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Nur 172 Exam 2/182 Complete Q’s and A’s
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Nur 172 Exam 2/182 Complete Q’s and A’s
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Nur 172 Exam 2/182 Complete Q’s andA’s
Local complications - - Hematoma
Phlebitis
Infiltration/extravasation
nerve injury
local infection
venous spasm
- Hematoma - - bruise
- Hematoma S/S - - Ecchymosis,
Site swelling and discomfort,
Inability to advance catheter,
Resistance during flushing
- Hematoma Prevention - - Use indirect method of venipuncture
Apply tourniquet before venipuncture
Use BP cuff for patients with fragile delicate skin
- Hematoma Treatment - - Remove catheter if indicated.
Apply pressure with 2- ×2-inch gauze.
Elevate extremity.
Cold compresses may be applied.
- Phlebitis - - inflammation of a vein, caused by chemical irritation(Vesicant)
or fragile veins
- Phlebitis S/S - - Site erythema
Streaks
Local swelling
Palpable cord
Pain
fever from infection
- Phlebitis Prevention - - Choose the smallest-gauge catheter for the
required therapy.
Avoid sites of joint flexion, or stabilize with an armboard.
Avoid infusing fluids or medications with a pH below 5 or above 9 through a
peripheral vein.
Avoid infusing fluids or medications with a final osmolarity above 500
mOsm/L through a peripheral vein.
Rotate sites every 72-96 hr according to established policy.
,Adequately secure the catheter.
Use aseptic technique.
For PICCs, teach patient to avoid excessive physical activity with the
extremity.
- Phlebitis Treatment - - D/C
warm compress
elevate extremity
determine cause
analgesics/anti inflammatory
notify doctor
- Phlebitis Scale - - 0 = No symptoms
1 = Erythema at access site with or without pain
2 = Pain at access site with erythema and/or edema
3 = Pain at access site with erythema and/or edema, streak formation,
palpable venous cord
4 = Pain at access site with erythema and/or edema, streak formation,
palpable venous cord >1 inch in length, and purulent drainage
- thrombosis - - blood clot
slow or no infusion
fever
malaise
unable to flush device
IV site pain
- thrombosis treatment - - Do not flush
Never aspirate
Stop infusion and remove short peripheral catheter immediately.
Apply cold compresses to decrease blood flow and stabilize the clot.
Elevate extremity.
Surgical intervention may be required.
For central venous catheters, notify the physician and obtain requests for a
diagnostic study. Low-dose thrombolytic agents can be used to lyse the clot.
- Infilitration (Non-vesicant) - - infusion of substance into tissue
- Infiltration S/S - - Coolness of skin around site,
Taut/blanched skin Edema above or be-low insertion site
Back flow of blood absent
Slowed infusion rate For extravasation: Complaints of pain Burning or
stinging at insertion site
Blisters
, - Infilitration and Extravasation Prevention - - Choose smallest cannula
Stabilize catheter
Avoid areas of flexion
Dont use veins with previous venipuncture
Avoid antecubital fossa
Turn patient carefully
- Infiltration treatment - - Stop infusion
remove peripheral catheters
apply warm compress
elevate extremity
monitor
insert new catheter in opposite extremity
Document
- Extravasation (vesicant) - - escape of blood from the blood vessel INTO the
tissue
**vesicants go on pump
- Extravasation s/s - - pain and/or burning at venipuncture site
blanching
edema
redness
leaking fluid
palpable cord
IV stops working/change in flow
tightness below site
decreased movement
no blood return
feels cool
Tissue sloughing
--usually apparent at 1 to 4 weeks
--result of tissue necrosis
Tissue Necrosis
--can involve small or large area
--can involve underlying connective tissues
- Extravasation Treatment - - Stop infusion, notify MD, administer antidote if
indicated. D/C catheter initially, make an unusual incident report,
avoid bending extremity
monitor
warm/cold compress
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