Complications of IV therapy
Inflammation of the veins that includes edema, throbbing, burning and warmth to the touch. A red line can be visible up the arm and palpable cord is present
Phlebitis?
The nurse notes coolness of the skin at the IV site and a slow infusion rate. What should the nurse do?
Stop the infusion
Inflammation of a vein
What is phelbitis
What will you include when teaching a patient to use an incentive spirometer?
Incentive Spirometer teaching: place lips around mouthpiece, inhale slowly and deeply, hold breathe as long as possible (count to three). Patient should strive for 10 attempts per hour if possible. Patient goal should be determined during teaching, determine the amount of mL to inspire.
Symptoms include distended neck veins, increased BP, SOB, crackles and edema.
Hypervolemia
SOB, elevated temp, angioedema, rash, itching, chills, pain, anxiety, death
Transfusion Reaction
IV site is cool to touch and pale
What is infiltration
What equipment will the nurse need to suction a tracheostomy tube?
Equipment needed – suction kit (with sterile container, sterile suction catheter and sterile gloves), saline, portable or wall suction unit with tubing, manual resuscitation bag connected to 100% oxygen.
IV solution or medication that leaks into the tissue.
Infiltration
A 20-gauge catheter or larger is needed to administer these products.
What are blood products and IV contrast
This should all be included when labeling an IV infusion with date, time and initials
What is site, tubing and solution
What type of O2 mask for:
A 20 year-old with a fractured nose and multiple chest contusions. The MD has ordered an F O2 of 90 % - 100 %.
Non-rebreather mask
Obstruction of vessel by air caused by disconnection between IV catheter and IV tubing, IV bag running dry or infusion of air into tubing.
Air embolism
Every 72 -96 hrs to reduce complications
What is change IV tubing
IV fluids running 24/day
What is continuous infusion
How would the nurse determine whether to use a Yankauer (tonsillar tip) suction or endotracheal suctioning for a patient without an artificial airway
A Yankaur suction is used for oropharyngeal suctioning. Endotracheal suctioning would be reserved for signs of respiratory distress, or secretions auscultated below the oropharynx. Labored breathing or ineffective cough would be an indication for the need for endotracheal suction.
Systemic infection with pathogens present in the blood
Sepsis/Septicemia
Outside the cell is called?
Extracellular
This catheter is inserted above or below antcubital fossa in proximal or cephalic veins.
Midline catheter
After suctioning a tracheostomy tube what will the nurse include in the documentation?
Document time of suctioning, lung sounds before & after suctioning, ability to cough up secretions, quality and quantity of secretions, trach site skin conditions, reaction to suctioning, pulse ox levels pre and post suctioning
Proper technique and applying pressure after removal of an IV until bleeding has stopped help prevent this complication.
What is a hematoma
This IV administration device is connected to a subcutaneous injection port. The port is surgically implanted in a subcutaneous pocket in upper chest wall. The port consists of a metal sheath with a self-sealing silicone septum.
Implanted port
After entering a patient’s tracheostomy with a suction catheter, the patient begins to cough and his face turns red. What action should the nurse take?
Pull back 1 cm, wait until coughing subsides to apply intermittent suction not to exceed 10 - 15 seconds
During patient/family teaching of tracheostomy care what would you include as signs to report immediately to the physician?
Increased drainage around trach site (esp. blood or purulent drainage), increased redness around trach site, increased secretions, blood tinged secretions, respiratory distress, fever.
Treatment for infiltration
Stop the infusion, elevate the extremity, encourage ROM, apply warm or cold compress, restart the infusion proximal (above) to site or at a different site
This tubing refers to a tubing set which contains two spikes (or arms) located above the drip chamber. One spike is attached to the blood product. The other spike is attached to a normal saline solution. NS is used to flush the IV tubing at the beginning and end of the transfusion
Y tubing
Patient vomits during suctioning?
turn patient onto side, suction vomit, assess lung sounds, and notify physician or provider if aspiration occurs.
Describe the rationale for intermittent versus continuous suction.
Intermittent suction and rotation of catheter prevent injury to tracheal mucosal lining. Constant suction may cause trauma to mucosal lining and removes air from the patient’s airway and can cause hypoxemia.
Strong bounding pulse, JVD, crackles are all indications of
What is fluid overload
This catheter is inserted through a vein of the the antecubital fossa, usually into the basilic or cephalic veins and advanced until tip in distal third of superior vena cava. Used for long term IV therapy.
What is Central venous catheter
In what situations might suctioning be contraindicated?
Suctioning is not indicated if patient has no secretions and can cough up on his own. Low pulse ox levels may indicate a need for increased oxygenation prior to suctioning. Suctioning should be avoided for patients with increased intracranial pressure.
The tip of centrally inserted catheters (also called central venous catheters [CVCs]) rests where?
In the distal end of the superior vena cava near its junction with the right atrium