intended location; needs of the patient
catheters and access devices vary depending on
1-
2-
peripheral vein
any vein that is not in the chest or abdomen
peripheral vein
peripheral access devices are used to access the bloodstream through a _______ _______
antecubital
vein on the inside of the elbow (basilic or median cubical vein)
needle and syringe
the simplest form of intravenous access is a
quick access; minimal equipment
advantages for needle and syringe:
1-
2-
over-the-needle catheter
needle inside a soft, flexible hollow tube; the needle pierces the skin, and then the soft catheter is held in place while the needle is removed; part of the catheter remains outside the skin and has a hub that can be connected to a syringe or an IV infus
angiocath
example of an over-the-needle catheter
over-the-needle catheter
most common venous access device used in health care facilities b/c it meets the latest safety requirements and is more comfortable for the patient; the flexible cannula allows the patient more mobility
frequently changed to prevent infections; short term use only
disadvantages of over-the-needle catheters
1-
2-
injection cap; PRN adaptor
sometimes a patient's peripheral catheter is used only for intermittent infusions; in this case an _________ or ________is inserted into the hub
saline flush
type of flush for a peripheral line
heparin flush
type of flush for a central line
2 mL-5mL
amount of fluid in flushes
wing-tipped; butterfly
the most common used steel needle
butterfly needle (steel)
used to deliver small quantities of medicines, to deliver fluids via the scalp veins in infants, and sometimes to draw blood samples.
butterfly needles
shorter and have a smaller diameter (gauge), which makes them easier to insert into a small or fragile veins
trocar
needle
lumen
the open space in the center of the tube
rigid needle
cause of most needlestick injuries
needleless syringes
used to administer medication through already-established IV lines
advantages of needless syringes
1- the patient can receive IV meds quickly through the existing injection port w/o having to be punctured repeatedly
2- b/c the syringes do not have needles, accidental needlesticks to patients and health care workers are avoided
3-an IV system w/ a needl
midline catheter
any catheter placed b/t the antecubital area and the head of the clavicle
midline catheter
type of catheter is inserted into the arm near the inside of the elbow and is threaded up inside the vein to a length of 6 inches; can last about 6 weeks
peripherally inserted central catheter
PICC
PICC
inserted into a peripheral vein, usually in the arm, and then is carefully advanced upward until the catheter reaches the superior vena cava or the right atrium
PICC
can have two parallel compartments each w/ its own eternal connector (double lumen) or (single lumen)
central venous line
catheters that take a more direct route into central veins; inserted by physicians or other specially trained personnel
internal catheter (port)
permanently placed under the skin w/ no catheter coming out through the skin
external catheter
catheter coming out through the skin
Groshong Catheter
valve at the tip that prevents blood from backing up into the catheter, so heparin is not necessary; usually thinner and more flexible that other type of catheters, and they do not require the bulky clamp that other catheters have ; after the catheter is
hickman or Broviac Catheter
inserted into the target vein and then "tunneled" under the skin to emerge a short distance away; this method reduces the risk of infection, b/c bacteria from the skin surface are not able to travel directly into the vein
darcon cuff
on the catheter just inside the skin tunnel forms a seal w the patient's skin that prevents bacteria from entering the bloodstream
port
is a central venous line that does not have an external connector; instead, it has reservoir implanted under the skin
venous access device selection
1-the type of fluids to be administered
2-the length of time that the patient is expected to be receiving IV fluids
3-the location, size, and condition of the patient's veins
4-the patient's age, level of activity, and consciousness
5-the method use to co
1/2-2 inch
lengths of catheters and needles
gauge
diameter of the needle/catheter
smaller; larger
______the diameter, the______the guage
14
the largest catheter is the ____gauge catheter and is normally reserved for trauma situations or for surgery
18 and 20
the most commonly used catheter sizes are ___ and _____gauges
22-26
the smaller access devices, such as ____gauge to _______gauge catheters, are used for elderly patients, for infants, and young children, and for patients who are dehydrated or who have small or poorly accessible veins
primary administration set
attached to a prefilled sterile bag of fluid and consists of a drip chamber, a long sterile tube w/ a clamp to regulate or stop the flow, a connector that attaches to the access device, and connectors for attaching another infusion set on the same line
drip chamber
allows the fluid to flow one drop at a time, which reduces air bubbles and makes it easy for you to observe the flow rate
secondary administration set
used for adding a medication to a continuous fluid drip
macrodrop tubing
allows larger drops 10-20 gtt/min to form and fall into the drop chamber
keep vein open
KVO
macrodrop
used for infusions of 80/mL/hour or more and is always used for operated room infusions
microdrop
allows smaller drops 60 drops/mL
microdrop
used for infusions of less than 80 mL/hour and is often used for slower infusions, such as KVO, useful for pediatric and critical-care IVs when very small volumes are used and accuracy is extermely important
secondary administration set
used for intermittent infusions or IV push meds, allows you to access the patient's vein w/o moving the catheter or causing trauma to the IV site
extension tubing
provides easy access for intermittent infusions and also adds length to the primary set when necessary
piggyback
consists of a connector, a long tube, and a container of medication
Y set
used for blood administration; 2 short arms of IV tubing, each w/ a spike; these arms come together at the drip chamber
filters
prevent impurities and particulate matter from entering the bloodstream of the patient; may be built into an infusion set or are sometimes added to the administration set
stopcock
device controls the direction of flow of the IV fluid; allow more than one fluid to flow into the patient through the same IV site; 3-way or 4-way
T ports, J loops, and U connectors
used to temporarily disconnect a patient from a continuous IV
electronic flow control devices
infusion pumps, rate controllers, syringe pumps, and patient-controlled analgesia pumps
gravity drip
hang the bag about 36 inches above the level of the patient and use the clamp to regulate the rate
slower
cold fluids drip ______than warm fluids
infusion pump
allows precise control over an IV's flow rate and the total amount of fluid delivered; forces the IV solution through the tubing; the pump on this infusion device applies pressure sufficient to deliver a set volume of liquid every minute into the patient'
infiltration
indicated by swelling, coolness, or discomfort at the insertion site
rate controller
relies on gravity to infuse an IV solution, but no clamp is used to adjust the flow rate; instead tubing is threaded through the controller, where a pincher maintains a preset flow rate
syringe pump
allows a syringe to be inserted into the pump unit; delivers medication or fluids that cannot be combined w/ other medications or solutions
patient-controlled analgesia pumps
device for patient to deliver their own pain med
volume-control set
Buretrol; used w/ manual IV setups and elctronic rate controllers to imporve the accuracy of fluid infusion, especially for small volumes of medication or fluid; calibrated in 1 mL increments, and their total volume capacity ranges from 100-150 mL; the me
buretter
a chamber designed to hold a smaller, controlled amount of fluid
dextrose; sodium chloride
solutions contain different concentrations of ______ or _________
osmolarity
concentration of a solution; determines the direction of fluid shift between the extracellular and intracellular compartments
isotonic solutions
have the same concentration, or osmolarity, that serum and other body fluids do
isotonic solutions
they expand the intravascular compartment of the body w/o causing a shift in fluids; provide hydration in patients who are dehydrated or can replace extracellular fluid losses in patients who have suffered blood loss;
isotonic solutions
given to treat hypernatremia (sodium excess); do not provide adequate calories and have even lead to protein loss
hypertonic solutions
have an osmolarity that is higher than that of serum
hypertonic solutions
when infused causes an increase in the osmolarity of the serum, and it pulls fluid from cells and interstitial compartments in the intravascular space; increases extracellular volume and causes cells to shrink
hypertonic solutions
reduce the risk of edema; stabilize BP; assist in regulating urine output; treat gastric fluid loss from diarrhea, vomiting, or nasogastric suctioning, given as a temporary treatment for circulatory insufficiency and shock; hypertonic solutions can be use
hypertonic solutions
not appropriate for patients w/ impaired heart or kidney function; D10W; D5 1/2; NS; and D5NS
hypotonic solutions
have an osmolarity that is lower than that of serum
hypotonic solutions
when administered, they cause a shift of fluids out of the intravascular space into the cells and interstitial spaces where the osmolarity is higher; cells become hydrated, and circulating volume is decreased
hypotonic solutions
increase extracellcular fluids they should not be given to patients w/ cerebral edema or increased intracranial pressures, burns, trauma, or low serum protein levels from malnutrition or liver disease; 1/2NS
normal saline
0.9% NaCl; isotonic; sodium and chloride levels that are slightly higher than the normal plasma levels of these electrolytes
0.45% NaCl
safely supplies normal daily amounts of salt and water; hypotonic
3% or 5% NaCl
hypertonic; correct severe sodium loss and water overload
sodium chloride
used to treat a variety of clinical conditions, including shock and hyponatremia (low serum sodium)l; fluid changes; replacement in diabetic ketoacidosis; resuscitation in trauma emergencies; infused w/ blood gtransufions
135-145
normal sodium levels
3.5-5.0
normal potassium levels
dextrose
________solutions provide calories as carbohydrates
17; 170
D5W supplies only ______calories per 100 mL (______cal/L)
34; 340
D10W supplies ______calories per 100 mL (______cal/L)
free water
dextrose solutions, which provide _____ ________in addition to calories can be used for administration of medications and for the treatment of hyperkalemia (high serum potassium)
hyponatremia
low serum sodium
hyperkalemia
high serum potassium
combination of NaCl and Dextrose
prevent some of the adverse effects that occur when sodium chloride or dextrose is administered separately
combination solutions
good choice for fluid replacement in patients w/ excessive loss of fluid due to sweating, vomiting, or gastric suction; patients w/ heart, kidney, or liver diseases must be monitored closely to prevent fluid overload
replacement fluids
replace electrolytes or fluids lost b/c of dehydration, hemorrhage, vomiting, or diarrhea
lactate; acetate
multiple electrolyte solutions may contain ______ or ______to treat metabolic acidosis, which is a disruption of the body's acid-base balance
maintenance fluids
maintain the balance of fluids and electrolytes in patients; trauma; fluid losses in the GI tract, dehydration, Na loss; acidosis, and burns
plasma expanders
act osmotically to expand the intravascular space; they are used to rapidly increase circulating volume in emergencies
dextran; mannitol; hetastarch
synthetic plasma ex panders
albumin
natural plasma ex pander
dextran
can be used to treat shock due to trauma, burns, or hemorrhage, but it is not a substitute for blood or blood products. complications include ANAPHYLAXIS; fluid overload; and dilution of electrolytes
mannitol
sugar alcohol substance that removes excess body fluids; promotes diuresis and excretion of toxic substances and is used to treat increased intracranial pressure and cerebral edema; complications include fluid and electrolyte imbalances, cellular dehydrat
hetastarch
similar to albumin; fluid is pulled from the cells into the intravascular space; used to replace fluids in the treatment of shock caused by decreased circulating volume; complications include: anaphylaxis, altered platelet function, volume overload, and f
albumin
used to treat shock related to circulating volume deficit, to provide protein and to bind to bilirubin; complications: fluid overload anemia, bleeding, dilution or depletion of electrolytes, and allergic reactions
5% sodium bicarbonate
used to neutralize excess acids and to restore balance in patients w/ metabolic acidosis or severe hyperkalemia (high potassium)
alcohol; hypertonic
5% ethyl alcohol and 5% dextrose in water; what type of solution?
blood
the body's main transport system for oxygen, nutrients, hormones, and other important substances
5 liters
the adult body contains about ______of blood
blood infusion
restores circulating volume, improves the ability of the blood to carry oxygen, and replaces blood components that the body is deficient in, including factors that enable blood to clot
whole blood; packed RBCs; leukocyte-poor RBCs; platelets; fresh frozen plasma
blood components that can be infused:
1-
2-
3-
4-
5-
plasma
liquid component of blood about 55% of blood volume and consists of water, protein, lipids, electrolytes, vitamins, carbohydrates, bilirubin, nonportein nitrogen compounds and gases
cellular portion
________ ________ of blood is composed of erythrocytes, leukocytes, and thrombocytes
erythrocytes
red blood cells (RBCs)
leukocytes
white blood cells (WBCs)
thrombocytes
platelets
autologous
blood from the recipient
hemolytic reaction
blood transfusion reaction caused by a donor/recipient incompatibility
ABO system
blood grouping system based on antigens present on RBCs and antibodies in the serum; the most important system for determining donor/recipient compatibility
AB
universal blood recipient
O
universal blood donor
transfusion reaction
headache, chest pain, chills, back pain, and fever
Rh system
inherited antigens found on the surface of RBCs; the 2nd most important system for determining donor/ recipient compatibility
parenteral nutrition
IV infusion of nutrients, including amino acids, dextrose, fat, electrolytes, vitamins, and trace elements
2.05-2.55
normal calcium levels
peripheral parenteral nutrition (PPN)
used to help a patient meet minimum calorie and protein needs of the patient does not need to gain weight; requires lower concentrations of dextrose and amino acids to decrease the risk of damage to peripheral veins; SHORT TERM THERAPY
total parenteral nutrition (TPN)
needed to restore or maintain nutritional status in patients w/ illnesses or injuries that have led to a decrease in or absence of oral intake, resulting in weight loss and decreased caloric and protein levels; LONG TERM THERAPY; MUST BE ADMIN THROUGH A C
heparin
used to prevent and treat various thromboembolic (blood-clotting) disorders such as deep vein thrombosis, pulmonary embolism, and atrial fibrillation w/ clotting
heparin
does not dissolve clots but instead keeps clots from expanding and prevents development of new ones; should be administered via an infusion pump
prothrombin time; international normalized ratio
(HEPARIN) PT; measures how long it takes for the patient's blood to clot, but because results may vary from lab to lab, a ratio called the _________ ________ ________ (INR) is used to standardize the results
0.9; 0.45; 250; dextrose
initially insulin is infused in a solution of either _____% NaCl or ______%NaCl; once the patient's blood glucose lowers to _____; ________is added to the infusion to maintain the blood sugar level for 12 to 24 hours
electrolytes
_______are added to IV solutions to replace patient losses.
electrolytes
the selection and amount of ______are based on the patient's renal and cardiac function, acid-base balance, electrolyte deficiencies, and disease-specific needs
precipitate
a solid substance separated from a solution; sediment
potassium
which electrolyte is irritating to the vein
vitamin C
which vitamin promotes wound healing
vitamin K
not part of many commercial preparations, so it may need to be added separately
folic acid
may be administered for macrocytic anemia (abnormally large RBCs)
folic acid and thiamine
patient's w/ a history of alcohol abuse (vitamins)
B vitamins
vitamins support the metabolism of carbohydrates and the maintenance of GI funciton
compatibility
ability to be mixed and administered w/o undesirable chemical or physical changes or the loss of therapeutic effect
order in which drugs are mixed; drug concentrations; length of time that drugs are in contact w/ other drugs or solutions; temperature; exposure to light; pH
factor affecting drug compatibility
incompatibility
occurs when the additives of a solution react or interact to change the expected action
physical; chemical; therapeutic
3 types of incompatibilities
chemical incompatibility
result of changes in either the medication or the solution; may or mat not be visible and may simply result in the deterioration of the drug (change in color)
physical incompatibility
occurs when multiple drugs area added to a solution or when a drug is added to an inappropriate solution; may cause the formation of precipitate (sediment) that is visible or is too small to detect (hazy or cloudy or develop gas bubbles)
therapeutic incompatibility
undesirable reaction that may occur when 2 or more drugs are given together; one medication may increase or inhibit the effects of another medication
trade name
name that is copyrighted by the pharmaceutical company that markets the medication
generic name
based on its chemical composition and is the name most often used in the inpatient setting
anti-infectives
prevent or treat bacterial, fungal, or vital infections by destroying or inhibiting the growth of the infecting organism
bacteriostatic
inhibiting growth or reproduction of bacteria
bactericidial
killing bacteria
fungicidal
killing the fungi causing the infection
fungistatic
stopping the growth of the fungi
central nervous system meds
control seizures; relieve pain; control agitation; and provide sedation; and treat alcohol withdrawal
cycle-specific agents
which act on the cells at various phases in the cell cycle; inhibit mitosis (cell division) or interfere w/ DNA synthesis, preventing reproduction
cycle-nonspecific agents
act on cells that are not going through the division phase; interfere w/ or inhibit DNA replication, synthesis, or repair
medication; patient; time; route; method; dose; documentation
seven rights of medication administration
rehydration
fluid replacement
anesthetic cream
reduce pain at the insertion site; either a topical cream or a local subcutaneous injection of a medication like XYLOCAINE
EMLA
one brand of topical cream; reduces the pain of the needlestick
IV flow sheet
fluid to be administered (IV administration record)
medication administration record
MAR
latex; tape; alcohol; iodine
what allergies to check for before IV infusion:
1-
2-
3-
4-
mastectomy
if patients has had a _____on breast start IV on opposite side
cellulitis
infection of the skin
distal
generally, you will start a peripheral IV at the most ______site that is available and appropriate for the situation
cannulation
act of inserting an IV access device into a vein
forearm; median cubital;
preferred sites in emergency care are the veins of the _______; followed by the _____ ______vein that crosses the antecubital fossa (SITE)
median cubital
in trauma patient;s the first choice is often to go directly to the ________ _______ vein b/c it will accommodate a large-bore IV and b/c it is generally easy to catheterize (SITE)
scalp
in infants and children, a vein in the ______may be utilized (SITE)
umbilical vessel
in newborns, an ________ ________is used (SITE)
valves
located inside the veins prevent backflow
valves
allow blood to flow against the force of gravity
venipuncture
puncture of a vein w/ a needle
palpate
means to feel
skin turgor
elasticity
immobilization
can be accomplished by either holding or wrapping the infant or child
back of the hand; forearm
the most common veins used for peripheral IVs are in the ___ __ ____ _____ and _______
date and time IV was started; guage and length of catheter; initials
when you start a new IV you must label the insertion site w/ the
1-
2-
3-
72
removing the catheter and restarting the IV in a different location should be done at least every _____Hours to reduce the incidence of infiltration or phlebitis
72 hours
peripheral IV sites are changed every
72 hours
tubing is changed every _____ w/ the site change
48 hours; 72 hours
a gauze dressing is changed every ______; a transparent semipermeable membrane dressing is changed every _____
24 hours
the solution is changed every
diaphoretic
means sweaty
grade 0
INS infiltration scale:
no symptoms
grade 1
INS infiltration scale:
skin blanched
edema <1 in. around site
cool to touch
with or without pain
grade 2
INS infiltration scale:
skin blanched
edema 1-6 in. around site
cool to touch
with or without pain
grade 3
INS infiltration scale:
skin blanched and translucent
gross edema > 6 in. around site
cool to touch
mild to moderate pain
possible numbness
grade 4
INS infiltration scale:
skin blanched and translucent
skin tight, leaking
skin discolored, bruised, swollen
gross edema >6 in. around site
deep pitting tissue edema
circulatory impairment
moderate to severe pain
infiltration of any amount of blood product
infiltration
inadvertent administration of a nonvesicant IV solution into surround tissue
infiltration
localized complication that occurs b/c the IV catheter is improperly placed or secured or becomes dislodged or b.c the veins are thin and fragile, as in elderly patients
infiltration
signs and symptoms: swelling, discomfort, burning, tightness, cool skin, and blanching
blanching
the whitish color that appears when pressure is applied to an area of the skin
extravasation
occurs when vesicant drugs, such as some chem drugs, infiltrate a patient's IV insertion site; can lead to severe tissue damage and requires emergency treatment
vesicant
a medication or agent that produces blisters
phlebitis
inflammation of the vein due to mechanical or chemical causes
mechanical
_________causes of phlebitis include using a large catheter in a small vein, improperly securing the catheter and thereby allowing movement, and over manipulating the IV catheter
chemical
_______causes of phlebitis is caused by irritating or vesicant medications or by solutions that are acidic or alkaline or that have a high osmolarity
erythromycin; nafcillin sodium; vancomycin; amphotericin B; potassium choloride
common medication and solutions that are irritating:
1-
2-
3-
4-
5-
erythema
means redness
phlebitis
signs and symptoms: erythema and/or tenderness at the top of the device, puffiness over the vein, skin that is warm to the touch at the IV site, a slow infusion rate, and an elevated temp
grade 0
INS phlebitis Scale:
no symptoms
grade 1
INS phlebitis Scale:
erythema at access site w/ or w/o pain
grade 2
INS phlebitis Scale:
pain at access site w/ erythema and/or edema
grade 3
INS phlebitis Scale:
pain at access site w/ erythema and/or edema
streak formation
palpable venous cord
grade 4
INS phlebitis Scale:
pain at access site w/ erythema and/or edema
streak formation
palpable venous cord
purulent drainage
fluid overload
signs and symptoms: respiratory distress, neck vein distension, and increased BP
hypersensitivity reaction
also known as an allergic reaction
bronchospasm
constriction of the air passages
hypersensitivity reaction
signs and symptoms: rash, itching; tearing eyes, runny nose; bronchospasm; wheezing; anaphylaxis;
air embolus
when air enters the heart and causes it to work harder
air embolus
if untreated an ____ _______ can lead to decreased cardiac output, shock, and death.
symptoms: respiratory distress and possible mid-chest and shoulder pain, nausea, and lightheadedness
left; down; atrium; pulmonary
when treating an air embolus close off the catheter immediately by using the clamp or by folding the tubing over on itself; place patient on ______side with head______; this position keeps the air bubble in the right ______ and prevents it from moving int
sclerosing
hard veins
hematoma
mass of partially clotted blood that has infiltrated into the tissue
ecchymosis
bruising of the skin surrounding the puncture site
ice packs
if a hematoma develops, apply ____ _______ to prevent enlargement but check your facility's policy b/c a physician's order may be needed
flow rates
the most common problems w/ IV infusions are related to ___ _____
2 to 3 minutes
how long do you hold pressure to prevent bleeding or hematoma at an IV site
size and type of catheter; number of attempts; date and time; site of insertion; type of solution and additives or medications; flow rate; pump information; type of dressing; name or initals
documentation for inserting an IV
1-
2-
3-
4-
5-
6-
7-
8-
9-
date and time; reason; condition of the catheter; catheter was intact (complete)
documentation after IV discontinuation:
1-
2-
3-
4-
infection
PROBLEM:
site is red, sore, swollen; patient is febrile
POSSIBLE CAUSE:
infiltration
PROBLEM:
site is swollen, cool to the touch, taut, uncomfortable for patient; IV has stopped or is sluggish
POSSIBLE CAUSE:
clot formation
PROBLEM:
site is sore, hard, warm, red line appears above site; IV is sluggish or has stopped
POSSIBLE CAUSE:
fluid overload
PROBLEM:
IV has infused ahead of schedule; patient is SOB, has increased respirations, has increased BP
POSSIBLE CAUSE:
hematoma
PROBLEM:
discomfort; bruising, and discoloration at the site
POSSIBLE CAUSE:
hemorrhage
PROBLEM:
blood around the site
POSSIBLE CAUSE:
air embolus
PROBLEM:
patient has cyanosis, low BP, weak pulse, discomfort along the vein, unconsciousness
1500-2000
most adult patients should take in ______ to ______mL of fluid per day
intake
measurement of all fluids taken in from any source: oral fluids, fluid from IV infusion, and fluid from nasogastric or gastric tube.
output
measurement of urine, wound or tube drainage, diarrhea, and vomiting
urometer
a specialized urine collection bag w/ a flow meter
IV to be absorbed (TBA)
the amount of fluid in the solution container at the time you total the fluid balance record or at the end of your shift
IV absorbed
the total amount of fluid absorbed during your shift
IV medication amounts
the type and amount of fluid absorbed w/ intermittent medications infused during your shift
anticoagulants
blood thinners