CPL Flashcards- Exam 2

Peripheral IV (most common)

• • Inserted by a RN

• • Small catheter and short in length

• • In peripheral vein

• • Short term

Peripheral Inserted Center Catheter (PICC)

• • Inserted by a certified RN

• • Via a peripheral arm large vein that extends through the venous system into the superior vena cava

• • In place for weeks to months

Central Venous Line (CVL)

• • Intensive settings (ICU, Surgery)

• • Directly into subclavian, internal, or external jugular veins

Why is caring for the IV site important?

• • Prevent what?

• • Infection

• • Phlebitis, infiltration, extravasation

• • Promote patient comfort

Caring for the IV Site

• Step 1: Assess the IV site for any redness, swelling, irritation, discharge, pain or discoloration.

• Step 2: Palpate the surrounding area to check for pain, temperature and edema

• • Step 3: Check Patency

  • • By ensuring that any continuous infusion fluids are actually running.

  • • Check for the correct ORDERED IV fluid rate

  • • Check that it is the correct ORDERED fluid

  • • **If no fluids are running: Flush the IV and ensure it flushes easily and with no pain/discomfort.

• • Step 4: 

  • Ensure that the dressing is clean, dry and properly secured. Replace the dressing if needed.

• Step 5: What if there are complications?

  • • Remove the existing IV catheter

  • • Insert a new IV catheter (with orders) in a NEW location

  • • Notify the provider for severe IV complications

  • • Replace the IV tubing according to facility protocol

  • • Ensure there are no kinks/obstructions in tubing

Phlebitis

• “Inflammation of the vein”

• • Warm Skin

• • Redness

Infiltration

• • IV fluids or IV Medications that have “leaked” into the surrounding tissues

• • Cool Skin

• • Can quickly lead to hematoma

Extravasation

• • Damaging MEDICATIONS that have leaked into surrounding tissues

• • Warm, red and PAINFUL skin

• • While rare…it can lead to limb loss

What medicines can cause extravasation?

• • Levophed (norepinephrine)

• • MANY chemotherapy drugs!!

• • Acyclovir (antiviral)

Discontinuing IV Site

• 1. Hand hygiene

• 2. Don clean gloves

• 3. Clamp the IV tubing (if fluids are running)

• 4. Remove the tape and dressing while holding the IV catheter

• 5. Apply a sterile gauze over the site without putting pressure on vein

• 6. Using the opposite hand withdraw the catheter by pulling straight back

• 7. Apply pressure until bleeding stops

• 8. Examine the site

• 9. Apply tape over the gauze

• 10.Check the catheter for intactness

• 11. Dispose of catheter

Assessing the IV and equipment:

• • Assess the IV site, tubing, and the pump (if used) every 1-2 hours starting on initial patient rounds or if the patient complains of pain/tenderness or the pump alarms

• • Change IV catheter per agency policy or for redness, swelling, pain, etc

• • Verify that the correct solution is infusing and at the correct rate. Solution should be <24 hours old

• • Ensure that the tubing is labeled with date/time. If not, prepare to change it during your shift

• • Ensure that the tubing is not kinked, laying on the floor, or laying underneath the patient

• • Ensure that the pump is plugged in and the extension cord is not a tripping hazard

• • Ensure that the pump alarms are not silenced

• • Change the IV site per agency guidelines or if complications develop

Frequency of IV Tubing Changes (check your agency policy):

• • All tubing must be change using aseptic technique

• • If possible, coordinate IV tubing changes with IV solution changes (i.e., change the entire system instead of tubing one day, and then new IV solution a few hours later). Decreases the risk of infection.

• • Every 72-96 hours for primary, continuous IV infusions

• • Every 24 hours for secondary set tubing

• • Every 24 hours for total parenteral nutrition infusions with fat emulsions

• • Sooner than the above recommended times if the tubing becomes disconnected or contaminated

• • Immediately if cloudiness or precipitate is seen in the IV solution or tubing

• • If the IV tubing is not labeled with time/date initiated

• • Blood tubing is changed between each unit of blood or every 4 hours whichever comes first

Tube occlusion

• • May occur if the tubing is kinked or bent. Tubing may become kinked if caught under the patient or on equipment, such as beds and bed rails.

Vein spasms

• • Irritating or chilled fluids may cause a reflex action that causes the vein to go into spasm at or near the intravenous infusion site.

• • Bring to room temperature prior to infusion.

Height of the fluid container

• The IV tubing drip chamber should be approximately 3 feet above IV insertion site for gravity infusions

Location/position of IV cannula

• • If the cannula is located in an area of flexion (bend of an arm), the IV flow may be interrupted when the patient moves around.

• • To avoid this issue, replace IV cannula or place the patient on a wrist or arm board (if replacement is not an option)

Needle or cannula gauge/diameter

• The smaller the needle or cannula, the slower the fluid will flow.

Accidental touching/bumping of the control clamp or raising arm above heart

• • Instruct the patient not to touch the roller clamp and to take care not to bump the clamp, as this may accidentally change the flow rate.

• • Instruct patient to keep hand/arm below heart level; an elevated hand/arm will slow or stop an infusion running by gravity.

Circulatory overload 

• • Distended neck veins

• • Increased BP and HR

• • SOB and decreased SpO2

• • Crackles in lungs

• • Edema

• • Confusion

• • Seizures

• • Cardiac arrythmias

  • • Stop the infusion and raise HOB

  • • Obtain VS and SpO2

  • • Notify the HCP

  • • Adjust the IV rate

  • • Administer O2 and diuretics and other medications as indicated

  • • Monitor I&O and electrolytes

  • • Document

Infiltration and Extravasation 

• • Pallor

• • Swelling

• • Cool skin temperature

• • Leaking or damp dressing

• • Slowed rate of infusion

  • • Stop the infusion and remove the IV catheter. Vesicants (i.e., chemotherapy) require actions per specific protocols

  • • Notify HCP for infusions with KCL, vasoconstrictors, or other potential vesicants

  • • Elevate the extremity

  • • Apply or warm or cold compress depending on the type of solution

  • • Restart the infusion proximal to the site or a different extremity

  • • Monitor old site closely for s/s of tissue damage and document

Phlebitis 

• • Edema

• • Throbbing, burning, or pain at insertion site

• • Warm skin temperature

• • Erythema or a red line up the vein

• • Slowed rate of infusion

  • • Stop the infusion and remove the IV catheter

  • • Elevate the extremity

  • • Apply warm compresses 3-4/day

  • • Restart the infusion proximal to the site or a different extremity

  • • Monitor old site closely for s/s infection and Document

Local Infection 

• • Throbbing, burning, or pain at insertion site

• • Warm skin temperature

• • Erythema or a red line up the vein

• • Possible purulent drainage

  • • Notify HCP and culture drainage (if ordered)

  • • Cleanse site with alcohol before removing the IV catheter. Save it for possible culture.

  • • Restart the IV proximal to the site or a different extremity

    • • Monitor old site closely and document

Air Embolism

• • Sudden onset of SOB, chest pain, hypotension, tachycardia, decreased LOC

  • • Clamp the IV tubing to prevent more air

  • • Place on left side with HOB up

  • • Call for emergency support

Bleeding at the IV insertion site 

• • Continued oozing at the insertion site

  • • Assess if IV catheter is still within the vein

  • • Apply clean sterile dressing or 2x2 gauze to absorb blood. Change as needed

• 0.9% NORMAL SALINE (NS)

• • ISOTONIC

• • INCREASES INTRAVASCULAR VOLUME

  • • WITHOUT ALTERING FLUID CONCENTRATIONS

• • MOST COMMONLY USED IV FLUID

• • TREATS VOLUME DEFICITS

  • • FLUID RESUSCITATION

• • USED TO ADMINISTER BLOOD

• • **CAUTION FOR FLUID OVERLOAD

• LACTATED RINGER’S (LR)

• • ISOTONIC

• • MOST PHYSIOLOGICALLY ADAPTABLE FLUID

  • • ELECTROLYTE CONTENT = BLOOD PLASMA

• • FLUID RESUSCITATION (GI TRACT LOSSES/BURNS)

• • METABOLIZED BY THE LIVER

  • • LACTATE → BICARBONATE

  • • USED IN METABOLIC ACIDOSIS

• • DO NOT USE IN LIVER DISEASE PATIENTS

• • HAS K+, USE CAUTIOUSLY IN RENAL DISEASE

• RINGER’S SOLUTION

• • ISOTONIC

• • DOES NOT CONTAIN LACTATE

• • SIMILAR TO LACTATED RINGER’S

  • • NOT USED IN METABOLIC ACIDOSIS

  • • NO LACTATE = NOT ALKALIZING

• D5W (5% DEXTROSE IN WATER)

• • ISOTONIC → HYPOTONIC

  • • DEXTROSE METABOLIZED QUICKLY

• • EXPANDS INTRACELLULAR & INTRAVASCULAR

• • TREATS HYPERNATREMIA

  • • DILUTES THE EXTRA SODIUM

• • DO NOT USE FOR VOLUME DEFICIT

  • • DILUTES ELECTROLYTES

• 0.45% NORMAL SALINE (1/2 NS)

• • HYPOTONIC

• • REPLACES NATURAL FLUID LOSSES

• • HELPS KIDNEYS EXCRETE EXCESS FLUID AND ELECTROLYTES

• • INTRAVASCULAR→ INTRACELLULAR

  • • HYDRATES CELLS

  • • MAY DEPLETE FLUID IN CIRCULATORY SYSTEM

• • ***WATCH FOR FLUID SHIFT!!

  • • HYPOTENSION AND HYPOVOLEMIA

• • AVOID

  • • INCREASED ICP, LIVER DISEASE, TRAUMA, BURNS

• D5NS (5% DEXTROSE IN NORMAL SALINE)

• • DEXTROSE ADDED TO FLUIDS MAKES IT HYPERTONIC

• • VOLUME EXPANDER

• • HIGHER CONCENTRATION OF SODIUM CHLORIDE THAN PLASMA

  • • USED TO TREAT HYPONATREMIA AND CEREBRAL EDEMA

• • INTRACELLULAR→ INTRAVASCULAR

• • MORE HIGH RISK→ CLOSE MONITORING

• • DO NOT USE HYPERTONIC IN DKA

• D5 1/2NS (5% DEXTROSE IN 0.45% NORMAL SALINE)

• • HYPERTONIC

• • MOST COMMON IN POST-OP PATIENTS

• • TREATS HYPERNATREMIA

• • CELLS→ INTRAVASCULAR

• • **CLOSE MONITORING

• D5LR (5% DEXTROSE IN LACTATED RINGER’S)

• • HYPERTONIC

• • INTRACELLULAR→ INTRAVASCULAR

• • MORE HIGH RISK→ CLOSE MONITORING

• OTHER FLUID CONCENTRATIONS

• • D10W

• • D20W

• • D50W

• • 3% NS

• • 5% NS

• • 0.33% NS

• • 0.2% NS

• • NOT COMMONLY USED

• What is an IV Pump?

• • A computerized device used to deliver fluids, medications, or nutrients directly into a patient’s bloodstream at a controlled rate.

• • Ensures accurate dosing and consistent flow rates to the patient.

• • Benefits of a pump over gravity:

  • • Precision: Delivers exact amounts of fluid/medication

  • • Safety: Built-in alarms for air, occlusions, and flow rate errors

  • • Flexibility: Supports multiple types of infusions (continuous, intermittent, bolus)

  • • Documentation: Intake and output, medication Safety rates, etc.

What is the Alaris Pump System?

• • Most commonly used at our clinical sites

• • Noland Hospital uses Hospira

• • Different hospitals use different pump systems

• • Alaris Pump: smart infusion system made of separate modules that work together

• • Each part has a specific job, and modules can be added or removed based on patient needs

• Infusion Module(s) (Channels)

• • Attach to the PC unit

• • Can add modules to each side of PC unit

• • Deliver fluids and medications at a programmed rate

• • The fluid/medication is attached though the channels

• • They are labeled A, B, C….etc.

• PC Unit (“The Brain”)

• • Central control screen for programming and monitoring

• • Stores drug libraries (Guardrails safety software)

• Drip/Drop Chamber: Clear chamber near the IV bag

• • Allows you to see and count drops (important with gravity sets)

• • Helps prevent air from entering tubing

• Roller Clamp

• • Controls the flow rate in gravity infusions

• • Usually left open when using a pump

• Injection Port(s)

• • Sites where medications can be injected with a syringe

• • Located along the tubing (Y-site ports)

• Backcheck Valve

• • Prevents backflow of fluids from the primary line into the secondary line

• • Found on primary tubing, important for secondary (piggyback) setups

• Slide Clamp

• • Used to stop flow completely

• • Always close before disconnecting tubing or changing bags

• Tubing Ends/Adapter End

• • Connects to the IV catheter on the patient

• Primary Infusion & Tubing

• • Main!

• •Used for continuous IV fluids (e.g., NS, LR, D5W)

• •Longer tubing Connects directly to the IV catheter via the pump

• •Often has multiple Y-site ports

• Secondary Infusion & Tubing

• • Secondary!

• • Used to infuse intermittent medications (antibiotics)

• • Shorter tubing

• • Connected to y-site of primary tubing (ABOVE the pump)

• • Infuses on a schedule, then switched back to primary

• Primary Setup: Step by Step

• 1. • Gather Supplies & Verify the Order

  • • Spike and Prime the Tubing

  • • Power On the PC Unit

• 2. Select and Program the Channel

  • •Press “Channel Select” on the front of the infusion module

  • •Choose “Guardrails Drugs” (for medication infusions) or

  • “Basic Infusion” (for plain fluids)

  • •Follow prompts for fluid type (if Guardrails is used)

• 3. Load the Tubing Cassette into the Module

  • •Open the channel door

  • •Insert the tubing cassette securely

  • •Close and clamp the door

  • •Listen for the “click” to confirm it's locked in

• 4. Enter Rate and VTBI (Volume To Be Infused)

  • •Rate: in mL/hr (e.g., 100 mL/hr)

  • •VTBI: total volume in the bag (or per order)

  • •Double-check with another nurse per

  • facility protocol

• 5. Start the Infusion

  • •Press “Start”

  • •Observe the screen to confirm flow

  • •Label tubing and document start time and Settings

• Secondary Setup: Step by Step 

• 1. • Gather Supplies & Verify the Order

  • • Spike and Prime the Secondary tubing (shorter)

  • • Double-check the secondary and primary are compatible to infuse

  • • Clamp the secondary tubing

  • • Spike the secondary bag

  • • Prime tubing

  • • Hang secondary bag (must be higher than primary bag)

  • • Clean y-site with alcohol

  • • Connect secondary tubing

  • • Unclamp secondary

• 2. Program the Channel

  • •Press “Channel Select” on the front of the infusion module

  • •Select “Secondary”

  • •Choose “Guardrails Drugs”

  • •Enter the medication, and rate and volume

  • •Confirm this matches the order

• 3. Start the Infusion

  • •Press “Start”

  • •Observe the screen to confirm flow

  • •Label tubing and document start time and settings

Air-in-line →

check for bubbles, re-prime if needed

Occlusion →

• check for kinks or closed clamps

VTBI complete

 reprogram or hang new bag

Door open →

re-seat tubing and close latch

• Safety Tips for IV

• DOUBLE-CHECK RATE AND DRUG SELECTION

• LABEL ALL TUBING AND LINES

• CHECK INFUSION SITE AT LEAST HOURLY

• USE GUARDRAILS DRUG LIBRARY WHEN AVAILABLE

• DOCUMENT PUMP SETTINGS PER FACILITY POLICY

• Carbohydrates

• • energy and fiber

• • Ex: whole grain bread, baked potato, brown rice

Fats

• • provide energy and vitamins

• • Ex: olive oil, salmon, egg yolks

Proteins

• • growth, maintenance, and repair of body tissues

• • Ex: beef, whole milk, poultry

Vitamins

• • necessary for metabolism

• • Fat soluble: A, D, E, & K

• • Water soluble: C, & B

• • Minerals

• • essential biochemical reactions

• • Ex: Calcium, Potassium, Sodium, Iron

Water

• • critical for cell function & fluid replacement

• • Ex: perspiration, elimination, respiration

• Factors Affecting Nutrition & Metabolism

• • Religious & Cultural Practices

• • Financial Concerns

  • • Nutritious food is expensive!

  • • Social Determinants of Health

• • Appetite

• • Negative Experiences

• • Environmental Factors

  • • Access to healthy food

  • • Food Deserts

• • Disease & Illness

• • Medications

  • • Alters taste and interfere with absorption

• • Age

  • • Impacts nutritional requirements & metabolic function

• • Disordered Eating

• Basic Intake & Output

• • Record I&O

• • Monitor I&O for clients with electrolyte imbalances

• • Weigh clients daily

  • • Same time

  • • After voiding

  • • Wearing same type of clothing

  • • If using bed scale, use same amount of linens and reset scale to zero

• Expected Findings of Poor Nutrition

• • Nausea, vomiting, diarrhea, & constipation

• • Flaccid muscles

• • Mental status changes

• • Loss of appetite

• • Change in bowel pattern

• • Spleen & liver enlargement

• • Loss of subcutaneous fat

• • Dry, scaly skin

• • Inflammation, bleeding of gums

• • Poor dental hygiene

• • Dry, dull eyes

• • Enlarged thyroid

• • Prominent protrusions over bony areas

• • Weakness, fatigue

• • Change in weight

• • Poor posture

• Assisting Clients with Eating

• • Advocate to advance diet as prescribed

• • Educate clients about diet regimen

• • Provide excellent oral hygiene

• • Try to order client’s favorite foods and minimize unappetizing smells

• • Educate clients on medications that might impact nutrition

• • Assist clients with feeding if & when needed

• Prevention of Aspiration

• • Client position

  • • High Fowler’s or chair during eating & for at least an hour after eating

  • • Instruct client to tuck chin when swallowing

• • Support upper back, neck, & head

• • Avoid use of straw

• • Observe for

  • • Aspiration

  • • Pocketing of food in cheeks

  • • Dysphagia (coughing, choking, gagging, & drooling)

• • Provide oral hygiene

• • Clear Liquid

• • Liquids that leave little residue

• • Ex: clear fruit juice, gelatin, & broth

• • Full Liquid

• • Clear liquids plus liquid dairy products, all juices, & pureed vegetables

Pureed

• • Clear and full liquids plus pureed meats, fruits, scrambled eggs

• Mechanical Soft

•  Clear and full liquids plus diced or ground foods

• • Soft/Low-residue

• • Foods low in fiber and easy to digest

Dysphasia

• • Pureed food & thickened liquids

• • High fiber

• • Lots of whole grains, raw & dried fruits

• • Low sodium

• • No added salt or 1-2 g sodium

• • Low cholesterol

• • No more than 300 mg/day of dietary cholesterol

Diabetic Diet

• • Balanced intake of protein, fats, & carbohydrates of about 1800 calories

Parenteral nutrition for those who need to rest their GI tract

(includes lipids, electrolytes, minerals, vitamins, dextrose, & amino acids

• • Administer IV fluids as ordered

• • Restrict oral intake & maintain strict I&O

• • Remove water pitcher from bedside

• • Inform dietary staff of amount of fluid to serve with trays

• • Inform staff on each shift about fluid restriction amount & how much client is to consume with each tray

• • Record oral intake

• • Inform visitors of restriction

• • Encourage oral intake of fluids

• • Provide fresh drinking water

• • Remind & encourage consistent fluid intake

• • Ask about beverage preferences

 Tube Feeding

• A method of delivering nutrition directly to the stomach or small intestine when a patient cannot eat enough by mouth. Also called enteral nutrition.

• • Reasons for Tube Feeding:

• •Stroke, surgery, or trauma affecting swallowing

• •Severe illness or malnutrition

• •Neurological conditions (e.g., ALS, dementia)

• •Gastrointestinal disorders

Nurses role in Tube feeding

• •Verify tube placement before feeding

• •Maintain head-of-bed at ≥30–45°

• •Flush before/after feedings and meds

• •Monitor for aspiration, residuals, and tube patency

• •Always hold feeding during: baths, repositioning, etc.

NG Tube (Nasogastric Tube)

• Through NOSE -> Stomach, inserted by nurse 

• Not surgically placed

• Temporary; Short-term

• G-Tube or PEG

• Through abdomen -> stomach

• Surgically placed in endoscopy suite or OR

• Long-term

• A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? Select all that apply.

• • B. Instruct the client to tuck their chin when swallowing.

• • F. Provide oral hygiene after the client finishes eating.

Sleep helps

• • Cell, tissue, & muscle repair

• • Strengthens the immune system

• • Helps process/store information

• • Improves focus, decision making & problem solving

• • Restores our energy levels

• • Improves productivity

• • Keeps cortisol in check

• • Associated with longevity

• What happens when we don’t get enough rest and sleep?

• 1. Poor concentration

• 2. Inability to problem solve

• 3. Poor judgment

• 4. Irritation

• 5. Moodiness

• 6. Increased chance of accidents

• Stage 1 NREM

• • Very light sleep

• • Relaxed & Drowsy

• • Only a FEW minutes

• • VS begin to decrease

• • You can be awakened easily

• Stage 2 NREM

• • A little deeper sleep

• • 10-20 minutes long

• • Requires more stimulation to awaken

Stage 3 NREM

• DEEPEST sleep; “Delta sleep”

• • Very difficult to awaken

• • VS low

• • BODY IS REPAIRING AND RENEWING

REM

• • Rapid eye movement sleep

• • Vivid dreams

• • Occurs about 90 minutes after first falling asleep

• • It reoccurs around every 90 minutes

• • Lasts about 20 minutes and gets longer with each sleep cycle

• • COGNITIVE RESTORATION

• • Very difficulty to awaken

• • Loss of skeletal muscle tone

• • Cognitive restoration

• Key differences between NREM stage 3 and REM

• NREM Stage 3 

  • Physical restoration 

  • Immune System Repair 

  • Usually no dreaming

• REM

  • Emotional processing 

  • Cognitive function restoration 

  • Vivid dreams 

How long should babies and toddlers sleep?

•  9-15 hr/day

How long should adolescents sleep?

• 9-10 hr/day

How long should adults sleep?

7-8 hr/day

• What Impacts Sleep?

• • Physiological Disorders: sleep apnea, nocturia, etc.

• • LIFE: change in work hours, children, traveling, etc.

• • Mental Health: Anxiety, fear, grief, stress

• • Diet: Too much caffeine, heavy/sugary meals before bedtime

• • Fatigue: Being overly-exhausted or stressed makes falling asleep challenging

• • Environment: too light, wrong temperature, noisy

• • Medications: Some interfere with sleep like bronchodilators, anti- hypertensives

• • Substance Use: Nicotine, caffeine, stimulants

Alcohol and sleep

• 1. Alcohol actually DISRUPTS your sleep cycle

• 2. Results in very poor sleep quality

• 3. Unrefreshed and groggy the following day

• 4. Can disrupt melatonin production

• 5. Diuretic → increased urine production

• 6. Avoid alcohol at least 3-4 hours before bedtime

• 7. Stay hydrated

• 8. Limit intake

Sleep as a nurse..

• Reduce the number of times you wake up clients during night

• Cluster your care

• Establish and assist patients with following bedtime routines

• Promote a quiet and relaxing environment

• CPAP

• Sleep promoting products: Melatonin or chamomile tea

• Last resort = medication

• Education on Sleep

• ● Ensure there is at least two hours between exercise and bedtime

• ● Promote an environment for sleep

• ● Limit the intake of caffeine, alcohol, and/or nicotine at least 4 hours before bedtime

• ● Limit your fluid intake 2-4 hours before bedtime

• ● Utilize muscle relaxation

INSOMNIA

• -VERY COMMON!

• -The inability to get an adequate amount of sleep to feel rested

• -Difficulty falling and/or staying asleep

• -Awakening too early

• -Not getting “good, deep, refreshing” sleep

• A) Acute (stress/personal): a few days, what is an example of this?

• B) Chronic (1 month of more)

• C) Intermittent insomnia: sleep well for a few days, insomnia a few days, switch

• -Who is at greater risk? Women & Older Adults

 SLEEP APNEA

• -5 or > breathing cessations, lasting longer than 10 seconds per hour while sleeping

• -Apneic episodes lead to a decrease in arterial oxygen saturation levels

 NARCOLEPSY

• SUDDEN attacks of sleep during the day

• ● Uncontrollable

• ● Excessive sleepiness during waking hours

• ● Leads to high risk of injury

Central sleep apnea

• • CNS dysfunction

• • Respiratory control center in brain fails to trigger breathing