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Med-Surg Nursing > objective 5 (1) > Flashcards

objective 5 (1) Flashcards

1
Q

delivers fluids directly into a vein
commonly used to treat many different fluid and
electrolyte imbalances

A

intarvenous therapy

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2
Q

what are the clinical indications of IV therapy?

A
  • Maintain or prevent fluid & electrolyte
    imbalances
     oral intake restricted
     client can’t swallow/absorb med by
    any other route
     GI absorption impaired
  • Administer medications
  • rapid drug effect needed
  • Replenish blood volume
  • Continuous therapeutic blood level
    desired
  • Assist in pain management
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3
Q

what are the risks of IV therapy?

A
  • phlebitis, ecchymosis, extravascular fluid infiltration, infection,
    thrombosis, and venous spasm.
  • Systemic complications may also occur, such as bacteremia and
    sepsis, air embolism, and pulmonary edema.
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4
Q

what are the benefits of IV therapy?

A

Giving drugs IV is rapid and effective
Drugs can also be delivered long term by continuous infusion, or
over short period, directly as single dose.

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5
Q

what are the commonly infused drugs?

A
  • antibiotics
  • thrombolytics
  • histamine-receptor antagonists
  • antineoplastics
  • anticonvulsants
  • cardiovascular drugs
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6
Q

what are the types of IV solutions?

A

isotonic
hypotonic
hypertonic

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7
Q

H2O & molecules suspended
(undissolved) substances i.e. blood cells
& blood products (albumin)

A

colloid

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8
Q

H2O & dissolved crystals i.e. salt
(sodium chloride) or sugar (glucose,
dextrose)

A

crystalloid

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9
Q
  • same concentration of dissolved
    substances as plasma (ECF)
  • RBCs does not shrink or swell
  • Use- clients who can’t eat/drink for short
    time
A

isotonic solutions

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10
Q

what are the types of isotonic solutions>

A
  • 0.9% NaCl (NS -normal saline)
  • 5% dextrose & H2O (D5W - glucose &
    H2O)
  • Lactated Ringer’s (RL: E- solution)
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11
Q

provides more water than electrolytes, diluting the
ECF
* Use
* rehydrating clients (cause body to
retain fluid, draws fluid into cells
causing blood cells to swell)

A

hypotonic solutions

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12
Q

what are the types of hypotonic solutions?

A
  • 0.45% NaCl (half strength saline)
  • 0.33% sodium chloride
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13
Q
  • more concentrated than plasma
  • Draws water from the ICF into the ECF
  • Use:
  • Total Parenteral Nutrition – TPN
  • D10W (Dextrose) or 3% Saline
  • useful in treatment of hypovolemia
    and hyponatremia
A

hypertonic solutions

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14
Q

how do we maintain therapy?

A
  • Nursing responsibility to check continuous IV every
    hour
  • Knowledge of the solutions being administered and
    principles of flow
  • Assess for local and systemic complications
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15
Q
  • Excessive IV fluids causes increased blood pressure and
    central venous pressure
A

pulmonary edema

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16
Q

what are the S&S of pulmonary edema

A

↓SpO2, ↑respiratory rate, dyspnea, coughing up
pink frothy sputum, auscultation of dependent fine
crackles

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17
Q

what is the nsg care for pulmonary edema?

A
  • Prevention: Use IV controller / pump to prevent accidental bolus.
  • Treatment: Must be immediate. ↑HOB, vitals, administer
    oxygen, notify prescriber. Anticipate
  • diuretics and slowed IV rates
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18
Q

at insertion site or systemically

A

infection

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19
Q

what are the S&S of infection?

A

Insertion site may become red, tender, swollen, or have
purulent drainage. Systemic signs and symptoms may
include malaise, fever, hypotension, or tachycardia

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20
Q

what is the nsg care for infection?

A

PVAD-short and midline catheters showing S&S of local
infection should be removed immediately. Monitor for signs
and symptoms of systemic infection

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21
Q

air enters circulatory system via
bubbles in tubing/solution running out
air travels to lungs

A

air embolism

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22
Q

what are the S&S of air embolism?

A

Palpitations, dyspnea, cyanosis,
hypotension, weak rapid pulse, loss of
consciousness, chest pain

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23
Q

what is the nsg care for air embolism?

A
  • Stop infusion, administer oxygen
  • position client on Lt side,
    Trendelenburg position, call doctor
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24
Q

movement of previously stationary blood clot to lungs

A

pulmonary embolus

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25
Q

what are the S&S of pulmonary embolus?

A

Sudden chest pain, Cyanosis, SOB,
decreased B/P, Tachycardia, anxiety

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26
Q

IV needle/catheter slips out of vein or not inserted
into vein
results in fluid build-up in extravascular tissue

A

infiltration

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27
Q

what are the S&S of infiltration?

A

swelling, pain, redness, decreased
infusion rate, coolness at site

28
Q
  • Similar to infiltration
  • Administration of irritant solutions into surrounding
    tissue
A

extravasation

29
Q

what are the S&S of extravasation?

A

Pain, burning, redness, blistering, inflammation,
necrosis

30
Q

 inflammation of vein from:
 prolonged use of vein
irritating solution

A

phlebitis

31
Q

what are the S&S of phlebitis?

A

Redness, heat, swelling & pain along
vein

32
Q

 inflammation of vein /c blood clot formation
 results from blood stasis inside vein at
catheter/needle tip

A

thrombophlebitis

33
Q

what are the S&S of thrombophlebitis?

A
  • Pain & tenderness
  • Redness & swelling
  • heat along vein path
  • Slowed infusion
34
Q

Blood leakage into tissue around insertion
site

A

hematoma

35
Q

what are the S&S of hematoma?

A

Ecchymosis, swelling, leakage of blood

36
Q

caused by a clot due to inadequate flushing protocol on locked sites or
infusion rates too slow to keep vein open

A

occlusions

37
Q

what are the S&S of occlusions?

A

Sluggish flow rate. Inability to flush or infuse IV solution
or meds. Frequent downstream occlusion alarms on the
IV controller / pump

38
Q

Result of kinked tubing, slow infusion rate empty IV
bag or failure to flush line after intermittent
medication or solution

A

clotting and obstruction

39
Q

what are the S&S of clotting and obstruction?

A

Slow infusion and blood back flow into line

40
Q

Caused by microorganisms that are introduced into
the blood through the puncture site, the hub, or
contaminated IV tubing or IV solution, leading to
bacteremia or sepsis

A

catheter-related bloodstream infection (CRBSI)

41
Q

what are the S&S of catheter-related bloodstream infection?

A

elevated temperature, flushed, headache, malaise, tachycardia, decreased BP,
and additional signs and symptoms of sepsis

42
Q
  • Regulate amount fluid over long period
  • Primary & secondary lines
A

continuous

43
Q
  • Solution (drug) given in shorter period
  • Piggy back, saline lock, & volume-control
    set
A

intermittent

44
Q

allows IV solutions to infuse into
client’s subcutaneous fat
* For first hour, rate should be set at
30 mls per hour

A

hypodermoclysis

45
Q
  • IV push
  • Delivers single dose (bolus) of a drug
  • Into a vein or existing line
A

direct injection

46
Q

what are the types of IV tubing?

A

primary
secondary
Y-admin tubing
vented
unvented

47
Q

used to admin lg volumes of IV
solution over long period of time

A

primary

48
Q

shorter tube, used to admin sm
volumes of solution through port in
1° tubing

A

secondary

49
Q
  • for admin whole blood/packed
    cells
  • 2 branches (1 for blood, 1 for
    N/S)
  • filter below branches to remove
    bld clots/cellular debris
  • N/S infuses before & after blood
    or during if transfusion reaction
    occurs
A

Y-admin tubing

50
Q
  • draws air into solution container
  • used for solutions packaged in glass
    bottles (lipids, in past) to facilitate flow
A

vented

51
Q
  • used for solutions packaged in plastic
  • does not draw in air (regular tubing
    set)
A

unvented

52
Q

what does tubing consist of?

A

1)Spike (insertion spike for accessing
solution)
2)Drip chamber (holds sm amt fluid)
3)Length of plastic tubing ( connects
solution to catheter)
4)One or more ports ( to instill IV meds,
additional solutions)
5)Roller clamp (regulates rate of infusion)

53
Q
  • Most common sites arm/hand (back of
    hand, arm, forearm or inner elbow
  • Avoid veins in foot/lower extremities -
    IV here restricts mobility &  risk for
    blood clots
  • Infants - scalp veins
A

superficial veins

54
Q

what are the common causes of IV flow interruption?

A

tubing block
faulty pump
air vent patency

55
Q
A
56
Q

how often is a continuous IV changed?

A

96 hrs

57
Q

how often is an intermittent IV changed?

A

24 hrs

58
Q
  • Parenteral Nutrition, extended IV
    therapy, solutions with PH > 9 or < 5;
    removal blood specimens; For clients
    with limited peripheral veins
  • Inserted antecubital area through
    basilic, cephalic, or median cubital
  • Tip in axilla region
  • Replace Q 2-4 wks
A

midline catheter

59
Q
  • Providing TPN, Monitor central venous
    pressure
  • Administering concentrated or irritating IV
    solution
  • Collapsed peripheral veins
  • Long term IV therapy
  • Peripherally Inserted Central Catheter
  • Upper arm (basilic or cephalic vein)
  • Inserted into jugular or subclavian vein to
    just above heart (superior vena cava)
  • Done at bedside; placement verified by
  • x-ray
A

peripherally inserted central catheters (PICC’s)

60
Q

 External Tunneled catheters
 Surgically implanted
 Held in place by Dacron cuff

A

hickman, broviac, groshong

61
Q
  • Surgically implanted
  • Via subclavian or jugular vein
  • Reservoir attached and placed in
    subcutaneous pocket
  • Angle needle inserted through skin for
    access
A

implanted venous ports

62
Q

what can infusion rates be affected by?

A
  • Changes in patient position,
  • Flexion of the IV site extremity
  • Occlusion of the IV device
  • Venous trauma
  • Manipulation of the VAD
63
Q
  • delivers a measured amount of fluid over a period of time (e.g., 100 mL/h)
  • computer system with a drug library and are associated with reduced risk for
    infusion-related medication errors
A

electronic infusion devices

64
Q
  • include flow regulators (i.e., dial or barrel-shaped)
  • volume-control devices deliver small volumes with the aid of gravity
  • height of the IV container, IV tubing size, or fluid viscosity) affect an IV gravity
    controller.
A

manual flow-control devices

65
Q
  • delivers standard volume of 60gtts/ml
  • delivers small-sized drops
A

microdrip

66
Q
  • drop size varies
  • 10, 15 & 20 gtts / ml
  • 10 is most common - delivers large-sized
    drops
A

macrodrip

Med-Surg Nursing (9 decks)

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