Vocab
Define: Infiltration
What would it look like? What are the patient symptoms?
What do you do if this happens?
Fluid goes into the surrounding tissue because the IV was improperly placed into the vein.
It would look like the skin is starting to swell and is cool to touch. It may be painful/numb for the patient.
Discontinue IV and relocate. Elevate the extremity and apply a compress to the area. Don't rub the area.
What are the nurses responsible for when caring for IV catheters?
Assessing an IV site, Examining the solution and bag, Priming and hanging a primary IV bag, Preparing and hanging a secondary IV bag, Calculating IV rates, Maintaining strict aseptic technique, Documenting IV fluid intake, Monitoring the effectiveness of IV therapy, Discontinuing a peripheral IV. Dressing changes, maintaining patency, etc.
Why are IV catheters used?
To deliver medications quickly, to restore fluid/electrolyte balance, to administer medications, to administer nutrition and to administer blood products.
What does a hematoma look like? What do you do if a patient develops this?
A collection of blood in the tissues. This may happen if you "Blow the vein." There may be bruising, a hard/painful lump, and blood at the site.
If this happens, elevate the extremity and apply pressure and ice.
A patient is ordered to receive 1,000 mL of NS to be administered at 125 mL/hour. How many hours will pass before you change the IV bag?
8 hours
1hr/125mL x 1000mL= 8
Define: Extravasation
What are some complications?
What do you do if this happens?
A medication that can be damaging to tissue leaks into the surrounding tissue (infiltrates) of the IV site.
This may cause tissue injury and possibly tissue death depending on the medication, site, and length of exposure.
Discontinue the IV and relocate. Elevate the limb and apply a cool/warm compress. (Same as infiltration)
What should you assess an IV catheter for?
Patency, dressing intactness/cleanliness, redness, swelling, pain, temperature, and signs of complications
When should you change the IV tubing for a continuous infusion? When should you change it for an intermittent infusion?
Continuous tubing: Every 96 hrs or facility policy
Intermittent: every 24 hrs or facility policy
What is sepsis? What can this look like?
What would you do if you suspect your patient is septic?
Bacteria that flow through the bloodstream causing a systematic infection. This can happen quickly with IVs and can be deadly.
May look like: Fever, tachycardia, decreased blood pressure, and malaise
Immediately notify the provider and you may obtain a culture before starting antibiotic therapy
Your patient needs 2,000 mL of saline IV over 4 hours for a patient with deficient fluid volume. How many milliliters per hour will you set on a controller?
500mL/hr
2,000mL/4hrs= 500mL/hr
Define: Phlebitis
What does it look like?
What do you do if this happens?
Inflammation of the vein
It looks like red streaks, warmth, and tenderness along the vein.
Discontinue the IV infusion immediately, and restart the infusion in another vein. Don't use that vein again.
When should you check IV patency? How do you? What would you do if your pump was alarming you about an obstruction?
When initiating IV therapy, before and after administering medications, when the pump is beeping about an obstruction, and when assessing the IV.
Trace to base
Hypotonic: For severe intracellular dehydration (lower solute concentration than the blood so it will move the fluids into the cells) 0.33% NS, 0.45% NS
Isotonic: For fluid and electrolyte replacement. Solute concentration is very similar to extracellular fluid. NS or LR
Hypertonic: Used during critical care situations. May treat hyponatremia and pulmonary edema. May also supply calories and fluid to the body. Solute concentration is higher than ECF and pulls fluid out of the cells into circulation. D5 LR, D5 NS
Speed Shock. What is it? What does it look like? What do you do for this?
When the infusion is too quick
May look like a pounding headache, fainting, rapid pulse, apprehension, chills, back pain, and dyspnea.
Stop the infusion immediately and notify the provider. Monitor VS consistently afterward
A health care provider prescribes 1,500 mL of normal saline to be infused over seven (7) hours. The drop factor is 15 drops/mL. The nurse should set the flow rate of the IV infusion pump at how many mL per hour (mL/hour) and drops per minute (drops/minute)?
mL/hr: 214 mL/hr
Drops: 1,500mL (volume) x 15 drops (drop factor)/60min x 7 hrs (time in minutes)= Drops/Min
22,500 x 420= 54 drops/min
Define: Thrombus
S/Sx
What do you do?
A blot clot
It would look like redness, warmth, pain, and edema at the insertion site.
Discontinue the infusion immediately and restart it on another site. Apply a warm compress if the provider orders and never rub/massage the affected area. Why?
How should an IV site look? What would be abnormal and require intervention?
Redness, swelling, cool or warm to touch, and the fluid should flow freely throughout the catheter.
What is a saline lock, why do we use it?
Flushing small amounts of saline through the IV. This is when the IV is capped off with normal saline when it isn't in use. This prevents clots from forming in the tubing and clears the line of any leftover medication.
What is fluid overload? What does it look like? What do you do if this happens?
Too much fluid is going into the circulatory system.
May cause a high BP, abnormal heart and lung sounds, change in LOC, distended neck veins, and dyspnea.
Slow the infusion rate, notify the provider, and continue monitoring the VS
A health care provider prescribes 1,200 mL of 0.45% normal saline solution to be infused at 125 mL/hour. The drop factor is 12 drops/mL. How many drops per minute should the nurse adjust the flow rate to safely administer the prescribed intravenous solution?
125mL (volume) x 12 drops (drops)/ 1hr x 60(min)= 25 drops/min
Infection at the IV site
S/Sx
What do you do if you suspect an infection?
What complication could come with this?
When microorganisms enter the body via the IV site
Local swelling, pain, redness, tachycardia, malaise, N/V, and fever. This can turn into sepsis if not treated immediately.
Remove the IV, notify the provider, obtain a culture, and administer antibiotics as ordered.
Do you obtain a culture before or after administering antibiotics?
How often should the flow rate be assessed? What can impact the IV flow rate?
Check every hour.
Kinks, infiltration, patient position, blood pressure, and height of the IV solution container can impact the IV flow rate
How would you discontinue an IV?
Why would you?
Hand hygiene and gloves, Check catheter tip for intactness while applying pressure to IV site with sterile 2x2, Document removal, condition of catheter tip, site assessment, and patient tolerance
The therapy may be complete, the patient is tolerating oral intake, IV med d/c, IV site complications/not patent.
Air embolus. What is it? What does it look like? What do you do about this?
An air bubble goes into circulation and blocks a vessel.
May cause respiratory distress, elevated HR, cyanosis, decreased BP, and change in LOC.
Pinch off the catheter, stop the infusion, and work to remove the air bubble. Position the patient on their left side or Trendelenburg position and call for immediate help. Monitor VS and pulse ox.
The nurse follows through an order to infuse 250 mL of plates intravenous over 2 hours and 30 minutes. The drop factor is 10 drops per mL. To safely administer the order, the nurse will set the flow rate of the IV pump at what mL per hour? Additionally, at how many drops per minute?
mL/hr: 250mL/2.5hours= 100mL/hr
Drops: 250mL (volume) x 10 drops/150 min (2hrs x 60min + 30= 150min)= 17 drops per minute