IV
This complication occurs when IV fluid leaks into the surrounding tissue, causing swelling, coolness, and discomfort at the insertion site.
What is infiltration?
This is the first step in the nursing process and involves collecting information about the patient.
What is assessment?
During a call to the provider, the nurse reports that the patient was admitted yesterday with pneumonia, has a history of COPD, and is receiving IV antibiotics.
What is the Background?
Two common signs of sepsis that the nurse should report immediately are an elevated temperature and this increased heart rate condition.
What is tachycardia?
This abbreviation stands for "nothing by mouth," often ordered before surgery or certain procedures.
What is NPO?
This potentially serious complication occurs when a vesicant medication leaks into surrounding tissue, potentially causing tissue damage and necrosis.
What is extravasation?
An LPN notes a blood pressure of 88/50 mmHg and a heart rate of 120 bpm. These findings are examples of this type of data.
What is objective data?
The nurse tells the provider, "I would like you to evaluate the patient and consider an order for oxygen therapy."
What is the Recommendation?
A patient with suspected sepsis may have this blood pressure abnormality due to poor tissue perfusion.
What is hypotension (low blood pressure)?
This abbreviation means "as needed" and is used for medications that are not given on a fixed schedule.
What is PRN?
Redness, warmth, tenderness, and a palpable cord along the vein are classic signs of this IV complication.
What are signs and symptoms of phlebitis?
This type of data is obtained directly from the patient and cannot be measured by the nurse.
What is subjective data?
This SBAR component should include objective findings such as vital signs, pain level, oxygen saturation, and changes in condition.
What is the Assessment?
Early recognition of sepsis often involves assessing for altered mental status, fever, rapid breathing, and this decrease in urine production.
What is decreased urine output (oliguria)?
This abbreviation indicates a medication should be given "twice a day."
What is BID?
Sudden shortness of breath, chest pain, and decreased oxygen saturation during IV therapy may indicate this life-threatening complication caused by air entering the bloodstream.
What are the signs and symptoms of an air embolism?
When assessing bowel sounds, an LPN should listen to all four abdominal quadrants for this minimum amount of time before determining bowel sounds are absent.
What is 5 minutes per quadrant?
An LPN begins a phone report by stating, "I'm calling about Mrs. Smith in Room 212 because her blood glucose is 52 mg/dL and she is symptomatic."
What is the Situation?
When caring for a patient with sepsis, obtaining blood cultures before administering this treatment helps identify the causative organism.
What are antibiotics?
This abbreviation is used on medication orders when a drug must be given immediately without delay.
What is STAT?
Fever, chills, redness, purulent drainage at the insertion site, and elevated white blood cell count may indicate this complication.
What is a catheter-related infection (or local/systemic infection)?
This abnormal lung sound is often described as a high-pitched, musical sound caused by narrowed airways.
What is wheezing?
An LPN reports: "The patient has crackles in both lung bases, respirations of 28 per minute, oxygen saturation of 88% on room air, and increased work of breathing."
What is the Assessment?
In the management of suspected sepsis, this acronym emphasizes obtaining cultures, checking lactate levels, starting antibiotics, administering IV fluids, and recognizing that every minute counts.
What is BLAST?
This abbreviation tells the nurse to administer a medication before meals and at bedtime.
What is ACHS?
(AC = before meals, HS = at bedtime)