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Question asked by: S3019638 - 11 months ago

Take a practice exam on the topic: Topical Anesthetics
EMLA Cream (Lidocaine/Prilocaine): Apply to the
site 30-60 minutes before the procedure to numb the
area. Cold Spray (Ethyl Chloride): Use immediately
before venipuncture for rapid numbing.
2 Subcutaneous Lidocaine
Administer a small amount of Lidocaine at the
venipuncture site to reduce pain associated with
needle insertion.
3 Site Selection
Choose a site that minimizes discomfort while
considering patient preferences and clinical
suitability. For example, use the forearm veins when
possible to avoid joints or areas with restricted
movement.
Importance of Patient Education
Educating the patient about their therapy fosters trust and
engagement in their care. Key points to address include:
The purpose and benefits of the I.V. therapy.
Potential side effects or complications to monitor (e.g.,
swelling, redness, or discomfort at the site).
Instructions for communicating concerns or discomfort
during the therapy.
Strategies for Managing Needle-Phobic Patients
Acknowledge Their Fear: Normalize their feelings by
saying, Its common to feel uneasy about needles, and
Im here to help make this as comfortable as possible.
Reassure and Educate: Explain that the process is quick,
discomfort is minimal, and the therapys benefits
outweigh the brief moment of discomfort.
Use Distraction Techniques: Offer options like deep
breathing, music, light conversation, or visualization to
shift focus away from the needle.
Minimize Pain: Apply a topical anesthetic or cold spray,
and use a small gauge needle if appropriate.
Empower the Patient: Let them choose the insertion site
or decide when to start, giving them a sense of control.
Provide Positive Reinforcement: Praise their bravery
and remind them how the therapy benefits their health.
Documentation and Monitoring
Accurate and thorough documentation is critical for continuity of care. Include the following details in the
patient's medical record:
Date, time, and site of I.V. insertion.
Type and volume of solution or medication administered.
Additives and their concentrations.
Infusion rate and any adjustments made.
Patient's response to the therapy and any interventions performed.
Ongoing monitoring of the patient during I.V. therapy is essential. Check the site for signs of infiltration,
phlebitis, or infection, and confirm that the infusion is running at the correct rate.
When documenting as a nurse, SBAR (Situation, Background, Assessment, Recommendation) is typically
used for communication.
For charting/documentation in the medical record, youd use objective, concise, and factual notes, often
guided by formats like SOAP (Subjective, Objective, Assessment, Plan) or DAR (Data, Action, Response).
For documenting an infiltrated IV, keep it simple and clear:
1.
2.
3.
4.
5.
Date/Time:
01/15/2025, 10:30 AM
Objective Description of the Infiltration:
IV site noted to be swollen, cool to touch, and pale. Patient reports mild discomfort at the site.
Action Taken:
IV stopped immediately. Catheter removed. Site elevated and cold compress applied.
Patient's Response:
Patient reports decreased discomfort after intervention. No signs of respiratory distress or other complications.
Notification:
Physician notified and new IV site ordered. New IV successfully inserted in the left forearm.
I.V. Therapy Setup and Maintenance
Gather and Prepare Supplies:
Before initiating the procedure, ensure all necessary supplies are collected and organized to avoid
interruptions. Required items include:
Bed padding
Fluid and infusion set
Extension tubing or end cap
Flush solution
Two catheters
I.V. start kit (tourniquet, gauze, alcohol/chloraprep, transparent dressing, tape)
Infusion device and optional arm board
Prepare the Environment:
1.
2.
3.
Bring all supplies into the patient's room.
Clean the bedside table with antimicrobial soap.
Wash your hands thoroughly before handling any items.
Inspect the Solution and Equipment
Examine the solution bag for:
Accuracy of the prescribed solution.
Clarity to ensure no particles or discoloration.
Expiration date and volume.
Container integrity to confirm its intact.
Proper labeling with additives and concentrations if applicable.
Set Up the Infusion Equipment
1.
2.
3.
4.
5.
6.
Remove the infusion set from its packaging and unwind the tubing. Secure the roller clamp in the off
position.
Remove the protective covers from both the solution bag and the infusion set spike.
Insert the spike into the bag's insertion port using a twisting motion while maintaining sterility.
Hang the solution bag on a pole or hook.
Squeeze the drip chamber until its half full.
Open the roller clamp gradually to prime the tubing, ensuring all air is expelled while keeping the end
sterile.
Prepare the I.V. Start Kit
1.
2.
3.
Unpack the I.V. start kit and prepare the tape:
Tear a 2-inch strip and split it down the middle.
Tear two additional 2-inch pieces and arrange them on a clean surface.
Attach the tourniquet and locate a suitable vein. Release the tourniquet temporarily.
If needed, trim excessive hair using scissors (avoid shaving to prevent skin abrasions).
Clean and Prepare the Insertion Site
1.
2.
3.
4.
Position the patient and lay a pad or towel beneath the limb.
Don gloves and cleanse the site with an antiseptic (alcohol, chloraprep, or chlorhexidine), covering a 2
inch radius.
Allow the antiseptic to air dry completely to ensure efficacy.
Reapply the tourniquet to visualize the vein clearly.
Insert the Catheter
1.
2.
3.
4.
5.
Use your non-dominant hand to stretch the skin below the insertion site gently.
Hold the catheter with your dominant hand, orienting the bevel upwards at a 10-30 angle.
Inform the patient and insert the needle swiftly.
Look for blood in the flashback chamber, then lower the angle and advance the catheter (not the
needle) until the hub meets the skin.
If resistance is encountered, do not force the catheter forward.
Secure and Test the Catheter
1.
2.
3.
4.
Apply pressure two inches above the insertion site using your non-dominant hand.
Remove the needle and engage the safety mechanism.
Attach the end cap or extension tubing to the catheter hub while maintaining sterility.
Aspirate for blood return and flush the catheter with saline to confirm patency. Check for swelling or
leakage.
Secure and Dress the Site
1.
2.
3.
4.
Clean around the catheter with gauze.
Apply the tape using a secure method, such as the Chevron or U method, ensuring stability.
Cover the insertion site with a transparent dressing.
Fasten the tubing to the patients arm, avoiding loops or excess length that could catch on objects.
Label and Document
Label the dressing with the date, time, catheter gauge, and your initials.
Document the procedure thoroughly, including:
Date and time of insertion.
Gauge and length of the catheter.
Insertion site and number of attempts.
Confirmation of blood return and ease of flushing.
Solution type, additives, and flow rate.
Any patient education provided and their understanding.
Monitor and Maintain the I.V. Site
1.
2.
3.
Observe Routine Care Protocols:
Check the site per facility policy (hourly, per shift, or during bag changes).
Replace the transparent dressing if it becomes wet or soiled.
Change Equipment Regularly:
Peripheral I.V. sites: Change every 72-96 hours, depending on facility policy.
Tubing: Replace every 72 hours unless stated otherwise.
Fluid bags: Change every 24 hours to prevent contamination.
Assess for Complications: Monitor for signs of infiltration, phlebitis, or infection, such as redness,
swelling, or pain at the site.
Troubleshooting Tips
If blood is not visible in the flashback chamber, gently retract the catheter without removing the needle
and adjust the angle.
If no blood return occurs after adjustment, remove the catheter and try a new site.
Avoid rethreading the needle into the catheter if separated.
Preventing Inflammation and Infection in Peripheral I.V. Therapy
Inflammation and infection are among the most common complications associated with peripheral I.V.
therapy. Adhering to routine care protocols is vital for minimizing these risks. Below is a summary of best
practices and recommendations:
Regular Site Monitoring and Documentation Frequency of Checks:
Frequency of Checks: Follow facility-specific guidelines, which often require checking the I.V. site:
Hourly
During each shift
With every medication delivery
At each fluid bag change
Observations to Document:
Redness, swelling, or tenderness at the insertion site.
Leakage or signs of infiltration.
Patient-reported pain or discomfort.
Dressing Maintenance: Replace the transparent dressing if it becomes wet, loose, or soiled. Ensure the
dressing is secure and covers the insertion site fully without impeding visibility for monitoring.
Peripheral I.V. Site Changes:
CDC guidelines recommend changing peripheral I.V. sites every 96 hours.
Many facilities mandate site changes every 72 hours to further reduce infection risks.
For patients with limited venous access (e.g., pediatric or elderly patients), site changes may be
extended or alternative therapies considered.
Tubing and Fluid Bag Replacements Primary and Secondary Tubing:
Primary and Secondary Tubing: Replace every 72 hours to ensure sterility.
Specialized Tubing:
Total Parenteral Nutrition (TPN): Change every 24 hours.
Lipid Tubing: Replace every 12 hours due to increased risk of contamination.
Fluid Bags: Change every 24 hours to prevent microbial growth.
Y-Port Cleaning: Always clean Y-ports with the facility-approved cleaning agent before connecting any
tubing. This reduces the risk of introducing pathogens into the system.
Special Considerations for High-Risk Patients
For patients with limited venous access or those prone to complications, consider:
Longer intervals between site changes.
Exploring long-term therapy options, such as central venous catheters or midline catheters.
By following these evidence-based practices and facility protocols, healthcare providers can significantly
reduce the risk of inflammation and infection, ensuring safer and more effective I.V. therapy for all
patients.
Discontinuing I.V. Therapy: Best Practices Properly discontinuing I.V. therapy is as critical as initiating it,
requiring careful attention to orders, patient safety, and accurate documentation. Below is an expanded
step-by-step guide to ensure the procedure is performed effectively and safely.
Verify the Physician's Order Confirm the Order:
Confirm the Order: Always review the physicians order or treatment plan before discontinuing I.V.
therapy to ensure that the discontinuation is appropriate and timely.
Check the Medication Record: Confirm that all prescribed doses or infusions have been fully
administered.
Prepare for Discontinuation:
Stop the Infusion:
If fluids are running, close the roller clamp to stop the infusion.
Turn off any infusion device, if applicable, to prevent accidental flow during removal.
Gather Supplies: Ensure you have gloves, sterile gauze, tape or a dressing, and a disposal container for
the catheter.
Explain the Procedure: Inform the patient about what to expect during the removal process and
reassure them if they have any concerns.
Remove the I.V. Catheter:
Don Gloves: Wear gloves to maintain sterility and protect against potential exposure to bodily fluids.
Remove Tape Carefully: Gently peel the tape toward the insertion site to minimize skin trauma. Use an
adhesive remover if needed to avoid pulling on the patients skin.
Apply Pressure While Removing the Catheter: Place sterile gauze over the insertion site before
withdrawing the catheter. Hold the gauze firmly in place while removing the catheter in a smooth,
controlled motion. Inspect the catheter immediately to ensure its length and integrity are intact.
Ensure Hemostasis and Apply Dressing Maintain Direct Pressure:
Maintain Direct Pressure: Apply firm pressure over the site with the sterile gauze for approximately
two minutes (longer if the patient is on anticoagulants or has a bleeding disorder) to achieve
hemostasis.
Apply a Dressing: Once bleeding has stopped, cover the site with a clean dressing or bandage to
protect it from infection.
Post-Procedure Instructions: Advise the patient to limit movement of the affected limb for 10 minutes
to ensure the site remains stable and to prevent reopening of the vein.
Document the Procedure: Accurate documentation is
essential for continuity of care. Include the following details:
Date and Time of Removal: Record when the I.V. was
discontinued.
Catheter Integrity: Note that the catheter was intact and
free from any defects (e.g., no missing pieces).
Condition of the Site: Describe the insertion site,
including the presence of redness, swelling, bleeding, or
signs of infection.
Patient Tolerance: Document how the patient responded
to the procedure, noting any discomfort or
complications.
Nursing Interventions: Include actions taken to address
any issues (e.g., prolonged pressure for bleeding,
additional patient education).
Monitor for Post-Removal Complications
Observe the Site: Check for delayed bleeding, swelling,
or signs of infection such as redness, warmth, or
drainage.
Patient Education: Instruct the patient to monitor the
site at home and report any concerning symptoms, such
as increasing pain or redness.
Methods of IV Administration
Administering fluids and medications via IV is essential for ensuring proper patient care. Below, we
outline the various methods and provide detailed formulas to help you effectively administer prescribed
therapies.
1 Continuous Infusion
Maintains a constant therapeutic drug level
or fluid infusion without interruption. This
method is ideal for medications that need
consistent blood levels.
3 Bolus Infusion
A large volume of fluid is rapidly infused,
typically in emergencies (e.g., hypovolemic
shock).
5 Saline/Heparin Lock
Provides venous access for intermittent
infusions or injections without the need for
a continuous infusion. The lock prevents clot
formation and maintains patency.
2 Intermittent Infusion
Medications are administered over several
minutes to hours. This method is commonly
used for patients with fluid restrictions.
Examples include antibiotics administered
every 68 hours.
4 Piggyback Infusion
Secondary medications are delivered over a
short duration. This requires a secondary
administration set, connected to the primary
IV line at a Y-port.
6 IV Push (Direct Injection)
A syringe is used to administer a precise
dose of medication over a set period. This is
often used for medications requiring rapid
onset.
Administering Intermittent (Piggyback) Therapy
A secondary tubing set, commonly referred to as a "piggyback" set, is a shorter IV tubing designed for
administering intermittent medications alongside an ongoing primary IV infusion. It connects to the
primary line, allowing a separate medication to be delivered while the primary fluids continue to flow. To
ensure the secondary medication flows properly, the secondary bag is typically positioned higher than the
primary bag.
1 Use
Secondary
Set
Use a secondary
administration
set.
2 Lower
Primary Bag
Lower the
primary fluid bag
using the hanger
provided in the
secondary
administration
set package.
5 Connect and Set
3 Spike and
Prime
Spike the
medication bag
with the
secondary set
and prime the
tubing.
4 Clean Y-port
Swab the y-port
on the primary
set with an
approved
cleaning agent.
Connect the secondary set to the y-port, open the roller clamp, and set the drip rate.
The primary tubing contains a check valve to prevent fluid from the secondary tubing from flowing back
into the primary fluid bag.
What is an Injection Cap?
An "injection cap" on an IV is a sterile, capped opening on the end of an intravenous catheter that allows
healthcare professionals to connect syringes or tubing to administer medications directly into the patient's
vein, essentially acting as a protected access point for injections while maintaining sterility; it is usually
changed regularly to prevent infection risks.
When to Change the Injection Cap
The number of punctures exceeds the manufacturer's guidelines.
The cap becomes contaminated.
Follow your facility's policy regarding cap changes. Common recommendations for changing the cap
include:
The cap has been removed from the end of the catheter.
Blood cannot be fully flushed from the cap after a blood draw.
There are signs of blood, precipitates, cracks, leaks, or other defects.
The septum is no longer intact.
A week has passed without the cap being changed (e.g., with a central line).
Familiarize yourself with the specific steps required for using a saline or heparin lock.
To replace an IV end cap, follow these steps:
Prepare the IV line: Clamp the line to stop fluid flow, clean the hub thoroughly with an alcohol swab,
remove the old cap, and attach a new sterile cap by pushing and twisting it until it is secure, ensuring you
do not touch the sterile end of the new cap. Unclamp the line and flush with a saline syringe if necessary.
Always adhere to your healthcare facilitys protocols.
Detailed Steps:
1.
2.
3.
4.
5.
6.
7.
Gather Supplies: Collect a new sterile end cap, alcohol swabs, a saline syringe (if required), and gloves.
Perform Hand Hygiene: Wash hands thoroughly with soap and water or use an alcohol-based hand
sanitizer before donning gloves.
Access the IV Site:
Expose the catheter hub by removing the dressing if necessary.
Clamp the IV tubing to prevent fluid loss.
Clean the Hub:
Clean the connection area between the old cap and catheter hub with an alcohol swab for at least 15
seconds.
Let the area air dry completely.
Remove the Old Cap:
Stabilize the catheter hub and twist off the old cap carefully.
Dispose of the old cap in a biohazard waste container.
Attach the New Cap:
Handle the new sterile cap carefully, avoiding contact with its sterile end.
Insert the new cap onto the catheter hub, push it firmly into place, and twist clockwise until secure.
Flush the Line (if needed):
Attach a saline syringe to the new cap.
Gently flush the line to confirm patency and remove any air bubbles.
Key Considerations:
Follow Facility Protocols: Adhere to your healthcare
facility's guidelines regarding when and how to change
IV caps, including the type of cap to use.
Aseptic Technique: Maintain sterile technique
throughout to reduce infection risk.
Avoid Contaminating the Sterile Cap: If the sterile end is
accidentally touched, discard the cap and use a new one.
Monitor for Complications: Observe the IV site for
redness, swelling, or discomfort, and address any
concerns promptly.
SASH and SAS Purpose and Methods
The SASH (Saline, Administer medication, Saline, Heparin) and SAS (Saline, Administer medication,
Saline) flushing protocols are used to maintain the patency of intravenous (IV) lines and prevent
complications such as clot formation, occlusion, or infection.
Purpose:
1.
2.
3.
4.
5.
Maintain Patency of IV Lines:
Prevent clots or blockages from forming within the catheter.
Ensure the line remains open for fluid or medication administration.
Prevent Infection:
The use of aseptic technique during flushing helps reduce the risk of introducing bacteria into the
IV line.
Avoid Medication Interactions:
Flushing with saline before and after medication administration ensures that no drug residue
remains, reducing the risk of medication incompatibilities.
Confirm Catheter Functionality:
Flushing helps assess the catheter's patency and ensures there is no resistance or leakage.
Heparin Use in SASH:
For certain types of catheters (e.g., central lines, ports), heparin is used as an anticoagulant to
prevent clotting in the catheter.
When to Use:
SAS Protocol: Typically used for peripheral IV lines or central lines not requiring heparinization.
SASH Protocol: Commonly used for central venous catheters (e.g., ports, Hickman lines) that require
heparin to maintain patency.
SASH Method
(Heparin Lock)
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2.
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4.
Saline: Flush with
saline.
Administration:
Administer the
medication.
Saline: Flush with
saline again.
Heparin: Flush with
heparin.
SAS Method (Saline
Lock)
1.
2.
3.
Guidelines and Procedure
Saline: Flush with
saline.
Administration:
Administer the
medication.
Saline: Flush with
saline again.
Cleaning: Before accessing the injection cap, whether to
flush or to attach tubing, clean with an approved agent
per facility guidelines.
Amounts: The amounts of saline and heparin used will
vary according to device and facility guidelines.
Verification: Before flushing with saline, draw back on
the syringe to verify blood return. If there is no blood
return, flush gently while watching for any leaking or
swelling.
Resistance: If resistance is met, do not exert pressure.
Positive Pressure: Maintain positive pressure during and
after each flush to prevent the reflux of blood back into
the injection cap. While flushing, clamp the tubing on
the extension set.
Positive Pressure End Cap: If using a positive pressure
end cap, do not clamp the tubing on the extension set.
Types of Infusion Sets
Several types of infusion sets are used for delivering I.V. fluids: primary, secondary, and volume-control
sets. All of these sets have drip chambers, which can be vented or unvented. Glass containers require a
vented infusion set, while plastic containers do not.
These infusion sets deliver fluids at rates of 10, 15, 20, or 60 drops per milliliter.
Macrodrip System
Delivering 10, 15, or 20 drops per milliliter
(gtt/ml), is suitable for infusing 100 ml/hr or more.
Micro Drip System
Delivering 60 gtt/ml, is designed for pediatric
patients and adults who need small or closely
regulated amounts of I.V. solution.
A microdrip system may come pre-attached to a Buretrol, or it may need to be attached separately. A
Buretrol can hold up to 150 ml of fluid at one time. When used for pediatric patients, no more than 2 hours'
worth of fluid should be added to the Buretrol at a time, following facility policy.
Infusion Set Characteristics
The drip factor is indicated on the packaging of the tubing.
Primary tubing can range from 70" to 110" in length and
may feature multiple Y-sites and a backcheck valve to
prevent medication delivered via the Y-site from flowing
back into the main fluid line.
A secondary administration set, which is shorter, is used to
deliver additional fluids or medications. Some facilities use a
"dial-a-flow" device, where the flow rate is adjusted using a
dial on the tubing.
IV Therapy Administration and Calculations
I.V. therapy is often administered using an infusion pump or a syringe pump. Many different pumps are
available, so it is important to become familiar with those used in your facility.
If pumps are not available, you will need to calculate the drip rate for fluid delivery. The drip rate indicates
the number of drops infused per minute.
Calculating IV Flow Rates and Dosages Drip Rate Formula
Explanation:
Total Volume in mL: The total quantity of fluid that needs to be administered, measured in milliliters.
Time in Minutes: The duration, in minutes, over which the fluid should be delivered.
Drip Factor: The number of drops per milliliter of fluid, determined by the specific IV tubing being
used.
Let's Practice!
Example:
You are required to administer 500 mL of fluid over 4 hours using IV tubing with a drop factor of 20 drops
per mL.
Use the following formula to determine the Drip Rate:
Total Volume (mL) x Drip Factor / Time (in minutes) = Drip Rate
Calculation:
1.
2.
3.
4.
Convert hours to minutes: Multiply the number of hours by 60 to get the total minutes. For 4 hours,
this equals 240 minutes.
Multiply the total volume by the drip factor: Multiply the amount of fluid in milliliters (500 mL) by the
drop factor of the tubing (20 drops per milliliter). This equals 10,000.
Divide by the total time in minutes: Take the result (10,000) and divide it by the total time (240
minutes). This gives 41.666 drops per minute.
Round to the nearest whole number: Round 41.666 to 42.
Drip Rate: 42 drops per minute.
Key Points to Remember:
Always ensure the time is converted to minutes when applying this formula.
The drop factor is essential and should be confirmed based on the specific IV tubing used.
Practice Question: A patient requires an infusion of NS at a rate of 125 ml per hour, and the infusion set
delivers 15 drops per milliliter, what should the drip rate be?
Your Answer: _____________________________
Drip Rate = (125 15) / 60 = 31.25 31 gtt/min
Flow Rate Calculation
An IV flow rate calculation is used to determine the precise rate at which a fluid or medication should be
administered to a patient through an intravenous (IV) line, ensuring they receive the correct amount of
medication or fluids within a specified timeframe.
Calculate the flow rate in milliliters per hour:
Flow Rate (mL/hr) = Volume to be infused (mL) / Time (hours)
Example: Administer 1.5 liters of Normal Saline over 24 hours:
1.
2.
3.
Convert liters to milliliters: Since there are 1,000 milliliters in a liter, 1.5 liters equals 1,500 milliliters.
Calculate the flow rate in milliliters per hour: Divide the total volume (1,500 milliliters) by the total
time (24 hours). This equals 62.5 milliliters per hour.
Adjust the flow rate if necessary: Round to the nearest whole number if required, so the flow rate
would be set to 63 milliliters per hour.
Flow Rate: 63 milliliters per hour.
Practice Questions: Flow Rate (mL/hr)
1.
Let's Practice!
Question: A patient needs 2 liters of D5W to be infused over 12 hours. What should the flow rate be in
milliliters per hour?
2.
3.
Question: You are instructed to administer 1,800 milliliters of Lactated Ringers solution over 9 hours.
Calculate the flow rate in milliliters per hour.
Question: A doctor orders 1,250 milliliters of Normal Saline to be infused over 5 hours. What is the flow
rate in milliliters per hour?
Answers:
1.
2.
3.
Convert liters to milliliters: 2 liters equals 2,000 milliliters. Divide 2,000 milliliters by 12 hours. Flow rate: 167 milliliters per hour.
Divide the total volume (1,800 milliliters) by the time (9 hours). Flow rate: 200 milliliters per hour.
Divide the total volume (1,250 milliliters) by the time (5 hours). Flow rate: 250 milliliters per hour.
Medication Dosage Calculation
Drug dosage calculations are required when the amount of medication ordered (or desired) is different
from what is available on hand for the nurse to administer. These calculations ensure the patient receives
the exact dose prescribed by the physician to achieve the intended therapeutic effect. Proper
understanding of dosage calculations is critical to avoid medication errors that could harm the patient or
compromise their treatment.
Practice Scenario:
A doctor orders Morphine 2 milligrams (mg) IV push for a patient who is in pain.
You have Morphine 10 milligrams per milliliter (mg/mL) available in the vial. How much of the
medication will you give?
Step-by-Step Solution:
1.
2.
3.
4.
Identify what you know:
The amount ordered is 2 milligrams.
The strength of the medication available is 10 milligrams per milliliter.
One milliliter contains 10 milligrams of the medication.
Use this simple formula:
(Amount ordered Dose on hand) Volume available = Amount to give
Plug in the values:
Amount to give = (2 milligrams 10 milligrams) 1 milliliter
Do the math:
2 divided by 10 equals 0.2.
Multiply 0.2 by 1 milliliter, which equals 0.2 milliliters.
Final Answer:
You will give 0.2 milliliters of Morphine.
Important Reminder:
Double-check the doctors order and the medication label before administering.
Follow your facilitys guidelines for safely giving IV push medications.
Administer the medication slowly to prevent side effects.
Let's Practice!
Formula: (Amount ordered Dose on hand) Volume available = Amount to give
Practice Question 1: The physician orders Ondansetron 6 mg IV push for a patient experiencing nausea.
The vial of Ondansetron you have is labeled 4 mg/2 mL.
How many milliliters will you administer? ___________________
Practice Question 2: The physician orders Furosemide 40 mg IV push for a patient with fluid overload.
The vial available is labeled 20 mg/2 mL.
How many milliliters will you administer? ___________________
Practice Question 3: The physician orders Midazolam 2.5 mg IV push for a patient requiring sedation.
You have a vial of Midazolam labeled 5 mg/5 mL.
How many milliliters will you administer? ____________________
Answer 1: Ondansetron (Zofran)
Ordered: 6 mg
On hand: 4 mg in 2 mL
Formula: (Ordered On hand) Volume
6 4 = 1.5
1.5 2 = 3 mL
You will give 3 mL of Ondansetron.
Answer 2: Furosemide (Lasix)
Ordered: 40 mg
On hand: 20 mg in 2 mL
Formula: (Ordered On hand) Volume
40 20 = 2
2 2 = 4 mL
You will give 4 mL of Furosemide.
Answer 3: Midazolam (Versed)
Do the Math: ______________________________________
You will give 2.5 mL of Midazolam.
Continuous Infusion Dosage Calculation
If a patient is receiving a continuous medication infusion, you will need to complete two calculations to
determine the unit dosage per hour. First, calculate the amount of medication per milliliter. Then,
calculate the infusion rate. Here's how you do it:
A patient is prescribed a heparin drip at a rate of 900 units per hour. The IV bag contains 25,000 units of
heparin mixed in 500 milliliters of solution. You need to calculate the infusion rate in milliliters per
hour.
Step 1: Calculate the amount of heparin per milliliter
Use this formula:
Amount of heparin per milliliter = Total units of heparin in the IV bag Total volume of solution in
milliliters
Substitute the values:
Amount of heparin per milliliter = 25000 500
Result:
Amount of heparin per milliliter = 50 units per milliliter
This means there are 50 units of heparin in each milliliter of the solution.
Step 2: Determine the infusion rate in milliliters per hour
Use this formula:
Infusion rate in milliliters per hour = Prescribed dosage per hour Amount of heparin per milliliter
Substitute the values:
Infusion rate in milliliters per hour = 900 50
Result:
Infusion rate in milliliters per hour = 18 milliliters per hour
Final Answer:
To deliver 900 units per hour of heparin, you should set the infusion pump to 18 milliliters per hour.
Let's Practice!
Practice Questions
1.
2.
A patient is prescribed a heparin infusion at a rate of
1,200 units per hour. The IV bag contains 25,000 units of
heparin in 500 milliliters of solution. What should the
infusion pump be set to in milliliters per hour?
A patient is prescribed a heparin infusion at a rate of 950
units per hour. The IV bag contains 20,000 units of
heparin in 400 milliliters of solution. What should the
infusion pump be set to in milliliters per hour?
Answers
1.
2.
Calculation: Amount of heparin per mL = 25000 500 =
50 units/mL Infusion rate = 1200 50 = 24 mL/hour. The
infusion pump should be set to 24 mL/hour.
Calculation: Amount of heparin per mL = 20000 400 =
50 units/mL Infusion rate = 950 50 = 19 mL/hour. The
infusion pump should be set to 19 mL/hour.
Medication Safety and Pharmacological Knowledge: A Critical Component of Nursing Practice
Medications are systematically classified by their function or therapeutic purpose, a method that
simplifies the identification of similarities and distinctions within and across categories. This structured
approach helps nurses and healthcare professionals understand medications' roles, mechanisms, and
potential interactions more effectively. Pharmacology resources often adopt this classification system,
presenting medications in subdivisions that may occasionally overlap, emphasizing the need for clarity
and precision.
Nurses must rely on trustworthy and updated printed resources, such as
nursing drug handbooks or the
Physicians Desk Reference (PDR), when preparing and administering medications to patients.
The Importance of Understanding Pharmacology: Critical thinking and care planning require a deep
understanding of how medications interact with the body. Nurses should consider the processes of
absorption, distribution, metabolism, and excretion, which influence a drug's therapeutic potential and
effectiveness. This knowledge allows for informed decision-making and better patient care.
Additionally, nurses must recognize the various interactions that medications can have, including:
Drug-drug interactions: How different medications may enhance or diminish each others effects.
Drug-food interactions: The impact of certain foods on medication efficacy (e.g., grapefruit juice interfering with statins).
Drug-herb interactions: The influence of herbal supplements like St. Johns Wort on prescription medications.
Drug-lifestyle interactions: Factors such as smoking or alcohol consumption that can alter a drugs effectiveness.
Drug-diagnostic test interactions: Medications that may skew diagnostic test results.
Being vigilant about these interactions helps nurses anticipate, identify, and respond to adverse reactions
or side effects, ensuring patient safety.
Heres an overview of common IV medications nurses administer, their indications, nursing assessments,
interventions, and key considerations:
Normal Saline (0.9% Sodium Chloride)
Indication: Fluid replacement for dehydration, electrolyte imbalances, and as a vehicle for medication
administration.
Nursing Assessment:
Monitor for fluid overload (edema, crackles in lungs, increased blood pressure).
Assess hydration status (skin turgor, mucous membranes).
Interventions:
Check IV site for infiltration or phlebitis.
Monitor intake and output.
What to Look Out For:
Signs of fluid overload, especially in patients with heart or renal conditions.
Lactated Ringer's (LR)
Indication: Electrolyte replacement, surgical or trauma fluid resuscitation, and metabolic acidosis.
Nursing Assessment:
Check for contraindications like liver failure or hyperkalemia.
Monitor electrolyte levels.
Interventions:
Use cautiously in patients with renal or liver impairments.
What to Look Out For:
Signs of fluid overload and changes in acid-base balance.
Dextrose Solutions (e.g., D5W, D10W)
Indication: Hypoglycemia, dehydration, or as part of total parenteral nutrition (TPN).
Nursing Assessment:
Monitor blood glucose levels.
Interventions:
Avoid use in patients with increased intracranial pressure or diabetes without close monitoring.
What to Look Out For:
Hyperglycemia and vein irritation.
Vancomycin
Indication: Severe bacterial infections (e.g., MRSA, C. diff).
Nursing Assessment:
Monitor renal function (BUN, creatinine) and hearing (risk of ototoxicity).
Check for Red Man Syndrome (flushing, rash).
Interventions:
Administer slowly (over at least 60 minutes) to prevent Red Man Syndrome.
Assess IV site for irritation or extravasation.
What to Look Out For:
Nephrotoxicity, ototoxicity, and infusion reactions.
Furosemide (Lasix)
Indication: Edema, heart failure, hypertension.
Nursing Assessment:
Monitor electrolyte levels (especially potassium).
Assess for signs of dehydration.
Interventions:
Administer slowly to avoid ototoxicity.
Encourage potassium-rich foods if not contraindicated.
What to Look Out For:
Hypokalemia, dehydration, and dizziness from hypotension.
Morphine Sulfate
Indication: Severe pain.
Nursing Assessment:
Assess pain levels and respiratory status.
Monitor for signs of sedation or confusion.
Interventions:
Have naloxone available for overdose.
Assess bowel function (risk of constipation).
What to Look Out For:
Respiratory depression and hypotension.
Heparin
Indication: Prevention and treatment of blood clots (DVT, PE).
Nursing Assessment:
Monitor aPTT levels and signs of bleeding.
Interventions:
Use caution with other anticoagulants or NSAIDs.
Rotate injection sites if given subcutaneously.
What to Look Out For:
Hemorrhage or heparin-induced thrombocytopenia (HIT).
Potassium Chloride (KCl)
Indication: Hypokalemia.
Nursing Assessment:
Monitor potassium levels and cardiac rhythm.
Interventions:
Administer via IV infusion (never IV push).
Dilute and administer slowly to prevent vein irritation.
What to Look Out For:
Hyperkalemia (arrhythmias, muscle weakness).
Magnesium Sulfate
Indication: Eclampsia, preeclampsia, torsades de pointes, magnesium deficiency.
Nursing Assessment:
Monitor reflexes, respiratory rate, and urine output.
Interventions:
Have calcium gluconate available as an antidote.
What to Look Out For:
Signs of toxicity (absent reflexes, respiratory depression).
Antibiotics (e.g., Ceftriaxone, Piperacillin-Tazobactam)
Indication: Bacterial infections.
Nursing Assessment:
Assess for allergies and monitor for adverse reactions.
Interventions:
Administer test dose if indicated.
Monitor infusion site for irritation.
What to Look Out For:
Allergic reactions (rash, anaphylaxis) and GI upset.
Metoprolol
Indication: Hypertension, angina, arrhythmias, heart failure.
Nursing Assessment:
Check blood pressure and heart rate before administration.
Interventions:
Hold for bradycardia (<60 bpm) or low BP.
What to Look Out For:
Bradycardia, fatigue, and hypotension.
Insulin (Regular IV)
Indication: Hyperglycemia, diabetic ketoacidosis (DKA).
Nursing Assessment:
Monitor blood glucose and potassium levels.
Interventions:
Administer with a dedicated line if using insulin drip.
What to Look Out For:
Hypoglycemia and hypokalemia.
Ondansetron (Zofran)
Indication: Nausea and vomiting.
Nursing Assessment:
Assess for effectiveness of symptom relief.
Interventions:
Administer IV push over 2-5 minutes.
What to Look Out For:
Headache and QT prolongation.
Hydralazine
Indication: Hypertensive crisis.
Nursing Assessment:
Monitor blood pressure and heart rate.
Interventions:
Use cautiously in patients with heart disease.
What to Look Out For:
Hypotension and reflex tachycardia.
Each of these medications requires careful assessment, proper administration techniques, and monitoring
for adverse reactions to ensure patient safety. Always refer to facility protocols and double-check physician
orders before administration.
Factors Influencing Medication Efficacy
1.
Nurses must understand how various physiological and pathological factors affect medication outcomes.
Key considerations include:
Age-related changes:
2.
Neonates and infants: Immature liver and kidney function may delay metabolism and excretion.
Older adults: Decreased renal and hepatic function alters drug clearance, increasing toxicity risks.
Chronic conditions:
Hepatic diseases: Impair the metabolism of medications.
Renal diseases: Affect the excretion process, leading to accumulation of drugs in the body.
These considerations require nurses to adjust their approach to medication administration and monitor
patients closely.
Pharmacodynamics and Pharmacokinetics in Nursing Practice
Understanding a medications pharmacodynamics (how it works in the body) and pharmacokinetics (how
it moves through the body) is vital for safe and effective care. Concepts like a drugs half-life, onset, peak,
and duration directly impact timing, dosing, and monitoring. For instance, nurses must recognize that a
medications effects might last longer in patients with impaired renal function due to reduced excretion
rates.
Medications often serve both primary and secondary purposes. A classic example is diphenhydramine
(Benadryl), an antihistamine for allergies, whose sedative side effect makes it useful for inducing sleep.
Such versatility underscores the importance of understanding both the intended and side effects of
medications.
Dosage Considerations and Special Populations: Medication dosages often vary based on their
therapeutic purpose and the patients characteristics. Special populations, such as children, the elderly,
and those with compromised renal or hepatic function, require additional precautions. Pregnant or
lactating individuals also present unique challenges due to potential risks to the fetus or infant. Nurses
must consult reliable pharmacological references to ensure the correct dosing and suitability of
medications, seeking clarification from the prescribing physician when necessary.
Ensuring Safety with Intravenous Medications
Safe medication infusion requires careful attention to
compatibility between drugs and their diluents. Nurses
should verify compatibility using reference materials such
as compatibility charts, the PDR, or by consulting
pharmacists. Common issues include:
Physical incompatibility: Visible reactions such as
precipitation, cloudiness, or gas bubbles indicate a
problem. For instance, Dilantin (phenytoin) should
never be mixed with glucose-containing solutions, and
calcium-containing solutions can interact adversely with
other medications.
Chemical incompatibility: Occurs when acidic and
alkaline substances interact. Factors like drug
concentration, pH levels, contact duration, temperature,
and light exposure play significant roles. Examples
include the incompatibility of heparin with gentamicin
and the need to shield drugs like amphotericin B from
light.
Therapeutic incompatibility: Happens when drugs
counteract each others effects. For example,
administering chloramphenicol and penicillin together
requires timing adjustments to preserve the efficacy of
both.
Nurses as Medication Safety Advocates: The role of a nurse
extends far beyond simply administering medications. By
understanding pharmacology, interactions, and patient
specific factors, nurses serve as critical advocates for patient
safety. When questions or uncertainties arise, consulting
reliable references or collaborating with pharmacists and
physicians ensures the highest standard of care. Mastering
these aspects equips nurses to provide safer, more effective
medication management, ultimately enhancing patient
outcomes.
Midline Catheter
A midline catheter is a thin, flexible tube that's inserted into a vein in the upper arm to deliver medication
or fluids intravenously. It's often used for patients who need long-term IV therapy or have difficulty
accessing their veins.
A midline catheter, typically ranging from 3 to 8 inches in length, is positioned approximately 1.5 inches
above or below the antecubital fossa. Its tip terminates in the peripheral vasculature below the axilla,
commonly inserted into one of the larger veins of the upper arm. This placement facilitates better dilution
of fluids and medications, reducing vein irritation.
It is preferred for intravenous therapy lasting beyond 6 days. To mitigate vein wall irritation, fluids and
medications administered through the midline catheter should closely match normal serum osmolality
and pH levels.
The
INS Standard guidelines for selecting sites and practicing criteria for midline catheters specify that
midline catheters are unsuitable for certain therapies. These include continuous vesicant chemotherapy,
parenteral nutrition formulas with dextrose exceeding 10% and/or protein exceeding 5%, solutions or
medications with a pH below 5 or above 9, and solutions or medications with an osmolarity surpassing 500
mOsm/L.
Key Nursing Considerations
Contractures in the upper arm, burns, scars, and various vascular or musculoskeletal issues might impede
successful insertion. This catheter is suitable for therapies lasting up to 4 weeks.
Prolonged use beyond this period should be determined by professional judgment, taking into account:
Sessions left in therapy
Peripheral vein health
Current state of the utilized vein
Patient's general well-being
Additional nursing considerations:
Avoid taking blood pressure measurements on the arm with the device.
Ensure the dressing remains dry.
Keep sharp objects away from the device.
Thoroughly clean the injection port before use.
Follow facility policy for flushing the port(s).
Adhere to facility policy for changing the end cap.
Change the sterile dressing every 7 days, or sooner if it becomes wet, soiled, or loose, following facility
guidelines.
Complications from midline catheters show similar signs and symptoms as those with peripheral IVs,
requiring the same nursing care.
Discontinuation Procedure
When removing a midline catheter, always follow your facilitys protocol. Start by putting on gloves and
stopping any infusion. Take off the dressing and tape, and place sterile gauze over the site without pressing
down until the catheter is out. Gently pull the catheter straight out, keeping it level with the skin. If you
feel resistance, dont force it! Instead, help the patient relax with deep breathing. If it still wont budge,
redress the site and apply a warm compress for 1-2 hours. If that doesnt work, call the doctor right away.
Once the catheter is removed, press firmly on the site for 1-2 minutes to stop any bleeding, then cover it
with sterile gauze and tape. Double-check that the entire catheter is out by measuring it, and document
everythingwhat you did, any challenges, and how the patient responded. Finally, leave the dressing on
for 24 hours.
Central Venous Therapy
Did you know that the average adult body contains around 5 liters of blood? Heres how it works: oxygen
depleted blood flows from the capillaries into the veins, traveling back to the heart via the superior and
inferior vena cava. From the right side of the heart, blood is pumped through the pulmonary arteries to the
lungs to pick up oxygen. It then returns to the left side of the heart through the pulmonary veins and is
pumped out to the body via the aorta.
Now, lets talk about central venous therapy. This technique delivers fluids and medications directly into a
major vein using a central catheter. The catheter tip is placed in the superior or inferior vena cava, and
insertion sites include large veins in the upper arm, subclavian vein, internal or external jugular veins, or
the femoral vein. Depending on the patients needs, different types of central line catheters may be used,
such as P.I.C.C. lines, nontunneled catheters, tunneled catheters, or implantable ports.
Why Use Central Venous Therapy?
Central venous therapy is essential in situations like these:
Multiple IV access is needed.
Peripheral veins are no longer viable.
Central venous pressure needs monitoring.
Parenteral nutrition is required (like more than 10% dextrose or 5% albumin).
Medications that are incompatible must be given.
Patients need frequent blood transfusions or long-term infusion therapy.
Temporary dialysis access is needed.
Repeated blood draws are required.
How Does Central Venous Therapy Work?
Blood flow around the central line tip moves fastup to 2,000 ml per minute! This rapid flow quickly
dilutes any infused fluids, making it safe to administer highly concentrated or even caustic medications. It
also helps reduce the risk of blood clots forming at the catheter tip.
Potential Complications & What to Look For
While central line therapy shares some risks with peripheral IVs, it also comes with specific, potentially
life-threatening complications. Heres what you need to know:
Thoracic Conditions: Pneumothorax, Hemothorax, Chylothorax, or Hydrothorax
Symptoms
Chest pain
Shortness of breath (dyspnea)
Bluish skin discoloration (cyanosis)
Crackling or popping sounds under the skin (crepitus)
Decreased breath sounds on the affected side
Abnormal chest x-ray findings
Potential low hemoglobin in hemothorax cases due to pooled blood
Interventions:
1.
2.
3.
4.
5.
6.
Confirm catheter placement with an x-ray.
Monitor for signs of fluid infiltration (like swelling in the neck, shoulder, arm, or chest).
Stop the infusion immediately and notify the physician.
Assist with removing the device, if needed.
Administer oxygen.
Be prepared to assist with needle decompression or chest tube insertion.
Document everythingsymptoms, interventions, and patient response.
7.
Air Embolism
Symptoms:
Difficulty breathing
Uneven breath sounds
Weak pulses
Increased Central Venous Pressure (CVP)
Low blood pressure
Changes in consciousness
Interventions:
1.
2.
3.
4.
5.
6.
7.
8.
Purge all tubing and end caps of air before connecting.
Clamp the catheter promptly after use.
Secure the catheter exit site.
Position the patient on their left side with the head lower than their body.
Avoid the Valsalva maneuver.
Provide oxygen.
Notify the physician immediately.
Document every step, from symptoms to interventions.
Thrombus Formation
A thrombus, or blood clot, can develop at the tip of the catheter or in the vein itself, leading to obstruction
or inflammation.
Symptoms:
Swelling in the neck, arm, or shoulder on the catheter side
Redness, warmth, or tenderness along the vein (signs of phlebitis)
Difficulty flushing the catheter or sluggish blood return
Pain or discomfort at the insertion site
Thrombus Formation Continued
Interventions:
1.
2.
3.
4.
5.
Regularly assess the catheter site for signs of clot formation.
Ensure catheter patency by following proper flushing protocols with heparin or saline, as prescribed.
Notify the physician if any symptoms of thrombus are present.
Be prepared for interventions like catheter removal or anticoagulant therapy.
Document all findings, symptoms, and actions taken.
Local Infections
Local infections occur at the catheter insertion site and can be caused by poor aseptic technique or
contamination during dressing changes.
Symptoms:
Redness, swelling, or tenderness at the insertion site
Drainage or pus from the site
Fever or chills (indicating possible systemic involvement)
Interventions:
1.
2.
3.
4.
5.
6.
Follow strict aseptic technique during catheter insertion and dressing changes.
Inspect the site regularly for early signs of infection.
Clean the site per facility protocols, using antiseptics like chlorhexidine.
Notify the physician if an infection is suspected.
Remove the catheter if directed and send the tip for culture.
Document your observations and any steps taken.
Systemic Infections (Sepsis)
If bacteria or other pathogens enter the bloodstream through the central line, it can lead to a serious
systemic infection known as sepsis.
Symptoms:
High fever or chills, generalized weakness or maliase
Increased heart rate (tachycardia)
Low blood pressure (hypotension)
Altered mental status
Interventions:
1.
2.
3.
4.
5.
6.
Monitor for early signs of sepsis in patients with central lines.
Draw blood cultures from the central line and peripheral sites if sepsis is suspected.
Start prescribed antibiotics promptly after obtaining cultures.
Administer IV fluids to stabilize blood pressure.
Notify the healthcare team immediately for further management.
Document all assessments, interventions, and the patients response.
Preventing These Complications
Prevention is key! Heres what you can do:
Practice meticulous hand hygiene before handling central lines.
Use aseptic techniques during catheter insertion and dressing changes.
Flush the catheter regularly to maintain patency.
Change dressings and caps as recommended to reduce infection risk.
Educate patients and caregivers on proper line care and what symptoms to report immediately.
Central venous therapy is powerful but requires careful attention to detail to ensure patient safety. By
staying alert and following these guidelines, you can manage risks and provide exceptional care. Keep
educating yourselfyour knowledge saves lives!
A central line is a catheter placed into a large vein, typically in the neck (internal jugular vein), chest
(subclavian or axillary vein), or groin (femoral vein), or through a vein in the arm (PICC line). While it has
significant benefits in patient care, such as delivering medication, fluids, or nutrition when peripheral
access is inadequate, it also comes with notable disadvantages and requires a physicians order due to its
invasive nature and potential risks.
Disadvantages of Using a Central Line
1.
2.
3.
4.
5.
6.
7.
Risk of Infection:
Central line-associated bloodstream infections (CLABSIs) can occur if aseptic techniques are not
followed during insertion or maintenance.
The longer the line is in place, the higher the risk of infection.
Thrombosis:
Blood clots can form in or around the catheter, potentially leading to deep vein thrombosis (DVT) or
embolism.
Mechanical Complications:
During placement, there is a risk of pneumothorax (collapsed lung), arterial puncture, or catheter
misplacement.
Catheter damage or kinking can impede function.
Cost and Resources:
Insertion and maintenance require trained professionals, sterile equipment, and additional
monitoring, increasing healthcare costs.
Patient Discomfort:
The insertion process can be painful or distressing for the patient.
The catheter may cause discomfort or limit mobility.
Long-term Risks:
Chronic complications, such as central venous stenosis, can arise in patients requiring prolonged
use of a central line.
Maintenance Requirements:
Central lines demand meticulous care, including regular dressing changes, flushing to maintain
patency, and monitoring for complications.
Medical Necessity for a Central Line
Central lines are used only when absolutely necessary due to their risks. Common indications include:
1.
2.
3.
4.
5.
Long-term IV Therapy:
Chemotherapy, antibiotics, or parenteral nutrition.
Hemodynamic Monitoring:
Measuring central venous pressure (CVP) in critically ill patients.
Frequent Blood Sampling:
Reducing the need for repeated venipunctures.
Administration of Irritating Medications:
Medications such as vasopressors or chemotherapy agents that can damage peripheral veins.
Emergency Access:
In cases of shock or severe trauma, when rapid large-volume resuscitation is required.
Physicians Order
Rationale for a Physicians Order:
Central line insertion is an invasive procedure requiring evaluation of the patient's condition and
weighing the risks versus benefits.
A physician assesses the medical necessity and ensures appropriate use based on the patients
clinical needs.
Documentation Requirements:
A detailed order specifying the type of central line (e.g., PICC, tunneled, or non-tunneled catheter)
and the intended purpose.
Justification for use, such as the need for long-term medication administration or lack of peripheral
access.
Legal and Ethical Considerations:
As a high-risk procedure, a central line insertion requires informed consent from the patient or
their representative, except in emergencies.
In summary, while central lines are invaluable in certain medical scenarios, their use should be carefully
justified and monitored due to the associated risks. A physicians order ensures appropriate use, aligning
the procedure with the patient's medical needs and minimizing complications.
Overview of Central Venous Access Devices (CVADs)
A Peripherally Inserted Central Catheter (PICC) is a long catheter placed in a vein in the upper arm, with
the tip located near the heart in the superior vena cava. It is ideal for long-term IV therapy lasting more
than 6 days and can remain in place for up to a year. PICC lines are reliable and carry lower risks compared
to other central venous catheters. They are used for administering medications, fluids, and drawing blood
samples.
Key Points:
Inserted by trained nurses at the bedside or in radiology.
Suitable for extended therapies.
Reduces risks of clots and infections.
Cost-effective and versatile.
Nursing Considerations:
Avoid blood pressure measurements on the arm with the PICC.
Use 10 ml syringes for flushing or medication administration.
Keep the dressing clean, dry, and intact.
Adhere to facility policies for flushing, cap changes, and dressing maintenance (change every 7 days or
sooner if needed).
Nontunneled Catheters: Nontunneled catheters are short-term devices inserted into large veins
(subclavian, internal jugular, or femoral) for therapies lasting 3 days to 2 weeks. These catheters are used
for emergencies or critical care situations. They offer quick access but carry varying infection risks
depending on the insertion site.
Key Points:
Often used in emergencies and critical care.
Subclavian site offers better mobility and lower infection risk.
Femoral site is reserved for emergencies due to high infection risk.
Nursing Considerations:
Keep dressings clean and intact; use sterile technique during dressing changes.
Monitor for signs of infection, such as redness or swelling.
Use specific lumens consistently for designated tasks.
Tunneled Catheters
Tunneled catheters like Broviac, Hickman, and Groshong are designed for long-term use, often lasting
months to years. These catheters are surgically placed, with a cuff under the skin that promotes tissue
growth, anchoring the catheter and preventing bacterial entry.
Key Points:
Durable and suited for frequent or long-term use.
Placement involves two surgical sites (insertion and tunneling).
Requires careful handling to prevent kinks or damage.
Nursing Considerations:
Handle carefully to avoid damage or displacement.
Regularly monitor for kinks, leaks, or signs of infection.
Follow sterile technique for dressing changes and flushing.
Implanted Ports
Implanted ports are small devices placed entirely under the skin, ideal for patients requiring intermittent
IV therapy over a long period. They are accessed using a special Huber needle and require minimal
maintenance when not in use.
Key Points:
Reduced infection risk as no external parts are exposed.
Patients can shower, swim, and exercise when the port is not accessed.
Require heparin flushes monthly to maintain patency.
Nursing Considerations:
Access with a Huber needle using sterile technique.
Monitor for infection or complications (e.g., redness or swelling).
Label ports for their designated purposes (e.g., medications, fluids, blood draws).
Flushing Guidelines:
Use the correct syringe size and solution (e.g., normal saline, heparin).
Follow facility protocols for specific catheter types and flushing schedules.
Document catheter function and any issues during routine assessments.
Hypodermoclysis: Understanding Subcutaneous Fluid and Medication Administration
Hypodermoclysis, the infusion of fluids and medications into the subcutaneous space, is a versatile
method used across all practice settings and age groups. This technique offers slow and consistent
absorption through perfusion, diffusion, hydrostatic pressure, and osmotic pressure, providing stable drug
levels.
Key Applications
1.
2.
3.
4.
Pain Management in End-of-Life Care: Offers comparable analgesic effects to IV infusions without the
sharp peaks and troughs of PRN dosing.
Dehydration Prevention: Useful for patients with dysphagia, confusion, or mild-to-moderate
dehydration.
Limited Vascular Access: An alternative for patients with difficult IV access.
Short-Term Therapy: Typically lasts up to 5 days, infusing a maximum of 3,000 mL per day at two sites.
Advantages
Low cost and comfortable for patients.
Suitable for home care and less distressing than IV insertion.
Minimal risks of thrombophlebitis or systemic infections.
Easy setup, manageable in almost any setting.
Disadvantages
Limited infusion rate (1 mL/min).
Common site reactions, including edema.
Not suitable for severe dehydration or high fluid requirements (>3 L/day).
Fluids and Additives
Fluids: Normal saline, D5NS, Lactated Ringers, Normosol-R.
Additives: Potassium chloride (20-40 mmol/L) and hyaluronidase (to enhance absorption).
Appropriate Sites
Upper arms, abdomen, thighs, and supraclavicular areas with at least 2.5 cm of pinchable
subcutaneous tissue. Avoid bony prominences, irritated areas, or sites interfering with mobility.
Hypodermoclysis is a procedure that involves
inserting a needle into the body to infuse
fluids into the subcutaneous space. The needle
is usually placed in the abdomen, chest,
thighs, or upper arms.
Hypodermoclysis sites
Steps for Hypodermoclysis
1.
Preparation
Abdomen: A common site for both
ambulatory and bedridden patients
Upper chest: A common site for
ambulatory patients, especially above the
breast or over an intercostal space
Thighs: A common site for bedridden
patients
Outer upper arm: A common site for
bedridden patients
Verify orders, gather supplies, and explain the procedure to the patient.
2.
Ensure aseptic technique and prepare fluids and tubing.
Insertion
3.
Pinch up the tissue and insert a 2325 gauge butterfly needle at a 4560 angle.
Aspirate to ensure proper placement (no blood return).
Infusion
4.
Administer at the prescribed rate (15 mL/min).
Use an infusion pump for medication or faster fluid administration with hyaluronidase.
Site Maintenance
Assess the site every 8 hours, rotating every 35 days or as needed.
Change dressings when soiled or moist.
Adverse Reactions
Site Reactions: Swelling, irritation, or pain.
Intervention: Discontinue infusion, apply cool compresses, and reassess.
Arterial Lines
Arterial lines, common in critical care, allow continuous blood pressure monitoring and frequent blood
sampling. Inserted into the radial, axillary, femoral, or pedal arteries, these lines demand meticulous care.
Key Considerations
Purpose: Accurate BP monitoring, blood gas analysis, and sampling.
Maintenance: Regular site assessments and dressing changes.
Risks: Accidental dislodgment can lead to hemorrhage.
Remember: No fluids or medications (except heparinized saline for patency) should be infused through
arterial lines.
To set up an arterial line transducer in nursing practice, you need to: ensure the transducer is positioned
at the level of the patient's right atrium (phlebostatic axis), prime the line with saline, pressurize the
flush bag, zero the system against atmospheric pressure, and perform a "square wave" test to check for
proper system damping; this involves placing the transducer at the intersection of the mid-axillary line
and the fourth intercostal space, ensuring no air bubbles are present in the tubing, and regularly
monitoring the waveform for accuracy.
Key steps:
Gather supplies:
Obtain the arterial line transducer set, pressure bag, normal saline, transducer holder, and appropriate
connecting tubing.
Prepare the transducer:
Open the transducer set, tighten all connections, and attach the pressure tubing.
Prime the line:
Spike the saline bag with the transducer set and flush the line to remove air bubbles.
Position the transducer:
Place the transducer at the phlebostatic axis, which is usually located at the level of the fourth intercostal
space on the mid-axillary line.
Zero the system:
Close the stopcock towards the patient, open it to the atmosphere, and press "zero" on the monitor to set
the reference point.
Pressurize the flush bag:
Fill the pressure bag with normal saline and pressurize to around 300 mmHg.
Perform a square wave test:
Quickly flush the line with saline to check for appropriate waveform damping (minima

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