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Block 2 > Exam 1: Perioperative nursing and IV therapy/venipuncture > Flashcards

Exam 1: Perioperative nursing and IV therapy/venipuncture Flashcards

(103 cards)

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1
Q

Nursing role for IV therapy

A

Venipuncture/insertion
Setting up equipment
Calculating infusion rate
Setting up pumps
Frequent observations
Determining site
Determining gauge
Determining when to remove IV and change sites if complications occur (phlebitis, infiltration, infection)
Patient education
Discontinuing

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2
Q

What should be assessed before IV therapy?

A

Medical dx
Has the patient had IVs before?
Hx of vasovagal reaction during previous venipuncture or seeing blood?
Activity level
Is the patient on anticoagulants?
Labs (Platelets, PT, INR)
Hx of fainting
Mastectomy

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3
Q

When should the RN ask the HCP for CVC or PICC?

A

Veins are poor or non-existent
Therapy is longer than 1-2 weeks
Therapy is irritant, vesicant, or hypertonic
Pt is going home on IVs for more than 1-2 weeks

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4
Q

How should the RN choose size of the IV device?

A

Expected duration of therapy
type of therapy
conditions of the patient’s veins
patient preference
RN/physician preference

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5
Q

Why would the RN choose a larger gauge (smaller number)?

A

If the solution is viscous
For rapid infusions during hemorrhage or shock

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6
Q

Why would the RN choose a smaller gauge (bigger number)?

A

Better blood flow around the catheter
Less discomfort
lower risk of phlebitis/thrombosis

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7
Q

How to choose the IV site

A

non-dominant extremity
round, stable, bouncy, straight vein
begin distal and work up

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8
Q

Veins to avoid

A

sclerosed or thrombosed veins (hard)
edema, inflammation, bruising
veins distal to previous IV infiltration, phlebitis, or scar
arm vein located on the same side as a mastectomy, CVA, or renal fistula
sites that interfere with surgery
joints and areas of flexion
impaired circulation

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9
Q

How to promote vein distention

A

tourniquet
BP cuff at 30 mm/Hg for fragile veins
warm moist compress for 10 minutes
gravity - hang arm below heart level
tap vein with fingers - do not slap
hydrated pt
multiple tourniquets
massage arm from proximal to distal end

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10
Q

What sites should the RN avoid sticking?

A

superficial antebrachial (near wrist) - sensitive and difficult to move around with
metacarpal veins (on hand) - last resort for elderly because their skin is fragile and it can result in bleeding and hematomas
feet - never use for diabetics and must have an order to use this site, can cause complications
digital veins - fragile veins, only can be used for isotonic solutions

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11
Q

how often should the RN rotate IV sites?

A

every 72h and prn

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12
Q

what gauge IV catheters are usually used for surgeries?

A

16-18 gauge

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13
Q

What size gauge is most commonly used?

A

20 gauge, 1-1.5 in

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14
Q

How should the IV site be prepared?

A

clip hair if needed, do NOT shave
chlorhexidine or alcohol and betadine scrubbed for 30 seconds (if allergic to both use alcohol x4 and keep skin wet for 1 minute)

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15
Q

What should the RN include on the IV site label?

A

date, time, initials, and gauge

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16
Q

What should the RN do if they are unable to access the vein or the vein blows?

A

release tourniquet
place gauze over the site and remove catheter
hold pressure for 1-3 min
assess the angiocatheter to ensure it is intact
tape gauze with pressure
try another site, if unable to do it again, have another RN do it
if starting in the same arm keep the other IV in place until the new one is started

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17
Q

How should the RN assess the IV?

A

check for pain, tenderness, redness, swelling, leaking
dressing is intact
tubing is taped securely
pt condition and response to therapy
IV is infusing properly
IV rate every time the RN enters the room
do not touch the bag while checking the volume of the bag
check F&E

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18
Q

what to do if a hematoma forms

A

release tourniquet immediately and remove the needle, apply firm pressure

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19
Q

What is phlebitis and what are the signs and symptoms?

A

vein inflammation
most common problem
causes: mechanical, chemical, bacterial, or post-infusion
s/sx: streak formation, palpable venous cord, vein may be thrombosed, IV flow may stop, might have purulent drainage

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20
Q

How can phlebitis be prevented?

A

rotating the IV site every 72-96 hours or at the first sign of phlebitis or infiltration

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21
Q

What should the RN do if they suspect phlebitis?

A

discontinue the IV
elevate the extremity and apply warm moist compress
notify physician

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22
Q

What is infiltration?

A

dislodgment of the cannula from the vein causes infusion into the subcutaneous tissue

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23
Q

signs and symptoms of infiltration

A

blanching
swelling
pallor
pain
during aspiration, blood may return with partial infiltrate or no blood may return

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24
Q

infiltration treatment

A

discontinue IV
elevate
apply warm moist compress or cold depending on what was infiltrated

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25
extravasations
infiltration of a medication that may cause tissue injury or necrosis
26
what might cause extravasations?
chemotherapy phenergan dilantin total parenteral nutrition
27
what should the RN do if they suspect an extravasation?
notify physician
28
IV infection s/sx and actions the RN should take
redness, warmth, tenderness, purulent drainage replace IV, notify MD, culture drainage or catheter
29
venous spasm and actions the RN should take
pain along the vein track, can be caused by cold or irritating solution assess for phlebitis, infiltration apply warm moist compress to vein slow the infusion prn
30
What should the RN do if a catheter embolism is suspected?
do not reinsert the needle do not apply pressure apply tourniquet above the site and send the pt to radiology with MD order
31
air embolism and s/sx
air gets into the venous system (50 ml over 3 sec) blocking pulmonary circulation s/sx: chest pain, anxiousness, wheezing, tachypnea, hypotension
32
causes of air embolisms
loose connections - end open to air air in IV line - did not prime tubing, glass bottle, vented tubing, dry plastic bag gravity infusion
33
air embolism treatment
call for help clamp catheter place on left side in trendelenburg administer O2 aspirate air prn
34
general guidelines to prevent complications
hand washing and aseptic technique prep skin well rotate site q 72-96 h or at 1st sign of phlebitis or infiltrate hang hydration bag for no longer than 24 h and change when some fluid is left to avoid running dry secure catheter to prevent movement and contamination assess site and pt q4h for adults and q2h for children and each time you enter the room educate pt on s/sx of complications and when to call the nurse
35
what is the vein of choice for venipuncture?
median cubital vein -it is more stationary than others, less painful to puncture, closer to the surface of the skin, and is not nestled among nerves and arteries
36
order of draw for blood cultures
red or tiger top blue top green top lavender top gray top
37
how much blood is collected from each site for a blood culture?
10-15 ml in a 20ml syringe
38
for anaerobic and aerobic cultures which should be inoculated first?
anaerobic bottle first
39
how should the blood culture be labeled?
at the bedside pt name, date, time, and RN initials send to the lab within 30 minutes
40
pt education after venipuncture
-do not bend arm - can cause bleeding in AC area compromising vessels and nerves -keep arm straight and elevated while applying pressure -keep dressing in place for a few hours
41
assessments and documentation after venipuncture
assess for bleeding or bruising record: -method used to obtain specimen, date and time collected, type of test, lab receiving specimen -site after collection -pt tolerance to procedure
42
geriatric considerations for venipuncture
use smaller needle (23g) wmc
43
What should the RN do if the pt continues to bleed at the venipuncture site?
apply pressure and a pressure dressing continue to monitor
44
what should the RN do if the pt develops a hematoma at the venipuncture site?
apply pressure to the site and document continue to monitor
45
What should the RN do if the collection is incomplete or no blood is obtained?
change the position of the needle/move it forward/move it backward/adjust the angle loosen the tourniquet try another tube - there might not be a vacuum re-anchor the vein - it might have rolled
46
what should the rn do if blood stops flowing into the tube?
vein might have collapsed -resecure the tourniquet to increase venous filling remove needle, apply pressure to dressing, and redraw
47
inpatient surgery
in the hospital pt is admitted day of surgery or is already hospitalized
48
what requirements must be met for a pt to have surgery in an outpatient setting?
surgery is less than 2 hours requires less than 3-4 hour stay in PACU low risk - no significant comorbidities, not an older adult or neonate, low risk of complications
49
local anesthesia
loss of sensation without LOC
50
regional anesthesia
loss of sensation to a body part without LOC nerve blocks, epidurals
51
What tasks does the RN complete during the pre op phase?
interview assessment diagnostic screening informed consent pre op teaching
52
pre op interview
health hx - allergies, past surgeries, medications, alcohol, street drugs, smoking, advance directive psychosocial assessment - anxiety, stress, spiritual beliefs, cultural beliefs past experience with surgeries concerns about surgery
53
pre op assessment
physical exam done by MD baseline assessment done by RN too VS, nutrition, sleep pattern, activity, elimination, sensory/perceptual, ADLs, last menstrual period, medications and supplements, neurological, respiratory, cardiac, GI, GU, skin
54
what factors can increase surgical risk?
hypovolemia dehydration F&E imbalance nutritional deficits extremes in age extremes in weight infection hepatic and/or renal dysfunction impaired immune respiratory disease cardiovascular disease pregnancy diabetes endocrine disorders
55
pre op diagnostic tests
CBC electrolytes UA chest x ray if over 40 y/o EKG depending on age and hx type and cross match
56
what is the RN's role in informed consent?
witnessing the signature the surgeon explains the procedure
57
pre op checklist
RN completes the whole checklist before the pt goes into the surgical area
58
pre op teaching
best done day before surgery and reinforced the morning of surgery NPO instructions incentive spirometer use, PCA use involve the family to increase compliance give rationale about why things are done pain control - ask before pain is too bad relaxation techniques leg exercises to prevent blood clots abdominal splitting with pillows enemas - to cleanse bowels
59
common pre op medications used
sedative and tranquilizers to reduce anxiety and induce sensation narcotic analgesics/opioids - decrease amount of anesthesia needed and reduces discomfort during procedure anticholinergics - decrease respiratory secretions, protects against aspiration, prevents bradycardia antiemetics - decreases nausea and vomiting prophylactic antibiotics - prevent infection
60
pre op preparation
hair in cap, gown untied, dentures out, no jewelry void/foley might be inserted IV might be inserted medicate if inpatient patient is transferred to the OR suite
61
Surgical environment - unrestricted area
Entry points for patients, holding area, staff locker rooms, nursing station
62
Surgical environment - semirestricted area
only authorized personnel allowed must wear surgical attire and cover head and facial hair
63
Surgical environment - restricted area
masks, shoe coverings, surgical attire OR suites, scrub sinks, clean core
64
Holding area
Entrance to intra-op - ensure that check list and consent forms are completed at this point Anesthetist meets with the patient - asks about surgical and medical hx and administers medication to relax the patient - discusses choices - answers questions
65
Circulating RN
non-sterile/not scrubbed in assists with room prep obtains needed items identifies and assess pt, charts, and admits pt. to the OR positions the pt, performs skin prep, records
66
What is the main function of the circulator/circulating RN?
to protect the patient - prevents wrong site, procedure, and/or surgery - ensures that sterility is maintained
67
How does the circulator protect patient positioning?
Allows accessibility of the operative site Maintenance of the patient's airway Prevents injury to nerves caused by compression of tissues or poor blood flow Provides correct skeletal alignment, adequate thoracic excursion, modesty Prevents falls
68
What are the dangers of improper positioning during surgery?
muscle strain, joint damage, pressure ulcers, nerve damage ultimately can cause permanent disability
69
Scrub RN, LPN, or tech
sterile requires certification assists with room prep scrubs, gowns, and gloves self and others prepare the instrument table and organizes the sterile equipment for use assists with draping, passes instruments, counts instruments, monitors solutions used, reports amounts of local anesthesia and epinephrine used
70
Anesthesia care provider
MD or CRNA assesses pt pre operatively prescribes pre op and adjunctive meds monitors pt. cardiac status and VS during OR
71
RN first assist
assists the surgeon and surgical team by - handling tissues - using instruments - providing exposure - assisting in hemostasis - suturing requires education and certification
72
What combination of meds are usually used during surgery?
anesthesia - loses pain sensation sedation - loss of consciousness muscle relaxants
73
general anesthesia
loss of sensation and loss of consciousness skeletal muscles relax ventilation and CV function might be impaired administered by IV, inhalation, or rectally
74
Phases of general anesthesia
Pre induction stage - conscious and ends with LOC, pre op meds given, IV access, application of monitors Induction stage - LOC, dreams, hallucinations, intubation, position for surgery Maintenance - during surgery, pt is monitored Emergence - surgery done, dressings applied, reversal of anesthesia and neuromuscular blocking agents, airway removed
75
Laryngeal mask airway
LMA placed by anesthesia care provider after induction of anesthesia reduces risk of aspiration
76
monitored anesthesia care
low dose of benzodiazepines administered IV analgesia, amnesia, reduced anxiety, no ventilation assistance needed, pt. remains responsive, regional or local anesthesia are often used as well No inhaled agents are used Pt. should have continuous pulse ox and reversal agents (Ramazicon) should be available
77
Local anesthesia
loss of sensation without LOC topically, IM, or SQ
78
regional anesthetics
loss of sensation to a body region without LOC specific nerve or group of nerves are blocked w/ administration of local anesthetic sedating agents are also used to reduce anxiety
79
risks of spinal anesthesia
respiratory depression place on pulse ox
80
Catastrophic events in the OR
Code - codes are run internally/without people from outside the surgical suite Hemorrhage - pts are blood typed and crossed Anaphylactic reaction - obtain a careful hx Hypoxia - inadequate ventilation, poor intubation, aspiration of vomit, lack of respiratory excursion. Monitor with pulse ox Unintentional hypothermia
81
unintentional hypothermia
from cold surgical environment, infusion of cold fluids, cold irrigation solutions at risk: pts. with advanced age and low body mass, long procedures, extensive blood loss monitor core temps, use IV fluids slowly, keep warm blankets near
82
Malignant hyperthermia
Genetic autosomal dominant disease Causes hyper metabolic stat in skeletal muscle S/x: tachycardia, tachypnea, fever, ventricular dysrhythmias Treatment: Dantrium Prevention: careful hx of surgical/anesthetic complications in patient and patient's blood relative Triggered by anesthetic agents Usually occurs during anesthesia but may occur during recovery
83
What information should the circulating nurse report to the PACU nurse?
Name Age Dx Anesthesiologist Surgeon Surgical procedure Pt. condition Why surgery was done Medical hx Medication allergies Current medications Comorbidities
84
What is a part of the immediate post op assessment?
ABCs neuro GU surgical site physiological needs (pain, N/V)
85
What respiratory problems might present in the post op period?
atelectasis is most common airway obstruction pulmonary edema hypoventilation aspiration atelectasis pneumonia hypoxemia
86
atelectasis: who is most at risk? what causes it during surgery?
at risk: smokers, thoracic and abdominal surgeries, poor cough effort what causes it: secretions obstructing bronchi, anesthesia and high levels of O2 administered during surgery
87
What are potential neuro problems in the post op period?
pain fever delirium hypothermia
88
what are potential urinary problems during the post op period?
urinary retention infection acute renal failure (ARF)
89
what are potential GI problems in the post op period?
n/v distention hiccups delayed gastric emptying
90
what are potential cardiovascular problems in the post op period?
hemorrhage hypotension shock thrombosis phlebitis pulmonary embolism postural hypotension
91
what are potential fluid and electrolyte problems during the post op period?
fluid overload fluid deficit hypokalemia acid-base disorders hypo/hyperglycemia
92
who is responsible for the patient until they are fully awake?
the anesthesiologist
93
who is responsible for the surgical site and talking to the family?
the surgeon
94
when can the patient be transferred or discharged?
transferred when they're VS are stable discharged when VS are stable, they have urinated, can keep down fluids, and pain is under control
95
what should the PACU nurse include when giving report to the staff nurse when the patient is being transferred?
dx type of surgery age pre op condition and VS anesthetics and drugs used during OR and PACU specimens sent to the lab amount and type of fluids given amount and type of pain/antiemetic meds administered in PACU EBL, tubes, drains, cath
96
once the patient is on the nursing floor, how often should the RN check VS?
every 15 min x4 or until stable then every 30 min x2 then every hour x4 then every 4 hours continuously check respiratory status, incision, color, circulation, motion, and sensation with each VS check
97
how will the RN know how much drainage is coming out of a wound?
circling the drainage
98
what nursing interventions should be done in the post op patient?
turning, deep breathing, and coughing incentive spirometer pain relief relaxation leg exercises ambulate increase fluids when allowed monitor I&Os monitor VS intermittent compression devices
99
what are complications during the post op phase?
n/v sore throat hiccups paresthesia pain headache gas urinary retention (usually resolves in 48 hours) shock hemorrhage DVT pulmonary embolism, atelectasis, pneumonia renal failure dehiscence or evisceration fistula infection, sepsis pressure ulcers
100
what are risk factors for dehiscence/evisceration?
poor nutrition, advanced age
101
what can help prevent dehiscence or evisceration?
splinting to prevent strain on wound edges
102
who is in charge of making sure the 2nd verification of the procedure and surgical site takes place?
the circulating nurse
103
when should the surgical site be marked?
prior to surgery with the surgeon and patient

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