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NURS 1120 Exam 1
IV, Periop, F&E 1
| Question | Answer |
|---|---|
| common indications for IV therapy | maintenance (prevention of loss of fluid, electrolutes, nutrition); replacement (fluid, blood, electrolytes, nutrition); medication administration; blood sampling |
| routine assessment data for patients receiving IV therapy | size, age and history of client, IV access site, vital signs, IV system integrity, correct medication |
| peripheral venous devices | IV access uses superficial veins in the hand or forearm; may use scalp veins for infants |
| central venous devices | tip of the catheter is in the superior vena caval used when peripheral access is inadequate for the duration or type of therapy needed, examples include PICC line, tunneled catheter, port-a-cath |
| three phases of perioperative care | preop (before surgery), intraop (during surgery), postop (after surgery) |
| components of preoperative assessment | nutritional status, dentition, drug or alcohol use, respiratory status, cardiovascular status, hepatic/renal functio, endocrine function, immune function, previous medication use, psychosocial factors, spiritual/cultural beliefs |
| common locations for peripheral IV access | cephalic vein, basilic vein, dorsal metacarpal veins |
| crystalloid IV solutions | aqueous solutions of mineral salts or other water-soluble molecules |
| colloid IV solutions | solutions that contain larger, insoluble molecules |
| factors that influence IV flow rate | tubing, drop factor, type of solution, fluid volume to be administered |
| flow rate | measured in mL/hour |
| drip rate | measured in gtt/min - number of drips per minute required to achieve desired flow rate |
| microdrip | 60 gtt/mL drip factor |
| macrodrip | 10, 15, 20 gtt/mL drip factor |
| common hypotonic solutions | 0.33% NaCl (1/3 normal saline), 0.45% NaCl (1/2 normal saline) |
| common isotonic solutions | D5W (5% dextrose in water), 0.9% NaCl (normal saline), Lactated Ringer's solution |
| common hypertonic solutions | 5% dextrose in 0.45% NaCl, 10% dextrose in water (D10W), 5% dextrose in 0.9% NaCl |
| infiltration | most common complication of IV therapy; caused by fluid leaking from vein into surrounding tissue; symptoms include coolness at the site, pain, swelling, lack of blood return |
| phlebitis | inflammation of the vein; symptoms include pain, redness, swelling, induration (hardness) at site, red line streaking along the vein, fever, sluggish solution flow |
| thrombophlebitis | irritation of the vein with the formation of a clot; symptoms include pain (more severe), redness, swelling and induration at the saite, red line streaking along vein, fever, sluggish solution flow |
| local complications of IV therapy | infiltration, phlebitis, thrombophlebitis |
| systemic complications of IV therapy | circulatory overload, speed shock, embolism, infection, allergic reaction |
| benefits of IV therapy | immediate, predictable therapeutic effect; fluid intake for patients with GI issues or NPO orders; accurate dosage titration; access line in case of emergency |
| risks of IV therapy | drug and solution incompatibility; adverse reactions; local reactions (infiltration, phlebitis, thrombophlebitis); systemic reactions (circulatory overload, speed shock, embolism, infection) |
| factors that influence type of IV access and therapy | body surface area, condition of patient, age, fluid composition, duration of therapy, pressure gradient of fluid, venipuncture, fluid temperature |
| equipment used to administer IV therapy | solution container (usually 1 L plastic bag), tubing (spiker, drip chamber, tubing, ports, clamps, luer lock hub), needles/cannulas/catheters |
| methods of regulating IV drips | IV pump - tubing runs through a pump and pressure allows medication to flow at the correct rate Gravity - manually regulate drip rate to deliver correct amount of fluid |
| types of IV pumps | controller (operates by gravity), positive pressure infusion pump, peristaltic pump, syringe pump, patient controlled analgesia pump |
| nursing responsibilities for IV equipment | inspect equipment before use, use filters when appropriate, use appropriate tubing, follow manufacturer's instructions for electronic infusion devices, set alarm limits, respond to alarms immediately |
| patient controlled analgesia (PCA) | type of infusion pump, patient controls bolus remotely when needed, programmable, cannot overdose, can be used in the hospital or at home |
| methods for delivering IV therapy | peripheral (most common), central venous, cut-down, arterial, intraosseous, hypodermoclysis |
| PICC line | peripherally inserted central catheter |
| tunneled catheter | tubing runs just inder the skin, then accesses one of the large chest veins |
| port-a-cath | subcutaneous reservoir of medication, medication is distributed over time rather than with a one-time push; often used for oncology because of toxic medications |
| types of infusions or IV delivery | continuous infusion, intermittent infusion (INT, saline lock); direct injection (bolus, IV push) |
| bolus | large dose of medication given quickly via IV |
| extravasation | leaking of fluid into surrounding tissues caused by tendency of certain medications to seep through the veins; symptoms include discomfort, burning, pain, skin tightness, blanching, inflammation, necrosis |
| infection related to IV therapy | caused by puncturing of the skin, breaking barrier; symptoms include purulent drainage at the site, tenderness, erthema (redness), warmth, hardness on palpation, fever, chills, malaise, nausea and vomiting, elevated white blood cell count |
| circulatory fluid overload | can occur gradually or suddenly; caused by overloading system with excess fluids; symptoms include elevated blood pressure, pulse, edema, weight gain, I>O, dyspnea, neck vein distention |
| speed shock | systemic reaction caused when foreign substance is rapidly introduced into the circulatory system; symptoms include facial flushing, irregular pulse, severe headache, decreased blood pressure, loss of consciousness, cardiac arrest |
| air embolism | caused by air entering the vein; symptoms include palpatations, lightheadedness, weakness, decreased blood pressure, increased pulse (weak, thready), respiratory distress, cyanosis, substernal chest pain, anxiety, change in mental status, LOC change |
| blood embolism | caused when a clot loosens from the cannula and travels to the lungs; symptoms may be nonspecific - chest pain, shortness of breath, coughing, tachypnea, apprehension, sweating, syncope |
| nursing actions related to patient safety when administering IV therapy | check IV order; follow medication protocol and six rights; do frequent, systemic and complete assessment of both the client and the IV system; assess and maintain infusion at beginning of shift, before and after infusion, every hour |
| systemic assessment of IV system and patient | solution container, air vent, tubing, machine, roller clamp, in-line filter, slide clamp, patient |
| IV incombatibilities | undesired physio-chemical reaction between the drug and the solution, the container, the tubing, or another drug; incompatabilities can destroy the drug's therapeutic effect and create a new or unwanted effect. |
| types of IV incompatabilities | physical - cloudy, layers, color changes, precipitate, gas bubbles; chemical - may not be visible and may cause decomposition of one or both drugs, may be toxic |
| prevention of IV incompatabilities | follow directions, check charts; if unsure whether drugs are compatible, don't mix; do not add meds to TPN or blood; only one medication per solution; flush tubing or lock between two incompatible meds and make sure the drip chamber is empty |
| factors affecting degree of incompatability | time in contact, temperature, order of mixing, relative amount of each drug, light |
| instability | inability of a drug to retain the same properties it possessed originally; a stable drug keeps at least 90% of its properties for a specified time |
| factors affecting instability | light, temperature, pH, time, degree of dilution, preservatives |
| intermittent additive set administration | IVPB into primary line, IVPB into INT (saline lock), volume control chamber (Buretrol) |
| direct infusion | direct injection of medication into INT, port, or hub; most dangerous type of IV medication administration; advantages include emergency administration, high serum concentration, can be direct injection or IV injection |
| SAS | separates incompatible drugs or solutions, commonly used with INT (lock) device. Consists of Saline (1-2 cc), Access (drug, solution, blood draw), Saline (1-2 cc) |
| health factors that put patients at risk for surgery-related complications | age, obesity, disabilities, ambulatory surgery patients, emergency surgery patients, smoking, infection, immune status, resp/cardio status, hepatic/renal status, NPO status, emotional status, mobility |
| informed consent | legal document signed by the patient and witnessed by nurse that explains the procedure, risks, etc.; must be given freely, wihtout coercion, |
| perioperative nursing measures that decrease the risk for infection and other postoperative complications | . |
| preoperative patient preparation and documents | . |
| components of preoperative teaching plan | . |
| interdisciplinary approach to patient care during surgery | . |
| principles of surgical asepsis | . |
| roles of surgical team members | . |
| adverse effects of surgery and anesthesia | . |
| reasons for surgery | diagnoses, cure, palliation, repair, prevention, exploration, cosmetic, reconstruction |
| types of anesthesia | |
| nurse's primary role in ensuring patient safety during the intraoperative period | ADVOCATE! |
| responsibilities of PACU nurse in prevention of immediate postoperative complications | baseline assessment upon admission, frequent assessment of Airway, Breathing, Circulation, surgical site, function of CNS, IVs, tubes and equipment, monitor for complications - airway, BO, temperature regular, nausea and vomiting, pain |
| responsibilities of floor nurse when patient arrives on the nursing unit | immediate: frequent assessment of vital signs, assess airway, breathing, circulation, assess pain; ongoing: skin integrity, activity, pain, infection, nutrition, constipation |
| common postoperative problems | infection, dehiscence, evisceration |
| variables that affect wound healing | . |
| assessment parameters appropriate for early detection of postoperative complications | . |
| GETA | General Endotracheal Anesthesia |
| MAC | Monitored Anesthesia Care |
| Phase I recovery unit | PACU - Post Anesthesia Care Unit, critical care |
| common respiratory issues after surgery | hypoxemia, hypercapnia, hypoventilation, atelectasis (alveolar collapse) |
| TCDB | Turn, Cough, Deep Breathe - technique that reduces risk of respiratory complications after surgery |
| types of hemorrhages | primary - during surgery, secondary - after surgery |
| hypovolemic shock | . |
| common post-op drains | nasogastric tube, Foley catheter, Jackson-Pratt drain bulb, Hemovac, chest tube, VAC wound system, Penrose drain |
| nursing actions that prevent post-operative complications | TCDB, incentive spirometer, leg exercises, TED hose or SCDs, early ambulation with pain control, act on complaints, watch for neuro changes |
| categories of surgery | optional, elective, required, urgent, emergent, minor, major |
| malignant hyperthermia | life threatening condition triggered by a certain anesthetic agent; patient becomes highly febrile and enters a hypermetabolic state where the body begins breaking down tissue. Serious, life-threatening condition. |
| medications that can affect the surgical experience | corticosteroids, diuretics, pehnothiazines, tranquilizers, insulin, antibiotics, anticoagulants; antiseizure medication, thyroid hormone, opioids |
| types of medications | prescribed, over the counter (OTC), herbal or dietary supplements, recreational drugs |
| common allergies | drugs, foods, latex, metal |
Created by:
pinklrt98
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