Nur 172 exam 2- IV THERAPY HONDROS
WHO recommendations - answer Wash hands(b4&after) when doing any FOLEY care.
No Acrylic Nails
Nails are to be no longer than 1/4 inch
Wash hands for 15-30 seconds
NO JEWLERY
Hematoma - answer Infiltration of blood in the tissues at the venipuncture site
S/S: swelling and discomfort at IV SITE
Causes of Hematoma
TX - answer Poor venipuncture technique
Patients taking steroids or anticoagulants/ASA
TX: direct pressure
Elevate extremity
Ice/cold pack
TX of Fluid volume overload (pulmonary edema)
S/S - answerS/S: Crackles
Blood tinged Sputum
SOB
Low pulse/Ox
TX: IM Lasix, Daily weights, fluid restrictions, Oxygen, slow IV rate or KVO or STOP it.
infiltrate - answerCommon complication; when IV fluid happens to make its way outside
the vein. This is why we check IV sites Q2-4H
S/S: cool, pale, edematous skin with pain
Tx: Heat/Cold compress, take IV out, check facility(MD ORDER) protocol, elevate
extremity, continue to monitor
Vesicant - answerA fluid/ medication that can cause injury or even death to tissue if
leaked outside the vein
Examples of vesicants - answer-Calcium Chloride
-Calcium Gluconate
-Contrast
-Dextrose 10%
-Vancomycin
-Potassium Chloride
, Extravasation - answerinfiltration of vesicant type medication
S/S: looks like Infiltration but, blisters develop and the skin starts to slough off.
Tx: STOP infusion IMMEDIATELY
Check for antidote before removing IV, check with Pharmacists for directions with heat
or cold or elevation of extremity, Monitor Patient closely.
What can happen when extravasation occurs? - answerProlonged healing
Potential infection
Multi-debriment surgeries
Cosmetic disfigurement
Loss of limb function
AMPUTATION
Venous Spasm - answerA sudden, involuntary contraction of a vein that temporarily
impedes the blood flow through the vessel
Causes: Infusing cold solutions or infusing them too fast
S/S: sharp pain above iv site
Prevention and TX of Venous spasm - answerRemove solutions from fridge to bring
them to room temperature
Administer Med/Iv solution at prescribed rate, ensure adequate dilution
TX: Apply warm compress to site
Slow IV rate down until spasm subsides
Venous air embolism - answer-Lethal but preventable
Happens during placement or removal of CVAD
Catheter fracture
Disconnection of the IV administration set and the catheter without a clamp
Failure to prime
Adding new bag to iv set ran dry
Loose connections
Venous air embolism - answerS/s lightheaded, dyspnea, Cyanosis, tachypnea,
expiratory wheezes, cough, mill wheel murmur, hypotension, chest pain & mental status
changes
Venous Air embolism Complications - answerSHOCK, DEATH
NEROINJURY and/or MI
Treatment of Venous air embolism - answerPrevent more air from entering patient
Place patient on left side and in trendelenberg
CALL rapid Response
intubate if needed
Monitor vitals
may have mill wheel murmur
Administer Oxygen
WHO recommendations - answer Wash hands(b4&after) when doing any FOLEY care.
No Acrylic Nails
Nails are to be no longer than 1/4 inch
Wash hands for 15-30 seconds
NO JEWLERY
Hematoma - answer Infiltration of blood in the tissues at the venipuncture site
S/S: swelling and discomfort at IV SITE
Causes of Hematoma
TX - answer Poor venipuncture technique
Patients taking steroids or anticoagulants/ASA
TX: direct pressure
Elevate extremity
Ice/cold pack
TX of Fluid volume overload (pulmonary edema)
S/S - answerS/S: Crackles
Blood tinged Sputum
SOB
Low pulse/Ox
TX: IM Lasix, Daily weights, fluid restrictions, Oxygen, slow IV rate or KVO or STOP it.
infiltrate - answerCommon complication; when IV fluid happens to make its way outside
the vein. This is why we check IV sites Q2-4H
S/S: cool, pale, edematous skin with pain
Tx: Heat/Cold compress, take IV out, check facility(MD ORDER) protocol, elevate
extremity, continue to monitor
Vesicant - answerA fluid/ medication that can cause injury or even death to tissue if
leaked outside the vein
Examples of vesicants - answer-Calcium Chloride
-Calcium Gluconate
-Contrast
-Dextrose 10%
-Vancomycin
-Potassium Chloride
, Extravasation - answerinfiltration of vesicant type medication
S/S: looks like Infiltration but, blisters develop and the skin starts to slough off.
Tx: STOP infusion IMMEDIATELY
Check for antidote before removing IV, check with Pharmacists for directions with heat
or cold or elevation of extremity, Monitor Patient closely.
What can happen when extravasation occurs? - answerProlonged healing
Potential infection
Multi-debriment surgeries
Cosmetic disfigurement
Loss of limb function
AMPUTATION
Venous Spasm - answerA sudden, involuntary contraction of a vein that temporarily
impedes the blood flow through the vessel
Causes: Infusing cold solutions or infusing them too fast
S/S: sharp pain above iv site
Prevention and TX of Venous spasm - answerRemove solutions from fridge to bring
them to room temperature
Administer Med/Iv solution at prescribed rate, ensure adequate dilution
TX: Apply warm compress to site
Slow IV rate down until spasm subsides
Venous air embolism - answer-Lethal but preventable
Happens during placement or removal of CVAD
Catheter fracture
Disconnection of the IV administration set and the catheter without a clamp
Failure to prime
Adding new bag to iv set ran dry
Loose connections
Venous air embolism - answerS/s lightheaded, dyspnea, Cyanosis, tachypnea,
expiratory wheezes, cough, mill wheel murmur, hypotension, chest pain & mental status
changes
Venous Air embolism Complications - answerSHOCK, DEATH
NEROINJURY and/or MI
Treatment of Venous air embolism - answerPrevent more air from entering patient
Place patient on left side and in trendelenberg
CALL rapid Response
intubate if needed
Monitor vitals
may have mill wheel murmur
Administer Oxygen
