Foundations Test 1
IV Basics
Terms
● Drop Factor – drops per mL
● Pumps – mL/hr
● Gravity Hang- gtts/min
● Micro drop – 60 gtts/mL
● Macro drop – 10 gtts/mL
● Adults – 16 to 20 gauge
● PEDS – 22 to 24 gauge
● Priming – Getting air out of line, typically flushed with 0.9% NS
Nursing Considerations
● Hypertonic solution for PT with edema to pull water out of the cells and back into the vessels
● Alcohol – Under 6 months of age, 60 second prep
● Chlorohexidine – Over 6 months of age, 30 second prep and 1 minute air dry. Don’t fan dry
● Make sure skin prep dries before placing tegaderm on
● Use alcohol on stat lock before removing catheter
● Always document catheter is intact when removing them
● Close roller clamp first before spiking bag as it will pour everywhere
● Chemistry profile 7 should be done daily for all patients on IV fluids
● Change central line dressings every 7 days
● Change PICC line dressings every 72 hours
● If greater than 0.5 round up, if less than 0.5 round drop down. No decimals in drops
● IV solution can only hang 24 hrs, discard the solution and hang another bag
● IV tubing needs changed every 24 hours for intermittent care
● IV tubing needs changed every 96 hours for continuous care
● Primary bag hangs lower then secondary bag
● When giving D5W, the dextrose is used up fast causing free water leading to hypovolemia
● If Pt. is receiving Coumadin IV and starts bleeding at the site, apply pressure for 5-10 mins
● PT most at risk for fluid overload via IV infusions are the young, old, CHF and renal issues
● Monitor all PT receiving fluids as they are fall/seizure risks
Tests
●
Passive Leg Raising – lay torso horizontal and passively raise leg at 45 degrees
●
Tilt Test – Take PT vitals laying, sitting, then standing to test fluid balance
●
MUSC Test – Score of 5 or more shows dehydration/sepsis
IV complications/Reactions
● Phlebitis – infection showing erythema with red streaks proximal from the IV site
● Infiltration – When the IV fluid is leaking into the interstitial space causing edema. Skin is
cold and swollen
● Extravasation – When a caustic substance has infiltrated through a peripheral IV site and
causes skin to slough off and necrose. Can lead to amputation
● Transfusion-related Acute Lung Injury – respiratory distress during transfusion from
female donated plasma and the antibodies it contains. Will need to be on Ventilator
● Transfusion Associated Circulatory Overload – when fluid is transfused too rapid
● Acute Hemolytic Reaction – The wrong blood type was given. The blood bank will ask for
a blood specimen to be take and a culture from their first void. They need to know if cross
matched wrong or if the wrong blood was ordered.
● Febrile Non-Hemolytic Reaction – an onset of fever and is most common. This is from
sensitization to donor blood products
Blood Products / Blood Transfusions
Terms
● Packed RBC’s – Low Hemoglobin and Hematocrit. Treats anemia. Normal is 12 and 36
● Platelets – Low platelets. Treats Thrombocytopenia. Normal is 150k to 400k
● Fresh Frozen Plasma – When there is a clotting problem. Helps reverse blood thinners like
coumadin
● Albumin – To expand or maintain blood volume. Helps with Hypovolemia during trauma
● Epogen – Used to treat anemia
● Neupogen – Used to stimulate white blood cell production, particularly Neutrophils
● O Negative – emergency release blood for trauma as its universal donor
● AB – Universal recipient
● Autologous Blood – Blood donated by PT for themselves if needed. Common in Jehovah’s
Nursing Considerations
● Packed RBC’s most common given
● Blood product must be started within 30 mins of getting from lab
● Check vitals before, Q15 mins after starting, and 1 hour after stopping
● When running blood products IV, equipment needs changed every 4 hours
● Only 0.9% NS can be run with blood
● 1 hour prior to running blood products, its typical to give Benadryl and Acetaminophen for
those who don’t like getting it
● Must give meds prior to running blood as nothing can be run with it
● Tubing for blood comes with a 10 gtts/min filter and must be immersed to work
● PT must sign consent and only the nurse can witness consent, provider can’t
● Blood is generally run slowly over a 2-4-hour period
● Run packed RBC’s slow, 120 ml/hr max
● Run Plasma slower to prevent fluid overload
● Run Platelets fast to prevent clotting
● Make sure PT needs first by checking Hgb / HCT / Platelets
Labs and Values
● Cross Match – testing before a blood transfusion to determine if the donor's blood is
compatible with the blood of an intended recipient and takes 45 minutes
● Type and Screen – determines both the ABO-Rh of the patient and screens for the presence
of the most commonly found unexpected antibodies. Type - The patient's blood cells are
mixed with serum known to have antibodies against A and against B to determine
blood type.
● Hemoglobin (Hgb) – 12 is normal range
● Hematocrit (HCT) – 36 is normal range
● 1 bag of packed RBC’s raises 1 Hgb and 3% Hct
● Platelet Count – Normal is 150,000 – 400,000
● 1 unit of platelets raises count by 10,000. Typically comes in a “6 pack”
Contraindications
●
Check vitals first, cannot give blood if PT is febrile
●
It is possible to get HIV when transfusing blood even if screened as the original donor may
not show antibodies of HIV for months
●
Run blood products slower if the PT has a history of Heart Failure
●
When running blood products, if any reaction occurs, STOP Immediately
Total Parenteral Nutrition (TPN)
● Provide fuel, energy and nutrients through the bloodstream
● A FSBS needs to be done every 6h because the pancreas stops producing insulin
● Bypasses the GI tract so absorption of protein is impaired
● Must start TPN slow and taper it slow because pancreas will still be secreting insulin, allow
pancreas to adjust to sugar load
● TPN in central line only, do not use femoral
TPN & Lipids
● lipids are usually mixed with TPN and used in a central line. There is a high concentration of
dextrose, and it can’t be given in a peripheral IV as its risk for infection
● Anything under 12% dextrose can be given peripherally
● Lipids alone can be given peripherally
● Lipids can come in vials, need to use a vented tubing
● 1.2 (blue) filter is used for lipids and 0.2 (clear) filter for TPN
● Lipids – 1.2 micron blue filter, bag is white
● TPN – 0.2 micron clear, mixture is usually yellow
● Lipid bags don’t hang for more than 18 hours, tubing changed ever 12 hours
● Add mixture - is white (with carbs, amino acids, fats, etc included)
● PICC lines last weeks at a time. Central line last 29 days?
● Given to patients who are NPO
● Common additives to TPN - sodium, potassium, magnesium, calcium, phosphate, chloride,
acetate, acid, vitamin A, D, B, folic acid, vitamin K, trace elements, interferons, insulin
● Higher doses of dextrose will make the patient more at risk for infection (grow bacteria)
Complications / Reactions
● Phlebitis
● Intravascular hemolysis
● Hyperlipidemia/pancreatitis
Three factors for incompatibilities with parenteral nutrition
●
Precipitation of calcium and phosphate
●
Creaming/cracking of lipid emulsion
●
Addition/simultaneous application of drugs with parenteral drugs
TPN main components
● Main Fuel – Protein, Carbs, Lipids
● Nutrients – Vitamins, Minerals, Electrolytes
● Water – 25-40 mL/kg/day
● 1 bag of TPN should last 24 hours
Partial Parenteral Nutrition (PPN)
● Given to pt. who can tolerate some oral feeding but cannot ingest enough to meet needs
● Given thru peripheral IV
● Two types of solutions: lipid emulsion and amino acid-dextrose solutions
● Not optimal for critically ill patients
● PPN solution generally is limited to less than 12% concentration to avoid phlebitis
Interventions for client receiving TPN
● Monitor weight
● Monitor intake and output
● monitor biochemical lab values (albumin and blood glucose, PT)
● Want to initiate feeding slowly to avoid “refeeding syndrome”
● Do not cold turkey stop the TPN as the patient will become hypoglycemic
● If no TPN available, you can give dextrose 10% to prevent hypoglycemia
● Change TPN tubing every 24 hours because dextrose grows bacteria
● Change Lipid tubing every 12 hours
● When using TPN in infants, make sure to keep a give them a pacifier to associate the feeding
with oral stimulation so they don’t lose sucking reflex
Patient controlled Analgesic – PCA
Terms
●
Continuous dose – a set, continuous rate the pump is set at by nurse if they cannot push
themselves
●
Bolus dose - infused set does a nurse does based on PT weight. This is a onetime dose, the
pump will need to be set after
●
PCA dose - patient uses the handheld device to give themselves a dose
●
Lock out – Time between doses allowed so Pt. does not overdose. The times pushed is
recorded even if locked out.
●
PCA Pump - gives a set, prescribed dose of meds based on body weight
Nursing Considerations
●
Morphine, hydromorphone (Dilaudid), and Fentanyl are common drugs given in PCA
●
Naloxone (Narcan) is the antidote and antagonist for morphine
●
Educate Pt. about which is PCA device and which is call bell
●
Makes a bird chirping sound when given. Only beeps if locked out
●
Patient gets 2L of oxygen through a special nasal cannula with PCA
●
Some have PCO2 monitors to prevent chance of respiratory depression
●
Usually given to kids 7 years or older
●
Carfentanyl is being laced in drugs, cannot be reduced by naloxone so wear thyick gloves
●
Need 2 nurses to waste a med, never leave opioid in syringe
●
Assess pain, respirations, PCO2 every 24 hours
●
You can be on PCA and continuous at the same time
●
Can't give meperidine (Demerol) in PCA because it contains metabolites that can build up
and lead to seizures.
●
Meperidine (Demerol) is contraindicated in MI events
●
Never used Demerol for chest pain because causes vomiting and nausea
●
PCA tubing good for 24 hours
Contraindications
●
Careful to not put hydromorphone (Dilaudid) or Fentanyl in the pump set as morphine as
they are much higher strength. I.E. 1mg hydromorphone = 10mg morphine
●
Carfentanyl is being laced in drugs, cannot be reduced by naloxone so wear thick gloves
●
Can't give meperidine (Demerol) in PCA because it contains metabolites that can build up
and lead to seizures.
●
Meperidine (Demerol) is contraindicated in MI events
●
Never used Demerol for chest pain because causes vomiting and nausea
Math Questions
● Volume in mL X Drop Factor
# of Minutes
● Nitroglycerin
● Dilazam
● Magnesium
● Lidocaine
● Heparin
● Burn formula
● Mcg/kg/min question
● Mcg/min question
Dr. Cherry’s “Fun Facts”
●
0.45% NS can cause brain swelling in PEDS but can be good for DKA
●
D5 ¼ % NS can be used in PEDS to prevent starvation ketosis
●
Lactic acidosis indicates poor tissue perfusion, check lactate levels as they are an early sign
of infection or kidney function
●
GFR > 90% is typical and monitor creatinine clearance and BUN
●
Too much 0.9% NS can cause Hyperchloremia
●
Don’t mix Heparin and antibiotics as they form a precipitate
●
Only physician call pull out a tunneled Hickman / Groshong IV. Usually for Chemo
●
Must flush out Intraosseous Catheter with 10 mL of 0.9% NS after giving each med
●
Huber needle needed for porta Cath, needs changed every 7 days
●
Use a Burette for PED’s so you can give it with minimal fluids
Read
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Pg. 961 charts 42-13 / 42-14
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Pg. 989 questions at the end of the chapter
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CH 42