What will you apply to a site with an IV infection?
- 1. sterile drerssing
- 2. warm moist compress
- 3. anti-infective as ordered
What are 3 ways to avoid venous spasms?
- do not give cold infusates
- properly dilute meds
- do not give IV fluids too quicklly
How can you treat a venous spasm?
- apply warm compress
- if no relief, remove IV and restart on opposite arm
What can happen to an IV if it isn't secured?
Inflammation occurs from irritation, which can cause a thrombus (clot)
T or F: If a clot is formed from an IV site, you should not flush it
true: the clot can be dislodged
What do you check for if you suspect a peripheral thrombus?
check for circulatory impairment
what position will you place a patient with an air emboli?
Will you administer O2 if an air embolism happens?
This term means inflammation in the vein. What are the general causes?
Phelbitis: results from mechanical, chemical or bacterial causes
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.
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
When should you change an IV site if a patient is to have one for a long duration?
How do infiltrations occur?
Occurs when an IV cath becomes dislodged or a vein ruptures and IV fluids enter the subq tissue.
What is extravasation?
when IV fluids (during an infiltration) contains additives damage tissue
You should not place a cath in an area of flexion because ____ can occur?
dislodgement of IV which can lead to infiltration
How many times can you try to stick an IV at the same vein site?
no more than 2x
Do you want to use the largest appropriate cath or the smallest appropriate cath for IVs?
smallest, shortest cath that will do the job
Say how often you will assess IV site for each:
1. Peds ____
2. Healthy Adult ___
3. Critically ill ___
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)
Extravasation occurs after _____.
Infiltration: cath dislodges from vein and IV fluids damage surrounding cells
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
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
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
What can happen to IV if rate is too slow?
- iv line clogs
- pt not receiving full amount of rx
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
State if VS will raise or lower during fluid overload
- O2 sat: lower
- weight: higher
- HR: higher
- RR: higher
- BP: higher
- (Input higher than output)
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
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
This term means when a rapid infusion of medication reaches toxicity, flooding heart and brain
what are s/s of speed shock?
- irregular pulse
- tightness in chest
- dizziness, facial and neck flushing
- pounding head ache
What is TKO and KVO
- TKO: to keep open
- KVO: keep vein open
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