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NURS2520 Health Assessment II

NURS2520 Health Assessment II

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NURS2520 Health Assessment II

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  1. NURS2520Health Assessment II IV and MEDS

  2. Objective OneExplain the legalimplications ofintravenous therapy

  3. The Five Rights of Medication Administration • Right patient • Right medication • Right dose • Right route • Right time

  4. The Three Checks of Medication Administration 1. Read the label of the medication as it is removed from the shelf, unit dose cart, refrigerator, or dispensing system 2. Read the label of the medication when comparing it with the MAR 3. Read the medication label again before administering the medication to the patient

  5. LOOK at the label for verification of the medication name, dosage, route, and expiration date • CHECK the medication itself, NOT just the pharmacy label • Be overly cautious with regards to dose, proper dilution, and administration rate • Watch decimal points • Be aware of the unit • Is the medication dispensed in mcg or mg? • What is ordered in comparison?

  6. Risk Management forInfusion Therapy • Know venous anatomy and physiology • Know appropriate vein selection • Use infusion equip. appropriately • Clarify unclear orders • Refuse to follow orders that you know are not within the scope of safe nursing practice • Know the infusion indications, side effects, and special considerations for IV medications • Administer medications and/or infusions at the proper rate and within the ordered intervals

  7. Risk Management (cont’d) • Assess the patient and monitor the IV site for complications • Use proper IV care and maintenance • Notify physician promptly of IV complications • Know and give appropriate treatments for complications • Provide proper patient education • Document all aspects of IV therapy, including patient education • Follow your institution’s policy/procedures • Abide by Nebraska’s Nurse Practice Act and standards of IV practice

  8. Objective TwoApply the concepts of standard precautions in infusion therapy

  9. Updated CDC Guidelines for Preventing Infusion Device-Related Infections • Prepping the skin • Use 2% chlorhexidine, which is more effective in lowering catheter-related bloodstream infection rates than 10% povidone-iodine and 70% isopropyl alcohol • Chlorhexidine persists on the skin longer, which is important because it kills organisms that could repopulate the insertion site from deeper skin layers • Use “back and forth” scrubbing motion rather than outwardly radiating concentric circles • Allow solution to dry • It has not been determined if chlorhexidine should be used on infants less than 2 months of age

  10. Peripheral IV site recommended for only 72 to 96 hours to prevent phlebitis • Maintain peripheral IV in place in pediatric patients as long as needed • Ensure site is free from complications • If catheter was placed in an emergency situation, replace within 48 hours • Follow hand antisepsis protocols (i.e. handwashing and alcohol-based hand rubs) • Use clean gloves to insert a peripheral catheter; do not touch access site after skin prep has been applied • Observe hand hygiene before and after palpating catheter insertion sites; before and after inserting an IV; and before and after replacing, accessing, repairing, or dressing an IV site

  11. Occupational HIV Exposure • Preventing exposures to blood and body fluids is the primary means of preventing occupationally acquired human immunodeficiency virus (HIV) infection • Universal precautions • Handwashing • Proper use of safety equipment • Follow institutional policy/procedures • Recommendations for post-exposure prophylaxis (PEP) include urgent medical treatment to ensure timely initiation • Prompt reporting of exposure • 4-week regimen of two antiretroviral medications to prevent seroconversion of HIV infection in health care workers • Counseling

  12. Objective ThreeDiscuss the risks, complications, and adverse reactions of intravenous therapy

  13. Extravasation

  14. Phlebitis

  15. Hematoma

  16. Infiltration

  17. *Infiltration refers to the inadvertent administration of nonvesicant solution into the surrounding tissue • Causes of infiltration include dislodgement of the cannula from the vein, puncture of the vein wall during venipuncture, friction of the catheter against the vein wall, use of a high pressure infusion device, and irritating infusate that weakens the veins • Signs and symptoms of infiltration— • Skin is taut and/or cool to the touch • Dependent edema • Absence of blood backflow or pinkish blood return • Slowing of the infusion rate • Complications of infiltration may include ulceration (after days/weeks) and compartment syndrome

  18. *Infiltration (cont’d): • Prevention of infiltration involves comparing extremities, assessing if infusion stops running when pressure applied 3 inches above catheter site • Treatment of infiltration— • Infuse antidote through the IV if applicable, then remove the IV • Apply warm compresses for antineoplastic agents, and cool compresses for most other medications • Elevate the extremity if this promotes comfort for the patient *Extravasation is the inadvertent administration of vesicant medication or solution into the surrounding tissue • Requires an incident report • Determine treatment BEFORE removing IV • Do not apply excessive pressure to the site

  19. *Thrombosis occurs when blood flow through the vein is obstructed by a local thrombus • S/S include earache/jaw pain, edema/redness at insertion site, tachycardia/tachypnea, malaise, unilateral arm/neck pain, absence of pulse distal to the obstruction, digital coldness/cyanosis/necrosis • Treatment of thrombosis involves discontinuing and restarting IV at a different site (never flush with force to remove an occlusion) *Phlebitis = inflammation of the vein • S/S include localized redness/swelling, warmth/tenderness, palpable “cord” along the vein, sluggish infusion rate, increased temperature • Prevention includes using smallest cannula appropriate, stabilizing the catheter, and correct venipuncture technique

  20. *Septicemia = a febrile disease caused by microorganisms in the circulatory system; septicemia is a major complication that occurs from cannula or infusate contamination • S/S include fever, flushing, profuse diaphoresis, altered mental status, nausea/vomiting, abdominal pain, tachycardia, hypotension • Treatment includes culturing IV catheter per order/agency protocol, administering oxygen if needed, antimicrobial therapy, IV fluids • Prevention of septicemia includes good handwashing, appropriate infusion site dressing, rotation of IV sites *Pulmonary embolism is associated with IV-related thrombus • S/S = shortness of breath, cyanosis, chest pain, tachypnea • Prevent by avoiding venipuncture in lower extremities and not applying pressure to regain IV patency

  21. *Pulmonary embolism (cont’d)– • Treated by positioning patient in left-sided trendelenburg, administer oxygen, and transfer to ICU *Air embolism is most frequent in central lines, and results from small amounts of air in the circulatory system • Causes include incorrect IV insertion, excessive catheter manipulation, and loose connections in the IV tubing • Accumulation of small bubbles can block pulmonary capillaries • Blockage may be fatal due to sudden vascular collapse • Symptoms include cyanosis, hypotension, ↑ venous pressure, and rapid loss of consciousness • Treatment includes immediately placing client in left-sided trendelenburg so that air becomes trapped in the right atrium and is prevented from entering the pulmonary artery; administer oxygen; notify the physician ASAP

  22. Objective FourIdentify central and peripherally placed vascular access devices utilized for various patient needs

  23. Central Lines

  24. PICC Line


  26. Huber needles for port access

  27. Objective FiveIdentify the pharmacological principles and administration of intravenous medications

  28. Vein Selection • Do not use veins in ambulatory lower extremities • Never access an arteriovenous fistula, graft, or shunt • Do not use veins in an extremity that is impaired as a result of a CVA • Do not use veins on the side of the body with radical mastectomy with lymph node dissection/stripping • Bypass veins in an extremity that has undergone reconstructive or orthopedic surgery • Do not use veins in an area with a recent infiltration • Do not use veins at or near 3rd degree burns • Avoid veins in an extremity that is partially amputated • Do not use veins that are irritated or sclerosed from previous use

  29. Tourniquet Application • Applying a tourniquet assists in venous distention • Apply tightly enough that venous blood flow is suppressed, but not so tight that it obstructs arterial flow • Should be able to palpate pulse distal to the tourniquet • Do not leave a tourniquet in place longer than four to six minutes • Tourniquet paralysis from injury to a nerve can occur if the tourniquet is applied too tightly or left for too long a period • Contraindicated in some patients

  30. Cannula Selection *Winged needles, referred to as butterflies, have one or two “wings” that are held upright during insertion to facilitate movement into the vein; once the needle is in the vein, the wings are taped to the skin to secure the device *Peripheral venous access catheters are the most commonly used IV device • Two-part flexible cannula in tandem with a rigid needle or stylet, which is used to puncture and insert the catheter into the vein • Connects with a clear chamber that allows for visualization of blood return, indicates successful venipuncture, and facilitates removal of the needle • Catheter is radiopaque so that it can be easily detected by radiology in case of embolus

  31. IV Administration Sets • The IV administration set determines the rate at which fluid can be delivered to the patient (i.e. the drop factor) • Extra large (macrobore) tubings are used in emergency surgical and trauma situations for rapid infusion of large volumes of blood or fluid • Extra small (microbore) tubings are used for the delivery of small amounts of precisely controlled fluid or medication for special volume restriction (neonatal care, epidural infusions) • Primary administration sets carry fluid directly to the patient through one tube • Secondary administration sets (also referred to as piggyback sets) are used to deliver continuous or intermittent doses of fluid or medication

  32. Objective SixDemonstrate peripheral venipuncture and discontinuation of IV push(*Lab Practice)

  33. Objective SevenDemonstrate calculation of IV drip rates and IV dosages

  34. The IV flow rate is the speed at which the IV fluid infuses into the body • Often measured in drops per minute (abbreviated “gtt/min”) • Factors affecting the flow rate include: • The amount of fluid to be infused • The time over which it is to be infused • The size of the tubing • The number of drops required to deliver 1 ml of fluid varies with the type of IV administration set (tubing) used; the size of the tubing is called the drop factor • There are 2 types of IV administration sets: • Macrodrip = 10, 15, or 20 gtt/ml • Microdrip = 60 gtt/ml

  35. In calculating the flow rate, ratio/proportion cannot be used because there are more than two components to calculate • The dosage calculation formula cannot be used because a dosage is not being calculated • When calculating the flow rate, all rates should be rounded to the nearest whole number • IV Flow Rate Formula: volume of infusion (in mL) x drop factor = Flow rate time of infusion (in minutes) (in gtt/min) *Note that time must be converted to minutes, and that the drop factor is in gtt/mL

  36. IV Calculation Examples Administer D5 ½ NS at 30 mL/h. The drop factor is a microdrip. 30mL x 60gtt/mL = 30gtt/min 60min An IV medication in 60 mL of 0.9% NS is to be administered in 45 minutes. The drop factor is a microdrip. 60mL x 60gtt/mL = 80gtt/min 45min

  37. Examples (cont’d) Administer 3,000 mL D5 ½ NS in 24 hours. The drop factor is 10 gtt/mL. 3000mL x 10gtt/mL = 21gtt/min 1440min Administer Lactated Ringer’s at 125 ml/h. The drop factor is 15 gtt/mL. 125mL x 15gtt/mL = 31gtt/min 60min

  38. Examples (cont’d) 1,000 mL of Lactated Ringer’s solution is to infuse in 16 hours. The drop factor is 15 gtt/mL. 1000mL x 15gtt/mL = 16gtt/min 960min Infuse 2,000 mL D5W in 12 hours. The drop factor is 15 gtt/mL. 2000mL x 15gtt/mL = 42gtt/min 720min

  39. Electronic Flow Rate • When using an electronic infusion device (IV pump), the flow rate is calculated in milliliters per hour (mL/h) • To find mL/h, you must divide the total milliliters by the total hours • You would then round your final answer to the nearest whole • Examples -- • 1000 mL in 8 hours = 1000/8 = 125mL/h • 500 mL in 24 hours = 500/24 = 21mL/h • If an order is given without total milliliters, this becomes a dose calculation; you would use ratio-proportion, dimensional analysis, or the Formula

  40. Recalculating the Flow Rate • Sometimes the IV infusion rate changes due to a change in the patient’s position • If you notice that the flow rate needs to be adjusted, assess the client and determine the percentage of change needed to correct the infusion • Please note that you can adjust the infusion flow rate by no more than 25% without consulting the physician or practitioner • In order to determine the percentage of increase or decrease of the flow rate: • Determine the actual change in the flow rate • Divide by the original flow rate • Multiply by 100

  41. Examples of IV Recalculation Original infusion order : 1000mL D5W IV to infuse over the next 10 hours. Infusion start time: 1300 hours. Drop factor = 10. Hourly rate = 100mL/h. Flow rate = 17gtt/min. At 1430 hours, the infusate level is at 900mL. 150mL should have already infused, leaving 850mL remaining to infuse over the next 8 ½ hours. The IV would be recalculated as follows: 900mL = 106mL/h – 100mL/h = 6mL/h 8.5h 6mL/h = 0.06 x 100 = 6% increase 100mL/h

  42. Recalculation Examples (cont’d) Original infusion order : 1000mL D5W IV to infuse over the next 8 hours. Infusion start time: 0900 hours. Drop factor = 15. Hourly rate = 125mL/h. Flow rate = 31gtt/min. At 1200 hours, the infusate level is at 850mL. 375mL should have already infused, leaving 625mL remaining to infuse over the next 5 hours. The IV would be recalculated as follows: 850mL = 170mL/h – 125mL/h = 45mL/h 5h 45mL/h = 0.36 x 100 = 36% increase 125mL/h

  43. Titrating Medications • Titrating means to adjust the medication until it brings about the desired effect • Always start with the low end of “safe” and increase dosage from there • Follow institutional protocol for titrating medications • Titrated medications are calculated in the same way as non-titrated drugs • An example of a titration order would be: • A client weighing 50 kg is to receive a Dobutrex solution of 250 mg in 500 mL D5W ordered to titrate between 2.5–5 mcg/kg/min