Exam (elaborations)
Nur 172 exam 2- IV THERAPY HONDROS/52 Q’s and A’s
Nur 172 exam 2- IV THERAPY HONDROS/52 Q’s and A’s
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Nur 172 exam 2- IV THERAPYHONDROS/52 Q’s and A’s
WHO recommendations - - Wash hands(b4&after) when doing any FOLEY
care.
No Acrylic Nails
Nails are to be no longer than 1/4 inch
Wash hands for 15-30 seconds
NO JEWLERY
- Hematoma - - Infiltration of blood in the tissues at the venipuncture site
S/S: swelling and discomfort at IV SITE
- Causes of Hematoma
TX - - Poor venipuncture technique
Patients taking steroids or anticoagulants/ASA
TX: direct pressure
Elevate extremity
Ice/cold pack
- TX of Fluid volume overload (pulmonary edema)
S/S - - S/S: Crackles
Blood tinged Sputum
SOB
Low pulse/Ox
TX: IM Lasix, Daily weights, fluid restrictions, Oxygen, slow IV rate or KVO or
STOP it.
- infiltrate - - Common complication; when IV fluid happens to make its way
outside the vein. This is why we check IV sites Q2-4H
S/S: cool, pale, edematous skin with pain
Tx: Heat/Cold compress, take IV out, check facility(MD ORDER) protocol,
elevate extremity, continue to monitor
- Vesicant - - A fluid/ medication that can cause injury or even death to
tissue if leaked outside the vein
- Examples of vesicants - - -Calcium Chloride
-Calcium Gluconate
-Contrast
-Dextrose 10%
-Vancomycin
, -Potassium Chloride
- Extravasation - - infiltration of vesicant type medication
S/S: looks like Infiltration but, blisters develop and the skin starts to slough
off.
Tx: STOP infusion IMMEDIATELY
Check for antidote before removing IV, check with Pharmacists for directions
with heat or cold or elevation of extremity, Monitor Patient closely.
- What can happen when extravasation occurs? - - Prolonged healing
Potential infection
Multi-debriment surgeries
Cosmetic disfigurement
Loss of limb function
AMPUTATION
- Venous Spasm - - A sudden, involuntary contraction of a vein that
temporarily impedes the blood flow through the vessel
Causes: Infusing cold solutions or infusing them too fast
S/S: sharp pain above iv site
- Prevention and TX of Venous spasm - - Remove solutions from fridge to
bring them to room temperature
Administer Med/Iv solution at prescribed rate, ensure adequate dilution
TX: Apply warm compress to site
Slow IV rate down until spasm subsides
- Venous air embolism - - -Lethal but preventable
Happens during placement or removal of CVAD
Catheter fracture
Disconnection of the IV administration set and the catheter without a clamp
Failure to prime
Adding new bag to iv set ran dry
Loose connections
- Venous air embolism - - S/s lightheaded, dyspnea, Cyanosis, tachypnea,
expiratory wheezes, cough, mill wheel murmur, hypotension, chest pain &
mental status changes
- Venous Air embolism Complications - - SHOCK, DEATH
NEROINJURY and/or MI
- Treatment of Venous air embolism - - Prevent more air from entering
patient
Place patient on left side and in trendelenberg
CALL rapid Response
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