56 terms

IV Therapy

Six rights to med admin
right client, drug, dose, time, route, documentation
Three med checks
when taking med from IV storage area the client's drawer or the fridge, before spiking IV bag with tubing either at client bedside or when preparing med at cart, when hanging med on IV pole in client's room
Two ID checks
compare MAR to ID bracelet, ask client to state his name
Gravity drip infusions
must calculate the flow rate, drops per minute, and manually count the drops using a watch
Continuous drip pump infusions
know how to operate the pumps
Intermittent infusions
recur on a regular basis such as every 6 hours, must be able to backflush the intermittent infusion tubing nad set the medication to run over the prescribed time
Direct IV push medications
must always look up the action, onset, peak, duration, and rate of admin in a drug book, check the dilution requirements and fluid incompatibilities of the medication, and monitor the client for incompatabilities or reactions during the med admin
Additional checks for IV fluids for administration
check the clarity of the soln, expiration date, compatabilities of additives and medications, and the correct volume to be administered over the correct time
Steril econnections
IV fluids and IV tubing have this. Must pay attention to sterility to avoid contaminating this when changing out the fluids
Instantaneous effects
IV solutions and fluids have this. Therefore, use meticulous care and med checks when administering them, including checking for allergies
Nursing responsibility
monitoring and maintenance of IV site and insertion site care
Provider with prescriptive authority
IVs are ordered by this person and the order must be legible, complete with a date and signature, and be written for the correct client
Complications of IV therapy
infection, phlebitis, infiltration, air embolism, thrombophlebitis, circulatory overload
inflammation of the vein with tenderness, redness, and warmth possible
leakage of fluid from the vein causing a cool, hard, swollen, and painful area
Air embolism
20 mL/sec required in peripheral line
blood clot with inflammation
IV meds
may be mixed by pharmacy or you may prepare them, depending on agency policy
Blood products
must be stored only in refridgerators and freezers monitored by the transfusion service.
Plasma derivatives
such as albumin are routinely stored at room temp and are commonly dispensed through the pharmacy or central stores
Nursing unit fridge or other unmonitored fridge
don't sotre blood precuts here
30 minutes
do not keep blood out of a monitored fridge for more than __ before the transfusion
warm blood
do not ____ blood in an unmonitored water back or sink or in a microwave
blood filter
don't administer blood without this
4 hours
do not use the same blood filter for more than __ hours
4 hours
do not transfuse a unit of blood for more than __ hours
add medications
don't __, including those used for IV use, to blood or components or infuse meds through the same admin set as the blood component
0.9% normal saline
do not allow any solution other than this to come in contact with the blood component or the admin set
blood bank
donot pick up a blood product from here until you confirm the order is signed by a provider, there is signed consent in the chart, the patient understands the procedure, and any premeds have been administered
transfusion reaction
when this occurs, stop the transfusion immediately!
.9% normal saline
with a reaction, keep the IV open with new IV tubing primed with this so no more blood is transfused
the reaction to the transfusion service and provider immediately
clerical check
do another one of these at bedside identifying tags and numbers
treat symptoms
per the provider's order ro agencypolicy and monitor vital signs including O2 sats
blood bag
sned this with attached admin set and labels to the transfusion service
blood and urine samples
collect these and sent to lab. Check with trnasufusion service to determine the specific ___ and ___ samples needed to evaluate reactions
the symptoms and your actions thoroughly on the transfusion reaction form and in the client chart
fever (rise of 1 degree C or 2 degrees F), chills, muscle aches or pain, back and chest pain, headache, heat at site of infusion or along vein
nervous system
apprehension, impending sense of doom, tingling, numbness
respiratory system
resp rate (tachypnea, apnea), dyspnea, cough, wheezing, rales
GI system
nausea, vomiting, pain, ab cramping, diarrhea (may be bloody)
CV system
heart rate (tachy or bradycardia), BP (hypo or HTN), peripheral circulation (color cyanoiss, facial flushing temp: cool/clammy, hot/flushed, dry, edema), bleeding (generalized, oozing at surgical site)
Renal system
changes in urine volume (oliguria, anuria, renal failure), changes in color (dark, concentrated, shades of red, brown, amber)
Integumentary system
rashes, hives, swelling, itching, diaphoreses
patient controlled analgesia
used to provide legally controlled opiates IV to a client frm an external infusion pump
developed to provide a more finely titrated control of client pain and opiate serim levels in post op clients, but are now routinely also used for chronic pain management and clients with burns or trauma
Criteria for selection of PCA
moderate to severe pain requiring repeated doses, client is able to understand and follow directions, willing to use PCA therapy
Commonly used opiates
morphine, hydromorphone, meperidine
the infusion pump program can/not be overridden by the client
often used for post surgical pain management and may be initiated in the PACI when the client is still sedated. Must continue to re educate your clinet on how to use the PCA the entire time they have it
discourage family members from administering doses while the client is asleep as this may ___ them
be aware of meds used to reverse or correct oversedation such as __, and where to locate them quickly
3 methods for deliverating PCA opiates
on demand only when the client uses the PCA button, as a continuous infusion scheduled to admin a dose of med to the clinet at pre programmed intervals aka basal infusion, a combination of both on demand and basal infusion
home health setting
here, PCAs are used SQ
here, the IV route is used for PCAs