Fundamentals of Transcultural Nursing - Vascular Access, Blood Transfusions, Pharmacology, IV Therapy, and Medication Administration

Comprehensive flashcards reviewing vascular access devices, blood transfusions, pharmacokinetics, medication administration safety, IV therapy goals and complications, and non-parenteral/parenteral route administration based on Chapters 23, 24, and 35 lecture materials.

What factors determine the selection of a vascular access device (VAD)?

The choice depends on the length of time of therapy, the type of medication or product being administered, the patient's vascular health, and overall health. The least invasive device with the smallest outer diameter and fewest number of lumens should be selected.

What are the clinical characteristics and restrictions for a midline catheter?

Midlines are inserted peripherally into upper arm veins (basilic, cephalic, brachial), are longer than 3 inches, and have an infusion duration of 5-14 days. They are not central lines and cannot be used for solutions with high pH or osmolarity, or for parenteral nutrition. They must be avoided in patients with a history of thrombosis, decreased venous blood flow, or end-stage renal disease.

What defines a Peripherally Inserted Central Catheter (PICC)?

A PICC is a central venous device $>20\,cm$ long with single or double lumens, inserted into a peripheral vein (basilic, brachial, or cephalic) that terminates in the superior vena cava. It is used for long-term therapy (weeks to years) for antibiotics, parenteral nutrition, high osmolality fluids, and chemotherapy.

What are the features and primary insertion complication of a nontunneled percutaneous central venous catheter?

It has a dwell time of $<14\,days$, contains double, triple, or quadruple lumens, and is inserted into the internal jugular, subclavian, or femoral veins for short-term critical access. Insertion into the subclavian vein carries a risk of pneumothorax, and femoral access should be avoided in adults.

What is a tunneled central venous catheter?

A central catheter implanted into the internal or external jugular or subclavian vein that is tunneled through subcutaneous tissue for 3-6 inches to its exit site, intended for long-term use with a lower incidence of infection.

What procedure must be completed after central line insertion and prior to its initial use?

Position and placement must be determined by x-ray after insertion and before use.

What positioning and patient instructions are required during central line insertion, tubing change, and line removal?

Place the patient in the Trendelenburg or supine position with the head slightly lower, and instruct the patient to perform the Valsalva maneuver (bearing down) to prevent air from entering the system.

How do autologous transfusion, intraoperative blood salvage, and hemodilution differ?

Autologous transfusion uses blood pre-donated by the patient. Intraoperative blood salvage collects the patient's blood during surgery from suction canisters/drains for reinfusion. Hemodilution removes blood into a closed system right before surgery, replacing it with a water and mineral-based solution, and reinfuses the blood after surgery.

What are the red blood cell compatibility rules for ABO blood types?

Type A has A antigens, Type B has B antigens, Type AB has both A and B antigens (Universal recipient), and Type O has no antigens (Universal donor).

What is the Rh factor considerations in transfusion and pregnancy, and how is Rh incompatibility treated?

Rh-positive blood contains the D antigen; Rh-negative lacks it. Rh-negative patients receiving Rh-positive blood produce anti-Rh agglutinins, causing clumping and hemolysis. In pregnancy with an Rh-negative mother and Rh-positive fetus, maternal antibodies cross the placenta to destroy fetal RBCs; the mother is given RhoGAM at 28 weeks and after birth.

What are the specific indications for transfusing Packed Red Blood Cells (PRBCs) and Fresh Frozen Plasma (FFP)?

PRBCs treat anemia (low H&H) by increasing erythrocyte count. FFPs restore coagulation factors and blood volume in massive blood loss or burns, improving coagulation studies (PTT) and resolving hypovolemia.

What are the clinical uses for Albumin and Platelet transfusions?

Albumin is used for hypovolemic shock, albuminemia, and liver failure. Platelets treat or prevent bleeding associated with platelet count or quality deficiencies, such as in cancer or leukemia patients.

What safety protocols, IV cannula sizes, and solution compatibility are required before starting a blood transfusion?

Pretransfusion safety checks require 2 licensed practitioners, an HCP order, current type and screen, and informed consent. Transfusions require a 20-24 gauge IV (18-20 gauge for rapid infusion), must be completed within 4 hours, and can ONLY be transfused with $0.9\%$ Sodium Chloride.

What is the protocol for monitoring vital signs and infusion rate during a blood transfusion?

Obtain vital signs prior to transfusion. Start slowly and monitor closely for the first 15 minutes (major reactions occur before the first $50\,mL$ is transfused). Recheck vitals 15 minutes after starting, increase rate after 15 minutes if stable, assess every 30 minutes, and check vitals at completion and 1 hour post-transfusion.

What are the characteristic symptoms of allergic, febrile, hemolytic, circulatory overload, and bacterial transfusion reactions?

Allergic: hives, itching, anaphylaxis. Febrile: fever, chills, headache, malaise. Hemolytic: facial flushing, fever, chills, headache, low back pain. Circulatory overload: dyspnea, dry cough, pulmonary edema. Bacterial: fever, HTN, dry flushed skin, abdominal pain.

What immediate nursing interventions are required if a patient experiences a blood transfusion reaction?

Stop the transfusion immediately and remain with the patient. Infuse $0.9\%$ Normal Saline using NEW tubing down to the insertion site to Keep Vein Open (KVO). Notify the HCP and blood bank, measure vital signs, prepare emergency medications, return the blood bag and tubing to the blood bank, and obtain/send blood and urine specimens.

How do generic names and trade names of medications differ?

The generic name identifies the active ingredient, is assigned by the original manufacturer, is universally accepted, and serves as the official name (e.g., Acetaminophen). The trade name (brand name) is given by the pharmaceutical company selling the product and is trademarked (e.g., Tylenol, Tempra).

What is the difference between a drug's pharmaceutical class and its therapeutic class?

The pharmaceutical class refers to the mechanism of action, physiologic effect, and chemical structure of the drug. The therapeutic class refers to the clinical indication or therapeutic action of the drug.

What are the four phases of pharmacokinetics and the main organs responsible for metabolism and excretion?

The four phases are absorption, distribution, metabolism (biotransformation), and excretion. The primary organ responsible for drug metabolism is the liver, and the primary organs for excretion are the kidneys.

How do absorption rates compare among IV, parenteral, oral, and topical routes?

IV administration has the fastest rate of absorption, followed by non-IV parenteral, then oral, while topical administration has the slowest rate of absorption.

What are the definitions of allergic effect, drug tolerance, toxic effect, and idiosyncratic effect?

Allergic effect is an immune response where the body forms antibodies against a drug. Drug tolerance occurs when the body becomes accustomed to a drug's effects. Toxic effect is a cumulative effect occurring when a dose is not metabolized before the next dose. Idiosyncratic effect is an unusual or unexpected response to a drug.

How are drug peak level, trough level, and half-life defined and measured?

Peak level is the highest plasma concentration, measured 1 hour after administration (when absorption is complete). Trough level is the lowest concentration, measured 30 minutes before the next scheduled dose. Half-life is the time required for $50\%$ of the drug's serum concentration to be eliminated.

What are the definitions of PRN, Stat, and routine/standing medication orders?

PRN orders are administered as needed (e.g., for pain, nausea, sleep). Stat orders are single doses given immediately, typically in emergencies. Routine or standing orders are given on a set schedule until cancelled or discontinued.

What seven components must be present in a complete medication order?

Patient's name and secondary identifier, date and time the order was written, drug name, dosage, route of administration, frequency of administration, and signature of the prescribing provider.

When must the nurse perform the Three Checks of medication administration?

1. When reaching for the unit dose package or container. 2. After retrieval from the drawer, comparing it with the EMAR during preparation. 3. At the bedside, just before administering the medication to the patient.

What procedure is required for counting, storing, and wasting controlled substances?

Controlled substances are stored in a double-locked cabinet or automated dispenser (Pyxis) and counted daily/at set intervals. Discrepancies must be reported immediately. Any discarded or wasted portion must be witnessed and signed off by a second RN.

What immediate steps must a nurse take upon discovering a medication error?

First assess the patient's condition, notify the nurse manager and prescribing physician, document the event, and complete an incident or occurrence report.

What are the primary goals of IV therapy?

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

What drop factors distinguish microdrop and macrodrop tubing, and what is the formula for IV drip rate calculation?

Microdrop tubing delivers $60\,drops/mL$, while macrodrop tubing delivers $10$, $15$, or $20\,drops/mL$. The calculation formula is: $\text{IV drip rate (drops/min)} = \frac{\text{Volume to be infused (mL)}}{\text{Time in minutes}} \times \text{Drop factor (drops/mL)}$.

What are the clinical guidelines for Peripheral Venous Catheter (PIV) gauge size and site selection?

PIVs are short ($<3\,inches$) over-the-needle cannulas. Higher gauge numbers indicate smaller catheter diameters (20 and 22 gauge are common). Access should use the smallest gauge needed. PIVs are inappropriate for vesicant chemotherapy or parenteral nutrition.

What site selection restrictions apply when initiating a peripheral IV in adults?

Forearm veins are preferred because forearm bones act as natural splints. Avoid antecubital veins if others are available. Lower extremity veins are contraindicated in adults due to thrombus risk. Upper extremity veins are contraindicated on the side of prior breast cancer surgery with lymph node removal, or an active AV fistula or catheter for dialysis.

How many failed attempts at peripheral IV insertion may a nurse perform before requesting help?

If unsuccessful after 2 attempts, a colleague with advanced skills should attempt to initiate IV access.

What are the clinical characteristics of Lactated Ringer's solution, and when is it contraindicated?

Lactated Ringer's is the only isotonic crystalloid solution containing electrolytes other than sodium (contains K, Ca, Cl, and lactate, which the liver metabolizes to \text{HCO}_3). It is contraindicated in patients with renal failure.

What protocol must be followed when accessing an IV port or hub?

Swab access ports with Chlorhexidine or $70\%$ alcohol, scrub the hub for 15 seconds, and allow the antiseptic to dry completely before connecting or injecting.

What are the differences in signs, symptoms, and immediate management between IV infiltration and extravasation?

Infiltration is non-vesicant fluid leakage into subcutaneous tissue, causing swelling, pallor, coldness, pain, and slowed flow; manage by stopping infusion, removing catheter, and restarting at a new site. Extravasation is vesicant solution leakage causing pain, stinging, burning, and redness; manage by stopping infusion, removing catheter, elevating the extremity, and applying warm/cold compresses (do NOT rub).

What are the signs, symptoms, and interventions for phlebitis and thrombophlebitis?

Phlebitis is vein wall inflammation causing tenderness, redness, warmth, and slight edema above insertion site; stop infusion, apply warm compress, and restart at another site. Thrombophlebitis is a blood clot causing severe pain and a hard, cord-like vein; stop infusion, apply warm compress, and do NOT rub or massage the area.

What are the signs, symptoms, and emergency interventions for IV fluid overload and air embolus?

Fluid overload causes engorged neck veins, elevated BP, dyspnea, tachypnea, crackles, and headache; slow infusion rate, elevate head of bed, monitor vitals, and notify doctor. Air embolus causes respiratory distress, tachycardia, cyanosis, hypotension, and LOC change; immediately place patient on their left side in Trendelenburg position and call for help.

What are the rules regarding scored, enteric-coated, and extended-release oral tablets?

Scored tablets may be divided along the score line if necessary. Enteric-coated and extended-release tablets must NEVER be crushed or chewed.

How are sublingual and buccal medications administered, and what instructions should be given to the patient?

Sublingual tablets are placed under the tongue; buccal medications are placed between the cheek and gum. Patients must not chew, swallow, or drink fluids until the tablet is completely dissolved. Alternate cheeks between doses for buccal administration.

What rules must be followed when applying a transdermal medication patch?

Remove the old patch before applying a new one to a different clean, dry, hairless skin site. Do not apply lotion, cream, or powder prior to application. Document the patch location and label it if difficult to see.

What is the rebound effect associated with nasal spray overuse?

Rebound effect occurs when nasal decongestant sprays are used so frequently that the drug works instantly upon application, but its effects wear off quickly, creating a constant need to reuse the medication.

How does the technique for administering ear drops differ based on patient age?

For adults and children over 3 years old, pull the pinna STRAIGHT UP & BACK. For infants and children under 3 years old, pull the pinna DOWN & BACK. Hold the dropper half an inch above the ear canal.

What procedures are used to administer vaginal and rectal suppositories?

Vaginal suppository: patient voids first, lies supine with knees flexed, suppository inserted along posterior wall, and remains supine 5-10 minutes. Rectal suppository: patient in left Sims position, lubricated suppository inserted rounded end first 3-4 inches along rectal wall using index finger, and remains on side 5 minutes.

What are the parameters for Intradermal (ID) injections?

Inserted into the dermis (inner forearm, upper back, under scapula) at a 5 to 15 degree angle with bevel up using a 1/4" to 1/2", 25- or 27-gauge needle. A small bleb (wheal) must form for the test to be valid.

What needle lengths, angles, and skin fold techniques are used for Subcutaneous injections based on patient tissue depth?

Subcutaneous injections target loose connective tissue (arms, abdomen, thighs, upper back/gluteal). For thinner patients, grasp 1 inch of tissue and insert a 5/8" needle at a 45° angle. For heavier patients, grasp 2 inches of tissue and insert a 3/8" needle at a 90° angle. Always rotate sites.

What sites are approved for Intramuscular (IM) injections, what angle is used, and what site is obsolete?

Approved sites are Deltoid (max 1-2 mL), Ventrogluteal, and Vastus Lateralis. Injections use a 90° angle and Z-track method. The Dorsogluteal site is NO LONGER USED due to sciatic nerve risk.

What is the correct 4-step sequence for mixing Regular (clear) and NPH (cloudy) insulin in a single syringe?

Step 1: Inject air into CLOUDY (NPH) vial. Step 2: Inject air into CLEAR (Regular) vial. Step 3: Draw up required dose of CLEAR (Regular) insulin. Step 4: Draw up required dose of CLOUDY (NPH) insulin.

What are the structural parts of a needle used for parenteral administration?

The main parts of a needle are the Bevel (slanted tip), Shaft (long metal tube), Hub (plastic piece that connects to the syringe), and Gauge number (marked on the hub indicating needle thickness).

What are the main structural parts of a syringe?

The main parts of a syringe are the Plunger (pushed to expel fluid), Barrel (body holding medication), and Tip (end where needle attaches). Doses are measured at the edge of the plunger stopper.

How does needle gauge relate to needle diameter size?

The lower the gauge number, the wider the physical diameter of the needle (e.g., an 18-gauge needle is wider than a 25-gauge needle).

What key safety rules must be followed to prevent needlestick injuries?

Use safety needles/needleless devices, never recap needles using two hands, never break needles off syringes, immediately dispose of used sharps in designated sharps containers, and report all needlesticks immediately.