What are the signs of infiltration?
- coolness of skin
- skin blanching, pallor
- edema and swelling above or below site
- leakage at site
- damp dressing
What is the treatment for infiltration?
- immediately discontinue IV
- encourage active ROM
- apply warm or cold compress
- restart infusion proximal to site or other extremity
- *prevent infiltration by selecting catheter site carefully and securing catheter carefully
What are the signs of phelbitis?
- Edema
- throbbing
- burning
- high skin temp
- red line up the arm with palpable band at vein site
what is the treatment for phelbitis?
- stop Iv, remove catheter
- apply cold or warm compress 3-4 x a day
- culture site and cath if there is drainage
- to prevent, rotate site every 72 hrs and avoid lower extremities.
What size gauge for trauma patients? for surgical? for all other?
Trauma patients- 16 G, rapid fluid volume
Surgical- 18 G, rapid blood admin
All other adults and children- 22-24 G
Things to consider when selecting IV site
- choose one least vulnerable to infiltration, and gives patient freedom for ADL
- start distal to proximal
- find vein that is visible and palpable
- avoid areas of movement
- avoid areas of joint flexion
- avoid area of masectomy, CVA, or A-V fistula
how often should continuous tubing be changed?
- every 96 hrs, and no sooner unless tubing is compromised
How often should primary intermittent tubing be changed?
- every 24 hrs
What is and IV Bolus?
- med given in small amounts of solution and either concentrated or diluted and injected over a short time of 1-2 min in emergent and non-emergent situations.
- also given to replace rapid fluid loss
- Many require dilution before injection
Notify the provider if patient with a VAD experiences:
- Signs and Sx of dislodged catheter tip–> pain in neck, ear, or on the affected side. Swishing or gurgling sounds or palpitations
- Port dislodgement–> swelling or difficulty accessing port
Signs and sx of air embolus how to prevent it from happening
- tachypnea
- apnea
- wheezing
- chest pain
-cyanosis
hypotension - prevent by having patients perform valsalva when changing the cap
What are the interventions for Air Embolus?
- Place in trendelenburgs position on left side
- instruct them to do valsalva
- cap end of cath or tape perforation in cath wall
- admin oxygen
- notify provider and preform frequent assessments
What are the clinical indicators for parenteral nutrition?
- patient cant tolerate internal nutrition as with paralytic ileus, intestinal obstruction, persistent vomiting
- client with hypermetabolic status as in case of burns and cancer
- client at risk of malnutrition because of recent weight loss of 10%.
- NPA for more than 5 days
- preoperative for severely depleted patients
Guidlines for blood transfusion
- administer within 4 hours, never for a rate over 4 hours
- use 18 or 20 G
- use Y-set because it has a filter
- NS only
- Observe patient frequently and monitor vital signs (usually monitor 1 hr before infusion, 15 min after start, and every 30-60 min, and at completion)
How should nurse react if patient shows adverse effects of blood transfusion?
- stop infusion
- KVO with NS but change tubing
- report to Dr.
- do clerical check of blood at bedside to verify the patient and expiration date, compatibility, etc.
- monitor vital signs
how often should the IV site be changed?
every 72 hrs (or hospital policy)
How long can a closed system hang for?
24 hrs
When starting a new infusion, nurse should always…
start iv with new tubing and new cath
