NURS1921: Exam III: IV Assessment

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  1. Infiltration
    • Definition: The escape of fluid into the subcutaneous tissue.
    • Possible Causes:
    • Dislodged needle
    • Penetrated vessel wall.
    • Signs & Symptoms:
    • Skin Blanching
    • Swelling
    • Pallor
    • Coldness or pain around the infusion site
    • Significant decrease in the flow rate.
    • Nursing Considerations:
    • Check the infusion site every hour for signs/symptoms. Discontinue the infusion.
    • Restart the infusion at a differemt site.
    • Limit the movement of the extremity with the IV.
  2. Phlebitis
    • Definition: An inflammation of a vein.
    • Possible Causes:
    • Mechanical trauma from needle or catheter.
    • Chemical trauma from solution.
    • Signs & Symptoms:
    • Local, acute tenderness.
    • Redness, warmth and slight edema of the vein above the insertion site.
    • Nursing Considerations:
    • Discontinue the infusion immediately.
    • Apply warm, moist compress to the affected site.
    • Avoid further use of vein.
    • Restart the infusion in another vein.
  3. Thrombus
    • Definition: A blood clot.
    • Possible Causes:
    • Tissue trauma from needle or catheter.
    • Signs & Symptoms:
    • Symptoms similiar to Phlebitis.
    • IV fluid flow may cease if clot obstructs needle.
    • Nursing Considerations:
    • Stop the infusion immediately.
    • Apply warm compress as ordered by the primary care provider/
    • Restart the IV at another site.
    • Do not rub or massage the area.
  4. Air Embolus
    • Definition: Air in the circulatory system.
    • Possible Causes:
    • Break in the IV system above the heart level allowing air in the circulatory system as a bolus.
    • Signs & Symptoms:
    • Respiratory Distress.
    • Increased Heart Rate.
    • Cyanosis - blue or purple coloration of the skin.
    • Deceased blood pressure.
    • Change in level of consciousness.
    • Nursing Considerations:
    • Pinch of catheter or secure system to prevent entry of air.
    • Place patient on the left side in Tremdelenburg position.
    • Call for immediate assistance.
    • Monitor vital signs and pulse oximetry.
  5. When would a patient be a candidate for home IV infusions?
    Patients who need long term medication administration, such as: Insulin infusions, pain medication, antibiotic therapy, chemotherapy, or TPN.

    • Candidates should meet the following criteria:
    • Medically Stable
    • Have a full or part-time caregiver
    • Have access to a telephone
    • Have a refigerator available for storage of prefilled medication cartridges
  6. What type of catheters would be used in a home setting?
    PICCs are the most common type of catheter used for home care patients. Port a Cath and Hickmann can also be used.
  7. What would be important for a patient to k ow about IV therapy before going home?
    • Sterile Technique:
    • Proper handwashing technique
    • Dressing changes
    • Proper technique for infusing medications

    • General Information:
    • Proper use of equipment
    • Assessing for any indications of an infection or other complications.
    • Obtaining supplies to continue home infusions.
    • Physican orders pertaining to the central line at home.
    • How and why to contact the physician or nurse if questions or problems arise.
  8. The Professional Nurse's Responsibility in Venous Access Device Care
    • Assessing the site
    • Maintaining patency of the site
    • Solution and tubing changes: Continuous IV (crystalloid fluids) tubing change every 72 hours. TPN solutions, Intermittent antibiotics and other fluids every 24 hours.
    • Capping the line for intermittent use: when continuous IV is no longer necessary, the primary IV line should be capped (to prevent contamination) and converted to an intermittent infusion device (medication or saline lock).
    • Discontinuation of the Device: The nurse assumes responsibility for discontinuing the access device when access is no longer needed or required.
  9. Steps for discontining a peripheral access device
    • Perform hand hygeine
    • Clamp IV tubing and remove adhesive strips & sterile dressing.
    • Withdraw catheter in line with the vein.
    • Apply pressure using a dry sterile gauze immediately to area just above the insertion site until hemostasis is achieved.
    • Apply an occlusive dressing to the site.
    • Document the date and time of removal, the name of the person removing the device and the assessment of the site.
  10. Steps for discontinuing a central access device
    • Wear clean gloves
    • Place the patient in supine position, with the arm straight and the catheter insertion site below heart level (to prevent risk for air embolus).
    • Remove the dressing while stabilizing the hub of the catheter.
    • Slowly remove catheter keeping it parallel to the skin in small increments using a smooth and gentle motion.
    • Apply pressure to the site with a sterile dressing until hemostasis is acheived then apply a small sterile dressing to the site.
    • Measure the catheter and compare it with the length listed in the chart when it was inserted.
    • Document the procedure, catheter length, site assessment and how the patient tolerated the procedure.
  11. Implanted Central Catheters
    Catheter that can last for years which is surgically implated under the skin and requires a non-coring Huber needle.

    Examples: port-a-cath, mediport and pas-port

    When is the use of implanted central catheters appropriate? Hematology and Oncology Patients. Sometimes Dialysis patients.

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  12. Tunneled Central Catheters
    A type of central venous catheter which is passed under the skin (which reduces infection) from the insertion site to a separate exit site, where the catheter and its attachments emerge from underneath the skin.

    Examples: (single or double lumen) Hickman, groshong and permcath

    When is the use of a tunneled central catheter appropriate? Well cared for catheters can be used for long term IV Antibiotics, TPN, etc...

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  13. Non-Tunneled Central Catheter
    Commonly used in acute care.

    Can have single - quadruple lumen

    Advantages: Can administer with fast access (fluids, blood, etc..), prevents multiple sticks with frequent blood draws, multiple infusions.

    Disadvantages: High risk for infection, more skill to insert (physician , advance practice nurse or PA) and possible pneumothorax.

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  14. PICC Line
    Peripherally Inserted Central Catheter which is threaded into the subclavian or jugular veins. Direct insertion into subclavian lines, internal jugular lines or femoral lines have higher rates of infection and risk for pneumothorax.

    Can inserted by specially trained nurses via basilic or cephalic vein for use of several days to months.

    In hospital or at home use.

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  15. Types of Cental Lines

    Non-Tunneled Catheter - Single to quadruple lumen. Quinton Catheter.

    Tunneled Catheter - Single or double lumen. Hickman or permcath.

    Implanted Port - Port a Cath
  16. What is an INT or hep-lock?
    INT: Intermittent Vascular Device/Hep-Lock - small tube attached inserted into the arm and held in place with tape in order to administer drugs and fluids without injecting patients multiple times. Flushed with saline or heparin to maintain patency.

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  17. A nurse is monitoring an older adult client who is recieving IV fluid therapy. Which of the following assessment findings should the nurse recognize as an adverse affect of excess fluid therapy?

    a. Edema
    b. Crackles in Lungs
    c. Oliguria
    d. Elevated BP
    e. Jugular venous distention
    a, b, d, e
  18. A nurse is caring for a patient receiving IV fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?

    A. Skin Blanching
    B. Warmth
    C. Bleeding
    D. Purulent Exudate
    A. Skin Blanching
    (this multiple choice question has been scrambled)
  19. A patient is reporting pain at the insertion site of his IV catheter. The nurse observes a red line extending outward from the insertion site. Which of the following actions should the nurse take first?

    A. place a warm compress over the site
    B. restart the IV line at a different site
    C. discontinue the infusion
    D. document the findings
    C. discontinue the infusion
    (this multiple choice question has been scrambled)
Card Set
NURS1921: Exam III: IV Assessment
Based on lecture by Mrs. Boatright
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