question

Infiltration

answer

inadvertent administration of a nonvesicant IV solution into surrounding tissue.

question

Infiltration

answer

localized complication that occurs because the IV catheter is improperly placed or secured or becomes dislodged or because the veins are thin and fragile, as in elderly patients. Use of infusion pumps with a pressure setting greater than 10 psi

question

Infiltration S/S:

answer

swelling, discomfort, burning, tightness, cool skin, and blanching.

question

How do you determine if a IV site is infiltrated?

answer

Apply slight pressure over the vein about 3 inches below the catheter tip, and the solution continues to run. IV is running at a slower rate or has stopped.

question

Not a reliable method to determine infiltration?

answer

Checking for blood return

question

Infiltration scale: 1

answer

Pt. has blanched skin, edema <1 in. around the site, cool to touch, with or without pain

question

Infiltration scale: 2

answer

Pt has blanched skin, edema 1 to 6 in. around the site, cool to touch, with or without pain.

question

Infiltration scale: 3

answer

Pt has blanched skin that is translucent, gross edema > 6 in. around the site, cool to touch, mild to moderate pain, possible numbness. May cause damage to tissues

question

Infiltration scale: 4

answer

Pt has blanched skin that is translucent, skin is tight and leaking, skin is discolored, bruised, or swollen, gross edema > 6 in. around site, deep pitting tissue edema, circulatory impairment, moderate to severe pain, caused by any amount of blood product, irritant, or vesicant.

question

Localized

answer

occurring at or around the IV insertion site.

question

Systemic

answer

occurring within the patient's vascular system, away from the insertion site. Can be life-threatening

question

Infiltration intervention and management

answer

Stop the IV and remove the catheter. Determine severity. Notify the Charge Nurse, and Physician. Elevate. Complete an incident report. Start IV in the opposite arm. Elevate extremity. Warm/Cold compress

question

Extravasation

answer

occurs when the unintentional escape or leakage of a vesicant drug infiltrates a patient's IV insertion site that can lead to severe tissue damage and requires emergency treatment. (Chemotherapeutic drugs and dopamine)

question

Extravasation S/S

answer

swelling, burning, tightness, cool skin, and blanching. Burning and pain will be felt around the IV site from the vesicant fluid.

question

Infiltration scale: 4

answer

Extravasation is always rated _______ regardless of the amount of fluid infiltrated.

question

Extravasation intervention and management

answer

Stop the infusion and replace the tubing. DO NOT remove the catheter because it may be needed to administer the antidote into the tissues. Remove/DC the catheter after the antidote is infused and start IV at a new site

question

After the antidote is infused

answer

When should the catheter be removed in extravasation?

question

Extravasation

answer

A patient presents with an ulceration around his IV site. The nurse knows that ulceration around the IV site indicates _______ and can lead to disfigurement, loss of function and/or amputation.

question

Complications

answer

Can result in lawsuits for medical negligence and malpractice

question

Phlebitis

answer

inflammation of the vein due to mechanical or chemical causes.

question

Mechanically caused phlebitis

answer

using a large catheter in a small vein, improperly securing the catheter thereby allowing movement and over manipulating the IV catheter.

question

Chemically caused phlebitis

answer

irritating or vesicant medications or by solutions that are acidic or alkaline or that have a high osmolarity.

question

Increases the risk of developing phlebitis

answer

prolonged use of the same IV site

question

Medications that may cause phlebitis

answer

erythromycin, nafcillin, vancomycin, amphotericin B, potassium chloride

question

Chemical phlebitis

answer

can be caused by particulates in the solution such as medications that do not fully dissolve but are not visible to the eye. Use a filter. Can also be caused by teflon catheters. Use silicone or polyurethane catheters

question

May prevent phlebitis

answer

1. Extra fluid if pt can tolerate it 2. Slowing the infusion rate of irritating infusions 3. Start IVs in larger veins w/ smallest cath appropriate for solution

question

2 to 3 days

answer

Phlebitis may occur _______ after continuous IV therapy

question

72 hours

answer

Replace peripheral catheters every ______ to prevent phlebitis

question

48 to 96 hours

answer

Phlebitis may occur _____ after remove of an IV cannula without the usual signs and symptoms.

question

Several days

answer

How long after cannula removal should sites be checked for phlebitis?

question

Phlebitis

answer

S/S: erythema and/or tenderness at the tip of the device, puffiness over the vein, skin that is warm to the touch over the IV site, slowed infusion rate, elevated temperature.

question

Phlebitis score: 1

answer

Redness at access site with or without pain

question

Phlebitis score: 2

answer

Pain at access site with redness and/or edema

question

Phlebitis score: 3

answer

Pain at access site with redness and/or edema, streak formation, palpable venous cord (hard vein)

question

Phlebitis score: 4

answer

Pain at access site with redness and/or edema, streak formation, palpable venous cord (hard vein), and purulent drainage

question

Phlebitis intervention and management

answer

Grade 2: report to RN or Dr as unusual occurrence, complete incident report Grade 1: stop the infusion and remove device, apply warm/cold compress Grade 3 or 4: Notify Dr.

question

Phlebitis causes

answer

local infection, severe discomfort, and possible sepsis

question

Sepsis

answer

serious systemic infection that is life-threatening

question

Fluid overload

answer

patient has received too much solution or is not able to tolerate increased amounts of fluid

question

Fluid overload signs/symptoms

answer

respiratory distress, neck vein distention, increased BP, bounding pulse

question

Fluid overload intervention/management

answer

Slow the infusion to keep open rate and notify Dr. Place patient in semi-Fowler's position (45 degrees), Administer diuretics and oxygen as ordered.

question

Hypersensitivity reaction

answer

allergic reaction

question

Hypersensitivity questions to ask

answer

Allergies, Family history of asthma, ask mother of 3 month or less infant if she has an allergies

question

after first dose of new medication

answer

When should the patient be assess for complications of hypersensitivity reaction.

question

Hypersensitivity S/S

answer

rash, itching, tearing, runny nose, bronchospasm, wheezing, anaphylaxis

question

Bronchospasms

answer

constriction of the air passages

question

Hypersensitivity intervention/management

answer

Stop the medication immediately and notify the Dr., maintain the vascular device, with continuous IV or as a saline lock. Assess for open airway and support respirations if reaction is severe.

question

Treatment for Hypersensitivity reaction

answer

epinepherine, antihistamines, steroids

question

Infection of IV site S/S

answer

extreme redness at site and purulent drainage

question

Infection of IV site intervention/management

answer

stop infusion, remove catheter, notify Dr., obtain culture from site and/ or catheter drainage as ordered, administer antibiotics as ordered. Monitor for sepsis

question

Patient's with central lines

answer

More prone to develop air embolus

question

air embolus

answer

Emergency situation where air enters the heart and causes it to work harder, if untreated can cause decreased cardiac output, shock, and death

question

May occur when catheter and tubing become disconnected

answer

Air embolus

question

Air embolus S/S

answer

respiratory distress, possible mid-chest, and shoulder pain, nausea, light-headedness

question

Air embolus intervention/management

answer

close off the catheter immediately by using the slide clamp or folding the tubing over on itself. Place patient on the left side, head down (keeps air bubble in the right atrium preventing it from moving into the pulmonary artery.) Start oxygen, and notify Dr. Emergent!

question

left-lateral decubitus (left side) and trendelenburg positions (head down)

answer

What position should a nurse place a patient that is experiencing a possible air embolus?

question

Common problems of IV therapy

answer

1. Difficult insertion 2. IV may not infuse at the correct rate 3. Problems after the IV site is removed

question

Problem encountered, actions taken, and patient response

answer

What should be documented if IV therapy problem occurs?

question

skin lesions or rashes, hard veins, obesity, edema, elderly with fragile veins

answer

Conditions that may lead to difficult venous access

question

Direct a light toward the site of the extremity to improve the visibility of veins

answer

Option to start IV in patients with hard to access veins. Dark skin, rash, dermatitis

question

Sclerosing veins

answer

If the patient has good circulation, use a smaller vein; patient may require central line if no adequate peripheral lines are available

question

Obese patients

answer

Buried veins, must use longer catheter (2 in) or may have shallow veins (causes no problems)

question

Edema patients

answer

Displace tissue fluid by pressing on the access site, insert catheter quickly to prevent the fluid from returning and making the site difficult to see; vein collapse is possible from the pressure; stopping the infusion

question

antecubital vein

answer

Used in patient's with edema if other sites aren't accessible

question

Elderly patients

answer

Because of fragile veins, use the smallest gauge catheter possible, and lower the angle of insertion. Stabilize the vein by pulling it tight, do not apply the tourniquet more than 1 to 2 minutes before you are ready to start the IV and do not apply it too tightly

question

Prevents over-distending and rupturing of fragile veins

answer

Why should the nurse not apply the tourniquet more than 1 to 2 minutes before starting the IV and does not apply it too tightly?

question

Infusion rates

answer

The most common problems with IV infusions are related to?

question

fluid over-load, overdosing, or under dosing of medications, clogged IV catheters, phlebitis, and infiltration

answer

Poorly regulated infusions can lead to:

question

patient-related, equipment-related, or vein-related

answer

Factors that play a role in flow rate control may be:

question

Blood pressure

answer

Patient related factor that leads to poor regulation of infusions

question

Infusion pumps

answer

What type of IV equipment would be used in the patient with high blood pressure to maintain the correct rate?

question

to prevent the family from altering the flow rate

answer

Why is a locking mechanism used on infusion pumps in patients with high blood pressure?

question

Equipment-related problems

answer

Clogged filters, kinked tubing, solutions with a higher viscosity or thickness may run slower, the roller clamp may slip, resulting in a faster rate, height of the pole, warm solutions drip faster than colder solutions, catheters that are against vein walls or the patents arm may bend

question

adjust the regulator to correct the drip rate and continue the infusion

answer

The nurse notices that Mr. Bobs infusion rate is too fast. To correct the problem the nurse must_______ and observe Mr. Bob for signs and symptoms of fluid overload or medication overdose

question

flow rate that is too slow and recalculation of the flow rate based on the remaining solution and the time remaining from the original order

answer

Nurse Sherry notices that Ms. Jones IV catheter is clogged and requires a restart because she's not receiving the correct amount of medication. Nurse Sherry attributes the clogged catheter to a ______ and intervention of________.

question

Infusion pump problems

answer

air in the line, kinked or obstructed tubing, occluded catheters

question

Infusion pump must not be turned off and the setting must not be changed by anyone without proper instruction.

answer

Patient/Family teaching when infusion pump alarm sounds:

question

Loss of IV site, administration of an incorrect amount of fluid, or medication

answer

Nurse Jay explains to a patient's family that the unauthorized setting change or turning off the infusion pump could result in:

question

Vein related problems

answer

infiltration, phlebitis, venous spasms

question

infiltration and phlebitis

answer

Can cause the flow rate to decrease

question

Venous spasms

answer

contraction of a vein that causes the blood to stop flowing through the vessel

question

Venous spasm causes

answer

infusion of cold or irritating solutions or from a solution that infuses too fast.

question

Venous spasm S/S

answer

flow rate will slow or stop, patient will complain of sharp pain that starts at the IV sire and moves up the extremity.

question

Venous spasm intervention/management

answer

dilute additives properly, warm refrigerated solutions before infusing and maintain proper flow rates

question

IV flow rate in primary line has stopped

answer

Check for blood return, use thrombolytic to unclot, check for compications

question

flow rate in secondary line has stopped or too slow

answer

Check that the primary line is lower than the secondary bag, check the solutions in the primary IV line

question

Hang a new IV solution bag, the volume limit has been reached

answer

If the alarm sounds and message displayed is "Infusion complete"

question

Check the insertion site, check for kinks in tubing check for closed clamps.

answer

If the alarm sounds and message displayed is "occlusion"

question

Plug machine into the outlet

answer

If the alarm sounds and message displayed is "Low battery"

question

Reload the medication set

answer

If the alarm sounds and message displayed is "Cassette"

question

Flush the line to clear the air

answer

If the alarm sounds and message displayed is "Air in line"

question

Bleeding and hematoma

answer

Can occur when an IV catheter is removed

question

Hold pressure 2 to 3 minutes with gauze, elevate the arm over the head or on a pillow, use an ice pack if one occurs but check facility policy because it may require Drs order.

answer

Nurse Henry advised the student LPN that Ms. Nutt is taking coumadin and to prevent bleeding and hematoma of the IV site upon removal she should:

question

hematoma

answer

mass of partially clotted blood that has infiltrated into the tissues; it is usually accompanied by bruising around the puncture site

question

Hematoma S/S

answer

swelling and discomfort at the site

question

Site can not be used again until the hematoma is resolved

answer

After a student Lpn removes a patient's IV his skin turns blue and he develops swelling and pain. Another IV is required. The nurse explains to the student that the:

question

1. By the insertion site, 2. on the tubing 3. on the solution bag

answer

Where should a IV set up be labeled?

question

1. date and time of the infusion 2. cannula size 3. solution, or additives 4. Nurse initials

answer

What should be provided on the label that goes on a IV set up?

question

date and time hung, initials

answer

What information should you put on the tubing label?

question

to help determine if the IV is on schedule

answer

What is the purpose of the time strip placed on IV solution bag?

question

patient name, name and amount of solution, name and amount of medication, infusion time, initials of preparer

answer

What information is required on a label for an IVPB solution?

question

solutions that hang longer than 24 hours and catheters that are in place for longer than 72 hours

answer

What factors increase the possibility of complications from IV therapy?

question

swelling, discomfort, tightness, cool skin, blanching, slow or stopped flow rate

answer

S/S of infiltrated IV

question

vesicants

answer

Agent that might cause extravasation

question

prolonged use of the same catheter site, use of irritating solutions, use of a catheter too large for vein

answer

Causes of phlebitis

question

blood pressure and rate changes made by a family member

answer

patient related factors that play a role in flow rate control

question

tubing is kinked under the patient

answer

Cause of an IV to run too slowly

question

Heparin

answer

Medication that increases the chance of bleeding when an IV is removed

question

vesicant

answer

a medication or agent that produces blisters

question

erratic flow rates

answer

Most common problem of IV therapy

question

2 inch catheter, smallest gauge, lower insertion angle

answer

Elderly patient IV access

question

Hand Washing

answer

#1 prevention of preventing infection

question

Always check for precipitation or cloudiness, Pharmacy mixes correctly to prevent complications

answer

To prevent fluid interactions

question

Must check blood levels to prevent ototoxicity, possible respiratory paralysis, after inhalation anesthetics, or neuromuscular blocking agents

answer

To prevent medication interactions

question

Aminoglycosides

answer

These antibiotics are generally incompatible:

question

Amikin-amikacin, cidomycin-garamycin, jenamicin-gentimicin, kantrex-kanamycin, mycifradin-myciguent, neomycin-streptomycin, nebcin-tobramycin

answer

Aminoglycosides that are incompatible

question

access device, infusion, medication

answer

Complications can arise from:

question

local or systemic

answer

Complications are considered:

question

your patient tells you

answer

Pain is what:

question

Ask him/her to rate their level of pain from 0-10

answer

To assess a patient's pain level:

question

the reason for IV therapy, the benefits, and estimated length of time they will be on it

answer

Before IV is started, explain to the patient:

question

Edema of an extremity

answer

What is the first indication of infiltration:

question

immobilized or debilitated patients

answer

Edema may not be due to infiltration in:

question

nerve or muscle damage and loss of function in affected extremity

answer

Severe infiltration may cause:

question

careful monitoring of the IV site

answer

Reduce the risk of infiltration by:

question

Nerve, Tendon, Ligament, and Limb damage Causes

answer

site is selected too close to a joint

question

Nerve, Tendon, Ligament, and Limb damage S/S

answer

tingling, numbness, loss of sensation, loss of movement, cyanosis, pallor, deformity, and paralysis

question

Nerve, Tendon, Ligament, and Limb damage Prevention

answer

Do Not move cannula back and forth in the subcutaneous tissue in an attempt to find a vein. Do not pull the cannula all the way out, pull it back a little, Do not probe, Seen most commonly in the antecubital/brachial nerve area (feels like a shock if hit)

question

Phlebitis insertion site may be cord like

answer

If the IV has been placed in the site for longer than normal, this can occur

question

extravasation

answer

stop fluids and notify dr. immediately

question

INS Phlebitis Grade is more than 2

answer

fill out incident report

question

Cellulitis

answer

Diffuse inflammation and infection of cellular and subcutaneous connective tissue

question

Cellulitis S/S

answer

warm, peau d' orange skin. red streaks over the vessel, vesicles may form and there may be purulent exudate, temp, chills, malaise

question

Cellulitis Intervention / management

answer

elevate limb, cool compresses alternated with warm moist compresses, meticulous hand hygeine, sterile dressings, assess for sepsis, antibiotics, analgesiscs, antypiretics, are adm.

question

Hypersensitive patient

answer

Stay with them and keep them war Slow or DC infusion/Do Not remove cath Take Vital signs and notify dr Have emergency equipment and drugs available

question

pulmonary embolism

answer

6 in 10 clots result in pulmonary embolism

question

air embolism treatment

answer

prevention, reassurance, monitor v/s, document, place in left lateral trendeleburg, CPR if needed

question

Catheter embolism

answer

Once discovered tie tourniquet high on the extremity

Monitoring and Maintaining IV Therapy – Flashcards

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