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A client was admitted 3 days ago and had an IV started. To meet the standard of care the nurse should:
- 1. Hang a new bag of IVF
- 2. Change IV tubing
- 3. redress the insertion site
- 4. Flush the IV with normal saline
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The nurse is monitoring a client's IV site. What signs/symptoms would indicate phlebitis?
- 1. Edema
- 2. Pain
- 3. Pallor and coolness
- 4. decreased sensation distal to IV site
- 5. redness and warmth
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Safety- Risk for injury R/T IV
Fluid volume overload:
- symptoms: shortness of breath, crackles, tachycardia. Causes excess workload of the heart.
- nursing management: slow IV rate, raise HOB, monitor VS, Notify HCP.
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Safety- Risk for injury R/T IV
Insertion site:
- symptoms: red &/or swollen &/or painful &/or has drainage
- nursing management: discontinue IV, notify HCP, insert new one if needed
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Safety- Risk for injury R/T IV
Infiltration
- IV fluid into tissues
- symptoms: swelling, pallor, coolness, pain increases-proportionately to amount of edema, possible decreased flow rate.
- Nursing management: remove the cath, raise extremity, apply warm moist towel 3-4x's a day, insert new IV if needed
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Safety- Risk for injury R/T IV
Phlebitis
- inflam of vein
- symptoms: pain, edema, erythema, increased skin temp over IV site
- Nursing management: remove IV, apply warm moist heat, insert new IV if needed
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IV Standards
- observe site every 1-2hrs (hosp policy)
- IVF should only hang 24hrs
- tubing can normally hang 3 days (CDC)
- TPN tubing hangs for 24hrs, chg with new bag
- site changed every 3 days (CDC)
- If patient complains of pain, etc, we can change IV site.
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Facts related to IV theapy
- if NPO and have normal renal function will probably receive KCL in IVF
- if client hasn't voided, need to wait until first void before adding KCl to IVF
- body doesn't conserve K and if not taking in orally, but excreting normally, will need supplement.
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