune Globulin?
Contains antibodies to Rh; would be administered to an Rh negative individual when it contact with an Rh positive individual such a mother and fetus this will prevent
89
What is irradiated blood?
Blood exposed to radiation to minimize bacteria; used for patient with poor immune system.
90
What does the nurse need to do prior to a blood transfusion?
Have a physician order, confirm consent has been signed, check IV site for patency, choose appropriate catheter size, compare product to physician order and baseline vital sign.
91
What emergency medications should be available during blood transfusions?
Epinephrine, Diphenhydramine, and Hydrocortisone.
92
In case of a reaction to blood transfusion what is Epinephrine and Hydrocortisone used for?
Anaphylaxis or any respiratory or cardiac issue
93
In case of a reaction to blood transfusion what is Diphenhydramine used for?
Minor allergic reaction; Rash
94
What is the only fluid that can be infused with blood?
Normal Saline
95
What medication can be given through a blood line?
None
96
When is a blood reaction most likely to occur?
Within the first 5 to 15 minutes.
97
At what rate do we run an infusion for blood when we first start?
1-2mL/min for the first 5 to 15 minutes
98
What do we do if we notice an adverse reaction while monitoring a blood transfusion?
Immediately stop the transfusion and do not flush line.
99
How often do we take vital signs during a blood transfusion?
Before the transfusion, after the first 15 minutes, then q1h until infusion is complete.
100
What is an Infectious Transfusion Reaction?
Disease transmitted by infected blood donors who are asymptomatic.
101
What is a Non-Infectious transfusion reaction?
Allergic reactions, hemolytic transfusion reaction, ABO reaction.
102
What is the most common reaction to Blood Transfusion? S/S? Treatment?
Febrile, Non Hemolytic. S/S: Sudden chills, fever, headache, flushing, muscle pain. Treatment: STOP infusion, notify MD, antipyretics
(acetaminophen) as ordered
103
What are S/S of Anaphylaxis? Treatment?
Anxiety, Urticaria (hives), wheezing, hypotension, shock, cardiac arrest. Treatment: Stop transfusion, notify MD, anticipate administration of epi, BP support an possible CPR.
104
What is AHTR (Acute Hemolytic Transfusion Reaction)? S/S?
Most serious complication; antibodies in recipients plasma attach to antigens on transfused RBCs destroying them. S/S: Chills, fever, low back pain, flushing, tachypnea, tachycardia and hypotension.
105
What type of transfusion reaction may your patient be having if they are experiencing lower back pain?
Acute Hemolytic Transfusion Reaction
106
What is circulatory overload? S/S? Treatment?
Fluid is administered faster than circulation can accommodate. S/S: Cough, dyspnea, pulmonary congestion, headache, hypertension, tachycardia, distended neck veins. Treatment: Sit upright and administer diuretics, morphine and oxygen.
107
What are nursing actions for transfusion reactions?
STOP transfusion, provide emergency care for ABC's, DO NOT flush, change IV set and start NS, notify physician
108
What is a massive transfusion?
Patients entire blood volume replaced within 24 hours. >10 units of RBCs
109
What 3 categories are surgery classified by?
Seriousness, Urgency, and Purpose
110
What factors can put a patient at risk for complications?
Cardiac, COPD, renal disease, diabetes, liver disease, nutritional status, obesity, age and fluid/electrolyte imbalance.
111
What is a normal INR?
0.9-1.1
112
What is general anesthesia?
Totally unconscious; 3 phases induction, maintenance & emergence.
113
What is Regional anesthesia?
Loss of sensation in an area of the body. Nerve blocks, spinal or epidurals.
114
What is Local Anesthesia?
Loss of sensation at a desired site; Infiltration or topical application.
115
What is Procedural sedation?
Combination of opioids and anxiolytics to produce sedation.
116
How often are Vital Signs taken Post Op?
```
Q15min x 4
Q30min x 2
Q1hour x 4
Q4hour x until stable
Q8H
```
117
What is a part of Post-Op care?
Wash patient, position patient comfortably, Ice/Heat application, early ambulation, when patient is stable bring family. Prioritize your care.
118
When can a patient eat after surgery?
After they pass gas :)
119
What do we do if there is shadowing on a post-op dressing?
Draw around the shadowing to assess drainage 15 minutes later. Do not take off dressing. Reinforce the dressing.
120
What are dermatones?
The level of anesthetic that is achieved. We test by using cold sensation.
121
When you are DARP charting where does "what have you done; tasks performed" go?
A for Action
122
When you are DARP charting where does "When will you follow up" go?
P for Plan
123
When you are DARP charting where does "Clients reaction to what you did" go?
R for Response
124
When you are DARP charting where does "Information gathered; observations" go?
D for Data
125
What are some peri/post operative complications?
Hemorrhage, Wound dehiscence, post-op delirium, VTE, PE, urinary retention, atelectasis, paralytic ileus, pain.
126
How do we focus on post-op respiratory care?
Assessments, deep breathing and coughing, incentive spirometry, splinting w/pillow, early ambulation, administer O2 if needed
127
Why do we need to prevent venous stasis and how do we prevent?
We dont want patient to end up with DVT or PE; prevent by pharmacological means aka anticoagulants, early mobilization, leg exercises, anti-embolism stockings, sequential compression devices (SCD's)
128
What is the diet progression of a post-op patient?
NPO, clear fluids, full fluids, soft, minced, regular.
129
How long do post-op dressings stay on the patient?
48 hours
130
When does discharge planning start?
Upon admission
131
What are indications for TPN?
Patient needs all nutrients delivered via TPN. Malabsorption issues such as crohn's, UC, cancers of the stomach such as pancreatic cancer, diverticulitis
132
What are 2 types of TPN
Total Nutrient Admicture (tna) is a one bag system and Two bag System (tpn)
133
What is TPN preferably administered through?
Central line or CVC
134
What is a common assesment for TPN management?
Daily weights, fluid balance w accurate intake output. Serum glucose levels. Infection & viral signs.
