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Medical Administration Part II

Terms in this set (34)

Initiating
Monitoring
Maintaining
Discontinuing
Role of Nurse in IV Medication Administration
-Type of solution
-Amount of solution
-Other additive to the solution
-Infusion rate (length of time over which it is to be given)
Components of IV Order
-Infiltration, Extravasation
-Thrombosis
-Phlebitis
-Thrombophlebitis
Local Complications
-Embolism: Pulmonary, air, catheter
-Systemic infection
-Circulatory overload
Systemic Complicaitons
Infiltration
Fluids are infused into the surrounding tissues instead of through the vein
Swelling
Coolness
Discomfort
S/S of infiltration
Check IV site frequently
Avoid sites over joints
Use sites over long bones
Teach patient to report S/S
Prevention of Infiltration
-Discontinue site
-Apply warmth to aid absorption (warmth dilates vessels)
-Elevate the limb (gravity dilates vessels)
-Notify provider if severe
-Assess circulation
-Document pt. condition and interventions
Infiltration nursing interventions
Vesicant
Agent that causes destruction of tissue, dangerous chemical

Ex: Chemotherapy (fine in blood stream, dangerous in tissue)

Infused more safely through central access than peripheral IV
Extravasation
Same as infiltration except involves vesicant
Use central access for vesicants or run very slowly

Close monitoring
Prevention of extravasation
Pain or burning

Swelling proximal to or distal to the IV site

Blanching and coolness of the skin

Slow or stopped infusion
S/S Extravasation
Stop IV

Do not remove IV
-There are medications that can be injected to decrease the effects of the vesicant

Apply cold compress to decrease edema and pain
-Avoid spreading
Extravasation nursing interventions
Phlebitis
Inflammation or infection of a vein, manifested by redness, swelling, and tenderness along the course of the vein
-Prolonged use of IV site
-Injury during venipuncture
-Irritating IV additives
-Incompatible solutions
-Vein too small for flow rate
Phlebitis results due to:
-Pain, warmth, and redness at site
-Red streak coming from IV and following vein
-Vein may feel hard and cordlike
-Slowed infusion rate
S/S Phlebitis
-Change IV sites Q72 hours
-Use large veins
-Dilute medications well and infuse slowly
-Use central lines for irritating solutions
Prevention of phlebitis
Discontinue IV
Apply warm compress
Phlebitis nursing interventions
Thrombosis
Damage to the endothelial cells of the venous wall that leads to the formation of a thrombus (clot) that blocks the blood flow

Occurs more with central lines than peripheral lines
Thrombophlebitis
A blood clot accompanies the inflammation of vein (phlebitis)

Risk for the development of embolism
-Painful, reddened, swollen vein
-Slowed IV rate
-Not just swollen at site, but the whole limb is swollen
S/S Thrombosis
-Discuss discontinuing PICC line with provider
-Ultrasound
-Apply warm compress
Thrombosis nursing interventions
-Maintain strict asepsis
-Good hand washing
-Change tubing and dressings Q72 hours or according to agency protocol
Prevention of IV therapy infection
Redness, warmth, and purulent drainage at the insertion site
Local infection S/S
Fever, chills, malaise, elevated WBCs
Systemic infection S/S
Notify provider
Infection nursing interventions
Monitor infusion rate
Prevention of Systemic Fluid Overload in IV Therapy
Elderly
Infants
Co-morbid conditions
-heart failure
-renal disorders
Those at high risk for systemic fluid overload
-Elevated BP
-Elevated HR
-Increased neck vein distention (jugular vein prominence)
-Crackles (fluid starts to seep into lungs, can hear crackly, become short of breath, difficult air exchange)
-Dyspnea
-Increased respirations
-Weight gain
S/S fluid overload
-Slow IV to keep open and notify provider
-High or semi-fowlers position
-Administer oxygen if needed
-Anticipate administration of diuretics
Fluid overload nursing interventions
Air embolism
Entry of air into the patient's circulatory system

Most common when central venous catheters are used

Rare
-Connectors--Luer lock
-Use air eliminating filters
-Instruct pt. to use Valsalva's maneuver when changing tubing or discontinuing a central line
Prevention of air embolism
-Pain in chest or shoulder
-Dyspnea
-Cyanosis
-Hypotension, thready pulse
-Loss of consciousness
S/S air embolism
-Place on L side, Trendelenburg position (left side and upside down so air stays in heart and doesn't go in to brain, since air is lighter than fluid)
-Notify provider
-Monitor VS
Air embolism nursing interventions
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