localized collection of blood outside of the vessels
Thrombosis
formation of blood clot inside a vessel
Phlebitis
inflammation of a vein
Thrombophlebitis
swelling of a vein caused by a blood clot
Infiltration
when an IV fluid or medication enters the surrounding tissue rather than the vein
Venous spasm
sudden involuntary movement or contraction of a vessel wall
Septicemia
bacteria in the blood that often occurs with severe infections
Pulmonary edema
abnormal build up of fluid in the air sacs of the lungs, which leads to shortness of breath
Air embolism
gas bubbles in a vascular system
Speed shock
a sudden adverse physiologic reaction to IV medications or drugs that are administered too quickly. Some signs of speed shock are a flushed face, headache, a tight feeling in the chest, irregular pulse, loss of consciousness, and cardiac arrest.
What are 6 nursing responsibilities of IV therapy?
1. Assessment
2. Five rights of medication administration
3. Site care
4. Documentation
5. Teaching
6. Discontinuance
What should be considered during the planning process of IV therapy?
•wear gloves
•maintain aseptic technique
•choose tubing and needle appropriate for solution to provide optimal blood flow
•attempt to enter vein at its lower end
•NEVER ATTEMPT TO RETHREAD A CATHETER
What is the preferred site for venipuncture?
Distal branches of a large vein
List 5 convenient veins that can be used for venipuncture.
1. Back of hand
2. Forearm
3. Inner aspect of elbow
4. Ankle
5. Foot
What are the steps taken when selecting a vein?
•perform hand hygiene, apply gloves
•apply tourniquet 3-5 inches below elbow
•look for vein with largest diameter and fewest curves or junctions
•clean site per policy
What are 3 common peripheral infusion devices?
1. Scalp vein needle (butterfly)
2. Over-the-needle catheter
3. Inside-the-needle-catheter
Define and describe scalp vein needles (butterflies).
Peripheral infusion device
•wings allow for ease of insertion
•not for long term use
Define and describe over-the-needle catheters.
Peripheral infusion device
•easy to insert
•patent longer
•stable which allows greater patient mobility
Define and describe insise-the-needle catheters.
Peripheral infusion device
•less likely to damage vein
•permits insertion into superior vena cavalry
•CVP monitoring
•rarely used
Name 2 types of central infusion devices.
Percutaneous catheters
Tunneled catheters
Define, describe and give examples of percutaneous catheters.
Central infusion device
•infraclavicular approach - no tunneling
•may remain for a few days to several weeks
•examples
Jugular
Femoral
Subclavian
Define and give examples of tunneled catheters.
Central infusion device
•Broviac
•Hickman
•Groshong
Describe a Broviac catheter.
•90 cm long
•1 mm diameter
•silicone, Silastic
•used primarily in pediatric patients
Describe a Hickman catheter.
modified Broviac with larger diameter
tunneled subcutaneously
Describe a Groshong catheter.
thin-walled translucent silicone rubber catheter
similar to Hickman
allows both fluid administration and blood draw through same lumen
What are the steps taken when inserting an IV catheter?
1. Hold skin taught, insert catheter with bevel up
2. Watch for backflow of blood, advance quarter inch
3. Remove needle, slide catheter into vein
4. Attach solution or cap
5. Secure according to policy
When assessing an IV site, what are you looking for?
No erythema (redness)
No warmth
No edema (swelling)
No infiltration (cold, swelling)
No leakage of blood or fluid
Dressing intact
Dressing should be dated
When caring for any patient with an IV, the nurse should _____________.
assess the SITE and the INFUSION RATE at least every HOUR
What are the 5 Rights of medication administration?
1. Right patient
2. Right medication
3. Right amount
4. Right route
5. Right time
When should an IV dressing be changed?
when it opens, when it becomes soiled or every 48-72 hours
How often should an IV be resited?
every 72 hours
What should the nurse assess when caring for a patient with an IV?
Daily weights
Compare I & O's
Vital signs (pulse)
Breath sounds
Skin turgor
Urine specific gravity
Lab values
What should a nurse document in the nurse's notes about a healthy IV site?
No s/s of infection or infiltration
Location and appearance of site
Date marked on the dressing
What should the nurse include in her documentation when initiating an IV?
Location and size of catheter used
Number of attempts
INT or continuous fluids
Patient toleration
Patient teaching
When should patient teaching about IV therapy be done?
Before and after cannulation
Before and after discontinuance
With IV administration, the solution is delivered directly into the ________________.
vascular compartment
Absorption of IV fluids is virtually ________________.
Instantaneous and complete
Once an IV med is given, _________________!!
it's given and can't be taken back
What are 3 reasons parenteral fluids are given?
1. Maintenance therapy
daily body fluid requirements
2. Replacement therapy
for present deficits with acute distress
3. Restoration therapy
for concurrent or continuing losses
Why are parental supplements beneficial?
to maintain or replenish body levels of essential chemicals
water provides hydration
Na+, K+ and Ca++ for normal nerve and muscle function
Cl- and Bicarb buffer to correct acid base balance
sugars in concentrations less than 10% carbohydrate calories
What are the 4 different types of parenteral fluids?
1. Hypertonic
2. Isotonic
3. Hypotonic
4. Blood
How do hypertonic solutions work?
They cause the ECF to shift from interstitial space to plasma
Why are hypertonic solutions used?
To replace electrolytes
What should a nurse keep in mind when giving hypertonic solutions?
Give slowly to prevent circulatory overload
What are some examples of hypertonic solutions?
D5NS 0.45%
D5NS 0.9%
D5LR
How do isotonic fluids work?
By expanding extracellular fluid (ECF)
What affects do isotonic solutions have on the body?
They have no affect on intracellular and interstitial compartments
What danger to the patient exists when administering isotonic solutions?
Danger is circulatory overload
How do hypotonic solutions work?
They cause fluid to shift out of vessels and into the interstitial and intracellular compartments
Why are hypotonic solutions given?
To hydrate cells while depleting circulatory system
What are some examples of isotonic solutions?
LR
0.9% NS
When should a hypotonic solution NOT be given?
with low blood pressure
What is an example of a hypotonic solution?
0.45% NS
What are crystalloid solutions?
electrolyte solutions
"True" solutions
Which fluids are considered crystalloid solutions?
hypotonic
isotonic
hypotonic
What are colloid solutions?
solutions that do not dissolve
What fluids are considered colloid solutions?
blood and blood products
Describe Dextrose and Water fluids.
hydrate intersitium more than intravascular space
difficult to get total calories needed
more than 20% cause vein damage
DO NOT mix with blood
Describe Sodium Chloride fluids.
provides ECF replacement
treats metabolic alkalosis
used with blood transfusions
Describe Dextrose and Sodium Chloride fluids.
replaces nutrients and electrolytes
temporarily treats circulatory insufficiency and shock
Descibe Hydrating fluids.
assess status of kidneys
use cautiously in edematous patients
hydrates medical and surgical patients
Describe reasons to use multiple electrolyte fluids.
may be balanced hypotonic or isotonic maintenance and replacement solutions
Describe Ringer's fluids.
fluid and electrolyte content similar to plasma
short time replacement for blood
substitute K+ and Ca++ for Na+
Describe Lactated Ringer's fluids.
less Na+, Ca++ and Cl-
adds bicarbonate precursor
assists in acidotic states
Describe plasma expanders.
increase blood volume
Describe alkalizing and acidifying.
bicarbonate levels increased or decreased
lactate or ammonium chloride
Why is parenteral nutrition (TPN) used?
for normal metabolism
tissue growth
weight gain
preparations containing concentrated sugars, amino acids and lipids
nutrients administered via IV replace those that normally would be absorbed from the GI tract
What types of patients would TPN be administered to?
cachectic or debilitated persons
client who cannot take adequate oral nutrition
clients going to surgery
clients with severe intestinal malfunction
as a temporary measure to imporve the prognosis
long term measure for maintaining clients with chronic malfunction
How is TPN administered?
parenteral formulas
What are some important considerations when administering TPN?
parenteral formulas containing sugars and amino acids are concentrated and CANNOT be infused into peripheral veins
high osmotic tonicity would damage erythrocytes, other cells and vessels
How is rapid dilution to normal tonicity achieved when administering TPN?
by directly infusing into the largest veins (vena cava, subclavian or jugular)
What are some dangers associated with TPN?
air embolism
lipid embolism
protein aggregation embolism
hyperglycemia
hyperammonemia
What are some interventions that can be done when a problem arises with TPN?
valsalva maneuver
left side, Trendelenberg
in-line filters
strict aseptic technique
monitor and assess
Define hematocrit (Hct) and how is it expressed?
the volume of red blood cells found in a 100mL of blood
expressed as a percentage
What symptoms might a patient with a low hematocrit (Hct) level exhibit?
blood loss or anemia
tired
pale
tachycardia
What symptoms might a patient with a high hematocrit (Hct) level exhibit?
dehydration
hypovolemia
Define hemoglobin (Hgb).
a protein substance found in red blood cells (RBC's)
composed of iron and carries oxygen
What might cause a patient to have a low hemoglobin (Hgb)?
anemia
iron deficiency or aplastic
severe hemorrhage
excess IV fluids
What might cause a patient to have a high hemoglobin (Hgb)?
dehydration
polycythemia
COPD
CHF
List different blood products that can be used for infusion.
whole blood
packed red cells (PRBC's)
plasma
platelets
albumin
clotting factors
gamma globulins
Why might a person need a blood transfusion?
hemorrhage
temporary correction for deficiencies
RBC, WBC, Platelets
bone marrow depression
hemolysis
True or False.
Patients may be transfused with synthetic blood.
false
What problems may arise with a blood transfusion?
antigen-antibody reaction
hemolysis
disrupts circulation
damages organs - especially kidneys
circulatory overload
hyperkalemia and hypocalemia
allergic reactions
infectious diseases
What are antigens?
substance capable of producing an immunological response
What antigen does type A blood carry?
A antigen
What antigen does type B blood carry?
B antigen
What antigen does type O blood carry?
no antigens
What antigen does type AB blood carry?
both A and B antigens
What will happen if A serum is mixed with B serum?
it will clump as a result of the antigen-antibody reaction
Which type of blood can a person with type A receive?
A or O
Which type of blood can a person with type B receive?
B or O
Which type of blood can a person with type AB receive?
A, B, AB or O
Type AB is known as the _____________.
universal RECIPIENT
Which type of blood can a person with type O receive?
O
Type O is known as the ______________.
universal DONOR
Does a person who is Rh+ have the D antigen?
yes
Does a person who is Rh- have the D antigen?
no
What type of blood must a person who is Rh- receive and why?
An Rh- person must receive Rh- blood to avoid the formation of antibodies to Rh+ blood.
What type of blood can an Rh+ person receive?
Rh+ or Rh-
What are some signs and symptoms of a transfusion reaction?
anxiety
restlessness
chest or back pain
flushing
increased pulse &/or respirations
shaking, chills, fever and cyanosis
OR ANY COMPLAINT OF ANYTHING STRANGE FROM THE PATIENT!
If you suspect a blood transfusion reaction, ________________________.
STOP THE TRANSFUSION IMMEDIATELY!!
What is the normal range for serum K+?
3.5-5.0 mEq/L
What is the normal range for serum Na+?
135-145 mEq/L
What is the normal range for serum Ca++?
8.9-10.3 mg/dl
What is the normal range for hemoglobin (hgb)?
women
12-16g/dl
men
14-18 g/dl
What is the normal range for hematocrit (hct)?
women
39-47%
men
44-52%
What is the normal range for serum glucose?
60-110 mg/dl
What is the normal range for BUN?
8-25 mg/dl
What is the normal range for creatinine?
0.6-1.5 mg/dl
Ordered: 1000 mL D5W every 12 hours.
How many mLs per hour would you infuse?
1000mL = XmL
12hr = 1 hr
X = 83.3 mls/hr
Ordered: 1000 mL D5W every 12 hours.
How many gtt/min would you infuse if using a microdrip?
