Show:
Assessment
Diagnosis
Plan
Intervention
Evaluation
100
Patients that have veins that are engorged, have great elasticity, and are well-hydrated!
What type of patients should you practice venipuncture peripheral intravenous lines (IVs) on?
100
Leaking of IV fluid into the surrounding tissue, usually caused by the catheter becoming dislodged or by the needle penetrating through the vein.
What is an infiltrated IV?
100
Nurse gathers IV catheter kit.
What is when nurse is going to start an IV line and order is in place?
100
Patient on anticoagulant has an INR 5.0.
What is contact doctor/anesthesiologist before starting IV, especially in an outpatient ambulatory setting prior to a procedure?
100
Nurse assesses site that was infiltrated from dobutamine with a huge hematoma where IV was discontinued an hour prior to start of her shift.
What is call doctor to receive an order for retavase that helps prevent damage to patient's vein from dobutamine?
200
Two attempts only!
What are the maximal number of unsuccessful venipuncture attempts before calling a more skilled practitioner for help?
200
What is Solution is flowing at a sluggish rate or not at all. Infusion site is cool and pale. Infusion site or extremity is swollen. Patient complains of pain, tenderness, burning, or irritation at the infusion site. Fluid leaking around infusion site. Absence of blood backflow when IV bag/bottle is lowered below IV site.
What is an infiltrated IV?
200
Call the nurse practitioner or doctor.
What nurse needs to remember a doctor's order is needed to start and discontinue an IV line?
200
An intervention measure to rule out an infiltration.
What is if flow is sluggish, pull back on the catheter a bit and rotate it or elevate and depress the catheter a bit. If elevating the catheter helps, a small piece of gauze may be placed under the needle to hold it in position. The bevel of the catheter may be resting against the side of the vein and this will help to free it?
200
Nurse demonstrates she is competent with starting IVs.
What is nurse has preceptor has watched her start an IV on a patient at least 3 times. Check with hospital orientation policy?
300
Every shift and every time nurse receives a new patient receiving IV fluids.
What is when to check a peripheral line?
300
•Inflammation (swelling) in the part of the body affected •Pain in the part of the body affected •Skin redness (not always present) •Warmth and tenderness over the vein
What is thrombophlebitis?
300
Nursing conversation with patient prior to starting an IV.
What is assess patient allergies (alcohol), plan to start IV r/t diagnosis, and explain any questions, anxiety issues patient may have related to IV?
300
Patient has infiltrated IV and a metaport is not accessed.
What is receive order from doctor to access metaport for IV versus starting another peripheral IV line?
300
Nurse realizes needle catheter tip has a pinhole in it after opening package.
What is nurse should discard that catheter in the sharps container and use a new catheter to start IV?
400
When to discontinue IV line.
What is when nurse flushes peripheral line that has no blood return on aspiration and there is a hematoma, when site in infected?
400
What is damage to mucous membrane, corneal, integumentary, or subcutaneous tissues. related factors (causes): fluid excesses, chemical irritants including medications vancomycin is one of the most irritating antibiotics that can be given into a peripheral vein.
What is Impaired Tissue Integrity?
400
What is stop the infusion and notify your supervisor. You may be directed to remove the IV and restart it in an alternate location if there is not a doctor's order. If in doubt, always get a second registered nurse to assess the site to confirm.
What is what the nurse does after assessing an infiltrated IV is harming patient?
400
Patient has a fistula in left arm and a tattoo on the other, start IV in right arm?
What is where to start the IV?
400
Nurse assesses patient realizing IV is almost out, IV pump is beeping and not infusing IV solution.
Nurse should discontinue IV, start new one since order should be in place for a continuous IV with fluids?
500
Preferably, at the most proximal site.
What is where you should start an IV, especially before surgeries?
500
Sepsis, dehydration, surgery, transfusion.
What is when patient will need a 20 guage sized catheter, if not a 22 guage?
500
Must keep pressure off the area to reduce pain and decrease the risk of further damage and raise the affected area to reduce swelling.
What nurse does to reduce tenderness, and hematoma after discontinuing an infiltrated site without a doctor's order after IV has been discontinued?
500
New nurse has never started an IV at her new job and nervous.
When new nurse should seek preceptor, experienced colleague to help her start IV, permitting an order is in place?
500
Nurse has order to start IV with saline infusion, and obtain labs.
What is nurse should obtain labs first off of IV catheter before starting the saline infusion in order to prevent sticking patient twice and infusion interfering with lab results?