Term
|
Definition
0.9 % Normal Saline (NS)
Lactated Ringers |
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Term
|
Definition
1/2 NS (0.45%)
1/4 NS (0.225%) |
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Term
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Definition
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Term
| Hypertonic Fluids: Action |
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Definition
| Pulls water from the cells into the vascular space to maintain the circulating blood volume. |
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Term
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Definition
| Pulls water into the cells and rehydrates them |
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Term
| Checking the bag of fluid: |
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Definition
1. Look for holes by applying gentle pressure to the bag
2. Check clarity of fluid: sediment? cloudy?
3. Check the expiration date! |
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Term
| Preparing the Venipuncture Site |
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Definition
1. Verify provider's orders and the MAR
2. Gather all equipment before entering the room
3. ID the client: use 2 identifers
4. Explain the procedure and provide privacy
5. Hang solution
6. Comfortable position for you and patient
7. Hand hygiene and gloves
8. Select right device
9. Select vein
10. Tourniquet
11. Prep site with alcohol or chlorhexidine |
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Term
|
Definition
The larger the number the smaller the gauge.
NS runs just fine in #22
Blood needs #18 or #20 |
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Term
|
Definition
Start distal and work your way up
Avoid: dominant arm, AC space, side of mastectomy |
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Term
|
Definition
1. Bevel up
2. Apply traction
3. Stop and separate: slide angiocath down
4. Release the tourniquet
5. Tape the catheter
6. Pressure above the distal end and remove needle
7. Connect catheter
8. Label the site |
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Term
|
Definition
Time/date
Location
Gauge
Number of attempts
Type of dressing
Flush administered?
Type, amount, rate
Status of site
Client response |
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Term
|
Definition
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Term
|
Definition
Catheter might be right up against the wall and irritating the vein.
Irritating solution
Patient moves around a lot |
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Term
|
Definition
Pain along the vein
Hard, palpable cord
Erythema, possibly a red streak
Edema
Site may feel warm to touch
Slowed rate |
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Term
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Definition
D/C the IV site
Apply warm compresses
Notify MD
Restart the IV elsewhere
Document everything |
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Term
|
Definition
Catheter has gone through the vein and now the fluid is leaking into the tissues.
Displaced cannula. |
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Term
|
Definition
| Improper placement or dislodgment of catheter |
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Term
|
Definition
Pain
Slowed or halted drip rate
Tissue/hand swelling: above the IV site
Tissue will be cool to touch |
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Term
|
Definition
D/C the IV
Elevate the extremity
Apply warm, moist compresses to reduce edema
Restart IV elsewhere, preferably the other arm |
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Term
|
Definition
Vesicant drug causes stinging or burning at the site
Medication leaks into the tissues and causes injury |
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Term
|
Definition
Redness
Swelling
Tenderness above the IV site
Absence of backflow of blood
Flow rate stopped or slowed |
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Term
|
Definition
D/C the IV
Elevate the extremity
Apply warm, moist compresses for 20 minutes Q4H
Notify MD
Document: location, appearance, solution & estimated amount, nursing actions, name of MD and time notified and orders given.
Administer an antidote if ordered |
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Term
| Phenergan (promethazine) administration |
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Definition
Administer in the port farthest from the IV site
Use large surface veins: avoid wrists, hands, AC sites
Dilute
Administer slowly |
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Term
| Phenergan dilution instructions |
|
Definition
| Each 25 mg. with at least 10-20 mL of NS |
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Term
| Phenergan administration instructions |
|
Definition
Give slowly over 10-15 minutes per 25 mg.
Follow each dose with a NS flush |
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Term
|
Definition
Increased pulse
Increased BP
JVD
Dyspnea
Moist crackles
Shallow, rapid respirations |
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Term
Fluid Volume Overload
Treatment |
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Definition
1. High Fowler's
2. Slow the rate to KVO (20 mL/hr)
3. Monitor VS
4. O2 as needed
5. Call MD |
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Term
|
Definition
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Term
|
Definition
| Chills with a high fever shortly after the infusion begins |
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Term
|
Definition
Contaminated fluids
Contaminated tubing |
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Term
|
Definition
STOP the IV, do NOT D/C it: may need immediate access
Call MD stat
Give symptomatic care
Identify other sources of infection
At some point the IV will be D/C, removed and sent to the lab for cultures, then you will establish a new site for medication/fluids. |
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Term
|
Definition
| Air in the circulatory system |
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Term
|
Definition
Empty solution container
Disconnected IV which allows air to be sucked in
IV tubing that runs dry or is not purged of air properly |
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Term
|
Definition
Respiratory distress
Unequal breath sounds
Weak pulse
Increased CVP
Hypotension
Loss of consciousness |
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Term
Air Embolism
Nursing Interventions: |
|
Definition
Immediately clamp tubing
Turn patient to LEFT
Head down, Trendelenberg
Monitor VS
O2
Notify MD
Document actions |
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Term
|
Definition
Tape all connectors or use Leur-Lock connectors
Instruct patient to use Valsalva maneuver when changing tubing on a central line. |
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Term
|
Definition
1. Check compatibility
2. Check for correct catheter prior to administration
3. IF PRN adaptor, flush with 2 mL NS prior to administration and 2 mL after administration (SAS) |
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Term
| Equipment for Blood Administration |
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Definition
Normal saline, 250 mL: start the bag at KVO and wait for blood.
Y-set tubing with filter
Venipuncture supplies: gauge of #18 or #20 |
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Term
Blood administration
Procedure: |
|
Definition
1. Verify provider's order
2. ID client: use two identifiers
3. Explain procedure and get CONSENT!
4. Type and cross-match
5. Pre-transfusion VS: notify MD if temp is 100 or greater
6. Obtain blood: hang within 20-30 minutes of arrival
7. Validate client's ID band with another RN: 2 RN's must verify
8. Document vitals: 5 min bf; 5 min after; 15 min after start; every 30 minutes until transfusion is complete. Last set after completion. |
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Term
| Bacterial Transfusion reaction |
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Definition
Sudden increase in temp
Hypotension
Dry, flushed skin
Abdominal pain
Headache
Lumbar pain
Sudden chill |
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Term
Bacterial Transfusion reaction
Interventions: |
|
Definition
Stop the transfusion immediately
Remove blood and tubing
Keep IV in place, but change the tubing
Start NS infusion
Notify MD |
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Term
Allergic Transfusion reaction
Mild |
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Definition
Urticaria and hives
Pruritis |
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Term
Allergic Transfusion reaction
Severe |
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Definition
Respiratory distress
Wheezing |
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Term
Allergic Transfusion reaction
Anaphylaxis |
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Definition
Shock
Loss of consciousness |
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Term
Allergic Transfusion reaction
Interventions: |
|
Definition
Mild: may give Benadryl or just continue to monitor
Severe or anaphylactic: Stop transfusion immediately |
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Term
| Hemolytic Transfusion reaction |
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Definition
Most severe reaction
Severe pain in kidney region and chest: FLANK pain
Pain at needle insertion site
Fever: may spike to 105
Chills, flushing
Dyspnea, cyanosis
Headache
Hypotension
Hematuria
Nausea |
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Term
Hemolytic Transfusion reaction
Interventions: |
|
Definition
Stop transfusion immediately
Remove blood tubing
Start NS infusion at KVO with new tubing
VS
Contact blood bank STAT
O2
Notify MD |
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Term
Transfusion Reactions
Management: |
|
Definition
Stop the transfusion
Maintain IV with NEW tubing and 0.9% NS
Assess carefully and notify MD with assessment info
Implement prescribed treatments
Notify blood bank
Send blood container and tubing to blood bank |
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