If you hear a loud churning sound (mill wheel murmur), what does it suggest? What should you immediately do?
Mill wheel murmur: an air embolism.
You must immediately roll the patient onto the left side with the head down (trendelenburg) to decrease risk of cerebral air embolism or a pulmonary artery
List Air Embolism Interventions
Trendelenburg on LEFT side
VS: call rapid response if severely compromised
O2 and monitor O2 sat.
Notify MD Promptly
1. What is the best practice position for d/c a short-term central line?
2. What will you instruct the patient to do?
3. What will you do if pulling cath out takes longer than one breath?
4. What do you do after removing line?
1. Supine or Trendelenburg if tolerated
2. Instruct patient to do a valsalva meneuver
3. If taking longer than one breath to pull cath, stop, aply pressure while pt. inhales, then continue again
4. After removing, apply pressure and apply an occlusive dressing. Leave in place for 24 hours.
List response times of each drug route
IV: within several mins
IM: 10-15 mins
Subq: 20-30 mins
PO: 20-40 mins
These 4 drug types will typically work better with IV route than the other routes
Emergency cardiac meds
List disadvantages of IV route
Interactions or Incompatibilities with multiple drugs
Speed shock, delivering too fast
Extravasaion w/ vesicant drugs (leaking of meds and damaging surrounding tissue)
Chemical phlebitis from infusates
Why is it important to label vials/synringes?
So you don't mix up the med if carrying multiple
What must be ALWAYS followed with all IV administration drugs?
Aseptic technique and standard precautions
No compatibility issues
9 rights acknowledged
Common knowledge of drug being given
Match: Heparin protocol orders are based on this lab value
List the range that is considered therapeutic. List the ranges that are considered at the lowest and highest range
Lowest: <1.2 - repeat a bolus and increase infusion rate
Highest: >3 - hold infusion 1 hour than decrease rate
Fill in for ongoing monitoring of Heparin:
After a dosage change, order an aPTT __a__ hours after.
Once __b__ (#) consecutive aPTTs are within the therapeutic range, order next aPTT __c__ hours after the 2nd one.
a. 6 hours
c. 24 hours
Which drug or additive can you not admix Phenytoin (anticonvulsant) with?
Dextrose: must be 0.9% NS, because dextrose can cause crystallization
Common Lab Acquired Body Substance Isolation
Fill in: An epidural infusion is __a__th of an IV dose, and __b__ times greater than intrathecal.
b. 10 times
Which of these drugs will need double RN checks?
a. Insulin drip
a. Insulin drip
List best practices for IV narcotic admin
1. know baseline VS
2. dilute as needed
3. label w/ name and concentration
4. give slowly and stay w/ pt for 5 mins to verify onset
5. reassess at peak time
6. be alert to VS changes (BP or dyspnea)
7. consider PCA or drip if requiring frequent pushes
Why must using morphine with an epidural have to be preservative-free?
Intravenous drugs formulated with preservatives are neurotoxic in epidural environments.
1. List acute short term uses for epidurals
2. Chronic Long term use
- Procedural anesthesia
- Severe acute pain management
- Bolus injection or continuous infusion in PCA
- Internal epidural implanted pump = severe chronic pain management
List Epidural Protocols
How often do you check RR?
No other narcotic analgesics during infusion and for 24 hours post single injection
Frequent checks of physiologic parameters (RR q30min for 1st 12 hours; then q1h for the next 12 hours)
What can low dose naloxone and high dose be indicated for?
How long is its duration?
Low: relieve pruritus
High: respiratory depression during narcotic overdose
Duration: 45 mins
List advantages and disadvantages of Epidural therapy
- for severe pain with little to no sedation
- prolonged relief w/ single injection
- Does NOT promote motor paralysis
- Most common risks: resp depression, pruritis, urinary retention, constipation and paresthesias
List most common indication for a subq infusion
How often do you change sites?
What is the recommended max rate/hour?
Most commonly for analgesia: d/t NPO, poor venous access, or during home management
- Also used in chronic immune globulin tx or w/ antiemetics for hyperemesis
Site rotation: q3-5days
Rec. max rate: 2ml/hr
Term: This device infuses medications once the tubing is unclamped that is attached to an elastic ballon holding the med.
Elastomeric Device: it is typically used post-op tissue/nerve site or Intermittent IV abx with home care. It is portable and can be carried in a pouch or pocket (doesn't deliver via gravity) and delivers meds at a specific rate.
What is an On-Q system used for? What is its benefits?
What is its mechanism of action (how med gets into pt)
On-Q: an infuser (a small balloon) that delivers local anesthetic to surgical site/tissue at incision.
Pro: used because it's less systemic narcotic needed, early DC, and faster post-op mobilization)
- Pt. can also resume normal activities and body fxns faster than with PO narcotics.
MOA: it's a slow "soaking" of med post-op and continuously delivers up to 5 days, keeping the incision site numb.
List causes for Hematoma
Causes: occurs during venipuncture or needle stick
s/s: ecchymoses, swelling, discomfort, cannot advance cath into vein
Prevention: indirect PIV insertion, apply tourniquet or use BP cuff prior to stick, use smallest gauge possible
tx: remove IV cath, apply light pressure, elevate extremity, apply ice to reduce swelling
Causes: 3 main causes are mechanical when cath rubs against vein, hub not well secured, or arm flexion
- 2nd cause is chemical irritation from a vesicus solution, hypertonic solution, inadequate dilution of med
- 3rd cause is bacterial
Prevention: proper hand hygiene, maintain asepsis during stick, choose smallest cath and secure hub, slow rate or stop IV, proper dilution of med
tx: d/c cath, restart in other extremity, use warm compresses, consider CVAD for irritating infusions
Local infection causes
Causes: lack of hand hygiene, not changing caths placed after emergent situations (ems or ED) within 48 hours, poor care, lack of cath stabilization
s/s: redness, swelling, drainage, possible fever
prevention: strict HAND hygiene and asepsis, apply antiseptic if required, clip your hair, change IV tubings per policy, keep PIV site dry, scrub the hub
tx: culture PIV as ordered, remove PIV, topical antimicrobial used and abx if ordered
Causes: (when IV solution escapes from vein into tissue) cath becomes dislodged, cath is too large or is unstable, too rapid infusion creating high pressure
s/s: gravity infusion hindered, pump occludes, no blood return, site is cool and blanched, swelling, leaking
prevention: avoid flexion around site, choose smallest cath, stabilize hub, use central line for irritating infusions
tx: d/c infusion immediately, restart elsewhere if needed, position limb for comfort, elevate limb, use warm OR cold compresses per pt toleration
Extravasation (infiltration of vesicant solution)
Causes: drugs including vasoactive drugs, electrolyte solutions, and some abx
prevention: Nurse expertise when handling special meds (eg. chemo-certified nurses), use long term VADs and central lines for vesicant solutions infusing >30-60 mins
tx: notify MD stat, leave IV in place, position limb for comfort, elevate as tolderated, use warm/cold compress per pt comfort and toleration (as indicated for specific vesicant agents)
T or F: you can use PIV for short term chemo pushes/IVPBs that are not older than 48 hours
False: may not be older than 24 hours to use with short-term chemo
List first interventions for Extravasation treatment
Notify MD stat
Leave IV in place
Attempt to withdraw as much fluid/med from the area as possible by aspiration at the IV hub
administer prescribed antidote
lastly, remove IV cath
IV sepsis causes?
Causes: 90% of cases are from central lines, especially subclavians, organisms primarily from pt's own skin flora