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foundations exam 2
central lines and blood administration
| Question | Answer |
|---|---|
| CVAD | central venous access devices |
| CVAD catheter types | tunneled and non tunneled |
| tunneled catheters | implanted about 3-6in under subQ tissue sutured in so for long term use |
| non tunneled catheters have | high risk of infection shorter dwell time <14 days |
| PICC lines | peripherally inserted central catheter |
| implanted ports are for | chemo or long term medications |
| PICC lines are a type of | CVAD |
| length of PICC lines | more than 20cm, depending on the pt size |
| PICC lines can be introduced into a | peripheral vein (usually the basilic, brachial, or cephalic vein) |
| PICC lines can be advanced so that | the distal tip dwells in the lower one third of the superior vena cava to the junction of the superior vena cava and the right atrium |
| documentation of dressing change and flushing of CVAD | Location, appearance and condition of CVAD site |
| Location, appearance and condition of CVAD site documentation should include | Presence or absence of signs of erythema, redness, swelling, or drainage and the external catheter length |
| documentation of CVAD should also include | if pt is experiencing pain or discomfort Clinical criteria for site complications Subjective comments of patient regarding any pain Patient’s reaction to procedure Patient teaching |
| Assessments Made When Accessing an Implanted Port | Inspect the skin over the port for swelling, redness, or drainage Assess the site over the port for any pain or tenderness, erythema or drainage Review the patient’s history for the length of time the port has been in place |
| when reviewing the patient’s history for the length of time the port has been in place, you should note | If the port has been placed recently, assess surgical incision If there is presence of adhesive skin closure strips, approximation, ecchymosis, redness, edema, and/or drainage |
| Assessments Made When Deaccessing an Implanted Port | Inspect the skin over the port Assess site over port for any pain or tenderness, erythema or drainage Review the patient’s history for the length of time the port and needle have been in place |
| when reviewing the patient’s history for the length of time the port and needle have been in place, you should note | If the port has been placed recently, assess surgical incision If there is presence of adhesive skin closure strips, approximation, ecchymosis, redness, edema, and/or drainage |
| what should you ensure before deaccessing the port | ensure that is it patent |
| CLABSI | Central Line Associated Blood Stream Infection |
| Prevention of CLABSI | Scrub the Hub Disinfection Caps Dressing changes should be sterile The patient will have a mask on in most cases |
| basic procedure of blood administration | safety/identification checks (2-nurse sign off) baseline VS once blood is released, you have 30 minutes to give it remain with the pt for the first 15 minutes to access for acute transfusion reaction may need to use blood warmer for administration |
| how quickly should blood transfusion be completed | within 4 hrs to reduce risk of bacterial growth |
| what needs to be done prior to blood administration | CONSENT need to have IV access Y-type blood tubing with filter can ONLY be hung with NORMAL SALINE |
| blood typing | identifies the patient’s blood group based on antigens on red blood cells |
| blood cross matching | test donor blood against the patient’s blood to ensure compatibility |
| Assessments Made When Administering a Blood Transfusion | Baseline assessment of the patient Most recent lab values from CBC Ask the pt about any previous transfusions and rxns Inspect the IV site Reassess VS frequently |
| what should the baseline assessment of the patient include before hanging blood | vital signs and heart and breath sounds |
| when inspecting the IV site, what should you note | if the gauge of the IV catheter is a 20- to 24-gauge |
| Assess vital signs within | 30 minutes prior to, 15 minutes after initiation, after completion, and then 1 hour after completion and as patient condition warrants |
| Complete Identification and Checks Required for a Blood Transfusion | Prescribed intervention for transfusion Informed consent Two independent pt identifiers Blood group and type Blood donor ID number Exp date/time, time of issue Inspect container of blood |
| what should you look for in blood bag | abnormal color, presence of clots, clumping, or excessive air/bubbles |
| What is the Number 1 thing you will do if you think a patient is having a transfusion reaction? | stop the transfusion immediately |
| If there is a reaction, | After you have stopped the infusion, call provider. Anticipate orders. |
| what happens to the blood bag if there is a transfusion reaction | The blood bag will have to go in a red bag and be sent back to blood bank |
| if a patient is having a transfusion reaction, what is it important to do | monitor your pt |
Created by:
leh195