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1.A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? "I flushed what I urinated at 7:00 a.m. and have saved all urine since." 2.A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? Calf swelling 3.A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines? A nurse asks a nurse from another unit to assist with her documentation. 4.A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take? Remove the stockings at least once per shift. 5.A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? Auscultate lung sounds 6.A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? "I can concentrate best in the morning." 7.A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use? Have the client stand with her arms at her side and her feet together. 8.A nurse is planning an deduction session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client? Chapter 8. Intravenous Therapy Patients are prescribed an IV solution (fluids) based on their electrolyte and fluid volume status. IV fluids are commonly categorized as colloids and crystalloids. Colloid solutions contain large molecules that cannot pass through semi-permeable membranes and are used to expand intravascular volume by drawing fluid from extravascular space via high osmotic pressure. Examples of colloid solutions are albumin, dextrans, and hydroxyethyl starches (Crawford & Harris, 2011). Crystalloid solutions contain solutes such as electrolytes or dextrose, which are easily mixed and dissolvable in solution. Crystalloids contain small molecules that flow easily across semi-permeable membranes, which allows for transfer from the bloodstream into the cells and tissues (Crawford & Harris, 2011). They may increase fluid volume in interstitial and intravascular space. Examples of crystalloid solutions are isotonic, hypotonic, and hypertonic solutions. Isotonic solutions have an osomolality of 250 to 375 mOsm/L. Isotonic solutions have the same osmotic pressure as plasma, creating constant pressure inside and outside the cells, which causes the cells to remain the same (they will not shrink or swell) and does not cause any fluid shifts within compartments. Isotonic solutions are useful to increase intravascular volume, and are utilized to treat vomiting, diarrhea, shock, and metabolic acidosis, and for resuscitation purposes and the administration of blood and blood products. Examples of isotonic solutions include normal saline (0.9% sodium chloride), lactated Ringer’s solution, 5% dextrose in water (D5W), and Ringer’s solution. It is important to monitor patients receiving isotonic solutions for fluid volume overload (hypervolemia) (Crawford & Harris, 2011). Hypotonic solutions have a lower concentration, or tonicity, of solutes and have an osomolality equal to or less than 250 mOsm/L. The infusion of hypotonic solutions lowers the osmolality within the vascular space and causes fluid to shift to the intracellular and interstitial space. Cells will swell but may also delete fluid within the vascular space. Examples of hypotonic solutions include 0.45% sodium chloride, 0.33% sodium chloride, 2.5% dextrose in water, and 0.2% sodium chloride. Monitor for hypovolemia and hypotension related to fluid shifting out of the vascular space, and do not administer to patients with increased intracranial pressure (ICP), as it may exacerbate cerebral edema. Use cautiously in patients with burns, liver failure, and traumas (Crawford & Harris, 2011). Hypertonic solutions have a higher concentration, or tonicity, of solutes and have an osomolality equal to or greater than 375 mOsm/L. The osmotic pressure gradient draws water out of the intracellular space into the extracellular space. Examples of hypertonic solutions include D5W and 0.45% sodium chloride, D10W, and 3% sodium chloride. Hypertonic solutions may cause intravascular fluid volume overload and pulmonary edema, and they should not be used for an extended period of time. Hypertonic solutions should not be used in patients with heart or renal disease who are dehydrated (Crawford & Harris, 2011). Read the article IV fluids: what nurses need to know for more in-depth information regarding colloid and crystalloid solutions. Although all IV fluids must be administered carefully, hypertonic solutions are additionally risky. An order for IV fluids may be continuous or as a bolus, depending on the needs of the patient. IV solutions are available in 25 ml to 1000 ml bags. The frequency, duration, amount, and additives to solution must be ordered by a physician or nurse practitioner; for example, an order may be “give NS at 125 ml/hr.” The most common types of solutions include normal saline (NS) and D5W. Patients may also have medications, such as potassium chloride, thiamine, and multivitamins, added to IV solutions. To discontinue an IV infusion, an order must be obtained from the physician or nurse practitioner (Perry et al., 2014). IV Administration EquipmentWhen a peripheral vein has a cannula inserted, an extension tubing is connected to the hub on the cannula and flushed with normal saline to maintain patency of the cannula. Most peripheral intravenous cannulas will have extension tubing, a short, 20 cm tube with a positive fluid displacement/positive pressure cap attached to the hub of the cannula for ease of access and to decrease manipulation of the catheter hub (Vancouver Coastal Health, 2008). The extension tubing must be changed each time the peripheral catheter is changed. When the peripheral cannula is not in use, the extension tubing attached to the cannula is called a saline lock. Intravenous fluids are administered through thin, flexible plastic tubing called an infusion set or primary infusion tubing/administration set (Perry et al., 2014). The infusion tubing/administration set connects to the bag of IV solution. Primary IV tubing is either a macro-drip solution administration set that delivers 10, 15, or 20 gtts/ml, or a micro-drip set that delivers 60 drops/ml. Macro-drip sets are used for routine primary infusions. Micro-drip IV tubing is used mostly in pediatric or neonatal care, when small amounts of fluids are to be administered over a long period of time (Perry et al., 2014). The drop factor can be located on the packaging of the IV tubing. Primary IV tubing is used to infuse continuous or intermittent fluids or medication. It consists of the following parts:
IV solution bags should have the date, time, and initials of the health care provider marked on them to be valid. Add-on devices (e.g., extension tubing or dead-enders) should be changed every 96 hours, if contaminated when administration set is replaced, or as per agency policy. Intravenous solution and IV tubing should be changed if:
Primary and secondary administration sets (see Figure 8.4) should be changed regularly to minimize risk and prevent infection (CDC, 2011; Fraser Health Authority, 2014). Change IV tubing according to agency policy. Table 8.5 lists the frequency of IV tubing change. Table 8.5 Frequency of IV Tubing Changes
Infusing IV Fluids by Gravity or an Electronic Infusion Pump (EID)To ensure therapeutic effectiveness of IV fluids, a constant, even flow is necessary to prevent complications from too much or too little fluid. A physician must order a rate of infusion for IV fluids or for medications. The rate of infusion for medications (given via a secondary or primary infusion) can be found in the Parenteral Drug Therapy Manual (PDTM). If an order for IV fluids is “to keep vein open” (TKVO), the minimum flow rate is 20 to 50 ml per hour, or according to physician’s orders (Fraser Heath Authority, 2014). A health care provider is responsible for regulating and monitoring the amount of IV fluids being infused. IV fluid rates are regulated in one of two ways:
An IV pump must be used for:
To calculate the drops per minute for an infusion by gravity, follow the steps in Table 8.6. Table 8.6 Calculating the Drops per Minute (gtts/min) for an Infusion by Gravity
Take the IV calculations quiz for more practice with IV fluid dose calculation. When an infusion is by gravity, there are several factors that may alter the flow/infusion rate (Fulcher & Frazier, 2007). In addition to regulating the flow rate, assess the IV system to ensure these factors are not increasing or decreasing the flow of the IV solution. These factors are listed in Table 8.7. Table 8.7 Factors Influencing the Flow Rate of Infusions
Assessing an IV SystemAll patients with IV fluid therapy (PIV and CVC) are at risk for developing IV-related complications. The assessment of an IV system (including the IV site, tubing, rate, and solution) (see Figure 8.6) often depends on what is being infused, the patient’s age and medical condition, type of IV therapy (PIV or CVC), and agency policy. Generally, an IV system should be assessed as described in Checklist 65. Figure 8.6 Assess IV site prior to use Checklist 65: Assessing an IV System
What are the complications of peripheral IV therapy?Common complications are:. Infection: Skin-based bacteria may enter through insertion site. ... . Phlebitis: Vein irritation. Due to the presence of the catheter/fluids or medication. ... . Infiltration/Extravasation: delivery of fluids or medications into surrounding tissue. If Infiltration/extravasation occurs.... How often should peripheral IV dressings be changed?➢ All short peripheral intravenous site dressings must be changed every 5-7 days, and more often as indicated. ➢ The continued need for the IV site should be examined daily, and catheters should be removed if no IV therapy is planned.
What are the signs and symptoms that a peripheral IV site needs to be changed?Signs and symptoms include pain, swelling, redness, skin surrounding insertion site is cool to touch, change in quality or flow of IV, tight skin around IV site, IV fluid leaking from IV site, and frequent alarms on the IV pump.
How often should a new peripheral IV site is required to prevent infection and other major complications?US Centers for Disease Control guidelines recommend replacement of peripheral intravenous catheters (PIVC) no more frequently than every 72 to 96 hours. Routine replacement is thought to reduce the risk of phlebitis and bloodstream infection.
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