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Intravenous therapy

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Local Complications
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Mechanical
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Identify and correct problem early: adjusting tourniquet insertion site swelling above, below or over catheter site catheter against vessel wall, kinked or bent at flexion point or patient position IV tubing or IV pump malfunction
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Ecchymosis/Hematoma
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Occurs during IV insertion causing local discoloration and may advance to form a hematoma Contributing factors: unskilled practitioner, use of fragile veins, multiple entries into vein, tourniquet on fragile skin, IV attempt to impalpable veins, patient use of steroids, anticoagulants
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Ecchymosis/Hematoma Interventions
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Remove catheter Adjust tourniquet Apply slight pressure to site Area will be sore but not painful Discoloration: resolve in 1-2 weeks If hematoma: remove catheter, apply direct pressure, elevate limb, dry dressing, ice to prevent further swelling, document, check frequently
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Infiltration
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Usually caused by dislodged catheter, causing fluid and medications to infiltrate surrounding tissue Blanching, coolness, tenderness, skin taunt at insertion site, difficult to flexor extend extremity
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infiltration
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Common and can be minor Hypertonic, acid, and alkaline fluids can cause necrosis (if not detected early) Edema occurs resulting in delay in patient receiving the correct amount of fluid as prescribed, limits veins for IV therapy Can predispose patient to infection
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Infiltration
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. To confirm infiltration apply tourniquet proximal to IV site and if infusion continues with venous obstruction then infiltration is confirmed Intervention is to remove catheter and restart IV in another site
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Extravasation
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Edema at site of infusion Blood return may be noted confirming placement in vein, however, not a reliable method, the catheter end may be in the posterior wall of vein but greater portion of catheter in tissues and infusion rate causes leakage and edema at catheter point Drugs contribute to necrosis from extravasations, cause direct cellular toxicity and ischemia Mechanical compression of site can cause increased damage, or infection of the wound Result can be superficial tissue loss Deep structure wound can be severe and lead to wide excision, debridement, grafting or amputation
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Phlebitis
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Common inflammation of the vein from IV infusion Pain and tenderness along the vein, erythema, swelling, warmth at the site & streak formation 3 types: mechanical, chemical,& bacterial Factors influencing inflammation: duration of infusion, solution type, site, veni-puncture technique
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Mechanical Phlebitis
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Catheter placement: areas of flexion increase risk of vein irritation causing injury and phlebitis To evaluate check tourniquet, site, catheter, solution bag, tubing, and involved extremity
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Chemical Phlebitis
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Veins response to chemicals in IV infusion causing inflammation More acidic the admixture, greater the risk Additives such as KCL, Vancomycin, & neoplastic agents Improperly diluted meds or administered too quickly, catheter material or extended dwell time
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Bacterial Phlebitis
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Cause of vein inflammation from bacterial infection Can become systemic if not treated early Hand-washing single most important intervention for preventing nosocomial infection Aseptic technique in IV insertion and care of site
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Post-Infusion Phlebitis
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Presents 48-96 hours after IV catheter is removed Factors are: poor insertion technique, poor vein condition, debilitated patient, hyper tonic or acidic solutions, infiltration, large bore catheter in small vein, failure to change: tubing, dressing’s, site caps or catheter as per policy
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Thrombosis
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An area that roughens or traumatizes the vein wall allows platelets to adhere and form a thrombus Thrombi form at the tip of the IV catheter in the vein, obstructing blood flow Creates a trap for bacteria that may cause an infection
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Thrombophlebitis
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Thrombosis and inflammation both occur Site: tender, erythema, swelling, pain along path of vein If catheter left in place thrombosis obstructs blood flow, vein becomes hard & tortuous, tender and painful Pain may persist indefinitely, incapacitate patient and limit veins for future therapy
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Phlebtothrombosis
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Thrombosis and inflammation not obvious Thrombus is poorly attached to the vein wall Associated with potential embolism
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Interventions/Prevention
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Hand-washing Gloves and gown Mask, eye wear, facial shield Patient care equipment Environmental control Linen Occupational health and blood borne pathogens Patient placement
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Occluded Peripheral Catheter
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Catheter is filled with blood or precipitant and prevents infusion flow Infusion rate slows or stops Resistance is met when flushing catheter Factors: positional catheter, kinked catheter, IV solution bag empty, administration of incompatible meds cause precipitant formation
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Occluded Peripheral Catheter
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Interventions Do not flush or force occluded catheter: may push embolism into circulation Remove catheter: insure intact
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Local Infection
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Infection at the skin catheter entry point Can occur in the absence of phlebitis Pain, swelling, inflammation at catheter entry point Discolored tissue and purulent drainage May occur with IV in site or after removal Intervention: remove catheter & culture site, notify Physician, apply antibiotic ung as ordered, IV antibiotics may be indicated, sterile dressing and assess
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Venous Spasm
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Sudden involuntary contraction of vein Results in temporary cessation of blood flow through vein Numbness to extremity, cramping, pain at catheter site, recognized by patient Pain usually due to tissue damage Factors: administration of cold or irritating meds or solutions
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Interventions venous spasm
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Catheter not discontinued Decrease infusion rate or further dilute medication Apply warm compresses to promote vasodilatation and increase blood flow Infuse cold solutions with blood warmer, if indicated, for rapid infusions
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Systemic Complications
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Occur in circulation Potential to affect all body systems Serious, require immediate intervention Include: Septicemia, pulmonary embolism, air embolism, catheter embolism, pulmonary edema, speed shock, allergic reaction
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Septicemia
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Pathogen enters the bloodstream causing a systemic illness First signs and symptoms: chills fever, general malise, and headache Increased HR, flushed face, backache, nausea, vomiting, hypotension Severe symptoms cyanosis, increased RR vascular collapse, shock and death
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septicemia
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Preventive Measures Hand-washing Check solutions and equipment before use Cleanse site for catheter placement Clip excess hair at insertion site, no shaving Secure catheter to prevent in and out movement Apply sterile dressings over catheter insertion site, change IV tubings, dressings, and site as per protocol.
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Pulmonary Embolism
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Occurs when a mass of undissolved matter floats to the right side of the heart occluding a pulmonary vessel Signs and symptoms: cardiac disturbances, pulmonary hypertension, dyspnea, pleuritic pain, restlessness, cough, sweats, tachypnea, tachycardia, cyanosis
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Interventions PE
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Place patient in semi-fowlers position Monitor V/S notify physician orders may include give oxygen, blood work, heparin infusion, lung scan Preventive measures: use filters if indicated for solutions with large particles, avoid veins in lower legs for IV therapy, use good judgment when flushing IV lines
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prevention PE
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Catheter placement by skilled practitioner Use smallest catheter required Use large veins for irritating fluids, and medications Secure properly
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Air Embolism
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Occurs when a bolus of air enters the vascular system Signs and symptoms chest pain, SOB, shoulder or back pain, cyanosis, hypotension, weak rapid pulse, churning sound over precordium, faint feeling, shock and arrest if not recognized or treated
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Contributing Factors AE
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Open port or leak in infusion system Solution containers run dry, IV tubing and connections become disconnected Failure to remove air from IV tubing or syringe before administration of fluids, or medications
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Interventions AE
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replace leaning or open infusion sets Place patient on left side with head lower than heart Asses V/S, notify physician, give oxygen, be prepared for emergency care
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Preventive Measures AE
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Clamp IV tubings before changing lines Change solution containers while solution remains in container, do not let containers run dry Change leaking set immediately Remove air from infusion sets before use
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Catheter Embolism
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Occurs when a piece of catheter is severed and enters circulation Caused by defective catheters, shearing of catheter during insertion, catheter rupture from forced injection, inappropriate clamping of silicone catheter Most common cause, withdrawal of catheter after insertion of a through the needle catheter causing catheter shearing
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Signs and Symptoms
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Local: catheter and hub separation Severed catheter noted on withdrawal Systemic: cyanosis, hypotension, weak rapid pulse, fainting, cardiac arrest Severity depends on location of embolism Severe symptoms can appear suddenly
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Interventions
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Interventions Notify physician, orders may include tourniquet placement above catheter insertion site, strict bed rest, radiographic studies, surgical intervention, continuous monitoring of patient Documentation: date and time, s/s and severity, cause if known, interventions and patient response
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Prevention
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Check catheter for integrity before use Avoid pulling through the needle catheters back through the needle during insertion Withdraw ONC stylets only when veni-puncture is complete
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Pulmonary Edema
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Occurs when there is more fluid volume than the circulatory system can manage, causes increase in venous pressure Danger of heart failure, shock, cardiac arrest if unrecognized or untreated Signs and symptoms early: restlessness, slow increase in pulse, headache, SOB, cough, progresses to hypertension, severe dyspnea, productive cough, severe engorged neck veins, moist rales
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Interventions
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Goal is to decrease the workload of the heart Decrease infusion rate, place patient in high fowlers position, assess V/S, notify physician, orders may include give oxygen, morphine, diuretics, vasodilators (nitro)
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Preventive Measures
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Assessment of patient before IV initiation Review patient cardiac and respiratory history Monitor patient for tolerance of IV infusion Maintain infusion rates as ordered
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Speed Shock
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A systemic reaction occurs when a foreign substance is rapidly introduced into the circulation, has been confused with pulmonary edema Signs and symptoms: early dizziness, facial flushing, headache, associated with medication administration Progressive symptoms: chest tightness, hypotension
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Allergic Reaction
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Immediate or delayed response to med, blood/ blood products or IV solution Signs and symptoms: chills, fever, erythema and itching, SOB with or without wheezing
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interventions
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Provide patient comfort Notify physician, orders Administer meds: antihistamines, epinephrine, cortisone, or aminophylline Preventive measures: know patients allergies on admission and check before administration of therapies Adequate screening of donor and recipient blood
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Risk factors for IV catheter related blood stream infections:
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Immuno-suppression or deficiency Severe underlying chronic disease Administration of multiple infusions Extended hospital stay Leukopenia Presence of concurrent infection Age Burns
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Extrinsic Factors Means of contamination
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Extrinsic occurs after manufacturing process; occurs in clinical most common
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Primary Causes: Inadequate hand hygiene, Improper admixing of medications, Veni-puncture procedure: contaminated site prep solution or catheter; failure to apply dressing or rotate sites
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Infection Control
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Infusion system failure to: Replace, maintain sterile closed system, accidental disconnection, blood in tubing Medication administration: using admixed meds, use of injection access ports, use of multi-dose vials
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Preventive Strategies
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Proper hand-washing Correct storage of admixture supplies Close inspection of fluids and equipment Maintain aseptic technique Routine rotation of sites (as per policy) Proper skin preparation Routine change of IV tubing and dressings Maintain dry and intact dressing and sterile closed infusion system
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Intrinsic Factors
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Occur during manufacturing process: Low rate of occurrence Regulatory process by industry Preventive Measures
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Preventive Measures
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Inspection of equipment before use for: Discoloration, torn packages, missing or improperly fitting port covers, expiration dates Inspection of fluids before use for: Clarity, particulate matter, puncture holes or cracks, loss of vacuum, damage to bag or bottle closures, expiration date
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Exogenous Contamination
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Caused by transmission of organisms from other than the intrinsic or extrinsic factors Occurs frequently Primary causative organisms staphylococci aureus Prevention: hand-washing and aseptic technique
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Endogenous Contamination
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Caused by patient’s own normal flora Occurs frequently in high risk severely ill patients Primary causative organism: staphylococcus aureus and others Prevention: proper site prep, aseptic technique, and rotation of insertion sites
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Occupational Safety Compliance
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Hand hygiene Universal precautions for blood and body fluids Use of protective equipment: gloves, face masks, gowns, eyewea Safety IV catheters Disposal of sharps
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Protocols for safe handling of blood or body fluids, infectious waste, and sharps need to be adhered to for your safety and the safety of others
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9. Identify the most appropriate veins selected for IV insertion in adults
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Considerations for Vein Selection
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Suitable location Condition of the vein Purpose of the infusion Duration of the therapy
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Vein Location
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Distal areas of upper extremities: *Refer to vein chart Selection after initial puncture is proximal to previous insertion site -Most common: Dorsal metacarpal veins, cephalic, accessory cephalic, median basilic and median cubital -Antecubital veins are poor choice for routine IV therapy (location, high risk dislodging, mechanical phlebitis) best for emergency care
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elderly
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Dorsal metacarpal veins poor choice for elderly, thin walled and thin skin and lack of support tissue makes it difficult to secure IV. Also may not be 1st choice in hypovolemia veins will not fill and distend for puncture.
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Vein Location-Basilic vein
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difficult to access- need to stabilize during puncture
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Upper cephalic
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difficult to visualize – good site for confused patients
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Median antebrachial –
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nerve endings prevent cannulation Always consider patient comfort when selecting location
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Avoid
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Wrists – b/c of close proximity to nerves Lower extremities in adults-small & distal to heart Below a previous IV infiltration or phlebitic area Sclerosed or thrombosed veins
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avoid
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Arm affected by edema, mastectomy, arteriovenous (A/V) shunt or fistula, blood clot or infection
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avoid
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Area of bruising, skin inflammation, disease or breakdown Other – fracture or CVA paralysis of arm
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Condition of Vein
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Palpate vein for depth, size & length Vein should feel soft, elastic & engorged Should NOT feel hard, bumpy, flat or palpate a pulse A large vein not visible but palpable may be a more suitable choice rather than a superficial vein with less blood
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Anatomy
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Veins have valves
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because the flow of blood is returning the heart against gravity
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Veins
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Less elastic, smooth muscle middle layer Thin and weak Lie close to the skin Return blood to heart Valves prevent backflow Will collapse Do not pulsate Have lower pressure
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Arteries
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More elastic, smooth muscle in middle layer Thick and strong Lie deep in tissues Do not have valves Do not collapse Pulsate Have a higher pressure
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IV fluids N/S,R/L, 2/3&1/3, D5W, Rate if high rate for rapid infusion large vein and large bore catheter. Usual rate 100/hr for maintenance post op smaller vein and smaller bore catheter. Patient condition at time of initiation IV dehydrated or hydrated. PICC Peripherally inserted central catheter CLC central line catheter
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Type of IV fluid:
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crystalloids, colloids, blood, blood products, chemotherapy, TPN, or medications pg 90