Unit 6: Circulation Flashcards
1
Q
A vein has blood that has pooled, and not being circulated. This condition is refered to as:
A
Venous stasis
2
Q
The patient has venous statis, is bed bound, and unable to move their legs. What circulatory complication should the nurse monitor the patient for?
A
Deep Vein Thrombosis (DVT)
3
Q
The nurse educates the patient that elastic hosiery act by:
A
Promoting Venous Return-applying external pressure to decrease venous blood from pooling in the extremeties.
4
Q
How does the nurse measure/fit a patient who has been ordered to wear below the knee elastic stockings?
A
Measure length from Achilles tendond to the popliteal fold.
Measure midcalf circumference.
Compare measurements to manufacturer’s chart to determine proper size.
5
Q
How does the nurse measure/fit the patient who has been ordered to wear thigh high elastic stockings?
A
Measure midcalf and midthigh circumference.
Measure length from gluteal fold to bottom of heal.
Compare measurements to manufacturer’s chart to determine proper size.
6
Q
The objective of elastic hosiery is to:
A
prevent venous stasis.
7
Q
How often should elastic hosiery be remover? Rationale?
A
Remove stocking each shift for 30 minutes.
RAT: Check for skin integrity.
8
Q
The patient has been ordered SCD’s. What does this stand for?
A
Sequential Compression Devices
9
Q
What are the three components of the SCD?
A
Air pump
Tubing
Extremetie Sleeves
10
Q
The patient is ordered SCD’s. When does the nurse assess the patients neurovascular status?
A
Before application, and each shift.
11
Q
What specific body systems will the nurse assess in the patient who is receiving SCD treatment?
A
Neurovascular at the lower extremeties.
12
Q
What may be present under the SCD? Why?
A
Elastic Hosiery, decrease irritation from the plastic and provide extra comfort.
13
Q
The nurse performing venipuncture has selected a needle that is short, beveled, and has plastic tips/wings. What type of needle has the nurse selected? When are these needles typically used?
A
Wind tipped infusion needles. Shoft term therapy, or IV therapy for children/infants.
14
Q
The nurse to perform venipuncture has selected a needle that has a sterile plastic catheter over the needle. What type of needle has the nurse selected?
A
Over the needle catheter (ONC)
15
Q
The nurse has performed venipuncture with an ONC. The patient asks why the nurse removed the needle. How does the nurse respond?
A
The needle was used to puncture the skin, and a flexible catheter is now in place inside the vein to allow access to the venous system.
16
Q
What type of devices are saline and heparin ‘hep’ locks?
A
Intermittent infusion devices.
17
Q
When are intermittent infusion devices (saline locks) indicated?
A
Used with patients who are receiving solutions or medication intermittently.
18
Q
How is flow rate adjusted in the patient who is receiving IV fluids by gravity?
A
Roller clamp adjusted to proper rate (GTT/MIN)
19
Q
What factors affect gravity IV flow rates?
A
1) Height of solution chamber (IV BAG)
2) Position of extremity
3) Position of the IV access
4) Tubing obstruction
5) IV patency
20
Q
What advantage do pumps offer compared to IV’s flowing by gravity?
A
Alarms warn of obstruction, infiltration, etc…
21
Q
What flow rate is used for IV fluids being administered by pump?
A
ml/hr
22
Q
What flor rate is used for IV fluids being administered by gravity?
A
gtt/min
23
Q
How does the nurse assess the patient who is wearing SCD’s for proper fit?
A
Fit two fingers between patients leg and sleeve.
24
Q
The patient is wearing SCD’s. What does the nurse monitor the tubing for?
A
Kinks or air leaks.
25
What does the nurse assess prior to applying SCD's? Rationale?
```
Pedal Pulses
Color
Capillary Refill
Temperature
Sensation: Touch/Temperature
```
RAT: Obtain baseline
26
What must be present before applying elastic hosiery or SCD's?
Dr's Order
27
The patient is to receive IV therapy. What does the nurse assess the patient for prior to initiating the physicians order? Rationale?
Assess vital signs.
| RAT: Baseline
28
Why must a Dr's Order be present for IV therapy?
Considered a medication
29
What should the nurse inspect the IV solution for?
Color, Clarity, and Expiration Date
30
Angiocath is another name for what type of needle?
ONC (Over the Needle Catheter)
31
The nurse assessing the Iv site observes swelling and pallor around the infusion site that is cool to the touch, and pt c/o pain. The nurse identifies that _________ has occured
Infiltration
32
The pt's IV has infiltrated, what would the nurse expect to see in regards to the IV flow rate? Rationale?
The IV flow rate would decrease.
| RAT: Increased pressure withing the subcutaneous.
33
What must the nurse do when the IV infiltrates?
Remove the IV, and restart the IV in another site.
34
What comfort measure can the nurse take for the patient who has an infiltrated IV site? Rationale?
Warm soask can be used to decrease swelling.
35
The pt asks why their IV site is swollen, cool to touch, and painful. How does the nurse respond?
The IV site has likely infiltrated, meaning the catheter has slipped out of the vein, or fluids are leaking from the vein and are accumulating in the subcuataneous tissues.
36
Inflammation of a vein is referred to as:
Phlebitis
37
Inflammation of a vein and presence of a clot is referred to as:
Thrombophlebitis
38
What factors contribute to the development of phlebitis/thrombophlebitis?
Catheter gauge and material.
Length of time the catheter is in the vein.
Type and pH of solutions.
Use of small veins, where venous return is slow.
39
What does the nurse look for when assessing for phlebitis?
Complaints of discomfort and a vein that appears red and feels warm and hard. Slow IV infusion is also likely, especially in thrombophlebitis.
40
How does the nurse decrease the incidence of phlebitis?
Changing IV sites every 72 hours.
41
What steps must the nurse take once phlebitis has been identified?
Discontinue IV site, and restart in another location.
42
What comfort measure may be taken to promote pt comfort when experiencing phlebitis?
Warm soaks
43
The nurse identifies the IV is running slower than the precribed rate. In an effort to 'catch up' on the missed fluid the nurse increases the rate beyond the normal prescribed rate. This action can cause:
Fluid Overload
44
Fluid overload is most likely to occur in:
The very young or very old.
45
What does the nurse assess for in the patient suspected to have fluid overload?
Weight Gain, Decreased Urine output, Adventitious breath sounds.
46
The nurse identifies the pt has Fluid Overload after assessing the patient to have adventitious breath sounds, weight gain, and decreased urine out put. The pt is recieving IV fluids. What actions will the nurse take?
Place the pt in semi/high fowlers position, slow the IV infusion, call the Dr.
47
How does the nurse minimize the risk on infection for the pt recieving IV therapy?
Handwashing, site preparation, use of sterile technique during insertion and maintenance are essential to minimize risk of infection.
48
What would the nurse expect to see if the pt's IV site has become infected?
Redness, warmth, purulent drainage.
49
The nurse identifies the pt IV site has become infected. What actions should the nurse perform next?
Discontinue the IV site and restart in another location. Save the catheter (may be needed for C&S) and call the Dr.
50
How does an air emolism occur?
Air in tubing, or loose IV connections
51
The nurse assessing the pt with and air embolism would expect to observe:
```
Pt chest, shoulder, back pain.
Dyspnea
Hypotension
Cyanosis
Thready pulse
Loss of Consciousness.
```
52
What actions should the nurse take when the nurse suspects the pt to be suffering from and air embolism?
Place the patient on their left side in the Trendlenburg position. Notify the physician immediately.
53
Why does the nurse place the pt suspected of having and air embolism on their left side in Trendlenburg position?
To allow the air to rise into the right ventricle and allow the blood to pass into the lungs.
54
What causes speed shock?
Reaction the body has to a substance that is injected into the circulatory system too rapidly.
55
What does the nurse assess the patient for when looking for speed shock?
Pounding headache, fainting, rapid pulse rate, apprehension, chills, back pain, and dyspnea.
56
What veins are used for central venous access devices?
Subclavian, Jugular, Cephalic or Basilic
57
Where is the catheter tip of the CVC placed?
In the superior vena cava at the entrance of the right atrium.
58
What is the benefit of a multi-lumen CVC?
Multiple medications can be administered simultaneously without the risk of incompatability or solutions.
59
What high risk complications exist with CVCs?
- Pneumothorax with insertion.
- Air embolism because tip lies in the superior vena cava/right atrium.
- Infection
60
What position is the pt placed in during insertion of the CVC? Rationale?
Supine with head lower than body to prevent the risk of air embolism.
61
When are CVCs used? Not used?
Used for hospitalized patients.
| Not used for pts recieving long term therapy.
62
What veins are used for PICCs?
Basilic and Cephalic in the antecubital.
63
Who can insert a PICC?
Physician or specially trained nurse.
64
Where is the tip of the PICC placed?
Superior Vena Cava
65
When are PICCs used? How long can they be left in place?
For pt receiving long term therapy. Left in place for months.
66
What must the nurse educate the patient with a PICC on when being discharged?
Care and maintenance. Complications and complication interventions.
67
What type of CVCs are more permanant? List the 3 types.
Tunneled CVCs.
- Hickman
- Groshong
- Broviac
68
How are tunneled CVCs placed? (Setting)
Surgically
69
What feature of tunneled CVCs anchor the catheter to the subcutaneous?
Dacron Cuff
70
What is the benefit of the Groshong CVC?
Specially designed valves eliminate the need for clamps and daily flush.
71
How is CVC placement verified?
XRAY
72
What veins are tunneled CVCs threaded through?
Subclavian or jugular.
73
What are the benefits of a tunneled CVC?
No sutures need to hold in place.
| Once incision site heals, no need for dressing.
74
Where are Ports inserted? (Setting)
Surgery (OR)
75
What needle is required to access a port?
Huber needle.
76
What are the benefits of a port?
Not visible.
Can be accessed 500-2000 X's
Decreased risk of air entering the system.
77
What is the most expensive type of CVC?
Port
78
Doppler studies can be used to identify:
Deep Vein Thrombosis
Aneurysms
Plaque in arteries.
79
Doppler can show:
Function, Flow, and Velocity within the vessel.
80
The patient with decreased circulating volume would expect to have ____-tension. (hypo/hyper)
hypo
81
What would the nurse expect to find the pulse to be in an extremety with poor circulation.
Weak, Diminished, Absent
82
The patient with decreased cardiac output would have ______ respirations. (Increased/Decreased)
Increased
83
Hypovolemia is also known as:
Extracellular Fluid Volume Deficit (Loss of ECF)
84
What does ECF contain? (Extra Cellular Fluid)
Sodium, Chloride, Bicarb, H20
85
Fluid inside the blood and lymphatic vessels is termed:
vascular volume.
86
Fluid between the cells is termed:
interstitial volume.
87
What does the nurse expect to see in the patient diagnosed with hypovolemia?
Thirst, Dry mucous membranes, weight loss, orthostatic changes in BP and P, decreased urine output, slow filling peripheral veins.
88
Hypervolemia is also known as:
Extracellular fluid Volume Excess
89
The nurse knows that patients with what disease processes are at risk for hypervolemia?
Cardiac Failure, Renal Failure, Liver Disease
90
What does the nurse assess the patient who is diagnosed with hypervolemia for?
Weight Gain, Edema, Increased BP, Bounding Pulse, JVD, Adventitious breath sounds.
91
True of False:
| All CVCs are flushed with Diluted Heparin daily.
False, the Groshong is only flushed with Saline before and after medication administration.
92
The nurse is prepping the IV tubing for a patient who is to recieve two units of packed red blood cells. The nurse will use what needle gauge?
18 is used for blood transfusion
93
The nurse is gathering supplies for the patient who is to recieve 2L of IV fluids. What needle gauge will the nurse select?
20-22
94
The nurse understands that a 17 gauge needle will have a ________ lumen than a 20 gauge needle.
Larger. (The smaller the gauge, the larger the lumen/needle)
95
How long can the nurse leave the tourniquet on while assessing the vein and performing venipuncture?
1 minute.
96
How often are IV dressings changed?
Every 72 hours, as needed, and per facility policy.
97
Where does the nurse document venipuncture for IV therapy?
IV Flow sheet.
98
When discontinuing a peripheral IV, how long does the nurse apply pressure after removing the catheter from the site?
2-3 minutes.
99
What are the next two steps after removing the IV catheter from the peripheral IV site?
- Apply firm pressure to the site for 2-3 minutes.
| - Examine/Inspect the catheter for intacness.
100
When discontinuing a peripheral IV, the nurse turns the roller clamp off. What are the next two steps the nurse will take?
- Put on clean gloves
| - Loosen the tape/dressing at the veinpuncture site while stabilizing the IV catheter.
101
When preparing to change a CVC dressing, the nurse knows that after placing the patient flat on their back, the next step is to:
Mask self/patient and ask pt to turn their head away from the site.
102
While changing the CVC dressing, the nurse has masked self and patient and turned pt's head away from site. What 2 steps will the nurse do next?
- Place a cuffed plastic bag near the work area.
| - Open the sterile dressing suplplies maintaining sterile technique.
103
The nurse assessing the Iv site observes swelling and pallor around the infusion site that is cool to the touch, and pt c/o pain. The nurse identifies that _________ has occured
Infiltration
104
The pt's IV has infiltrated, what would the nurse expect to see in regards to the IV flow rate? Rationale?
The IV flow rate would decrease.
| RAT: Increased pressure withing the subcutaneous.
105
What must the nurse do when the IV infiltrates?
Remove the IV, and restart the IV in another site.
106
What comfort measure can the nurse take for the patient who has an infiltrated IV site? Rationale?
Warm soask can be used to decrease swelling.
107
The pt asks why their IV site is swollen, cool to touch, and painful. How does the nurse respond?
The IV site has likely infiltrated, meaning the catheter has slipped out of the vein, or fluids are leaking from the vein and are accumulating in the subcuataneous tissues.
108
Inflammation of a vein is referred to as:
Phlebitis
109
Inflammation of a vein and presence of a clot is referred to as:
Thrombophlebitis
110
What factors contribute to the development of phlebitis/thrombophlebitis?
Catheter gauge and material.
Length of time the catheter is in the vein.
Type and pH of solutions.
Use of small veins, where venous return is slow.
111
What does the nurse look for when assessing for phlebitis?
Complaints of discomfort and a vein that appears red and feels warm and hard. Slow IV infusion is also likely, especially in thrombophlebitis.
112
How does the nurse decrease the incidence of phlebitis?
Changing IV sites every 72 hours.
113
What steps must the nurse take once phlebitis has been identified?
Discontinue IV site, and restart in another location.
114
What comfort measure may be taken to promote pt comfort when experiencing phlebitis?
Warm soaks
115
The nurse identifies the IV is running slower than the precribed rate. In an effort to 'catch up' on the missed fluid the nurse increases the rate beyond the normal prescribed rate. This action can cause:
Fluid Overload
116
Fluid overload is most likely to occur in:
The very young or very old.
117
What does the nurse assess for in the patient suspected to have fluid overload?
Weight Gain, Decreased Urine output, Adventitious breath sounds.
118
The nurse identifies the pt has Fluid Overload after assessing the patient to have adventitious breath sounds, weight gain, and decreased urine out put. The pt is recieving IV fluids. What actions will the nurse take?
Place the pt in semi/high fowlers position, slow the IV infusion, call the Dr.
119
How does the nurse minimize the risk on infection for the pt recieving IV therapy?
Handwashing, site preparation, use of sterile technique during insertion and maintenance are essential to minimize risk of infection.
120
What would the nurse expect to see if the pt's IV site has become infected?
Redness, warmth, purulent drainage.
121
The nurse identifies the pt IV site has become infected. What actions should the nurse perform next?
Discontinue the IV site and restart in another location. Save the catheter (may be needed for C&S) and call the Dr.
122
How does an air emolism occur?
Air in tubing, or loose IV connections
123
The nurse assessing the pt with and air embolism would expect to observe:
```
Pt chest, shoulder, back pain.
Dyspnea
Hypotension
Cyanosis
Thready pulse
Loss of Consciousness.
```
124
What actions should the nurse take when the nurse suspects the pt to be suffering from and air embolism?
Place the patient on their left side in the Trendlenburg position. Notify the physician immediately.
125
Why does the nurse place the pt suspected of having and air embolism on their left side in Trendlenburg position?
To allow the air to rise into the right ventricle and allow the blood to pass into the lungs.
126
What causes speed shock?
Reaction the body has to a substance that is injected into the circulatory system too rapidly.
127
What does the nurse assess the patient for when looking for speed shock?
Pounding headache, fainting, rapid pulse rate, apprehension, chills, back pain, and dyspnea.
128
What veins are used for central venous access devices?
Subclavian, Jugular, Cephalic or Basilic
129
Where is the catheter tip of the CVC placed?
In the superior vena cava at the entrance of the right atrium.
130
What is the benefit of a multi-lumen CVC?
Multiple medications can be administered simultaneously without the risk of incompatability or solutions.
131
What high risk complications exist with CVCs?
- Pneumothorax with insertion.
- Air embolism because tip lies in the superior vena cava/right atrium.
- Infection
132
What position is the pt placed in during insertion of the CVC? Rationale?
Supine with head lower than body to prevent the risk of air embolism.
133
When are CVCs used? Not used?
Used for hospitalized patients.
| Not used for pts recieving long term therapy.
134
What veins are used for PICCs?
Basilic and Cephalic in the antecubital.
135
Who can insert a PICC?
Physician or specially trained nurse.
136
Where is the tip of the PICC placed?
Superior Vena Cava
137
When are PICCs used? How long can they be left in place?
For pt receiving long term therapy. Left in place for months.
138
What must the nurse educate the patient with a PICC on when being discharged?
Care and maintenance. Complications and complication interventions.
139
What type of CVCs are more permanant? List the 3 types.
Tunneled CVCs.
- Hickman
- Groshong
- Broviac
140
How are tunneled CVCs placed? (Setting)
Surgically
141
What feature of tunneled CVCs anchor the catheter to the subcutaneous?
Dacron Cuff
142
What is the benefit of the Groshong CVC?
Specially designed valves eliminate the need for clamps and daily flush.jj
143
How is CVC placement verified?
XRAY
144
What veins are tunneled CVCs threaded through?
Subclavian or jugular.
145
What are the benefits of a tunneled CVC?
No sutures need to hold in place.
| Once incision site heals, no need for dressing.
146
Where are Ports inserted? (Setting)
Surgery (OR)
147
What needle is required to access a port?
Huber needle.
148
What are the benefits of a port?
Not visible.
Can be accessed 500-2000 X's
Decreased risk of air entering the system.
149
What is the most expensive type of CVC?
Port
150
Doppler studies can be used to identify:
Deep Vein Thrombosis
Aneurysms
Plaque in arteries.
151
Doppler can show:
Function, Flow, and Velocity within the vessel.
152
The patient with decreased circulating volume would expect to have ____-tension. (hypo/hyper)
hypo
153
What would the nurse expect to find the pulse to be in an extremety with poor circulation.
Weak, Diminished, Absent
154
The patient with decreased cardiac output would have ______ respirations. (Increased/Decreased)
Increased
155
Hypovolemia is also known as:
Extracellular Fluid Volume Deficit (Loss of ECF)
156
What does ECF contain? (Extra Cellular Fluid)
Sodium, Chloride, Bicarb, H20
157
Fluid inside the blood and lymphatic vessels is termed:
vascular volume.
158
Fluid between the cells is termed:
interstitial volume.
159
What does the nurse expect to see in the patient diagnosed with hypovolemia?
Thirst, Dry mucous membranes, weight loss, orthostatic changes in BP and P, decreased urine output, slow filling peripheral veins.
160
Hypervolemia is also known as:
Extracellular fluid Volume Excess
161
The nurse knows that patients with what disease processes are at risk for hypervolemia?
Cardiac Failure, Renal Failure, Liver Disease
162
What does the nurse assess the patient who is diagnosed with hypervolemia for?
Weight Gain, Edema, Increased BP, Bounding Pulse, JVD, Adventitious breath sounds.
163
True of False:
| All CVCs are flushed with Diluted Heparin daily.
False, the Groshong is only flushed with Saline before and after medication administration.
164
The nurse is prepping the IV tubing for a patient who is to recieve two units of packed red blood cells. The nurse will use what needle gauge?
18 is used for blood transfusion
165
The nurse is gathering supplies for the patient who is to recieve 2L of IV fluids. What needle gauge will the nurse select?
20-22
166
The nurse understands that a 17 gauge needle will have a ________ lumen than a 20 gauge needle.
Larger. (The smaller the gauge, the larger the lumen/needle)
167
How long can the nurse leave the tourniquet on while assessing the vein and performing venipuncture?
1 minute.
168
How often are IV dressings changed?
Every 72 hours, as needed, and per facility policy.
169
Where does the nurse document venipuncture for IV therapy?
IV Flow sheet.
170
When discontinuing a peripheral IV, how long does the nurse apply pressure after removing the catheter from the site?
2-3 minutes.
171
What are the next two steps after removing the IV catheter from the peripheral IV site?
- Apply firm pressure to the site for 2-3 minutes.
| - Examine/Inspect the catheter for intacness.
172
When discontinuing a peripheral IV, the nurse turns the roller clamp off. What are the next two steps the nurse will take?
- Put on clean gloves
| - Loosen the tape/dressing at the veinpuncture site while stabilizing the IV catheter.
173
When preparing to change a CVC dressing, the nurse knows that after placing the patient flat on their back, the next step is to:
Mask self/patient and ask pt to turn their head away from the site.
174
While changing the CVC dressing, the nurse has masked self and patient and turned pt's head away from site. What 2 steps will the nurse do next?
- Place a cuffed plastic bag near the work area.
| - Open the sterile dressing suplplies maintaining sterile technique.
