Chapter Therapy (descriptions Assessment Findings Nursing Interventions)

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Circulatory Overload of IV solution:
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– IV solution infused too rapidly or in too great an amount.
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Infiltration or extravasation:
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– IV fluid entering subcutaneous tissue around venipuncture site – Extravasation: technical term used when a vesicant (tissue-damaging) drug enters tissues.
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Phlebitis:
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Inflammation of inner layer of a vein
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Local infection:
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Infection at catheter-skin entry point, during infusion or after removal of IV catheter
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Bleeding at Venipuncture site:
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Oozing or slow, continuous seepage of blood from venipuncture site
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Circulatory Overload of IV solution — Assessment Findings?
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-Depends on type of solution -ECV excess with Na+ containing isotonic fluid (crackles in dependent portions of lungs, shortness of breath, dependent edema) -Hyponatremia with hypotonic fluid (confusion, seizures) -Hypernatremia with Na+ containing hypertonic fluid (confusion, seizures) -Hyperkalemia from K+ containing fluid (cardiac dysrhythmias, muscle weakness, abdominal distention)
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Infiltration or extravasation — Assessment Findings that you can expect?
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Skin around catheter site taut, blanched, cool to touch, edematous; may be painful as infiltration or extravasation increases; infusion may slow or stop
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Phlebitis — Assessment findings you can expect?
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Redness, tenderness, pain, warmth along course of vein starting at access site; possible red steak and/or palpable cord along vein
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Local infection — Assessment findings to look for?
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Redness, heat, swelling at catheter-skin entry point; possible purulent drainage
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Bleeding at venipuncture site — Assessment findings you should look out for?
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Fresh blood evident at venipuncture site, sometimes pooling under extremity
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Circulatory overload of IV solution — Nursing Interventions
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-If symptoms appear, reduce IV flow rate and notify patient’s health care provider. -With ECV excess raise head of bed; administer oxygen and diuretics if ordered. -Monitor vital signs and laboratory reports of serum levels. -Health care provider may adjust additives in IV solution or type of IV fluid; watch for and implement order.
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Infiltration or Extravasation — Nursing Interventions
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-Stop Infusion – Discontinue IV infusion if no vesicant drug -If Vesicant drug, disconnect IV tubing and aspirate drug from catheter. Agency policy and procedures may require delivery of antidote through catheter before removal. -Elevate Extremity -Contact health care provider if solution contained KCl, a vasoconstrictor, or other potential vesicant. -Apply warm moist compress or cold compress according to procedure for type of solution infiltrated. -Start new IV line in other extremity.
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Phlebitis — Nursing Interventions
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-Stop infusion and DC IV line -Start new IV line in other extremity or promal to orevious insertion site if continued IV therapy is necessary. -Apply warm moist compress or contact IV therapy team or health care provider if area needs additional treatment
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Local infection — Nursing interventions
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-Culture any drainage (if ordered). -Clean skin with alcohol; remove cather and save for culture; apply sterile dressing. -Notify health care provider. -Start new IV line in other extremity. -Initiate appropriate wound care if needed.
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Bleeding at venipuncture site — Nursing Interventions
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-Assess if IV system intact. -If catheter is within vein, apply pressure dressing over site or change dressing. -Start new IV line in other extremity or proximal to previous insertion site if VAD is dislodged, IV is disconnected, or bleeding from site does not stop.

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