Flashcards in ATI CH 4 Deck (26)
What does intravenous therapy consist of?
It involves administering fluids via a IV catheter for the purpose of providing medications, supplementing fluid intake, or giving fluid replacement , electrolytes, or nutrients.
Large volume IV infusions are administered for how long?
On a continuous basis
How may a IV medication be mixed?
It may be mixed in a large volume of fluid & given as a continuous IV infusion OR mixed In a Small amount of solution and given intermittently.
What is a fluid bolus?
A large amt of IV fluid given in a short period of time, usually in less than one hr. It is given to rapidly replace fluid loss
That could be caused by dehydration, shock, hemorrhage
, burns or trauma.
What are the appropriate size gauges for IV's?
16 guage for trauma clients
18 guage for surgical clients, rapid blood administration
22-24 guage for all other adult clients.
How do you select a vein for IV solutions?
Choose distal veins on non dominant hand
A site that is not painful or bruised
A vein that is resilient, with a soft, bouncy feeling.
What are signs of infiltration?
Pallor, local swelling, decreased skin temp around the site, damp dressing, slowed infusion.
What is the treatment of a IV that has been infiltrated?
Stop infusion & remove catheter
Encourage active range of motion
Apply cold or warm compress based on the type of solution that infiltrated the tissue.
Check w/ provider to see if IV still needed.
What are the complications of a extravasated IV?
Pain, burning, redness, swelling
What is the treatment of a extravasated IV?
Stop infusion, notify provider
Follow facility protocol, which may include infusing an antidote through the catheter before removal.
What is a nursing intervention of a hematoma (ecchymosis) at IV site?
Do not apply alcohol
Apply pressure after catheter removal
Use warm compress and elevation when bleeding stops
What are some preventions of a hematoma(ecchymosis) at the IV site?
Minimize tourniquet time
Remove tourniquet before starting IV infusion
Maintain pressure after catheter removal
What would you do if you found a catheter embolus?
( missing catheter tip when discontinued, severe pain at site with migration, or no symptoms of migration)
Place the tourniquet high on the extremity to limit venous flow
Prepare for removal via X-ray or surgery
Save the catheter after removal to determine the cause
What are preventions of a catheter embolus?
Do not reinsert the stylet into the catheter
Check to be sure the IV catheter
Is intact at the time of IV removal.
What are signs of fluid overload via IV?
Distended neck veins, increased BP, tachycardia, SOB, crackles in the lungs
What are nursing interventions of fluid overload?
Slow the IV rate to keep the vein open in accordance to facility policy.
Raise the head of bed
Assess vital signs
Adjust rate as prescribed
Anticipate administration of diuretics
What are preventions for fluid overload?
Use an infusion pump
What are signs & symptoms of cellulitis in IV therapy?
Pain, warmth, edema, induration, red streaking, fever, chills, and malaise.
What is a nursing intervention of cellulitis?
Promptly discontinue the infusion n remove catheter
Apply warm compress 3-4x per day
Culture the site and cannula if drainage is present
Administer...antibiotics, analgesics, antipyretics
What are some prevention strategies for cellulitis?
Rotate site at least every 72 hours
avoid the lower extremities
Use hand hygiene
Use surgical aseptic technique
What are signs and symptoms of phlebitis/ thrombophlebitis?
Throbbing, burning, or pain at the site
Increased skin temp
Red line up arm w/ a palpable band at the vein site
What are treatments for phlebitis/ thrombophlebitis?
Promptly d/c infusion & remove catheter
Document size of infiltrated area/ estimate Amt of fluid present/ monitor site
Apply a cold compress to minimize the flow of blood, then a warm compress to increase circulation
Check w/ provider to see of still needed.
What finding is indicative of phlebitis?
Palpable hard mass above insertion site
Pain at site
What will minimize the risk of a catheter embolism?
Avoid reinserting the needle into an IV catheter.
What are indicative findings of fluid overload?
Crackles in lungs
Distended neck veins