MedSurg Test 1 2nd Semester

To restore/replace, to maintain fluid balance, to correct fluid/electrolyte imbalances, and as a medium for medication administration.

To increase extracellular volume.

To prevent and treat cellular dehydration by providing free water to the cells.

Hypotonic IV fluids are contraindicated in acute brain injuries because cerebral cells are very sensitive to free water, absorbing it rapidly and leading to cellular edema.

Total Parenteral Nutrition contains water, protein, carbohydrates, fats, vitamins, and trace elements that are necessary to the healing process. It is a very strong hypertonic solution. It must be given through a central venous catheter to allow rapid mixing and dilution.

Monitor infusion/flow rate, weigh patient daily, accurate I&O, sterile dressing changes, tubing changes every 24 hours, finger stick every 6 hours, daily electrolytes, and central line care.

• volume x gtt factor(60)
• time in minutes

Infiltration, phlebitis, thrombophlebitis, infection, circulatory overload, air embolism, and extravasation.

An accumulation of fluid in the tissue surrounding an IV catheter site. It is usually caused by penetration of the vein wall by the catheter and leads to dislodgment out of the vein and into the tissue.

• Flow rate may slow or stop (IV pump will beep occlusion)
• Site becomes cool and hard
• Site may become pale and swollen
• Patient may complain of pain, tenderness, burning or irritation at site
• Fluid may leak around the site

• Stop infusion and remove catheter
• Elevate extremity
• If noticed within 30 mins of onset, apply ice to decrease inflammation
• If noticed later than 30 mins, apply warm compress to encourage absorption
• Document
• Restart IV in another location

• Properly secure catheter hub to the limb
• Stabilize extremity by applying an arm board if necessary
• Assess site every hour
• Keep flow rate at the prescribed rate
• Change IV site and tubing every 72 hours
• Avoid areas where flexion occurs

Inflammation of the wall of the vein

• Sluggish flow rate
• Swelling around site
• Patient complaint of pain or discomfort at site
• Redness and warmth along vein

• Stop infusion and remove catheter
• Elevate extremityIf noticed within 30 mins of onset, apply ice to decrease inflammation
• If noticed later than 30 mins, apply warm compress to encourage absorption
• Document
• Restart IV in another location

The presence of a blood clot and vein inflammation

• Stop infusion and remove catheter
• Elevate extremityIf noticed within 30 mins of onset, apply ice to decrease inflammation
• If noticed later than 30 mins, apply warm compress to encourage absorption
• Document
• Restart IV in another location

Infusion of fluids at a rate greater than the patient can tolerate

• SOB
• Cough
• Moist breath sounds
• Engorged neck veins
• Edema
• 3rd heart sound

• Slow the IV rate
• Call doctor
• Monitor VS
• Give diuretics as ordered

The obstruction of a blood vessel (usually occurring in the lungs or heart) by air carried via the blood stream

• Failure to remove air from IV tubing
• Allowing solution bags to run dry
• Disconnecting IV tubing

• Abrupt drop in blood pressure
• Weak, rapid pulse
• Cyanosis
• Chest pain

• Prime tubing
• Monitor solution levels carefully and change bag before it becomes empty
• Frequently check to assure that all connections are secure

• Notify rapid response
• Place patient of left side with feet elevated to allow the pulmonary artery to absorb small air bubbles
• Administer O2 prn

Leakage of a vesicant IV solution or medication into the extramuscular tissue

• Flow rate may slow or stop (IV pump will beep occlusion)
• Site becomes cool and hard
• Site may become pale and swollen
• Patient may complain of pain, tenderness, burning or irritation at site
• Fluid may leak around the site
• Tissue sloughing appears in 1-4 weeks

To restore blood volume after severe hemorrhage and to replace loss due to disease processes

Blood donated by you to you

Donor blood

Only Rh- blood

May receive Rh- or Rh+ blood

When hgb/hct are low

2-4 hours

• When platelet count is decreased such as in thrombocytopenia.
• Platelets must be cross matched

15-30 minutes

• Used as a volume expander for shock, post-op, liver disease
• Must be kept frozen until ready to use

It is derived from thawing FFP and recovering the precipitate (clotting factors)

A fractionated portion of plasma used as a volume expander to support BP

• Obtain order (type, crossmatch, and transfuse)
• Explain procedure to patient
• Verify consent and order
• Obtain baseline vital signs
• Notify blood bank
• Have two nurses verify blood and patient
• Administer within 30 minutes of leaving blood bank

• Use an 18-20 gauge IV and correct tubing
• Start transfusion slowly
• Transfuse with NS
• Change tubing after 2 units
• Stay with patient for first 15 minutes

• Febrile reactions
• Allergic reactions
• Acute hemolytic reactions
• Anaphylactic reaction
• Circulatory overload
• Sepsis

• Caused by antibodies to donor white blood cells
• Most common reaction

• Chills 
• Fever - Increase in body temp of 1*F within two hours after initiation of transfusion

Foreign protein sensitivity

• Uticaria
• Flushing

• Antibodies react with antigens on donor erythrocytes causing massive hemolysis
• This is the most dangerous reaction

Infusion of immune globulin A (IgA) proteins to IgA recipient with anti-IgA antibodies

• Anxiety
• Uticaria
• Wheezing

• Edema
• Increased BP and HR
• SOB
• Coughing

Diuretics

Bacterial contamination of a blood product

• Chills
• High fever
• Vomiting
• Diarrhea
• Hypotension progressing to shock

• Stop the transfusion
• Keep the IV line open with a different NS bag and tubing
• Notify doctor
• Notify blood bank
• Recheck blood unit identification and patients
• Return blood and tubing, with documentation, to blood bank
• Document using blood transfusion record
• Remain with and treat patient per orders
• Monitor for signs and symptoms of shock
• Obtain blood and urine tests as ordered
• Monitor coagulation studies if hemolytic shock is suspected
• Monitor renal function

• Hypotension - increase IV fluids
• Hemorrhage at insertion site - rapid surgical intervention
• Catheter migration - can cause respiratory/cardiac arrest
• Wet tap - tear in dura mater
• Infection - rare

• Excessive fluid loss
• Insufficient fluid intake
• Failure of regulatory systems
• Third spacing

• Thirst
• Dry mucous membranes
• Decreased urinary output
• Altered mental status
• Fatigue
• Dry skin, pale, cool extremities
• Tachycardia
• Decreased BP
• Weight loss

• Mild - water
• Moderate - sports drinks
• Severe - IV fluids

• Weight gain in a short period
• Distended neck and peripheral veins
• Full bounding pulse
• Tachycardia
• Increase central venous pressure
• Dyspnea with cough
• Moist crackles, pulmonary edema
• Polyuria
• Ascites - third spacing
• Peripheral edema

135-145 mEq/L

Primary regulator of volume, osmolality, distribution of ECF, and maintain neuromuscular activity

• Excess sodium loss through kidneys, GI tract, skin
• Water gains r/t renal disease, heart failure, liver failure
• Excessive hypotonic IV fluids

• Anorexia - GI
• N/V - GI
• Diarrhea, abdominal cramping - GI
• Headache - neuro
• Altered mental status - neuro
• Seizure and coma - neuro
• Muscle cramps, weakness, tremors - neuro
• Decreased serum sodium and osmolality

• Altered thirst mechanism
• Profuse sweating
• Diarrhea
• Diabetes insipidus
• Oral electrolyte solutions
• Excessive IV fluids
• Inability to respond to thirst or obtain water

• Thirst
• Dry, sticky mucous membranes
• Altered mental status - restlessness, decreased LOC
• Weakness
• Muscle twitching
• Seizures