fundamentals quiz two - IV therapy and vascular access devices

goals of IV therapy

maintain/prevent fluid and electrolyte imbalances, provide/maintain nutritional support, administer medications, replenish blood volume, assist in pain management

IV fluid therapy

1 L or 500 mL bags for fluids; 50, 100, or 250 mL bags/glass bottles for intermittent IV medications

IV tubing and administration sets

primary (continuous) and secondary IVPB; specialize administration sets for blood, electronic infusion devices, syringe infusion pumps, TPN, and lipids

drip chambers

microdrop (60 drops/mL) and macrodrop (10, 15, 20 drops/mL); use the formula: volume to be infused/time in minutes x drop factor

IV filters

adhere to policies for TPN, lipids, blood products; change filters every 24 to 72 hours to prevent bacterial growth; used to trap blood clots or remove fluid contaminants

peripheral venous catheters (PIV)

short (<3 inches) over-the-needle plastic cannulas inserted into a peripheral vein for short term administration of fluids/electrolytes and medication; access site with smallest gauge needed to do the job (20-22 g); more common infiltration and phlebitis; not appropriate for vesicant chemotherapy or parenteral nutrition

common IV sites for infants

basilic veins, dorsal metacarpal veins, cephalic veins, frontal vein, temporal vein, occipital vein

what are the suitable anatomical sites for peripheral IV placement in adults

vein of the hand, forearm, and antecubital fossa (forearm veins are most frequently used because the forearm bones act as a natural splint)

when should the antecubital fossa veins be used for IV insertion

avoid using AC veins if another suitable vein is available because bending the elbow can bend, pinch, kink, or block the line

why are lower extremity veins contraindicated for IV insertion in adult patients

high risk of thrombus (blood clot) formation

what upper extremity conditions contraindicate selecting a vein on that side

history of breast cancer with ipsilateral (same side) lymph node removal; presence of an AV fistula or graft for hemodialysis

how do you determine if a potential vessel is an artery rather than a vein

if the potential site is pulsating, it’s likely an artery and must not be used

should you start an IV distally or proximally on an extremity, and why

start distally to allow the option of moving proximally up the extremity if future access is needed

which arm (dominant or nondominant) should be prioritized for venipuncture?

nondominant side, but both arms should be assessed first

what are the key procedural precautions regarding the arm with an IV line

do not take blood pressures on the arm receiving an IV infusion if possible; do not place restraints directly over the venipuncture site; use an arm board prn if the site is located in an area of flexion

what should you do if client access is difficult or after unsuccessful insertion attempts

consider ultrasound-guided peripheral IV placement; if unsuccessful after two attempts, have a collegue with advanced skills attempt access

total parenteral nutrition (TPN)

nutritional formulas provided to patients intravenously

colloids

solutions with high osmotic pull pressure (blood, albumin); used for volume expansion; dummy version: large particles that are suspended in water are too big to easily pass through cell walls/blood vessel membranes so they stay in the bloodstream and act as sponges, pulling fluid out of surrounding tissues into the circulatory system and increasing the overall volume of blood and raising blood pressure

crystalloids

isotonic, hypotonic, and hypertonic solutions used for volume expansion, cellular hydration, Na/water replacement

lactated ringer

isotonic solution that contains electrolytes other than Na (K, Ca, Cl); also contained lactate which is metabolized by the liver into HCO3; dummy version: because the fluid concentration matches the blood, it stays primarily within the blood vessels without pulling fluid into or out of surrounding body cells and is used to restore fluid volume in the bloodstream

which patient population is lactated ringer’s contraindicated in and why

patients with renal failure because of its potassium content

what nursing actions are required prior to administering IV solutions regarding order and compatibility

obtain a healthcare provider order for IV solutions and additives; assess the compatibility of the medication and the IV solution

what safety and monitoring checks must a nurse perform when managing IV solutions

ensure serum electrolytes are monitored and replicated prn (especially for patients who are NPO or have inadequate oral intake); assess for adequate renal function

whats the rule regarding labeling and writing on plastic IV bags

check the IV solution against the order and do not write with ink/markers directly on plastic bags

what assessments must a nurse perform before administering IV solutions?

assess health status and medical disorders; identify client conditions that contraindicate the use of a particular IV solution

what hand hygiene and infection prevention protocols are required when inserting or managing IV lines

wash hands, use aseptic technique when inserting and changing the line

what physical precautions must be taken with IV tubing to prevent contamination

do not allow the IV tubing to touch the floor

how should access ports be cleansed before adding medications or accessing a line

swab access ports with chlorhexidine or 70% alcohol; scrub for 15 seconds and allow to dry

what type of dressing is used to secure and over an IV insertion site

a transparent dresing

infiltration

non-irritating IV fluid or medication in the surrounding subcutaneous tissue, usually caused by a dislodged needle or penetrated vein wall; can cause swelling, pallor, coldness, pain around the site, and the flow rate slows; infusion and access should be discontinued and restart at a different site with a stabilization device

extravasation

the accidental leakage of a vesicant (a medication or solution capable of causing severe tissue damage, blistering, or necrosis) into the surrounding tissue; can cause pain, swelling, stinging, burning, or redness; stop infusion and remove access immediately, restart IV in opposite extremity; elevate and apply warm/cold compress over site and DO NOT rub area

phlebitis

inflammation of the inner wall of a vein, resulting from insertion or chemical trauma; can cause tenderness, redness, warmth, and slight edema; if there are no signs of infiltration or phlebitis, rapidly infuse; discontinue infusion immediately, apply warm compress, avoid using the vein again, restart access in another vein

thrombophlebitis

inflammation of the vein wall accompanied by the formation of a blood clot inside the vessel, usually triggered by catheter or needle trauma; can cause inflammation, intense pain, redness, warmth, hardness; stop infusion immediately, apply warm compress and do not rub or massage the area

fluid overload

condition caused when too large a volume of fluid infuses into the circulatory system; causes engorged neck veins, increased blood pressure, dyspnea, tachypnea, crackles, and headache; slow rate of the infusion, elevate the head of bed, assess respiratory status and edema, monitor vitals, and notify doctor immediately

air embolus

air in the circulatory system; biggest prevention: priming IV lines; can cause respiratory distress, increased heart rate, cyanosis, decreased blood pressure, change in level of consciousness; place patient on left side in trendelenburg position, call for assistance, and monitor vital signs

infection

the longer that therapy continue, the higher the risk for infection; can cause erythema, edema, induration, drainage at the insertion site, fever, malaise, chills, and vital sign changes; always perform hand hygiene before accessing, assess catheter site frequently, notify doctor immediately, maintain strict asepsis, change tubing and site dressing

IV line precautions

IV line can cause some pain or discomfort; the IV puncture provides route for microorganism entry into the body; adverse reactions may occur immediately because it goes straight to bloodstream; fluid overload/electrolyte imbalances can occur from excessive or too rapid infusion of IV fluids; incompatibilities between certain solutions and medication can occur

clients with chronic diseases, older adult clients, and very young clients cannot tolerate…

excessive fluid volume; high risk for fluid overload

clients with congestive heart failure are usually not given…

solutions containing saline due to the risk of water retention

clients with diabetes mellitus usually do not…

receive solutions with dextrose

discontinuing IV sites

IV access may be discontinued if therapy is completed or local complications occur; follow infection-prevention guidelines; catheter removed parallel to skin, apply pressure using dry, sterile gauze immediately to the area just above the insertion sites until hemostasis is achieved

types vascular access devices

peripheral venous catheters, midline catheters, central venous access devices (CVADS)

what factors determine the type of vascular access device (VAD) chosen for a patient

intended length of therapy time, type of medication or product being administered; patient’s vascular health and overall health status

what’s the goal of choosing the right type of VAD

select the least invasive catheter with the smallest diameter and fewest lumens

what are the key indications and precautions for a midline catheter

dwell time: 5 to 14 days; length/insertion: >3 inches long, inserted into upper arm veins (basilic, cephalic, or brachial); precautions: not a central line, do not use for solutions with high pH/osmolarity or TPN; avoid in patients with history of thrombosis, reduced venous blood flow, or end-stage renal disease; do not get wet

what is a peripherally inserted central catheter (PICC)

length: >20 cm (single or double lumen); insertion/tip: inserted into a peripheral arm vein with the tip terminating in the superior vena cava (SVC); can draw blood, minimize infiltration/phlebitis risks and frequent re-sticks; do not get wet

what are the characteristics of nontunneled percutaneous central venous catheters

dwell time: <14 days (short-term critical access for unstable patients); insertion sites: internal jugular, subclavian, or femoral veins; precautions: avoid femoral access in adults if possible; pneumothorax is a key risk during subclavian insertion

what is a tunneled central venous catheter

a catheter implanted into the internal/external jugular or subclavian vein after tunneled through subcutaneous tissue for 3-6 inches; intended for long-term use with a lower risk of infection

what is the primary complication of a central venous access device

catheter-related bloodstream infections; meticulous care is needed for infection prevention

what must be done after insertion and before use of a central venous access device

position and placement must be determined by x-ray

what position should the patient be in for central line insertion, tubing change, and line removal

trendelenburg or supine position with head slightly lower; instruct patient to perform valsalva maneuver (a breathing technique where you forcefully exhale against a closed airway, which raises pressure inside your chest and changes your heart rate and blood pressure)

antigen

a substance that triggers antibody formation

antibody

a protein developed by the body in response to an antigen

agglutinin

an antibody that causes clumping of specific antigens

blood transfusion

infusion of whole blood or a blood component such as plasma, platelets, and RBC’s

blood recipient

person receiving blood

blood donor

person giving the blood

blood typing

determining a persons blood type

cross matching

determines blood compatibility

autologous transfusion

patients donate their own blood for transfusion

intraoperative blood salvage

a patient’s own blood can be collected from specialized suction canisters, tubes, and drains to allow for autologous transfusion

hemodilution

blood is removed in a closed system, and the patient’s own blood is returned after surgery; cell saver; blood is removed and replaced with water and mineral based solution; helps maintain blood volume without transfusion

allogenic transfusion

giving blood from a compatible donor to a patient who is not the same person as the donor

ABO system

A: A antigen; B: B antigen; AB: A & B antigens and are universal recipients; O: no antigens and are universal donors

Rh factor

a persons whose blood contains a D antigen is Rh positive; they can only receive blood from another Rh negative

what happens if an Rh negative person receives Rh positive blood

they develop anti-Rh agglutinins, causing reactions with clumping and hemolysis

Rh incompatibility and pregnancy

a pregnant women who is Rh negative can have an Rh positive fetus but the mother will make antibodies that cross the placenta and destory the baby’s RBC’s

what medication can be administered to prevent mother and fetus Rh incompatibility

RhoGAM can be administered at 28 weeks and after birth to neutralize fetal blood cells in the mother’s circulation

packed red blood cells (PRBC’s)

red blood cells in a concentrated form and treats anemia (low hemoglobin and hematocrit) and will increase erythrocyte count

fresh frozen plasma (FFP’S)

used in emergencies that involve massive blood loss because it restores coagulation factors and blood volume and for burn patients who lose plasma at the burn areas; improvement in coagulation studies, PTT, and resolution of hypovolemia

albumin

component of plasma used for hypovolemic shock, albuminemia, and liver failure

platelets

treatment or prevention of bleeding associated with deficiencies in the number or quality of a patient’s platelets; used for cancer and leukemia patients or people with bleeding issues

blood transfusion initiation

2 licensed practitioners perform pretransfusion safety checks; must have an order and a current type and screen, obtain consent; 20-24 gauge peripheral IV, but 18-20 if rapid infusion is needed; blood needs to be administered within 4 hours; use appropriate tubing and equpment, can only be transfused with 0.9& sodium chloride; begin transfusions slowly; major reactions occur before the first 50 mL has been transfused; complete baseline assessment (vital signs, lung assessment, and current lab values)

transfusion of blood

obtain vitals; start transfusion slowly and closely monitor patient; check vitals 15 minutes after start, after the infusion is done, and 1 hour after the transfusion; increase the transfusion rate after 15 minutes; assess patient every 30 minutes; stop transfusion immediately if signs and symptoms of reactions is seen

allergic reaction

hives, itching, anaphylaxis

febrile reaction

fever develops during transfusion with chills, headache, and malaise

hemolytic reaction

immediate onset with facial flushing, fever, chills, headache, low back pain

circulatory overload

dyspnea, dry cough, and pulmonary edema

bacterial reaction

fever, HTN, dry, flushed skin, abdominal pain

adverse transfusion reaction: interventions

stop transfusion (remain with patient); infuse new tubing down to insertion site and keep vein open; notify HVP and blood bank; measure ital signs, temp, and lung sounds; prepare to administer emergency medications; return blood product/bag and tubing back to blood bank; obtain and send blood specimen and urine specimen