Which of the following should the nurse recognize as a possible complication related to IV therapy?
In this situation the patient has nausea and vomiting. The nurse should investigate possible causes, discuss any decision to not saline loc the IV with the prescriber Show 2. During night shift rounds, the patient who was restless all night has pulled apart their IV tubing. The CVC remains in situ. As the nurse, describe your subsequent actions. Answer: the nurse should consider:
Source: Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby. 3. A first year nursing student is shadowing you, the nurse, for the day and asks how you would know if someone is experiencing fluid overload from their IV therapy. How might you respond? Answer: As the nurse I would explain that fluid overload from IV therapy is a condition caused by excess fluid accumulation in the lungs due to excess fluid in the circulatory system and / or inability of the body to manage the IV fluid being infused. Signs and symptoms include ↓SpO2, ↑respiratory rate, dyspnea, coughing up pink frothy sputum, auscultation of dependent fine crackles, anxiety. Knowing the patient’s history can provide insight into conditions that put some patients more than others at higher risk for fluid overload. Definitive diagnosis cannot be done by the RN. Timely consultation with respiratory therapy and / or the prescriber is important for better patient outcomes. Sources: Fraser Health Authority. (2014). Clinical practice guidelines: Intravenous therapy. http://physicians.fraserhealth.ca/media/2014%2005%2015%20IV%20Therapy%20CPG%20FINAL.pdf. Fulcher, E. M., & Frazier, M. S. (2007). Introduction to intravenous therapy for health professionals. St. Louis, MO: Elsevier. Interior Health. (2012). Parenteral practices manual. http://insidenet.interiorhealth.ca/Clinical/parenteralccr/Pages/Manual.aspx. McCallum L., & Higgins, D. (2012). Care of peripheral venous cannula sites. Nursing Times, 108(34-35), 12-15. Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby. Singh, A., Kaur, A., Singh, M., & Kaur, S. (2015). CT guided removal of iatrogenic foreign body: a broken intravenous cannula. Journal of Clinical & Diagnostic Research, 9(9), PD28-PD29. https://dx.doi.org/10.7860%2FJCDR%2F2015%2F14344.6549.
Sources: Baskin, J. L., Pui, C. H., Reiss, U., Wilimas, J. A., Metzger, L. M., Ribeiro, R. C., & Howard, S. C. (2009). Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. Lancet, 374(9684), 159. doi: 10.1016/S0140-6736(09)60220-8. British Columbia Institute of Technology (BCIT). (2015a). CVC complications worksheet. In, NURS 3020. BCIT BSN program. Vancouver, BC: BCIT. Brunce, M. (2003). Troubleshooting central lines. ModernMedicine Network. http://www.modernmedicine.com/modern-medicine/content/troubleshooting-central-lines. Fraser Health Authority. (2014). Clinical practice guidelines: Intravenous therapy. http://physicians.fraserhealth.ca/media/2014%2005%2015%20IV%20Therapy%20CPG%20FINAL.pdf. Fulcher, E. M., & Frazier, M. S. (2007). Introduction to intravenous therapy for health professionals. St. Louis, MO: Elsevier. Interior Health. (2012). Parenteral practices manual. http://insidenet.interiorhealth.ca/Clinical/parenteralccr/Pages/Manual.aspx. McCallum L., & Higgins, D. (2012). Care of peripheral venous cannula sites. Nursing Times, 108(34-35), 12-15. Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby. Prabaharan, B., & Thomas, S. (2014). Spontaneous migration of central venous catheter tip following extubation. Saudi Journal of Anaesthesia, 8(1), 131–133. doi: 10.4103/1658-354X.125975. Singh, A., Kaur, A., Singh, M., & Kaur, S. (2015). CT guided removal of iatrogenic foreign body: a broken intravenous cannula. Journal of Clinical & Diagnostic Research, 9(9), PD28-PD29. https://dx.doi.org/10.7860%2FJCDR%2F2015%2F14344.6549. 2. Symptoms of air embolism include: Select all that apply
3. Air embolisms can be caused by: Select all that apply
4. S&S of circulatory overload include: Select all that apply
5. Situations that put the client at risk for circulatory overload include: Select all that apply
6. IV solutions infusing via PICCs and Central lines should be infused with an IV pump to reduce risk of accidental IV fluid overload true / false Answer: True…the risk of circulatory overload is great when IVs are infusing into large vessels such as the vena cava & subclavian. 7. Jane has had a central line inserted into her right subclavian vein. 10 minutes following the insertion (and before an XRAY confirms placement) you notice she is short of breath and is using her accessory muscles to breathe. You auscultate her chest and find diminished air entry in the right lung fields, no adventitious sounds. You recognize this as a possible complication of central line insertion. Which complication do the symptoms suggest? Select all that apply. DistractorsAnswera.Fluid overloadIncorrect. Fluid overload might happen following IV infusion. At this point in the scenario, the central line was inserted only 10 minutes ago. Placement will have to be confirmed before the nurse begins IV therapy through the central line.b.PneumothoraxCorrect. During insertion of central lines there is risk of accidental puncture of the pleura resulting in pneumothorax. The nurse should always auscultate lung sounds post central line insertionc.InterstitialIncorrect. Interstitial means the IV fluid is infusing into the surrounding tissuesd.PhlebitisIncorrect. Phlebitis is inflammation of the veinSource: Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby. 8. Which of the following statements are true in relation to Biofilm and PICCs and central lines: Select all that apply. DistractorsAnswera.It consists of bacteria that migrates from the skin down to the catheter site which then colonizes the catheter.Correctb.It begins to develop within 5 minutes of catheter insertionCorrect.c.It always results in sepsisFalse. Biofilm can be the person’s normal florad.Can be eliminated with correct site asepsis (i.e. chlorhexidine 2% isopropyl alcohol 70%)False. Biofilms might be controlled with site asepsis using the recommended antiseptic solution…but often cannot be completely eliminatedSource: Center for Disease Control (2017). Guidelines for the prevention of intravascular catheter-related infections: Summary of recommendations. https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html. What are the concerns associated with administering IV medications?Examples of IV side effects include:. Infection. Infection can occur at the injection site. ... . Damage to veins and injection site. A vein can be damaged during injection or by the use of an IV catheter line. ... . Air embolism. ... . Blood clots.. What are the precautions for IV administration?Do not enter a medication vial, bag, or bottle with a used syringe or needle. Never use medications packaged as single-dose or single-use for more than one patient. This includes ampoules, bags, and bottles of intravenous solutions. Always use aseptic technique when preparing and administering injections.
What should you assess with the IV prior to administration?Before giving an intravenous medication, always assess the IV needle insertion site for signs of infiltration or phlebitis.
What is the best way to protect a patient from an IV site injury?Use a site into which a primary solution is already infusing.. Assess the IV site before initiating the IV piggyback medication.. Select a relatively small vein to infuse the IV medication.. |