Exam 2 - NURS 366

What is phlebitis?

What is phlebitis?

The inflammation of a vein because there's blood clotting inside it or the vein walls are damaged

What are the signs and symptoms of phlebitis?

Redness, swelling, and warmth at the IV site. Vein feels hard when palpated

What are the nursing interventions to treat phlebitis?

Discontinue the IV, elevate the extremity, and use a warm compress

What is infiltration?

Non-irritating fluid leaks out of the vein and into the surrounding soft tissue

What are the signs and symptoms of infiltration?

Pain, coolness, and swelling at the site. The IV dressing is leaking, and the pump is beeping occlusion on patient side

What are nursing interventions for infiltration?

Discontinue IV, elevate extremity, use warm or cool compress depending on pH of solution (warm: normal-high pH solutions, cool: low pH solutions)

What is extravasation?

Irritating fluid leaks out of the vein and into the surrounding soft tissue

What are the signs and symptoms of extravasation?

Redness, swelling, or a stinging sensation at the IV site. Tissue may become necrotic

What are the nursing implications for extravasation?

Discontinue the IV, aspirate any residual medicine you can from line, administer antidote to medication, then elevate extremity, and apply warm or cool compress

What is an isotonic solution?

IV fluid concentrations that have a similar concentration of dissolved particles as blood. Creates constant pressure inside and outside the cells, which causes the cells to remain the same. Ex: DW5; 0.9% NS

What is a hypotonic solution?

IV fluid concentrations that have a lower concentration of dissolved particles than blood. Cells will swell. Ex: 0.45% NS, 2.5% Dextrose

What is a hypertonic solution?

IV fluid concentrations that have a higher concentration of dissolved particles than blood. Causes cells to shrivel. D5W and 0.45% sodium chloride, D10W

What should the nurse be monitoring during IV fluid administration?

During an assessment of an IV, the nurse should be looking for blood in the IV tubing, making sure that the dressing is clean and intact, and assure that there is no swelling or infection at the IV site

What action should be taken with an IV site that is not WNL?

Discontinue the IV. Release all the dressings, pull the catheter out, and stick some cotton balls and tape on their site. Look at the catheter, make sure that it is fully intact

What equipment is needed for IV insertion?

Gloves, tape, dressing (Tegaderm), alcohol prep pad, tourniquet, gauze, IV catheter, connector tubing, saline flush, drip set, IV fluid

What would a 25g IV needle be used for?

Newborn

What would a 24g IV needle be used for?

Pediatric; frail elder

What would a 22g IV needle be used for?

IV fluids, antibiotics, low flow fluids

What would a 20g IV needle be used for?

Blood products, hypertonic solutions

What would a 18g IV needle be used for?

Operation room, labor and delivery, blood products, high flow fluids

What would a 16g IV needle be used for?

Operation room, trauma

What are appropriate IV sites for an adult patient?

Forearm, antecubital fossa, hand veins, foot is last resort

What are appropriate IV sites for a pediatric patient?

Forearm, antecubital fossa, hand veins, foot is last resort

What are appropriate IV sites for a newborn patient?

Foot (if not walking), cephalic (only less than 9 months, bigger than hand and feet veins, have no valves, and do not roll), or others, they have a lot of subcutaneous fat in the extremities which makes IV insertion difficult. Larger vein in leg (great saphenous) is better than hand.

How should you prepare to insert an IV in an infant?

Have someone be there to hold the child, holder makes the site more visible while making sure the child does not move, hold a transilluminator over the extremity so you can insert the IV, etc. Have all of the supplies ready by you so you do not have to go running for something before the IV is secured. Cool extremities have small, flat veins, so you may have to use heel warmers to promote vasodilation for infants, for older children, use warm blankets or tape the heel warmer right to the spot for 5-7 minutes

What are the hand veins for an IV?

Digital veins, metacarpal veins, dorsal vein, cephalic vein, basilic vein

What are the foot veins for an IV?

Great saphenous vein, lesser saphenous vein, dorsal venous arch

When do you use foot veins for IV access?

In the adult population, we do NOT start IVs in the foot, unless we have a MD order because getting fluid back up is hard, especially when the patient is lying down, can be used in a patient that cannot walk or will not be walking during hospital stay

What are characteristics of a good vein for IV insertion?

Superficial, smooth, bouncy, no pulsation, avoid the vein bifurcations, not close to a joint, skin is normal (no contraindications)

What could lumpy veins indicate?

Multiple valves

What could hard veins indicate?

Sclerosis

What could pulsation indicate when inserting an IV?

Could be an artery

Why might IV insertion/therapy be needed?

Dehydration, surgery (deliver medications, anesthesia, etc.), malnutrition (TPN), medication administration, fluid and electrolyte replacement, receive a blood transfusion, treatments

What should you do prior for IV insertion for an infant less than 1 year?

Focus on educating the parents: generally, the younger the child, the more worried a parent is. Pacifier, possibly dipped in an oral sucrose solution. Encourage the infant to hold his or her favorite blanket or toy

What should you do prior for IV insertion for a toddler aged 1-3 years?

Keep the explanation simple and short, but make sure the child understands the body part involved and that the procedure will be limited to that area. Describe how the stick will feel and that it will be brief. Tell the child it is ok to cry or yell, but NOT to kick, bite, or hit. Use pacifier if they still have it (although anyone over 1 should not). Encourage the child to hold his or her favorite blanket or toy

What should you do prior for IV insertion for a preschool-aged child ages 3-5 years?

Talk to the child; get child life involved. Perform modified IV start on a stuffed animal or doll. Let them observe IV start on doll. Allow child to touch and handle the tourniquet, alcohol pad, tape, and plastic IV catheter. Start IV ASAP after explanation (longer the wait, the more apprehensive they will become). Encourage the child to hold his or her favorite blanket or toy. Talk to the child as you are performing the procedure (praise child for cooperation even if they are not; tell them they are so brave)

What should you do prior for IV insertion for a school-aged child ages 6-12 years?

Give a brief step by step explanation of what you will do and why you will do it. Stress the benefits of procedure. Assure them that you will try hard to not put IV in their dominant hand so they can color, write, text, etc. Give them a sense of control by allowing to help decide if mom/dad stays in room. Distraction works at this age. If a parent stays, have parent hold the child's hand and talk to the child. Tell the child to focus on something else such as the TV, iPod, etc.

How should you assess a central line?

Assess the site for redness, edema, warmth, drainage, tenderness, or pain, observe the catheter for misplacement or slippage

What is important to note about central venous line dressing changes?

Sterile dressing changes, with masks, and sterile gloves and equipment, maybe with a Biopatch. Change every 5-7 days depending on facility protocol and integrity of the dressing

How do you draw blood from a central venous line?

Push-pull method with a syringe

How do you flush central venous lines?

Scrub hub for 15 seconds. Before use, flush with saline only 5-10 mL (IN A 10ML SYRINGE); after use, saline and heparin; routine flush when not in use is typically saline followed by heparin. Flush with saline to push the medication all the way out of the line; leave it locked with heparin if it is not going to be used because heparin sitting in the line prevents clots from forming. Cover all lines that are not infusing with Curos caps

When is heparin not indicated for central venous lines?

If line is infusing continuously (medication or fluid)

What is the heparin flush concentration for children greater than 12 months and adults?

100 units:1 mL

What is the heparin flush concentration for children less than 12 months?

10 units:1 mL

How do you flush a peripheral IV?

Scrub hub for 15 seconds. Flush enough normal saline to clear the tubing in order to maintain patency; you also flush following administration of medication if peripheral IV is not infusing; you flush peripheral IV 1-2 times a shift with saline when not in use, just for patency; Heparin flush is NOT used for PIV. Cover all lines that are not infusing with Curos caps

How many lbs is one kg?

2.2lbs

How many ml are in 1 tsp?

5ml

How many ml are in 1 tbsp?

15 mL

how many mL in one fluid oz?

30ml

How many grams in one kg?

1000g

How many mg in a gram?

1000mg

how many ml in a liter?

1000ml

How many chambers of the heart are there?

4 chambers of the heart (2 atria and 2 ventricles)

Where is the heart located?

Lies mid mediastinum in the thoracic cavity

What is a normal heart rate for an adult patient?

60-100 bpm

What are the three cardiac layers of the heart?

Epicardium, myocardium, and endocardium

What helps maintain unidirectional flow through the heart?

AV valves (tricuspid and mitral), semilunar valves (pulmonic and aortic), chordae tendineae

What separates the right atrium and right ventricle?

Tricuspid valve

What separates the right ventricle and pulmonary artery?

Pulmonic valve

What separates the left atrium and left ventricle?

Mitral valve

What separates the left ventricle and aorta?

Aortic valve

What are components of cardiac conduction?

Automaticity, excitability, conductivity, contractility

What is automaticity in cardiac conduction?

Ability to initiate impulses regularly and spontaneously. Unique to myocardium. Prominent in SA node

What is excitability in cardiac conduction?

Response to stimuli

What is conductivity in cardiac conduction?

Ability of cardiac cells to respond and transmit impulses

What is contractility in cardiac conduction?

Ability to respond and contract

What are aspects of cardiac electrical activity?

Depolarization and repolarization

What is depolarization?

Reversal of resting state. Influx of Na+ into the cells, K+ moves out. This causes electrical impulses

What is repolarization?

Return to resting state. Na+ leaves the cells and K+ returns

What is the pathophysiology of a myocardial infarction?

Caused by thrombotic occlusion of a coronary vessel. Ischemia in the affected myocardium causes rapid depression of systolic function. Lack of oxygen supply to the working myocardium, leading to cardiac muscle death

What is the pathophysiology of congestive heart failure?

Myocardium unable to maintain sufficient cardiac output to meet metabolic needs, cardiac output less than 4-8L/min, ejection fraction is less than 45%. It can be left sided, right sided, or both

What is coronary artery disease?

Progressive disease in which a damaged endothelium has lipid deposits under it which develop into atherosclerotic plaques

What are clinical manifestations of coronary artery disease?

Stable and unstable angina

What are risk factors of coronary artery disease?

Age, gender, ethnicity, family history, other heart issues, nicotine, sedentary lifestyle, obesity, anxiety, depression, bitterness, substance abuse, high homocysteine levels

What is stable angina?

Caused by myocardial ischemia; manifests as chest pain relieved by nitroglycerin and/or rest

What is unstable angina?

Caused by a rupture of unstable plaque; manifests as new onset or chronic angina that increases in frequency/severity, occurs at minimal exertion or rest, and lasts more than 10 min. Can indicate STEMI or NSTEMI

What are the manifestations of left sided heart failure?

Paroxysmal nocturnal dyspnea, pulmonary congestion (cough, wheeze, bloody sputum, tachypnea), restlessness, confusion, orthopnea, tachycardia, exertional dyspnea, fatigue, cyanosis

What are the risk factors of left sided heart failure?

HTN, MI, valve disease, Drugs/ETOH, idiopathic cardiomyopathy, pregnancy, hyperthyroidism, congenital

What are the manifestations of right sided heart failure?

Fatigue, increased peripheral venous pressure, ascites, enlarged liver/spleen, distended jugular veins, anorexia, GI distress, weight gain, dependent edema

What are the risk factors of right sided heart failure?

Sleep apnea, lung disease, right sided MI, valve disease, congenital

What are components in the management of stable angina?

A: antiplatelet, antianginal, ACE inhibitors. B: beta blockers, BP control. C: cigarette cessation, cholesterol management, Ca2+ blockers, cardiac rehab. D: diet, diabetes mellitus management. E: education, exercise. F: flu vaccine

What are components in the management of unstable angina?

12-lead EKG, have IV access, order troponin count, beta blockers, ACE, ARBs, statins, MONA

What does MONA stand for?

Morphine, oxygen, nitroglycerin, aspirin

What is a NSTEMI?

Non-ST elevation myocardial infarction; manifests as pain, nausea, vomiting, anxiety, tachypnea, dyspnea, tachycardia, BP changes, and impending doom. Less damaging than a STEMI

What is a STEMI?

ST-elevation myocardial infarction; manifestations are pain, nausea, vomiting, anxiety, tachypnea, dyspnea, tachycardia, BP changes, impending doom

What are the components in the management of NSTEMI?

MONA, stress testing, anticoagulants (heparin), percutaneous coronary intervention, stent, coronary artery bypass graft

What are the components in the management of STEMI?

MONA, percutaneous coronary intervention (door to balloon 90 min), thrombolytic therapy, coronary artery bypass graft, antiplatelets/anticoagulants

What does the P-wave indicate on an EKG?

Impulse moves through atria

What does the PR-interval indicate on an EKG?

The amount of time for the impulse to travel from atria to ventricles

What does the QRS indicate on an EKG?

Impulse moves through ventricles

What does the T-wave indicate on an EKG?

Ventricles repolarize

What does the end of the T-wave to the start of the P-wave indicate on an EKG?

Whole heart at rest

What are common diagnostic studies and their physiologic basis for patients with cardiac disease?

Chest x-ray, EKG, echocardiogram, cardiac catheter, lab values

What is a chest x-ray used for in diagnosing cardiac conditions?

Cardiomegaly

What is an EKG used for in diagnosing cardiac conditions?

Assess for rhythm and rates

What is an echocardiogram used for in diagnosing cardiac conditions?

Assess valve function, ejection fraction, and wall motion

What is a cardiac catheter used for in diagnosing cardiac conditions?

Checks for pulmonary pressures, filling pressures, etc.

What occurs with sodium lab values in heart failure?

Decreased

What occurs with calcium lab values in heart failure?

Decreased

What occurs with BUN lab values in heart failure?

Elevated