IV Flashcards
Nursing interventions for infiltration?
Take it out Apply warmth Elevate Measure amount of edema Document
If a patients IV site is cool, pale and swollen what complication has occurred?
Infiltration
-when the IV cannula has broken through or dislodged itself from the vein and the IV fluid is now leaking into surrounding tissue
A pt has an IV insitu and is receiving therapy, how often should the nurse assess patient?
Every 1 hr
Nursing interventions for phlebitis?
Check to see what is infusing Turn it off -alert RN because all of med is possibly now not infused Cool compress Repositioning Frequent assessment -spread of inflammation -signs of thrombus -any drainage?
A patient is receiving PRBC. The nurse tells the patient to report what immediately?
Feeling strange or different SOB Nausea Itchy Pain Headache Feeling warm or chills Leaking at site
What should nurse always assess before patient receives blood?
Consent
Baseline vitals, LOO, LOC
Dose, type of blood to be infused
Where should you send a blood bag and equipment to if your patient has a transfusion reaction?
Transfusion hospital services
Blood bank
Common IV complications?
Hematoma -occurs when there is leakage of blood from vessel into surrounding tissue Phlebitis/thrombophlebitis Infiltration/extravasation Local infection Nerve injury -pricking of a nerve during insertion Venous spasm -spasm on vein Septicemia Air embolism
What is extravasation?
Leaking of IV medications into space/tissue around infusion sites
A patients IV site appears to be reddened, warm, painful with slight edema.
What is this a sign of most likely?
Phlebitis
-inflammation of the vein
What can cause I local infection around IV site?
Poor aseptic technique during initiation -poor skin prep, contaminated cannula Contaminated blood Air contaminations Pt might have already been septic
Factors to be considered when choosing a vein for venipuncture?
Vein condition -presence of valves, thrombosis Duration of infusion Type of infusion Pt preference Presence of pre-existing conditions -stroke, fistula Age Skill level Anticipated surgery?
Considerations when choosing a cannulation device?
Condition of vein
Type of therapy
Fast/high volumes need large
Age
Things to document after insertion of a peripheral IV catheter?
Gauge of cannula Location Number of attempts If you were unsuccessful -how many times? Type of dressing Type of solution Client response Any teaching
What is IV fluid therapy?
Used when clients are unable to take food and fluids orally
Supply’s fluids directly into the vascular fluid compartment and replaces electrolyte losses
Isotonic solutions?
Same osmolarity as body fluids
-remains in vascular compartment
Ex. 0.9% NaCl, NS, lactated ringers
What is D5W?
Defined as isotonic but becomes hypotonic when dextrose is metabolized in plasma and then supplies only water
Hypotonic solutions??
Lower concentrations than body fluids
Used to provide water and treat dehydration
Ex. 0.45% NaCl, 0.33% NaCl
Fluid moves into cells and makes them bigger
Hypertonic solutions?
Greater than normal body fluids
- draw fluid out of intracellular and interstitial compartments into vascular compartment
- expands vascular volume
Ex. D5NS, D5LR
Make cells small d/t fluid escaping from cells
Why do we not insert IV into an artery?
Not easy to visualize externally
Generally in deep tissue and often protected by muscle
Characteristic of veins?
Thin walled vessels with valves Do not pulsate Usually above muscle and tissue Potential to collapse Easier to visualize externally
Why does venipuncture pose a risk for thrombus formation?
Because it damages the tunica intima
-build up of platelets=potential for thrombus
Upper vs lower extremity veins?
Upper:
-located on dorsal and central surface
Lower:
-should be avoided d/t the potential of embolism and thrombophlebitis
Considerations for peripheral intravenous?
Client consent Purpose Duration Location Vein condition
(Short term use)
