Adult Health II Quiz 1 Study Guide, Study Guides, Projects, Research of Nursing

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Adult Health II Quiz 1 Study Guide Adult Health Nursing Care Settings American Nurses Association Medical-Surgical Nursing • The area of nursing practice concerned with the care of adults with predicted or existing physiologic alterations, trauma, or disability • The ANA has formally recognized medical-surgical nursing as a specialty; focused practices areas are seen as subspecialties The Academy of Medical-Surgical Nurses (AMSN) • The backbone of modern nursing and the practice foundation of virtually all health care The ANA Standards of Clinical Practice • Standards of Care: address nursing process and competency in nursing care • Standards of professional performance: address expected quality of care, ethics, collaboration, and other responsibilities Factors influencing the practice of Medical-Surgical Nursing • Increasing cultural diversity (immigration) • Aging population with accompanying increase in chronic conditions • Advances in medical science and technology • Affordable Care Act o While insurance is readily available, people may not have it or are underinsured • Monetary constraints • Available nursing workforce Evidence-Based Practice (EBP) • Clinical expertise • Individual patient rights and situations • Best practices (as determined by research and the evaluation of said research) Clinical Pathways Case Management • Guidelines for patient care • Diagnosis—course of treatment • Outcome driven • Maximize quality • Minimize costs of care • Coordination of health care services • Decrease length of stay • Decrease costs Nursing Informatics • NANDA Taxonomy: Provides the framework for nursing diagnostic terminology • NIC: provides standardized classification of nursing interventions • NOC: provides standardized outcomes reflecting patient status after nursing interventions Focus on Patient Safety and Quality Care • Just Culture—reporting of errors or a near miss o THROUGH INCIDENT REPORTS!! • National patient safety goals • IOM competencies- patient centered care • QSEN- quality & safety education in nursing • Collaboration- Inter-professional- SBAR Just Culture Attributes • Transparency • Blamelessness • Accountability • Understanding that human error is inevitable • Non-punitive Acute Illness • One caused by a disease or condition that produces sign/symptoms soon after exposure to the causative agent • Short course • Full recovery or abrupt death Chronic Illness • Medical condition that produces signs/symptoms within a variable time period • Runs a long course, only partial recovery • Associated with 70% of all health care costs in the US Associate with factors such as stress, smoking, sedentary lifestyle • Goal of a nurse for a chronic illness: Symptom management and improve their quality of life Chronic Illness Characteristics • It is permanent • It leaves residual disability • It is caused by nonreversible pathologic alteration • It requires a long period of supervision, observation, or care • Remission—exacerbation Practice Settings • Acute care • Skilled nursing facilities • Rehabilitation—inpatient/ outpatient • Outpatient settings—clinic, primary care, surgical, oncology care o Morse Fall Scale ▪ Haven fallen in the past ▪ Having an IV ▪ Assistive devices (canes, crutches, walkers) o Falls are associated with increased morbidity and mortality • Skin Breakdown Purpose of SPICES • Gross assessment of these points. In an older adult, these 6 areas are at higher incidence of occurring. So, use this framework to assess for potential problems. Fluid and Electrolytes Total Body Fluid • Approximately 60% of total body weight is water • Varies according to: o Muscle mass o Electrolytes o Body fat o Age Distribution • Intracellular- fluid INSIDE the cell. (66%) o The adult has the highest amount of fluid intracellularly • Extracellular- fluid OUTSIDE the cell (34%) o Interstitial- fluid between the cells (75%) o Intravascular- fluid inside vessels (25%) o Transcellular- third spacing (1%) Fluid Compartments • Intracellular o 66% of total body weight • Extracellular o 34% of total body weight Electrolytes • Cations: positively charged ions o Potassium, calcium, sodium, magnesium • Anions: negatively charged ions o Chloride, phosphate and bicarbonate • Measured in milliequivalents (mEq) • Serum levels indicate extracellular concentration Movement of Fluid • Osmosis- water moves across a semi-permeable membrane from an area of low solute towards a region of higher solute concentration o “Passive Transport!” o Osmolality/osmolarity: number of PARTICLES in a solution or the concentration of a solution ▪ Normal: 275- 300 mOsm/kg ▪ The higher the osmolarity the dryer the patient. “Don’t leave a patient high and dry” ▪ Less than 275 means overhydration ▪ Greater than 300 means dehydration ▪ Regulated by release of antidiuretic hormone (ADH) • Tonicity o The measurement of the osmotic pressure of a solution – osmolality ▪ ISOTONIC- a solution with the SAME osmolality of serum and other body fluids • Lactated ringers, 0.9% Saline • Same tonicity as plasma • Purpose: increase intravascular volume • Examples: give to someone who has bleed, hypovolemic shock ▪ HYPERTONIC- a solution with an osmolality higher than that of serum, causes intracellular fluid compartment to shrink • Dextrose 5% 1/2 Normal Saline (0.45%) • Fluid moves out of the cell and become extracellular, causing the cell to shrink ▪ HYPOTONIC- a solution with an osmolality lower than that of serum, causes intracellular fluid compartment to swell • D5W in clinical practice is hypotonic • Fluid moves from extracellular to intracellular, causing the cell to swell • Don’t give to patient within 24 hours of cerebral swelling. Also, may cause swelling Movement Between Vascular and Interstitial Spaces • Colloid Oncotic Pressure: pulling pressure exerted by proteins/colloids in the blood. THE PULL • Pulls or absorbs fluid from the interstitial space o Ex. ALBUMIN ▪ The protein pulls fluid inside the blood vessel and maintains colloid oncotic pressure ▪ If colloid pressure is low, you can hang a liter of saline to increase volume, but the saline leaks into the interstitial space; have to give colloids so it doesn’t leak! ▪ Patients with low oncotic pressure: alcoholics, liver failure, malnourished, etc. ▪ Patients with liver failure have a lot of edema and ascites due to decrease protein ▪ As a nurse, look for edema and fluid • Hydrostatic Pressure: created by the weight of fluid pressing against the wall of blood vessels. THE PUSH o The higher the hydrostatic pressure, the fluid can leak out  edema o Seen in hypertension patients, fluid overload, and heart failure Primary Factors regulating Water in the body • Thirst: stimulated by factors associated with water loss and extracellular osmolality; causes oral fluid intake o The earliest response we have to decreased fluid volume or dehydration is thirst o In older adults, thirst response is DIMINISHED! Puts them at greater risk for dehydration • Antidiuretic Hormone (ADH)- stimulated by decreased blood volume or increased serum osmolality; causes reabsorption of water o Senses increases in solutes (particles) or decrease in volume, so it tells kidneys to hold onto water o Also promotes potassium excretion Renin-Angiotensin-Aldosterone Cascade • When there is a decrease in volume… • Juxtaglomerular cells in afferent arteriole secrete renin⟶ Renin converts angiotensinogen to angiotensin I ⟶ ACE converts angiotensin I to angiotensin II o Angiotensin II ▪ Increases blood pressure—potent vasoconstrictor ▪ Stimulates adrenal cortex to secrete: ▪ Water follows sodium! ▪ Notify family + dietician Electrolyte Balance and Imbalances Sodium • Sodium Normal Range: 135-145 mEq/L o Predominant electrolyte in ECF. Controls water distribution o Sodium imbalances are usually associated with parallel changes in water loss or gain o Transmission of nerve impulses and muscle contraction. Hypernatremia Causes High sodium can be related to two factors: • Absolute hypernatremia: due to too much sodium coming into the patient • Relative hypernatremia: fluid Relative hypernatremia (Lose water High Na) • Diabetes insipidus • Osmotic diuresis • Decreased fluid intake Absolute hypernatremia (Excessive Na intake) • Intravenous solutions Clinical presentation • Dehydration • Thirst • Dry mucous membranes • Decreased LOC • Seizures Treatment Relative (Water loss > Na Loss) • Free water boluses • Hypotonic fluid replacement (or Isotonic) Absolute (Excessive Na intake) • Diuretics • Diet management o Avoid processed foods, condiments, salad dressings, lunch meat, nitrates Complications: LOC, seizures  BIG SAFETY CONCERN Hyponatremia Causes Excessive water intake (Relative) • SIADH (retain urine) • Water intake no Na Sodium Loss (Absolute) • Diuretics • GI Loss • Diaphoresis Clinical Manifestations • S/S of fluid overload: edema, crackles in lungs, shortness of breath, tachypnea, JVD • Neurological impairment • Change in LOC • Muscle weakness • Seizures Treatment Too much waterlow Na (Relative) • Fluid restrictions • Diuretics Sodium Loss (Absolute) • Replace sodium – IV, PO, Enteral feeding Potassium • Potassium Normal Range: 3.5 – 5.0 mEq/L  NARROW RANGE • Functions: o Main abundant cation in ICF o Transmission of nerve fibers o Contraction of skeletal, smooth, and cardiac muscle Hypokalemia Causes: • Decreased intake • Increased Loss o Increased Aldosterone (retaining sodium and water and excreting potassium) • Shift of Potassium into cells o Metabolic Alkalosis o During treatment of DKA, giving regular inulin IV can lead to low potassium Clinical Manifestations of Hypokalemia: • GI: anorexia, vomiting, paralytic ileus (no bowel sounds) • CNS: lethargy, diminished DTR’s, confusion • Muscles: muscle weakness & leg cramps o Weakness of diaphragm  RESPIRATORY ARREST (most probable cause of death) o ALWAYS ASSESS RESPIRATORY STATUS • Cardiovascular: cardiac arrhythmias, low potassium and magnesium potentiates digitalis toxicity, EKG’S: PROMINENT U WAVE! Treatment for Hypokalemia • Potassium replacement o IV: NEVER GIVE IV PUSH. MUST BE DILUTED (HIGH RISK DRUG) o PO o Enteral • DIETARY. Food to eat that contains potassium o Meats o Dairy products o Dried fruit o Bananas, cantaloupe, kiwi, oranges o Avocados, broccoli, dried beans/ peas, lima beans, mushrooms, potatoes, seaweed, soybeans, spinach o SALT SUBSITUTES like Mrs.Dash Hyperkalemia Causes • Excess Intake • Decreased Loss o Potassium sparing diuretics o Renal failure o Adrenal insufficiency (ADH not working) • Shift of Potassium out of Cells o Extensive trauma o Crushing injuries o Metabolic acidosis Clinical Manifestations of Hyperkalemia • GI: Nausea, vomiting, diarrhea, colic • CNS: Numbness, paresthesias • Muscles: irritability, weakness(think of the heart and diaphragm), flaccid paralysis • Cardiovascular: conduction disturbance, ventricular fibrillation, cardiac arrest o MOST SEVERE PROBLEMS AND MOST COMMON CAUSE OF DEATH o EKG: PEAKED/TALL T WAVE! • Urine: Oliguria, anuria Treatment for Hyperkalemia • Emergency Situations o Glucose + insulin ▪ Give regular insulin IV because it pushes potassium back into the cell then give dextrose 50% (since their glucose will drop after insulin) ▪ Will elevate calcium since it lowers the phosphate • Dietary intake o Salmon, GLV’s, Bok choy, spinach, cereals, orange juice, sardines, dairy products • Give them a calm environment since they are over stimulated from the electrolyte imbalance Hypercalcemia Causes • When you think of high calcium think of bone involvement • Loss from bones o Immobilization o Carcinoma • Excess intake o Antacids • Increase in factors causing mobilization from bone o Increase in parathyroid hormone o Increase in Vitamin D Clinical Manifestations of Hypercalcemia • Kidneys: Stones o Push fluids to protect the kidneys and decrease risk of stones • CNS: decrease in deep-tendon reflexes, lethargy, coma • Bones: bone pain, osteoporosis, fractures • Muscles: fatigue • Cardiovascular: depressed activity, dysrhythmias, cardiac arrest Treatment of Hypercalcemia • Normal saline infusions/ loop diuretics (protect kidneys) • Corticosteroids to decrease GI absorption • Mithramycin  opposes parathyroid hormone Magnesium • Magnesium Normal Range: 1.3 – 2.2 mEq/dl • Functions: o Second most abundant intracellular cation (remember first abundant is Potassium) o Contracts the myocardium o Influences transport of Na/K across cells Hypomagnesemia Causes • Decreased Intake o Prolonged malnutrition ▪ Alcoholics o Starvation • Impaired Absorption from GI Tract o Diarrhea, draining GI fistulas, malabsorption fistulas • Excessive Excretion o Increase in aldosterone o Conditions causing large urine loss Clinical Manifestations of Hypomagnesemia • Mental Changes: Agitation, Depression, Confusion • CNS: Convulsions, paresthesia’s, tremor, ataxia o INCREASES EXCITABILITY OF NERVE CELLS • Muscles: Cramps, spasticity, tetany • Cardiovascular: Tachycardia, hypotension, dysrhythmias o Torsades de pointe, patient may not have a pulse ▪ Polymorphic ventricular tachycardia Treatment of Hypomagnesemia • Magnesium replacement: o IV (High risk drug) o Food (fruits, brans, GLV’s) • Treat cause o **Hypomagnesemia causes digoxin toxicity** Hypermagnesemia Causes • Increased Intake o Excessive antacids, enemas, laxatives o Excessive administration of magnesium sulfate • Decreased excretion o #1 CAUSE IS RENAL FAILURE ▪ In renal failure patients, magnesium, potassium, and phosphorous tend to be high Clinical Manifestations of Hypermagnesemia • CNS/ Mental Changes: Drowsiness, confusion, coma • Muscle: muscle weakness, paralysis, hyporeflexia, respiratory muscle paralysis • Cardio: Hypotension, flushing, increased skin warmth (vasodilation), increased PR interval, shortening QT interval, T wave changes, Bradycardia, cardiac arrest Treatment of Hypermagnesemia • Fluids/Loop diuretics o These will increase excretion of Magnesium • Dialysis o Makes sense, since number 1 cause is renal failure • Calcium Gluconate o Stabilize the cardiac muscle (dysrhythmias), but won’t treat the high magnesium levels • Treat underlying cause o Most likely renal failure. Make sure these patients avoid antacids Nursing Care of the Surgical Patient Perioperative Nursing o Pre-Operative Phase o Intraoperative Phase o Postoperative Phase Surgical Procedures • Common surgical suffixes o Ectomy- removal of an organ or gland ▪ Craniectomy- skull taken out due to swelling. Placing skull in the peritoneal cavity while swelling goes down ▪ Appendectomy ▪ Mastectomy o rrhaphy- repair/ to suture. o Ostomy- providing an opening (stoma) ▪ Colostomy o Otomy- cutting into ▪ Craniotomy- cutting into skull to possibly remove some tumor in the brain o Plasty- formation or plastic repair ▪ Cranioplasty- patient goes back to OR. Remove skull from the peritoneal cavity and put it back on patient’s head ▪ Rhinoplasty- Nose job o Scopy- looking into ▪ Laparoscopy ▪ Endoscopy Extent of Surgical Procedures • Minimally invasive: Fiberoptic endoscopes, smaller incisions, customized instrumentation, robotics • Endoscopic: Uses natural body opening or porthole incision • Open: traditional opening of body cavity, more extensive surgical approach, might produce more postoperative pain, longer recovery • Simple: limited to defined anatomic location • Radial: involves dissection of tissue and structures beyond immediate operative site Purpose of Surgery • Diagnostic: aids in diagnosis (ex. Breast biopsy) • Curative: resolves condition by removing diseased tissue Pre-Operative Diagnostics: ALWAYS ASSESS THESE BEFORE ACTING ON ANYTHING • CBC: RBC, H/H, WBC (5,000-10,000) • Basic Metabolic Panel: electrolytes, blood glucose level, BUN, Serum creatinine • Coagulation studies: INR, PTT, Platelets • HCG: pregnancy test • 12 Leak EKG • Chest X-Ray: establish baseline • Pulmonary function tests: COPD patients, asthma • U/A: Urinalysis o Tests for abnormal substances in the urine that could indicate kidney disease • Type and Cross Match: draw blood and look at Rh and their blood type, mix it with the donor blood Dietary Restrictions o NPO: patient advised not to ingest anything by mouth for 6- 8 hours before surgery o Decreases risk for aspiration o Risk Factors for Aspiration ▪ Full stomach ▪ High gastric pressure and incompetent esophageal sphincter ▪ GERD ▪ Hiatal hernia ▪ Pregnancy ▪ Bowel obstruction ▪ Obesity o Patients should be given written and oral directions to stress adherence o Surgery can be cancelled if not followed Administering Regularly Scheduled Medications • Medical physician and anesthesia provider should be consulted for instructions about regularly taken prescriptions before surgery • Drugs for certain conditions often allowed with a sip of water before surgery o Cardiac disease o Respiratory disease o Seizures o Hypertension Intestinal Preparation • Bowel or intestinal preparations performed to prevent injury to the colon and to reduce the number of intestinal bacteria • Enema or laxative may be ordered by the physician Skin Preparation • A break in the skin increases risk for infection • Patient may be asked to shower using antiseptic solution (chlorohexidine) • Electric clippers • 30-60 minutes of incision antibiotics should be given in the OR Nursing Diagnosis • Anxiety o Allow the patient to verbalize why they feel anxious • Risk for ineffective airway clearance • Risk for ineffective peripheral tissue perfusion • Knowledge deficit Patient Using Incentive Spirometer • Purpose of Incentive spirometer: Prevent atelectasis (alveoli collapse or airless) • Ask them to suck in and note how high the ball goes • Ask them to hold it as long as they can or at least 10-15 seconds • Patient should use it 10 times every hour • Splinting: putting a pillow on the surgical wound o Purpose: to prevent dehiscence and evisceration and to decrease pain Patient Using SCD’s • Sequential compression devices (SCD’s) o Return blood to the right side of the heart o Decrease venous pooling and clots o Heparin o Post op: early ambulation Preoperative Preparation (Done in collaboration with surgeon, nurse, patient) • Preoperative Checklist: Site marking, identification o Making sure you have the right patient. Ask patient what they are having surgery for o ASK: Name, DOB, medical record number o Making sure the right limb is being operated on (YES and the initials of the surgeon should be written in permanent marker on the patient) • Dentures must be locked up • The OR team will remove the hearing aid in the OR • As a nurse: Need to know the results of the labs and if something is abnormal notify the health care provider before they go to surgery Intraoperative phase • This phase begins with transfer of the patient onto the OR bed and continues until the patient is admitted to the PACU • Surgical Team: o Primary surgeon  in sterile field o Surgeon’s assistants  in sterile field o Scrub nurse  in sterile field ▪ Has to have a specialty in the field o Circulating nurse  HAS TO BE AN RN! (outside sterile field) ▪ Uses clinical decision-making skills to develop a plan of care and coordinates, oversees, and implements nursing care interventions to support the patient during the surgical procedure ▪ Monitors sterile field and provides sterile supplies and medications to the sterile field ▪ Circulating nurse documents, get supplies, call time-out, do the count, maintain sterility o Anesthesiologist and Anesthetists – CRNA Principles of Surgical Asepsis • Scrubbed persons function within sterile field; gowns and gloves provide a barrier to transfer of microorganism from person to surgical wound • Sterile drapes create a sterile field and impede movement of microorganisms from a nonsterile to sterile area • All items used in sterile field are sterile • Sterile field is monitored and maintained during movement of persons and instruments • Surgical scrub reduces the number of resident bacteria • Preoperative skin preparation reduced the risk of postoperative wound infection Surgical “Scrubbing In” • Broad spectrum, surgical anti-microbial solution • Vigorous scrubbing that creates friction used from fingertips to elbow • Continues for 3-5 minutes Surgical attire • Hat: put on first; prevents contamination of scrubs • Scrubs: closely woven, shirt tied or tucked • Shoe covers: worn if splashes or spills anticipated • Masks: prevent contamination by droplets • Face shield and eyewear: protect from splashing and spraying • Lead aprons and thyroid shields: protect from exposure to radiation Anesthesia • Induced state of partial or total loss of sensation, occurring with or without loss of consciousness • Used to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and in some cases, achieve a controlled level of unconsciousness ▪ increased levels of calcium o Dantrolene: muscle relaxant o Treatment: Give Dantrolene, give fluids, cool the patient down, cool the IV fluids, bicarbonate Considerations • WHO Safety Checklist  TIME OUT (before surgery, before any invasive procedure) • Bloodless Medicine (for people who refuse blood transfusions [Jehovah’s Witnesses]) • Latex Allergies Nursing Management • Identification safety • Assessment: upon arrival to OR and intraoperative • Positioning o Goals of Positioning: prevent skin breakdown and nerve injury o Supine  Heels, Scapula, Occipital (Pressure Points) o Prone  Back + Airway o Side lying  Ears, greater trochanter, malleolus, etc. o Lateral ileum, greater trochanter, malleolus, ribs o Lateral kidney position  nerve damage (brachial plexus nerve, peroneal nerve) o Lithotomy  Nerve damage to peroneal nerve + losing ability to dorsiflex foot ▪ Most of the blood is in the trunk ▪ When you let their legs down, that can lead to hypotension Nursing Diagnoses for Patient undergoing surgery may include: • Risk for perioperative- positioning injury • Risk for injury • Risk for imbalanced body temperature • Risk for imbalanced fluid volume o Mostly due to blood loss • Risk for infection Nursing Interventions for the patient undergoing surgery might include: • Preventing and reducing complications related to prolonged immobility • Promoting electrical, chemical, physical, and environmental safety in OR o Surgical fires are a concern because of high amounts of oxygen • Monitoring and maintaining patient core temperature • Monitoring fluid volume balance • Monitoring and maintaining aseptic technique • Teaching patient/family perioperative routines Impaired Skin Integrity and Impaired Tissue Integrity Nursing Interventions: • Plastic adhesive drape • Skin closures, sutures and staples, nonabsorbable sutures • Insertion of drains • Application of dressing • Transfer patient from the operating room table to stretcher Wound Closure • The surgeon removes the initial surgical dressing • Notify the HCP that the wound is draining and add more gauze • If the surgeon changed the initial dressing, look for signs of infection, redness, drainage, warmth, and if the suture is well-approximated Montgomery Strap • Used to decrease the risk of skin breakdown Drains • Hemovac • Jackson-pratt • Make sure the drain is patent • Measure • Note the color • Day 1: sanguineous drainage • Day3: sero-sanguineous Postoperative Focus of nursing care in the immediate postoperative period • Maintain ventilation and circulation (ABC’s!) (ESPECIALLY FOR GENERAL ANESTHESIA) • Monitoring oxygenation and level of consciousness • Preventing shock • Managing pain/anxiety • Preventing complications • Maintaining safety Immediate Respiratory Complications • Respiratory complications are the leading cause of morbidity and mortality in the immediate postoperative period • Complications that might occur: o Airway obstruction ▪ Secretions ▪ Inflammation (from tube being in there) o Hypoxemia ▪ Effects of anesthesia not wearing off, so patient may continue to hypoventilate. o Aspiration o Laryngospasm ▪ Stridor so CALL RAPID RESPONSE Urinary Retention • Characterized by inability to void over 6-8-hour period o Check intake and Output o Palpate for distention o By the 8th hour, you have to call the HCP for an order to catheterize • Can occur after spinal anesthesia; surgery of the rectum, colon, gynecologic structures • Usually resolves within 48 hours • Urinary tract infection o Anti-Cholinergics are sometimes given to patients prior to surgery to DRY UP SECRETIONS. A side effect of this is  urinary retention o If patient hasn’t voided, assess abdominal distension, I’s and O’s, stand them up… always start with least invasive Potential Complications related to wounds • Wound healing: factors include advanced age, nutritional status, vascular disease, diabetes, STEROIDS • Hemorrhage: most likely to occur within 48 hours postoperatively; might be related to sutures or small vessel leakage • Infection: factors include hematoma, foreign body, dead space, hypothermia • Dehiscence and evisceration: usually occur 3-10 days postoperatively; separation associated with technical factors, obesity, coughing, infection o Dehiscence: the surgical site has opened o Evisceration: the wound is open and body parts are coming out ▪ Stop the activity like coughing, getting out of bed, have someone else call rapid response, then apply a sterile moist saline dressing over the organ, give reassurance to the patient that the surgeon is on the way o Assess patient’s vital signs Priorities of Care Pre-Op • Assessing • History and physical • Consent • Pre-op teaching • The site is marked • Labs have been evaluated Intra-Op • Identification • Positioning • Safety • Time out • Sterility • Review the role of the circulator Post-Op • Airway • Breathing • Circulation • Pain Infusion Therapy Vascular Access Devices **Want to use sterile technique to avoid catheter related bloodstream infection** Purpose of a Vascular Access Device o To provide an access route for the administration of parental fluids and medications o Types o PERIPHERAL ▪ Short peripheral venous catheters ▪ Midline Catheters o CENTRAL LINE ▪ Peripherally insert CVC (PICC) ▪ Not tunneled/ Tunneled CVC ▪ Implanted Ports ▪ Hemodialysis Catheters (don’t need to know) Peripheral IV Access o Advantages: o Easily inserted o Low cost o Minimal complications o Disadvantages: o Use is limited to certain fluids/meds o Local tissue injury- infiltration o Easily clotted o Use: o DWELL TIME: 72- 96 HOURS (3-4 days)  SHORT TERM USE o Common Sites o Don’t start an IV: ▪ On any moveable areas like the wrist ▪ The side where a mastectomy was done ▪ AV graft or fistula ▪ Paralysis or neurological dysfunction ▪ Avoid antecubital because fire rescue uses that site o Start an IV: ▪ NURSES SHOULD ALWAYS ATTEMPT DISTALLY FIRST (hand) ▪ Start on nondominant hand and distal (if it infiltrated at the antecubital you lost access for anything below it) Peripheral IV Device • 18 gauge o Largest o If you want to get fluids in fast and blood o Preferred for blood o Green • 20 gauge o Can give blood o Pink • 22 gauge (blue) o Smaller o Use on the older adult o Can’t use for blood o Blue • Turner kit obstructs venous flow • Should still feel a pulse • Have patient use a stress ball to pump the hand to distend the veins • Clean with chlorohexidine and let it dry • Have on clean gloves • Bevel up • Once you get in you should see blood come back • Flush with normal saline before you start!!!! • Transparent dressing goes on top • The date, time, initials of the nurse, and the gauge used should be labeled on it Peripheral IV access- Nursing Management • Assess IV site: redness, swelling, tenderness, blood return, secure site • Calculation of administration • Good hand hygiene • Replace: 72- 96 hours • Complications: o Infiltration: rather than fluid going into vein, fluid is LEAKING INTO THE TISSUE ▪ NON-VESICANT is leaking into the tissue • Ex. Normal Saline ▪ Signs and symptoms: Swelling/edema, pain ▪ Nursing Intervention: Stop the infusion. Remove the catheter. Assess the area. Put a cold compress. Elevate the edematous area. Document. Start IV in another site. o Extravasation: VESICANT fluid is leaking into the tissue • Ex. Chemo drugs (those with higher osmolality) o With a peripheral catheter, you won’t always get blood return since the catheter is in a peripheral vein • Assess the track of the vein (observe, palpate) • Infusion pump alarm settings • IV tubing (leur-locked, leaks, clouding, precipitate, blood in tubing) • Observe upper arm and chest wall for signs of edema, collateral vein formation Dressing Changes • Dressings function to secure the catheter and protect from site contamination • Dressing changes o Transparent semi-permeable membrane type ▪ Dressings should be changed every 7 days ▪ Becomes tape and gauze dressing is gauze is present o Dressings should be individualized to the needs of the patient • Documentation o Document complete assessment o Sterile technique o Prep solutions o Type of dressing o Change of add-on device o External length of the catheter Catheter Complications • Bleeding/drainage from the site • Difficulty advancing the catheter • Catheter malposition • Catheter migration • Nerve damage • Catheter sepsis • Phlebitis/Cellulitis (infection in the tissue itself) • Cardiac associated problems o Can cause dysthymias if inserted too far • Catheter or air emboli o Remove all air from syringe! • Arterial damage Central Venous Catheters- Non-Tunneled • Most commonly used vessel is subclavian vein • Nurse must wear a mask and clean gloves • Nursing Actions to rule out pneumothorax: o Diminished or absent breath sounds o Shortness of breath o Asymmetrical chest expansion CVC Management • NEED X-RAY TO CONFIRM PLACEMENT in superior vena cava and rule out pneumothorax • Single lumen or multi-lumen catheter • Recommended for short term use • Assess insertion site for signs and symptoms of infection or pain • Assess for blood return • Assess and prevent complications o During insertion ▪ Pneumothorax • Diminished or absent breath sounds • Shortness of breath • Asymmetrical chest expansion ▪ Arterial puncture • High pressure and bright red color blood ▪ Arrhythmias o Post insertion ▪ Infection- sterile dressing change ▪ Dislodgement ▪ Occlusion ▪ Air embolus • Removal consideration: MAKE SURE THE TIP IS INTACT! Central Venous Catheter- Tunneled • Long term use • The catheter is tunneled through the subcutaneous tissue and it exits the skin lower • Does not exit from the insertion site • Major Advantage: decrease the risk of infection due to antimicrobial agent that is impregnated in the cuff of the catheter • INSERTED IN THE OR • Should get blood return Implanted Port • Long term use - Home therapy • Subcutaneous port place under subcutaneous pocket, requires accessing – Huber needle • Minimal care Older Adult Care • Skin care • Wein and catheter selection • Cardiac and renal changes • The older adult is at risk for fluid overload and fluid deficit