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NURSE 3170: FINAL EXAM
hypovolemia S&S
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o Rapid HR
o Flattened neck veins
o Normal or d/c BP
o Severe cases = hypovolemic shock can occur
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hypervolemia S&S
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o d/c hematocrit & plasma proteinconcentration
o distended neck veins
o increased BP
o edema formation
o ultimately, pulmonary edema and HF may develop
§ diureticscommonly used for treatment
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phlebitis S&S and treatment
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o Inflammation
o Can indicate infection. Culture may be needed!
o S&S: WARM, painful, red streak
§ StartIV in other arm
§ d/caffected IV
§ warmmoist pack
§ obtainculture if needed
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infiltration S&S and treatment
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o Leakage of fluid into the tissue
o S&S: swollen, COOL to the touch
o Vein is NO LONGER accessible
§ d/cIV
§ elevateextremity
§ ICEpack
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extravasation S&S and treatment
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o Leaking of a VESICANT medication into tissue
§ STOPthe fluid!
§ ASPIRATEif possible
§ doNOT flush the IV!
§ Notifyprovider, request antidote
§ Infuseantidote if available
§ d/ccatheter
§ elevateextremity
§ warmor cold pack depending on medication
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complications of short term central line catheters?
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o May cause damage to vessel wall due tostiffness. Sites:
§ Jugular:tortacholis (stiff neck, shortened sternocleidomastoid muscle)
§ Femoral:infection bc of excrement in that area
§ Clavicular:pneumothorax from needle puncture in wrong spot
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complications of central line therapy
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§ Thrombusformation, arterial puncture, pneumothorax, hemothorax, hydrothorax (collectionof fluid), catheter embolism, air embolism, infection
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When would you use gravity drip tubing? An IV pump? Piggybacks? Miniinfuser?
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Gravity drip tubing
o When giving a rapid bolus
IV Pump
o Continuous infusion; maintains steady serumlevels
Piggybacks
o Commonly used with drugs given over shortperiods at varying intervals
·Mini infuser
o When need to push a med for longer than 5minutes
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What 2 purposes does the volutrol (or burette) serve?
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· Prevents fluid overload by not allowing morethan 2 hrs worth of fluid to infuse
· Prevents adverse effects of too much medicationat once
· Should be used in pediatric and geriatricpopulation, and if patient is at risk for fluid overload (CHF, RF etc.)
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what is the purpose of positive pressure flushing?
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· Prevents backflow/reflux of blood into thecatheter
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Why do you need to use pulsatile flushing with a port-a-cath?
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· Creates turbulence and cleans the inside of thecatheter. It will minimize reflux of blood into the tip of the catheter andthus prevent clotting
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Explain why you can run 3 incompatible medications at the sametime through a triple lumen catheter.
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· Each lumen is its own tubing, therefore themedications do not touch one another until they are in the blood
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hypotonic fluids and when to use
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§ 0.45%saline (1/2 NS)
§ 0.33%saline (1/3 NS)
o Use if patient is hemodynamically stable but isdehydrated
o Should be avoided if pt has cerebral edema (headinjury) or if pt is edematous
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isotonic fluids and when to use
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§ LR– USE W/ BURN PATIENTS
§ 0.9%saline (NS)
§ 5%albumin
o Used when fluids need to stay in the vasculature
o ONLY FLUID USED WITH BLOOD TRANSFUSIONS
o Increases blood pressure by increasing cardiacoutput
o May cause fluid overload if patient has heartfailure
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hypertonic fluids and when to use
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§ D50.45% saline (D51/2 NS)
§ D50.9% (D5 NS)
§ D5LR
§ 25%albumin
o Regulate urine output
o Head injuries – will draw cerebral edema out
o Pulls fluid from interstitial tissue intovasculature
o Hopefully it gets to kidneys (more perfusion),then more urine output to help decrease edema
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Who wouldbe contraindicated to receive hypotonic fluids?
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· Cerebral edema! (Head injury)
· Edematous patient
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What type of patient should not receive hypertonic fluids?
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-condition causing cellular dehydration ex. diabetic ketoacidosis
-impaired heart or kidney fxn
-watch for fluid overload
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Who shouldnot receive Lactated Ringer’s? Why?
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-kidney failure
-liver disease
-lactic acidosis or alkalosis
-contains bicarb!
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What are the steps in collecting a 24 hour urine?
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· Initiate a collection at a specific time (recordthis time) by asking the patient to void
· Discard this urine and then collect all urinevoided for the next 24 hours
· At the end of the 24 hours, ask the patient tovoid.
· Add this urine to the previously collectedurine.
· Send the entire specimen to the lab
· All specimens may be kept separate or combineddepending on the type of exam
· The lab will specify whether a specimenpreservative should be used and whether the specimen should be keptrefrigerated or on ice
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What are the steps in collecting a urine for culture and sensitivity?
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· Have pt. void into a CLEAN bedpan, urinal orreceptacle (e.g. a specimen hat in the toilet)
· Avoid contamination with feces
· Make a note if a female pt. is menstruating
· Instruct the pt. not to put toilet paper intothe bed pan or specimen hat
· Using aseptic technique, pour the urine into anappropriate container
· Label container with pt’s name, data and time ofcollection
· Do not leave urine standing at room temp. for anextending period of time (may alter appearance and chemistry of urine)
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differences in placing a foley: women
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-12-16 fr
-clean each labial fold/meatus w/ separate swab top to bottom
-lubricate 1-2" of cath tip
-insert until urine appears (2-3") then insert another 2-3"
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differences in placing a foley catheter: men
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-16-18 fr
-use circular motions starting at meatus and moving down glans, three times w/ separate swabs
-insert 10 ml of lube with a syringe
-insert to bifurcation of the ports
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what does diarrhea cause in relation to acid base?
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acidosis
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what does vomiting cause in relation to acid base?
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alkalosis |
tap water enema
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HYPOTONIC
o Moves fluid from colon into tissue – can lead towater intoxication
o Distends intestine, increased peristalsis,softens stool
o Do NOT used to patient has weakened colon walls
o Do NOT do more than 2
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normal saline enema
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ISOTONIC
o Distends intestine, increases peristalsis,softens stool
o Large volume but does not lead to waterintoxication
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soap solution enema
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o Distends intestine, irritates the intestinalmucosa and softens stool
o Can work as a lubricant
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hypertonic solution enema
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o Distends intestine, irritates intestinal mucosa
o Pulls fluid from tissue into colon to helpstimulate the intestine
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oil enema
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lubricates stool and intestinal mucosa
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type of stool coming from an ileostomy?
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liquid, highly acidic
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type of stool coming from ascending transverse ostomy?
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liquid to semisolid consistency, odorous, possibly gaseous
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type of stool coming from sigmoid and descending ostomy?
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semisolid to solid, gaseous, odorous
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55) Which placement area has the highest rate of infections for centrallines?
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femoral |
advantages/disadvantages of a short term central line
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· Advantages
o Can give incompatible meds through the same line(triple/quad lumen)
· Disadvantages
o May cause damage to the vessel wall due tostiffness
o Jugular insertion – risk of torticollis
o Femoral insertion – risk of infection
o Clavicular insertion – risk of pneumothorax
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advantages/disadvantages for long term central line - hickman
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o Adv: Tunneled, does not require need stick toaccess, decreased infection (skin adheres to felt)
o Disadv: Body image issues, needs daily care
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advantages/disadvantages for long term central line - implanted port
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o Adv: Not readily visible, only flushed q 4 – 8weeks, less risk of infection and disturbed body image
o Disadv: Requires a needle stick to access
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Why do we not put gauze routinely under central line dressings?
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· Gauze covers the insertion site, which makes itdifficult to monitor
· Gauze absorbs sweat and secretion, which is abreeding ground for bacteria
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Why would you saline lock a person’s IV? How do you care for a salinelock?
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· Saline lock an IV if we do not currently needthe IV to give medications, but anticipated needing to use it soon
· Keeps the IV patent
· Must flush q 8 hours
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S&S hyperkalemia
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-fatigue
-N/V, anorexia
-muscle weakness
-d/c bowel motility
-cardiac arrhythmias
-polyuria, nocturia, dilute urine
-orthostatic HoTN
-ECG changes
-parasthesias/tender muscles
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S&S hypernatremia
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Thirst
Increased temp.
Dry/swollen tongue, sticky mucous membranes
If severe:
Disorientation
Hallucinations
Lethargy
Irritable
Seizues
Coma
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S&S hypercalcemia
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Trousseau’s and Chvostek’s signs
Numbness and tingling of fingers/toes
Mental changes
Seizures
Spasm of laryngeal muscles
ECG changes
Muscle cramps inextremities
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