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What will you apply to a site with an IV infection?
- 1. sterile drerssing
- 2. warm moist compress
- 3. anti-infective as ordered
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What are 3 ways to avoid venous spasms?
- do not give cold infusates
- properly dilute meds
- do not give IV fluids too quicklly
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How can you treat a venous spasm?
- apply warm compress
- if no relief, remove IV and restart on opposite arm
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What can happen to an IV if it isn't secured?
Inflammation occurs from irritation, which can cause a thrombus (clot)
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T or F: If a clot is formed from an IV site, you should not flush it
true: the clot can be dislodged
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What do you check for if you suspect a peripheral thrombus?
check for circulatory impairment
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what position will you place a patient with an air emboli?
trendelenberg
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Will you administer O2 if an air embolism happens?
yes
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This term means inflammation in the vein. What are the general causes?
Phelbitis: results from mechanical, chemical or bacterial causes
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How can meds cause phlebitis?
acidic or hypertonic IV solutions, rapid IV rate, or IV drugs such as KCl, vanco, and pcn can irritate the veins.
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List the reasons why you would stop an IV
- 1. after infusion of prescribed amount of fluid
- 2. when infiltration, phlebitis, or local infection occurs
- 3. if the IV infusion slows or stops, indicating a thrombus
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When should you change an IV site if a patient is to have one for a long duration?
Q72H
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How do infiltrations occur?
Occurs when an IV cath becomes dislodged or a vein ruptures and IV fluids enter the subq tissue.
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What is extravasation?
when IV fluids (during an infiltration) contains additives damage tissue
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You should not place a cath in an area of flexion because ____ can occur?
dislodgement of IV which can lead to infiltration
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How many times can you try to stick an IV at the same vein site?
no more than 2x
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Do you want to use the largest appropriate cath or the smallest appropriate cath for IVs?
smallest, shortest cath that will do the job
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Say how often you will assess IV site for each:
1. Peds ____
2. Healthy Adult ___
3. Critically ill ___
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What scale would you give this (infiltration scale)?
Skin blanched, Edema 8cm ,cool to touch, without pain
2 (if edema <2.5cm, would be 1)
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Extravasation occurs after _____.
Infiltration: cath dislodges from vein and IV fluids damage surrounding cells
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List steps of what you do if extravasation occurs
- 1. stop iv and contact MD
- 2. photograph
- 3. D/C IV
- 4. apply heat/cold compress
- 5. elevate arm
- 6. if ordered, give antidote
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What 5 main groups will you assess for all PTs with an IV?
- 1. labs
- 2. vs
- 3. s/s of infection
- 4. skin turgor
- 5. current condition
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What 3 kinds of pts are high risk and need slower and/or lower volume IVs?
- 1. very old
- 2. renal dz
- 3. cardio dz
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What can happen to IV if rate is too slow?
- iv line clogs
- pt not receiving full amount of rx
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What can happen to IV if rate is too rapid
- 1. pulmonary edema or CHF develop
- 2. osmotic diuresis occurs, resulting in dehydration
- 3. irritating solutions cause phlebitis
- 4. cardio and respiratory complications develop
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State if VS will raise or lower during fluid overload
O2 sat
weight
HR
RR
BP
- O2 sat: lower
- weight: higher
- HR: higher
- RR: higher
- BP: higher
- (Input higher than output)
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What meds will you anticipate for fluid overload? 3
- 1. loop diuretic
- 2. vasodilator/morphine for venous dilation and improved blood flow
- 3. Aminophylline (bronchodilator) for wheezes
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What nursng interventions can you provide for fluid overload?
- 1. administer ordered meds
- 2. O2
- 3. semi-fowlers
- 4. daily weight
- 5. decrease flow rate, keep pt. warm
- 6. swan-ganz cath
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This term means when a rapid infusion of medication reaches toxicity, flooding heart and brain
speed shock
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what are s/s of speed shock?
- hypotension
- irregular pulse
- tightness in chest
- dizziness, facial and neck flushing
- pounding head ache
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What is TKO and KVO
- TKO: to keep open
- KVO: keep vein open
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What are the flushing intervals and amounts for peds and adults?
- Peds: q6h, 2-5Ml OF 0.9%NS
- Adults: q8h, 5-10mL 0.9%NS
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