EXAM 1 MED SURG STUDY GUIDE LATES

EXAM 1 MED SURG STUDY GUIDE LATEST Unit 1 Specialty practice of medical-surgical nursing Promote, restore, or maintain optimal health for patients 18 years and older Nurses must have knowledge, skills, and attitudes to be Care coordinators Transition managers Caregivers Pt educators Leaders Advocates for the pt and family The joint commission: effective care coordination and transition management Understandable discharge instructions for the patient and family Explanation of self-care activities Ongoing or emergency care information List of community and outpatient resources and referrals Knowledge of the pts language, culture, and health literacy Medication reconciliation Safety The ability to keep the patient and staff free from harm and minimize errors in care Nursing safety priority boxes Critical rescue Action alert Drug alert The join commission: a culture of safety Blame-free approach Patients and families are safety partners w/hcp and organizations Serious events must be reported Teamwork and interprofessional collaboration Collaborate with interprofessional health care team Interprofessional education collaborative competencies Values/ethicsforinterprofessional practice Role-responsibilities Interprofessional communication Teams and teamwork Communication: SBAR Formal method of hand-off communication between two or more health care team members 4 steps s-situation (name, age, dx) b-background (history, home meds, allergies) A-assessment (ivs, v/s, labs) Recommendation/request (plan, pt updates) teamSTEPPS Delegation Process of transferring a selected nursing task or activity to a competent UAP (unlicensed assistive personnel) The nurse is always accountable for the task/activity delegated! Nugget** Make sure they understand, and it is within their scope of practice!! Be specific Prioritization and delegation Physiological, psychological, acute, chronic, unstable,stable, unpredictable, predictable Five rights of delegation Right task Right circumstances Right person Right communication Right supervision Supervision Guidance or direction, evaluation, and followup by the nurse to ensure a task/activity is performed appropriately Evidence-based practice (EBP) Integration of the best current evidence and practices to make decisions about patient care Ethics Considers patient preferences and values Considers one own clinical expertise for delivery of optimal health care Addressesissues and questions about morality Attributes Autonomy Beneficence Nonmaleficence Fidelity Veracity Social justice Common health problems of older adults Concepts The priority concepts are mobility nutrition and cognition Subgroups of late adulthood Young old- 65 to 74 years Middle old 75-84 years Old old – 85 to 99 years Elite old- 100 plus Common health issues and concerns Performance of adls Participation in social activities Losses Health promotion Special considerationsfor older adult clients Decrease tolerance to meds Decrease iv rate to avoid fluid overload Increase risk of: Respiratory depression Pneumonia Disorientation Skin breakdown Problems w/ Circulation Nutrition Constipation Fluid and electrolyte balance Increase balance and decrase falls Sudden increase in confusion Urine infection Hypoxia Electrolyte imbalance Clinical management Treat coexisting medical disorders Cardiac problems Pvd Neurological disorders Nugget** Copd Resp. issues Common health issues and concerns Impaired nutrition and hydration Impaired mobility strokes, risk falls Stress, loss, and coping Accidents Drug use and misuse Impaired cognition Substance use Elder neglect and abuse Nugget** Depression Health need: seeing MD as needed Impaired nutrition and hydration Increased need for calcium, vit a/c/d, fiber Diminished taste and smell, tooth loss, poor dentures can impact nutrition status Constipation concers Loneliness Skin breakdown Nutrition support Avoid friction,shearing Reposition and provide support surfaces Increase mobility and activity Clean skin, use moisture barriers Rehabilitation interprofessional team Nurses, nursing assistants Physicians and physician assistants Advanced practice nurses Physical therapists and assistants OT and assistants Speech-language pathologists and assistants Neuropsychologists Social workers Psychologists Spiritual care counselors Registered dietitians Pharmacists Cardiovascular and respiratory assessment Assess for decrease in cardiac output Chest pain Weakness and fatigue Plan care to maximize limited energy resources Frequent rest periods Major tasks in morning Determine level of activity that can be done without invoking symptoms Nugget** Fluid in lungs and DVTs SOB Crackles,rhonchi Improving physical mobility Safe patient handling practices Position changes(bed to chair, commode, or wheelchair) Provide assistance w/ transfers Gait training Use of assistive devices/ambulatory aids(canes and walkers) Implementing ROM routines/exercises Coordinate care w/PT and OT Assess pts mobility levels using standardized tool Nugget** look at chart 6-1 Canes and walkers** Cane opposite affected leg (COAL) Walker, with, affected leg (wandering Wilma’s alwayslate) Skin and tissue integrity assessment areas Assessskin integrity Actual or potential interruptions in skin and tissue integrity Pressure injury: asses problem and possible cause Observe for areas of further breakdown and relive the pressures on these Measure depth, diameter of open skin areas Photographs may be taken based upon agency policy and consent obtained Reposition pts every 1-2hrs Maintaining skin integrity Frequent position changes w/ adequate skin care,sufficient nutritional intake (protein) Turn and reposition at least every 1 to 2 hrs Provide adequate skin care Ensure sufficient nutrition Use pressure-relieving or pressure-reducing devices Nugget** Take into consideration Diabetics and geriatrics Sandals Too tight shoes or high tops Pressure ulcer Sustained pressure ofsoft tissue that becomes compressed between bony prominence and external surface for extended period Mechanical forces create ulcers Friction: rubbing together Shear: friction and gravity Pressure ulcerstaging Stage 1: nonblanchable erythema of intact skin, area usually over bony prominence Stage 2: partial thicknessskin loss, ulcer involves epidermis or dermis (skin tear, blister) Stage 3: full thickness, skin loss with subcutaneous damage, ulcer extends down to fascia, presents asshallow center. Bone, tendon, muscle not exposed, may have undermining and tunneling Stage 4: full thickness, skin loss with extensive destruction, tissue necrosis, damage to muscle, bone, tendon or joint capsule (worse case), undermining and tunneling common with sinus tracts possible, slough and eschar often present Laboratory and diagnostic assessment Exposed chronic wounds are colonized w/microorganisms but not alwaysinfected Swab cultures are helping identifying bacteria on surface Infection is diagnosed based on clinical indicators,systemic signs Arterial blood flow studies Prealbumin, albumin, total protein Pressure ulcer: risk factors Medical conditions: DM,stroke, dementia Ams Moisture (sweating, incontinence) Age over 65 h/o pressure ulcers body type/size: obese or very thin immobility anemia ischemia immunosuppression poor nutrition external pressure General principles of wound care Keep wound bed moist (promotes healing) Cleanse would with NS or wound cleanser, pat dry Stage 1: take pressure off the wound, dressing or ointment may not be required Stage 2: clean with NS. DO NOT USE BETADINE OR PEROXIDE. Hydrocolloid dressing (noninfected wounds) Stage 3 or 4: Moisten gauze with NS, gently pack into wound using q-tip Infected wound-wound culture first then antibiotics Wound care products Hydrocolloid dressing Hysept 50 sodium hydrochloride solution: used for infected wounds or prevention of surgical wound infection Wound vac: diabetic, PAD Braden pressure ulcer risk assessment Sensory perception Moisture Activity Mobilty Nutrition Friction or shear Herpes Zoster (shingles) Pathophysiology Varicella-zoster virus Maintains a dormant state for some time Reactivation after a stressful event (orsignificant illness) Follows a dermatome type outbreak Areastypically affected Chest, back, face Risk factors Advanced age, previous varicella exposure, immunosuppression,stressful event Manifestations Severe pain, fluid filled blisters(vesicles), malaise (feeling of unwell), fever, and itching 10-30% increases w/age Rarely crosses midline; band-like pattern Neuropathic pain; treat pt for nerve pain Dx Nature of the pain, dermatome pattern Tx Antivirals(virs) Nurse pain (gabapentin) Nursing care Maintain appropriate precautions, pain medications as prescribed and anti-viral Vaccine Zostavax (live vaccine) Recommending for those 50 and older; prevents shingles in 50% of cases, reduce risk of post-herpetic neuralgia: contraindicated in immunosuppressed individuals Shingx- new vaccine 90% prevent, inactivated vaccine If you received chicken pox vaccine still can get shingles just much less likely Shingles: isolation If patient is immunocompetent and rash islocalized, standard precautions and cover lesions If it is disseminated, standard plus airborne/contact (rash is everywhere, blisters open) Psoriasis Chronic autoimmune, inflammatory disorder Pathophysiology Hyperproliferation (thicken) of cells of epidermis, known as keratinocytes Manifests as erythematous red plaques covered with silvery scales Pruritis Auspitz sign: scratching the scale can lead to bleeding Location Affects extensor surfaces such asthe elbow or knee, also scalp or back of neck Triggers Genetic, 1/3 pts have someone in their family w/psoriasis Injury to the area: sunburn, surgery Cold Infection: strep pharyngitis Medications: beta-blockers, lithium Stress Treatment High potency corticosteroid ointment (betamethasone), vit D3, analog creams. Methotrexate (decrease inflammation), immunomodulating drugs(cause immunosuppression) (test for TB) Helpful: naturalsunlight, active lifestyle, uv radiation Nursing care Trigger education Emotionalsupport Advise against tanning beds Cellulitis Support groups Psoriatic arthritis: complication, as many as 30% of pts. Joints are affected Bacterial infection of the skin and subq tissues Often caused by staphylococcus aureus also GAS Those at high risk are IV drug users, diabetics, PAD, elderly, and immunocompromised, cancer, venous stasis, immobility Manifestations-localized pain, erythema, warmth, edema, pyrexia Treatment-antibiotic, pain control, and supportive care Complications are higher in those who smoke have diabetes, and pad Osteomyelitis Nursing care Administer antibiotics Monitor for response to treatment Warm soaks Elevate extremity Skin cancer Uncontrolled, abnormal growth of cells Basal cell carcinoma: most common,slowest growing, least likely to metastasize; develops from cells in the epidermis; appears small, pearly skin colored bump or nodule Squamous cell carcinoma: second most common; develops from cells in the epidermis known as squamous cells. This type is more dangerous and more likely to reoccur after surgery and to metastasize. Looks like red nodule or rough scaling patch Malignant melanoma: life-threatening skin cancer that develops from melanocytes. Presents as black or brown mole, may appear red, white, blue, or grey, least common but most dangerous Overexposure to sunlight is the leading cause Risk factors-occupation, tanning bed use,skin color, individuals who have a large number of moles and freckles. Also family history Primary prevention-discourse tanning bed use and reinforcement regarding sunblock (spf 30 or higher) hats, light colored clothing and when to go outdoors (11am-3pm) A-asymmetry the mole is irregular B- border the border of the mole is irregular raised or notched c- color the color is dark d- diameter greater than 6mm e evolving mole that looks different from other moles or that is changing in size shape or color is another warning sign of melanoma prevention and management of skin cancer prevention protective clothing (hat,sunglasses) sunblock-apply at least 30 minutes before sun exposure (every 2hrsreapply) body mapping monthly skin self-exam surgical cryosurgery mohssurgery nonsurgical drug therapy 5 fluorouracil cream Topical chemotherapy Melanoma BRAF indication Bedbugs A parasite cimex species; 30 species Larger than scabies Bitesthe host skin prefers nocturnal feeding Bites are painless Skin reaction: Pruritis Erythema Wheal Tx: not usually required, possibly corticosteroid cream or antihistamine Prevention: insecticides, eliminate hiding spots Nursing care- belongings should secured (double bagged) and not confined to a specialized area Client should be bathed Contact precautions Scabies Skin infestation by a mite, parasite that infectsskin, lives I the epidermis, creates tunnels Risk factors- transmitted person to person, poor hygiene, dorms, health happens in crowded placessuch as schools and homelessshelters. Treatment with permethrin cream Sx: intense pruritisthis is especially severe at night. Erythematous papules, sites of involvement finger web spaces, flexorsurface of wrist/elbows, axillary folds, beltline, lower buttocks, genitalia, Tx: permethrin or lindane; must also treat contacts and wash all clothes and bedding in boiling hot water Nursing care- belongings should secured (double-bagged) and not confined to a specialized area Client should be bathed Very contagious Contact precautions Pediculosis Head lice Manifested by intense itching Risk factors- hair to hair contact, sharing personal items, occursin people with longer hair Lice attach to hair, lay eggs, feed on blood from scalp Treatment with permethrin or lindane cram Nursing care belongingsshould be secured (double bagged) Educate pt on preventing the transmission wash all clothing and bedding Client should be bathed Contact precautions Nail assessment Dystrophic nails may occur with a serious systemic illness, or local skin disease involving the epidermal keratinocytes Occupation can also have significant impact on the condition of nails (chemical exposure) Examine the nails by looking at the curvature and surrounding tissue. Palpate the nails to assess for sponginess, tenderness or edema Nail disorder Clubbed nail Hypoxia, COPD, CF, chronic HD Spoon nail Iron deficiency, poorly controlled DM, chemical irritants Physiologic defenses Body tissues Phagocytosis Inflammation Immune systems Antibody-mediated Cell-mediated Methods of infection control and prevention Hand hygiene Disinfection/sterilization Standard precautions Transmission-based precautions Airborne Droplet Contact Staff and pt placement and cohorting Isolation precautions Standard Contact Droplet Airborne Reverse isolation Donning your PPE #1 hand hygiene #2 gown #3 respiratory protection #4 eye protection #5 gloves Doffing your PPE #1 gloves #2 eye protection #3 gown #4 respiratory protection #hand hygiene Contact precautions(in addition to standard precautions) Stop visitors: report to nurse before entering Gloves Hand hygiene Gowns Patient transport Limit, ensure pt body are contained and covered Pt care equipment Use disposable or clean Mrsa, vre, pediculosis, scabies, RSV Contact precautions(Clostridium difficile; c. diff) Everything as above just wash hand only with soap and water no alcohol-based sanitizers Droplet precautions Visitor report to nurse before entering Don mask Hand hygiene Private room 3ft away from pts or visitors Patient transport limited; pt to wear mask and follow respiratory hygiene/ cough etiquette Influenza Mumps Pertussis Meningitis(bacterial only, n. meningitides or h. influenza type b) Airborne precautions Visitorsreport to nurse Pt placed in negative pressure room Keep door closed at all times Pt transport pt must wearsurgical mask and follow respiratory hygiene/cough etiquette Hand hygiene Nurses wear n95 or anting higher level when entering room TB Measles Chicken pox (airborne and contact w/open weeping lesions) Shingles(airborne and contact for those w/disseminated lesions) Methicillin-resistant staphylococcus aureus(MRSA) Does not respond to methicillin or other penicillin-based drug Susceptible to vancomycin, linezolid, cefazoline fosamil Spread by Indwelling urinary catheters Vascular access devices Endotracheal tubes Community- associated MRSA Causesinfectionsin healthy non-hospitalized people Heath teaching is important Perform frequent hand hygiene, including use of hand sanitizers Avoid close contact with people with infectious wounds Avoid large crowds Avoid contaminated surfaces Use good overall hygiene Unit 2 Pain defined Official definition an unpleasant sensory and emotional experience associated with actual or potential tissue damage More personal definition pain is whatever the pt says it is existing whenever he or she says it does Pt is the authority on pain Self report is the most reliable indicator Assess pain using a standardized pain assessment tool M-morphine O-oxygen N-nitro A-aspirin If pt refuses morphine due to any condition call MD for new orders Types of pain Acute pain Short-lived: usually hrsto days Resultsfrom sudden, accidental trauma,surgery, ischemia, inflammation Sympathetic response, increased b/p, HR, dilated pupils Potential warning sign Chronic (persistent) pain Usually longer than 3 months Ex. Cancer pain, osteoarthritis Gradual onset Can lead to deconditioning Sympathetic nervous system speeds up except for GI Fight or flight response Pain protects Chronic pain can be adaptive NUGGET** Acute up to 3wks Ischemia causes pain-dead tissue Inflammation process-WBC rush to area Can lead to deconditioning -pain and don’t want to move or do anything Chronic pain-assess how pain impacts pt ADLs Categorization of pain by underlying mechanisms Nociceptive Somatic Cutaneous orsuperficial Deep: bone, muscle Visceral Pain that typically originates at the organ level (pancreatitis, appendicitis) Stimulation of nerve cells due to inflammation or injury Sprain, bruise, etc. Neuropathic pain DM, phantom limb pain, HIV, neuropathies , may be described as burning or numbness (shooting, shock like, stabbing) Dysfunctional pain Nerve injury Malfunction of the nervous system due to other disease or injury. Ex. Shingles, vitamin b12 deficiency Pain assessment Nurses role Accept pts self-report Do not label pts, always advocate for proper pain control Assess frequently many pts are reluctant to report pain (older adults) Act promptly to relieve pain Respect values and preferences of patient Family centered approach to gathering information about pain Assess after pain meds IV-15-30mins PO- within 1hr Always use a standardized pain assessment tool Numeric scale most used 1-10 Wong-baker FACES pain rating scale-used in peds Pain assessment in advanced dementia PAINAD PTS who are confused Faces pain scale- similar to wong-baker used for adults Pain assessment in vented pts #1 yes/no signal, thumbs up or down (if awake/alert) #2 communication boards (if awake/alert) Not sedated!!! Pain assessment PQRST acronym (very important) P- what precipitatesthe pain? Exercise? Rest? Q- what is the quality of pain? Dull? Ache? Sharp? used? R- doesthe pain radiate? Referred pain S- severity? What is the severity of the pain on a scale 1-10? Other scales that may be T- what treatment worksfor you usually? When did the pain start? Meds in older adults absorb slower watch pain meds when given can cause resp depression. Pharmacologic management of pain (NUGGET) Basic principles of pain management: prevent and control pain Multimodal analgesia: using two or more classes of analgesia to target different pain mechanisms may allow for lower doses of each drug Post operative pain: combination therapy Pre-medicate before procedures, activity Oral route is preferred, IV can be used if pt is NPO or nauseated, or if pain is severe or escalating Opioids mainstay in management of moderate to severe nociceptive types of pain Mu agonists(morphine like) are first line, ex. Morphine, fentanyl, hydromorphone, oxycodone, hydrocodone The desired outcome of titration isto use the smallest dose that provides satisfactory pain relief w/ the fewest side effects Older adults: start low and go slow, starting dose should be 25-50% lower Meperidine (Demerol) is not recommended for treatment of any type of pain (toxic, used to manage shivers) PCA infusion pump Can deliver pain medication IV or epidural Useful for those requiring ATC pain control Postsurgical Basal rate (automatic dose) Demand dosing Oxygenation concerns v/s education verification; two nurses only the pt should push button to administer medication educate both pt and family ptshould also have Narcan prn ordered (for antidote) used for 24-48hrs Lethargic stop meds Caring for a client with an epidural (ex. Thoracic surgery) Combination therapy ropivacaine and fentanyl Respiratory depression** Monitor pulse oximetry closely Blood pressure changes Hypotension is the most common Report 25% change (15-20 mmHg difference) Infection Mentalstatus changes Pyrexia Nuchal rigidity (neck stiffness) Post procedure headache (CSF leakage) Report promptly Bp drops when inserted-CSF fluid Check v/s-hypotension (give bolus before given) Post procedure headache-losing CSF fluid Assessing the client w/ an epidural Frequent vs Pain intensity rating Sedation score Degree of motor/sensory block Motor assessment: patient should be able to bend knees/lift buttocks Epidural tubing should be yellow lined without injection ports and labeled Monitor insertions site for REED (redness, erythema, edema, drainage), make sure dsg secure Absolutely no anticoagulants!!! May end up w/spinal/epidural hematoma Surgical emergency Severe pain, weakness, numbness, difficulty walking, loss of bowel or bladder control, urinary retention, paralysis Pain intensity rating- check if epidural is working Sedation score-medication effects CNS Opioid concerns: physical dependence, tolerance, and addiction Physical dependence: normal response (rely on med) Tolerance: increased dosesrequired to achieve same effect ( decrease in side effects) Opioid addiction: chronic neurologic and biologic disease (craving and continuous use despite harm) Pseudo addiction: mistaken diagnosis of addictive disease Opioid naïve (not used to taking meds) vs opioid tolerant Sickle cell always in pain Effects of opioids Side effects are dose related - constipation - nausea - urinary retention - vomiting - pruritus - sedation leading to respiratory depression; falls!!! - respiratory depression - reversal agent: naloxone (Narcan) NUGGET** Pain meds slows everything Resp rate 12-20 Safety falls!! Non-opioid pharmacological management Lidocaine Patch and topical cream (on for 12 off for 12) Shingles pain, localized pain Acetaminophen Max dosing (4g) Antidote: acetylcysteine Contraindicated liver disease NSAIDs(ibuprofen, naproxen, Toradol, aspirin) Side effects: increased risk for bleeding/bruising GI bleeding, renal insufficiency Nephrotoxic HTN use cautiously COX-2 inhibitors(Celebrex) Caution w/ heart disease Less side effects Non-pharmacologic interventions Elevation of affected body part RICE Relaxation Distraction (music, TV, visitors, someone to talk too, reading book Heat/cold: do not apply directly to skin use a barrier!! No more than 15-30mins (3 or 4x a day) Never ok to deliver a placebo, violate informed consent laws Physical interventions-TENS Transcutaneous electrical nerve stimulation unit Stimulate nerve fibers thereby stimulating the release of endorphins Client adjuststhe current to a sensation described as pins and needles Disposable electrodes Is an adjuvant treatment (used in addition to other pain management measures) May cause tingling or pins/needles type sensation Placed directly over or near site of pain A minimum of two or up to for pads may be used Startsto work immediately may take up to 30mins for desired effect May be used as long as desired typically 30mins- two hrs May cause some minorskin irritation NUGGETT** Help minimize pain addition to pain medication Working if you feel pins and needles Miscellaneous analgesics Dual mechanism Tramadol Ultracet Neuropathic pain Anticonvulsants Carbamazepine Topiramate (Topamax) gabapentin first line for persistent neuropathic pain antidepressants TCAs poor choice for older adults(orthostatic hypotension) SSRIs SNRIs Considerations for older adults: opioids Start with low doses and titrate slowly More prone to side effects and adverse reactions Polypharmacy concerns and interactions Systematic assessment of pt response Avoiding meperidine (shivering) Teach caregivers measuresto reduce falls and accidents Home safety assessment is recommended Perioperative care Urgency, degree of risk and extent ofsurgery Urgency Elective: hernia repair, cataract removal (non acute problem) Urgent: bone fx, kidney stones (fix within 24-48hrs) Emergent: trauma, AAA, cardiac cath (has to be done now) Degree of risk Minor: biopsy Major: CABG Extent Simple; only most overtly affected area Radical; more extensive Minimally invasive; endoscopic Many different reasons Cosmetic Curative; resolves a health problem Palliative; improve symptoms Diagnostic; lap Pre-operative safety checklist Surgical care improvement project (SCIP)(to reduce complication) Focuses on a safe transition through pre-and post-operative care. Ten core measures are associate with SCIP Prophylactic ABX within a specified time frame. Within one hr prior to surgical incision (do not give send w/pt give in OR) Discontinue 24hrs after administration (up to 48hrs) Hyperglycemia avoidance Less than 200 mg/dL (postop to heal) Post-op urinary catheter removal Within 24-48hrs Do not stop beta-blockers prior to surgery; continue BB post operatively Appropriate VTE prevention: heparin/lovenox, scds Hair removal: use clippers not razor!!! Temperature management- greater than or equal to 36 degree Celsius Pre-operative teaching Smoking-client should be counseled to abstain from smoking; at least 24hrs prior to surgery NPO- pt not to ingest anything by mouth for 6-8 hrs before surgery Decreases risk for aspiration Give pt written/oral directions to stress adherence Surgery can be canceled if instructions not followed Clarify medication orders(may give with sip of water (up to MD)) meds for cardiac or respiratory disease, seizures and hypertension are commonly allowed; insulin dependent diabetics may receive reduced dose of insulin before surgery Addressfear and anxieties(reassurance) Education on pre-operative routine; NPO, blood samples, IV lines, catheters Start post-op teaching in pre-op setting; incentive spirometry, c & DB, SCD’s,splinting, pain management Skin preparation Break in the skin increases risk for infection Pt may be asked to shower using antiseptic solution Hair removal by electric clippers (chlorhexidine) Shaving of hair creates risk for infection Preoperative medications Promote relaxation (sedatives, hypnotics) Diazepam, lorazepam, Vistaril, midazolam Specific purpose drugs; metoclopramide (Reglan), famotidine (h2 blocker) (used to reduce gastric acid) Given before going down to surgery or day surgery setting Nugget** Consent before these meds are given!!! Rails up (3), bed in lowest position, call light in place Preoperative nursing responsibilities Vitalstatistics Age, height, weight, allergy, complete medical/surgical hx Complete medication hx, family hx Anesthesia reactions*** Blood transfusion reactions Diagnostics Lab work (HCG, CBC, COAGS, CMP) Type and screen (UA/UDS) Pulmonary functioning tests, ekg, chest x-ray Legal and ethical Discharge method Completed blood and surgical consents (3) Advance directive family Misc. Is the client competent? Patent large bore IV (one in each arm Removal of jewelry and personal effects(hearing aids, nails, dentures): give to Pre-operative antibiotics Post-op teaching Have the client empty their bladder NUGGET*** Interview-hx, allergies, medications, Consents(before preop meds-under influence); also blood consent signed; consent can be withdrawn anytime!! Spiritual Blood transfusions, religion Physchologial needs Scared Nurse teaching Pre and post op care, limits Lab WBC, (infection no sx), HH (blood), electrolytes-potassium controls heart Cough, turn, deep breath-expanding lungs prevents collapsed lung (atelectasis); give insensitive spirometer Leg exercise-prevent DVT Pain meds-constipation (give stoolsoftner) Pulse less then 94% report it, s/s of infection (fever), PT INR watch Malignant hyperthermia-muscle rigity, elvated temp, genetic Pre op checklist day of surgery Know PT, INR, K 3.5-5, mag 1.5-2.5 Allergy band-medication what able to give Id band -right pt Vs-make sure pt isstable NPO-document last time intake-prevent aspiration Document valuable-send w/family, yellow/white Why you can’t eat or drink before surgery Risk of aspiration Risk of infection and surgery complication Bowel prep interference Risk of nausea and vomiting Refrain from food and fluids 6-12 hrs prior to surgrey unless your doctor tells you otherwise Post op-meds Zofran (nausea), pain meds IV catheter sizes 20 or larger (smaller # wise) is a large bore needle 24g-peds Blue 22g Green 18g Pink 20g Orange 14g Gray/purple 16g Informed consent Surgeon obtains signed consent before sedation and or surgery Nurse witnesses signature clarifies facts and dispels myths about surgery Nurse not responsible for providing detailed information about procedure No abbreviations on the consent Translator phone must be used!!!-mandatory Special consideration Pt who cannot write may sign X Two person witness In emergency, telephone authorization is acceptable Two person witness Physician override in emergentsituations Client can withdraw consent at any time Risk, benefits and alternatives- must be explained by surgeon Nugget** MD to mark surgical site Time out-right PT, right time, and right physician Older adults: changes of aging as surgical risk factors Decreased Cardiac output, peripheral circulation Vital capacity, blood oxygenation Blood flow to kidneys, glomerular filtration rate Nutritional deficiencies Co-morbid conditions Increased Blood pressure Risk forskin damage, infections Sensory deficits Deformitiesrelated to osteoporosis/arthritis Not healthy Clearance forsurgery National pt safety goal Surgical time-out Critical to prevent wrong-pt or wrong-site surgeries Standard identification process Verifying the surgical procedure and consent Verifying the right site Document the time out and the participants Mandatory to be performed before the procedure The surgeon putsthe mark on correct site before surgery Anesthesia An induced state of partial or total loss os sensory perception, with or without loss of consciousness Used to block nerve impulse transmission,suppressreflexes, promote muscle relaxation, and in some cases achieve a controlled level of consciousness Types General Local or regional Moderate sedation- partially but sleep and still follow commands General anesthesia Reversible loss of consciousness induced by inhibiting nerve impulses with the CNS Results in analgesia and amnesia Delivered via IV and gas Medication used is based on individual pt. General anesthesia complications: malignant hyperthermia Acute, life-threatening complications May be genetic Pre-operative testing Begins with skeletal muscle exposed to specific agent Causes increased metabolism, calcium levels in muscle cells Manifestations: increased co2 production, acidosis, fever(temperature greaterthan 38.8), muscle rigidity, tachycardia, delirium, Coca-Cola colored urine 100% oxygen (intubation is preferred) Terminate surgery if possible ABG Assess ECG/I&O/ICU admission Anti-dote: dantrolene sodium Notice extreme high temperature first Nugget** Tachycardia happensfirst, cocoa urine, intubation, check ABG, ECG, I&OS Local or regional anesthesia Briefly disrupts sensory nerve impulse transmission from a specific body region reducing pain perception Local Delivered topically or by local infiltration (injection), into the area affected Regional Blocks impulses nerves offering a regional affects(field block, nerve block,spinal, epidural) Nugget** Regional-monitor VS (it can go system)-bolus before bp drops Postoperative period Immediate period 1-4hrs aftersurgery Intermediate period 4-24hrs after Extended period 1-4 days after PACU not good time for teaching Post-operative areas of assessment Respiratory Complete vs collection Patent airway-advanced airway RR, characteristics (bradypnea, accessory muscle use) Oxygen saturation greater than 92% Breath sounds, diminished at first. Adventitioussounds(stridor, crackles) Incentive spirometer goal to reach baseline Cardiovascular Continuous monitoring (arrhythmias) BP (low blood pressure= hypovolemia) (high blood pressure= pain) All pulses Thermoregulation (preventing hypothermia)(layer warm blankets) Neurological LOC Following commands appropriately Extremity movement Fluids and electrolytes Strict I&Os (surgical drains as well, and color of drainage) Post op IV fluids Continual H&H Urine output Operative site Drain output Pain management All pulses Assess surgical site for signs of infection (REED) Gastric Nugget** n/v diet order gi prophylaxis(h2 blocker) constipation (stoolsofteners) ambulation!!! Po fluids Anesthesia Bradycardia and hypothermia DVT-warmth, calf pain,redness,swollen Electrolytes-watch K, sodium and mag Nugget** Respiratory pts 80-85% Check extremities no pulse-doppler-if can’t find pulse check bilateral for circulation 80% o2 check LOC, o2 stat, resp. rate, lung sounds Bolus-rapid amount of volume in a short time. Usually to stabilize BP. Careful with CHF patients MAP-systolic and diastolic together. Under 65 organs not working probably Nugget** Fluids & electrolytes HH=bleeding Output- urine excretion-filtration, hydration Operative Drains-equal balance what goes in must come out Blood greater than 150cc call MD pca-pt controls Pain management-increases bp can cause rupture aftersurgical procedure, comfort Gastric Pulses-circulation, always monitor distally Monitorstie for infection-yellow green odor REED Nausea meds-aspiration Ice chips-toleration Constipation-pain meds closed suction drain Jackson pratt drain Keep an eye on drainage and color Get immediate vitals, rapid response team called Nice large iv Immediate intervention fluids (bolus) (isotonic, normal saline) Wound disruption Dehiscence: reopening of the surgical would caused by excessive force on the suture line Evisceration is when body organs protrude through the open wound Both usually occur 5-10 days following surgery Risk factors- obesity,smokers, diabetics, immune deficiency, malnutrition,steroid use Action items Stay w/ the client and notify the physician promptly Place the pt in a supine position w/knees bent Cover the wound w/sterile non-adherent or saline dressing keep it moist Occur during coughing, sneezing Nugget** Obesity more stress on the incision Diabetics slow healing Smokers vasoconstriction Open- cover, wet, non adhesive dressing Abdominal binder Useful for those clients who pull dressings or tubes or the client is obese. This binder provider taut compressions for abdominal wounds Drains Penrose drain-gravity Jackson-pratt Hemovac Post op complications Circulatory Pulmonary embolism Chest pain Dyspnea Increase resp rate Tachycardia Increase anxiety Diaphoresis Decrease orientation Decrease bp Blood gas changes Hypovolemic shock Decrease urine Decrease bp Weak pulses Cool clammy Restless Increase bleeding Increase thirst Decrease CVP Anything less 65 map Urinary retention Unable to void 8-10hrs post op Palpable bladder Frequent,small amount voiding Pain suprapubic area Respiratory Atelectasis Dyspnea Tachypnea Decrease breath sounds Asymmetrical chest movement Tachycardia Increase restlessness Pneumonia Rapid RR Shallow respirations Fever Wet breath sounds Asymmetrical chest movements Productive cough Hypoxia Tachycardia Leukocytosis Infection Redness Purulent drainage Fever Tachycardia Leukocytosis-increase WBC Dehiscence Separation of incision (pt that are on long time use of steroids is a risk dur to paper thin skin) Evisceration Evidence of bowel through incision Increase pain Gastric dilation n/v abd distention paralytic ileus decrease bowel sounds no stool or flatus n/v abd distention abd tenderness little or no movement Patients at risk for VTE remember SCIP Higher risk Obsess pts Age 40 or older History of cancer or decreased cardiac output Decreased mobility, immobile,spinal cord injury History of VTE, PE, varicose veins, edema Oral contraceptives Smoking Hip fracture, total hip/knee surgery (SCD ,Heparin, lovenox) Post-op nursing care Analysis of electrolytes Hyperglycemia-delayed healing (below 200) Depletion of electrolyte (k, mg) CDC ABGs Post operative antibiotics d/c in 24hr Encourage use of incentive spirometer Urine and renal laboratory tests Foley catheter (remove POD 1-2) Ambulation Prevents many complications PNA, constipation, deconditioning Drains, dressing, and discharge instructions Nursing assessment Dressing-first change usually done by surgeon Interventions Drug therapy, irrigation to treat would infection Debridement Surgical management required for wound opening Died considerations High in protein, vitamin C, folic acid, and zinc promotes wound healing Discharge instructions Very specific to surgery. However, a presence of a fever, purulent drainage, pain not relieved by the prescribed medication should all be reported to the provider Any pt going home who will be doing their own dressing change or emptying a drain and recording output, make sure you teach and then observe them doing it properly Teach back- pt will teach you what you just taught them Hematological Assessment and disorders RBC life cycle B12 and folate are required for maturation Liver and spleen Liver Spleen Produces prothrombin and other clotting factors Vitamin k synthesized by bacteria in the gut stored in liver Stores excess iron Producesthrombopoietin Highly vascular Antibody production Stores platelets and WBCs Storage of RBCs Graveyard of rbcs: engulfs old RBCs Assessment methods Pt history Use of medication Anticoagulants(warfarin, xaralto) NSAIDS (COX) Antiplatelet-aspirin, clopidogrel, prasugrel Direct thrombin inhibitors-apixaban Nutritional status Alcoholism Family history (sickle cell) Genetic risk Current health problems Renal disease Assessment: noticing and interpreting Age, gender Liver function Drug use Dietary patterns Socioeconomic status(afford food) Previous radiation therapy Occupation, hobbies Location of home Use of blood thinners, NSAIDS Nugget** Concerned w/ medication with RBC-ibuprofen Occupation, hobbies-any dangerous unnecessary bleeding Before giving blood-compatibility, fever (cant give if have high temp, check HH Physical assessment Skin/nails Pallor or cyanosis Bruising (meds, low platelets) Petechiae Spooning nails (iron deficiency anemia) Head and neck Conjunctiva Lymph nodes assessment Tongue may be smooth or beefy red in anemia due to nutritional deficiencies (b12) Fissures at corners of mouth (iron) Respiratory Accessory muscle use/sob Cardiovascular Weak, thread pulses Hemic murmur Low bp Gi Melena Hematochezia Kidney and urinary Hematuria Abdominal Enlarged spleen may be palpable and tender CNS Cognition and the lack of b12 Diagnostic assessment CBC w/differential H+H Leukocytes Platelet count Peripheralsmear- morphology Reticulocyte count Immature RBCS Elevated causes Serum ferritin, transferrin, and tibc PT/INR PTT Inr preferred because of consistency of control values Inr is preferred normal 0.7-1.2 Warfarin therapy 2-6 Assess the intrinsic clotting cascade II, VIII, IX, XI, and XIII Heparin therapy Bilirubin Found in file Waste product of RBC breakdown Increase in RBC destruction=increased production of bilirubin (sickle cell disease Sickle cell anemia Chronic disease Mostly in African Americans Autosomal recessive inheritance Abnormal shape that is sensitive to hypoxia HbS Lifespan is 10-20 days=anemia They can become rigid and sticky Men are mostly the ones that have trait Sickle cell crisis (vaso-occlusive event- VOE) Dehydration, infection, emotionalstress, pregnancy, altitude changes, cold weather, anesthesia, strenuous exercise Precipitating factor-anything that increase oxygen demand or decreases oxygen supply to the tissues Symptoms of sickle cell anemia Pain, pallor/cyanosis, jaundice, lower extremity ulcers, chronic kidney disease, cardiovascular issues, musculoskeletal issues Assessment of sickle cell anemia Pain is the most common complaint Fatigue, SOB, jaundice, itching, skin ulcers, abdominal pain, joint pain and limited ROM Inquire about precipitating factors Lab changes(leukocytosis, low H&H, high bilirubin, high reticulocyte count) Severe complications- renal failure, CVA or MI Nursing care sickle cell anemia Pain control and rest Opioids Oxygen Repletion of fluids Hypotonic Encourage PO intake ROM exercise Extremity assessment Comfort measures Warm room temperature Blood transfusions Continuousinfection assessment because of spleen enlargement Long time management Immunizations and genetic counseling Hydroxyurea Folic acid Treating sickle cell crisis Administer oxygen Prescribed pain meds Hydrate pt w/ hypotonic IV fluids and with beverages of choice w/o caffeine orally Remove constrictive clothing Keep room temperature above 72 Avoid taking blood pressure with external cuff Check circulation in extremities every hr Anemia Reduction in either the number of RBCs, or amount of H&H Clinical indicator (notspecific disease): manifestation ofseveral abnormal conditions Many sub-types of anemia Normocytic, microcytic (iron), macrocytic (b12, folic) Generalized anemia symptoms Tiredness, weakness, pale skin, irregular heartbeat, SOB, chest pain, dizziness, cold hand and feet, headache Diagnostic laboratory testing CBC!!! (H&H) Mch the amount of Hgb per cell Mcv size of the RBC 80 Microcytic 100 Macrocytic (b12, folate) Transferrin Ferritin TIBC B12/folate Iron-deficiency anemia Most common-affects more women Poor diet, poor gi absorption, lack of adequate nutrition, blood loss Assessment- weakness, pallor, PICA, tongue pain RBCs are small (microcytic) Labs, H&H, ferritin, transferrin, TIBC Asses the client for GI bleeding Advise for an increase in dietary iron ( organ and red meats, egg, lentil, leafy green veggies, and raisins) Rx Supplemental iron may be prescribed to a client. Advise that the client take between meals to minimize GI upset. Parental iron should be given through the z-track method Liquid iron should be given w/straw Stools may be black or tarry. Advise plenty of fluids because of constipation Enhance iron absorption take vitamin C B12 (pernicious) deficiency anemia Needsthe intrinsic factor produced by the stomach Intrinsic factor is produced by the parietal cells of the stomach and following a gastrectomy anemia may occur. No intrinsic factor= no absorption of b12 RBCs are large (macrocytic) Assessment- glossitis, paranesthesia, pallor, vitamin b12 Is necessary for myelination of nerves. Deficiency leads to nervous system problems!!! Assess diet (vegans) and advise the increase in b12 rich roods (animal products: fish, meats, eggs, milk, cheese) Nursing care Teach on dietary practices, administer parental b12 as prescribed Pernicious anemia is autoimmune Cause nerve damage Numbness and tingling in extremities, not acting right B12 deficiency symptoms Generalized anemia symptoms, depression, anxiety (low o2), memory issues, numbness/tingling in arms/legs B12 deficiency treatments Increase b12 dietary intake (fish, meats, nuts, and dairy, dried beans, citrus, leafy greens) B12 injections weekly Po,sublingual, or nasalsupplements after b22 stabilizes with injections Folic acid deficiency anemia Symptoms similar to those of b12 except nervous system remains normal Causes- poor diet, crohns disease (malabsorption), oral contraceptives,sulfa drugs, methotrexate, alcoholism, those with increased folic acid requirements Nursing; encourage diet rich in folic acid: green leafy veggies, liver, yeast, citrusfruits, dried beans, nuts Administer folic acid replacement therapy Blood and blood products Packed red blood cells Most commonly used Requirestype and crossmatch!!! 200-250ml Uses Anemia (Hgb 6), due to trauma, surgery, or other Nugget** Need to know compatibility, know which one will give interaction 2 nurses to verify, check exp date Pt must have blood band one, consent Stay wit pt 15 mins- reaction happens in the first 10-15mins Use 20 gage/18 gage length 1 to 1 ¼ Assessment-positive (RH factor as antibodies) Universal OBlood runs 2-4hrs Change tubing q4hr Platelet transfusions Does not need type and crossmatch 200-300ml Infuse immediately over 15-30 min with a special transfusion set (shorter than stander PRBC set) Uses: thrombocytopenia (low platelets) Fresh frozen plasma (FFP) Uses: to replace blood volume and clotting factors Type and crossmatch required 200ml Rapid infusion (astolerated) Give via regular y-set tubing Blood administration Determine clients Allergies Previoustransfusion reactions Administer with 30 minutes of receive from blood bank Never add any meds to blood products Check crossmatch record with 2 nurses: Abo group RH type Pt name ID blood band Hospital # Expiration date Do not warm unless risk of hypothermic response then only be specific blood warming equipment Infuse each unit over 2-4hrs but no longer than 4hrs Key points Verify pts ID Check the dr. orders Check labels on blood bag and blood bank transfusion record Baseline vitals #18G or 20G needle Normal saline IV solution Blood administration set w/filter Severe reactions most likely first 15 min and first 50ml Blood tubing should be changed after 4hrs Change tubing after each bag MD will sometimes order lasik to pull some fluid off to prevent CHF Transfusion reactions (occurs 1 st 10-15min or 1 st 50ml of blood) Allergic Febrile Mild Severe Fever Chills Facial flushing Hives/rash Increase anxiety Wheezing dyspnea Decrease bp Anxiety Headache Tachycardia Tachypnea Hemolytic Hemoglobinuria Chest pain Apprehension Low back pain Fever Tachycardia Decrease bp Increase RR Nugget** Stop transfusion and flush w/NS Pt feeling warm-allergic reaction-vasodilation, late stage ofsystemic hematological response Blood type compatibility Universal donor OUniversal recipient AB+ Types of transfuions Whole blood Red blood cells Platelet transfusion Blood products Fresh frozen plasma Granulocytes (WBC) Safety to alwaysremember Special tubing; blood filter tubing Monitor pt; special muststay with pt the 1 st 15mins Whole blood Rare RBC Common Trauma pt, lot blood during surgery Infuse within 4hrs Platelets Help blood clot Platelet count under 10,000 give transfusion Thrombocytopenia and actively bleeding Special tubing give 15-30 mins only Do not push!! Do not need to be typed and crossmatched Fresh frozen plasma Replaces blood volume and clotting factors Required type and cross-matched 30-60 minstransfusion Granulocytes (wbc) Neutropenia Rare Follow policy Assessment prior to administration Health history (previousreaction) (had transfusion) Verify prescribed type and amount Ensure that type and cross matched has been obtained by lab (every 72hrs) Know institutional policies and procedures (pt consent) Must have patent IV access with angio cath greater than 19G Obtain appropriate blood product tubing Blood tubing with filter used with blood products May not run blood and blood product with other solutions/meds Obtain v/s (initial vs before start, 15 min , hrly) Access urine output Obtain blood from blood bank Verify accurate blood products and patient with another nurse (2 nurses) Nursing priority during infusion Remain with pt for first 15mins Complete forms required Assess vs and possible reactionsthroughout administration process Typically red blood cells must be infused within 4hrs of obtaining from blood bank If reaction occurs Stop blood and disconnect from IV Replace w/new bag and tubing Assess pt and take v/s Report to healthcare provider Return all blood and tubing to blood bank Once infusion infused Flush IV Access patient Discard bag and tubing Document Types of transfusion reactions Acute hemolytic reaction- blood type, RH factor mismatch Febrile transfusionsreaction- multiple transfusion;s/sfever, chills, tachy, tachypnea, hypotension Allergic transfusion reaction- first 24hrs Bacterial transfusion reaction- contaminated blood Circulatory overload- to quickly Transfusion-associated graft-versus-host disease- immunocompromised, 1-2 wks after Transfusion-related acute lung injury- antibodies and antigens- 6hrs Acute pain transfusion reaction- chest, back, joint pain Blood transfusion complications Fluid overload Crackles in lung fields Hypertension Jugular vein distension Dyspnea Confusion Management Vital signs Respiratory and cardiovascular assessment Skin care Injury prevention Strict i/o Increased serum iron levels More common w/multiple repeated transfusions Polycythemia (more RBCs than normal) Blood is thicker than normal Risk for thrombosis Chest pain Management Oral or iv hydration DVT prophylaxis- anti embolic stockings, scds Monitor for cardiac rhythm changes Hypocalcemia Muscle spasms Paresthesia, tingling and numbness in hands and feet Trousseaus signs- bp cuff inflated greater than the systolic blood pressure and held in place for 3 min; flexion of wrist and phalangeal joints can be observed w/extension of interphalangeal joins and adduction of the thumb) Chvostek’s sign (tapping skin over facial nerve, ipsilateral contraction of facial muscles is positive) Hypotension and cardiac rhythm changes Management Monitor bp Monitor cardiac rhythm changes Injury prevention Seizure precautions Hyperkalemia More common w/donor blood that is several weeks old Cardiac rhythm changes Hypotension Muscle twitching in hands, feet and around mouth Paralysis Diarrhea Management Monitor for cardiac rhythm changes Monitor blood pressure Injury prevention Contaminated blood (hep b,c &D, HIV) Relatively low risk Fever Chills Unexplained fatigue Management v/s including temp injury prevention labs H&H RBC WBC labs pt education PLATELET COUNT URINALYSIS SERUM IRON SERUM CALCIUM SERUM POTASSIUM Cultural and age considerations Older adults at higher risk for fluid overload and transfusion reactions Total Parenteral Nutrition Main fuels Protein Carbs Lipids Water 26-40 ml/kg/day Nutrients Vitamins Minerals Electrolytes Nugget** Short term solution Carbs and lipids-energy and maintain glucose Protein-wound healing Water-hydration TPN- weight gain Electrolytes- calcium, mag, potassium, sodium Positive outcome-wound healing, gaining weight Look at total protein levelsindicated they are getting proper nutrition Nursing considerations Always have 2 nurses verify the prescription matches the TPN label before hanging Never stop abruptly, if TPN runs out before another bag available, hang 10%, or 20% dextrose IV solution until another TPN bag arrives Must be infused via pump Change iv tubing q24hrs PICCS are most often used for TPN Dressing changes every 48-72s hrs; monitor for s/s DVT in catheter arm; monitor s/s of infection at both insertion site and systemically Nugget** Tpn is classified as medicaiton 2 nurses-many nutrients in the bag check off every single order, allergies, flow Never stop abruptly-if you odn’t supplement glucose will drop Change iv tubing q24hrs because bacteria followssugar Mark tubing TPN PICC-no bruising, redness indicate infection-needs to be pulled TPN complications Fluid overload Monitor daily weights and i&O Electrolyte imbalance Monitor BMP Hyperglycemia Monitor blood glucose q6hrs or q4hrs depending on MD orders Infection Parenteral nutrition: providing the required nutrientsto the body intravenously Vitamins Trace minerals May also contain insulin and heparin Used in pts GI tract is nonfunctional or inadequate Unable to ingest good Disorders where intake unable to meet body requirement Advantages Control nutrition making it balanced Correct nitrogen/ maintain it too Disadvantages Central cath needed Risk for infection High glucose content Can crate imbalancesin electrolytes Normal findings Health history Presence of GI disorder or other debilitating condition Level of consciousness Nutritional intake history Ability to feed self Weight and BMI Risk factors Burns Malnutrition GI disorders AIDS Cancer Major psychiatric disorders Expected findings Weight loss, decreased muscle mass, fatigue/weakness, hypovolemia, negative nitrogen balance, low H&H, decreased albumin and prealbumin levels Medical/surgical management Placement of CVAD prescribes Various lab evaluations Individualized PPN + TPN solution Finger stick glucose (accu checks) Daily weights Labs H&H Serum albumin and prealbumin Serum electrolyte levels Serum glucose levels Priority nursing care Order checking (2 nurses) Solution storage May only hang for 24hrssome 12 hrs New tubing w/each bag and must be filtered Inspect solution Must be weaned off Start infusion slowly Perform a complete and thorough physical assessment Monitor 10% dextrose to infuse if no new solution available Do not alter rate of infusion if solution not on time PPN and TPN are not compatible with any other solution Complications/priority nursing care Clotted catheter Cracked or broken connections Pneumothorax Sepsis Metabolic complications Hyperglycemia Hypoglycemia Fluid and electrolyte imbalances Cultural and age considerations Elderly at greater risk for complications related to the aging. Process Central venous access devices Administer hypertonic IV solutions and meds Used when peripheral access is no longer an option Hemodynamic monitoring Can run more than one solution at a time as most have multiple lumens Non-tunneled CVAD Inserted into subclavian or intrajugular, may be placed in femoral vein, ending at superior vena cava Hemodynamic monitoring catheters are inserted into heart Used for short term IV therapy Usually have multiple ports and may be used intermittently Tunneled CVAD Hickman, broviac, groshong Long term Usually inserted in surgery, into lower chest, into subclavian vein, ending at entrance to right atria May be used intermittently Implanted Port CVAD Port-a-cath, mediport, infusaport Long term Implanted under the skin, usually in upper chest into subclavian vein Accessed by feel, has self sealing port and huber needle PICC (CVAD) Long term Inserted in basilic median cubital, cephalic, or antecubital vein May be used intermittently Care of pt w/CVAD Use aseptic technique Avoid sharp objects Assess insertion site Tubing and solution Securing catheter Dressing changes(occlusive/clear) (every 7 days) (other every 48hrs) Flushing of catheters (once a shift) Obtaining blood Removing non tunneled and picc catheters Ports removed by MD or NP Documentation Flushing of catheters Unused infusion port flushed w/normal saline every shift Use heparin flush solution to prevent clots from forming Never force may dislodge clot Ensure no air in syringes being used Obtaining blood from CVAD Obtain waste sample Clean port Attach 10ml syringe Open clamp Aspirate 10ml blood Close clamp Remove syringe and discard Obtain blood test sample Clean port Attach 10mlsyringe Open clamp Aspirate blood Close clamp Remove syringe Flush the line Clean port Attach 10ml ofsaline Open port Flush Close clamp Remove syringe Label and send to lab Place blood in vacutainer Label Send to lab Removing non-tunneled and PICC catheters 1. Place patient flat in bed 2. Loosen dressing and statlock 3. Have pt perform Valsalva maneuver 4. Gently and steadily remove catheter 5. Hold pressure 10 min and apply pressure dressing 6. Ensure catheter isintact Documentation Type and site of CVAD Length of catheter exposed Solution infusion observations Posts flushed Assessment ofsite Dressing Pt teaching Aseptic care Proper care during administration Complications and when to notify healthcare provider Instruct pt in proper use Complications Pneumothorax Catheter migration, dislodgement or breakage Catheter occlusion CR-BSI infection Air embolus Fluid volume overload Elder adults are greater risk for overload and infections Peds-overload Immunocompromised-infections Intravenous infusions therapy Delivery of medsin solutions and fluids by parenteral route Iv therapy most common route Iv therapy most common invasive therapy administered to hospitalized pts Types of infusion therapy fluids Iv solution Blood and blood components Drug therapy Administering IV meds Med safety Rapid therapeutic effect Never assume iv administration is same as giving that drug by other routes Prescribing infusion therapy Nugget** 5 rights Rapid infusion 20g needle Vascular access devices Major types Short peripheral catheters- peripheral IV Midline catheters- longer length cath usually in upper arm PICC Nontunneled percutaneous central venous catheters- pt critically ill hooked up to monitor and read bp Tunneled catheters- nurses don’t touch-go into OR Implanted ports- cancer pts have to be certified access with huber needle at 90 degree angle Hemodialysis catheters Peripheral IV therapy Superficial veins of dorsal surface of hand and forearm Dwell for 72 to 96hrs, then require removal and insertion into another site Portable vein transilluminators available Avoid the use of veins in the lower extremities of adults Usually want to change iv within 24hrs because of infections control if it was put in the field Avoid the use in LE in adults-skin thinner and movement Remember Veins cannot be used in pts with Mastectomy, axillary lymph node dissection, lymphedema, paralysis of upper extremities, dialysis graft or fistulas PICC Length 18-29 inches Chest xray determines placement Power iccs used for contrast injection; can also attack to transducersfor CVP monitoring Removal of picc Position must be laying flat and take a breath and hold Remember Change lipid tubing every 24hr Change blood tubing within 4hrs Local complications of IV therapy Infiltration Phlebitis and post-infusion phlebitis Thrombosis Ecchymosis and hematoma Site infection Venous spasm Nerve damage Older adult care Skin care Vein and catheterselection Cardiac and renal changes