Page 1 of 2NR 226 Sept 2013 Session Exam 1Chapter 16 20 Nursing Process, Chapter 41 Fluid and Electrolyte, acid base balance, IV therapy, blood administration, IV flow rate calculationBlue PrintNursing Process The five steps-Assess- Gather info about the patients condition-Diagnose-Identify the patients problems-Plan-Set goals of care and desired outcomes and identify appropriate nursing actions-Implement-Perform the nursing actions identified in planning-Evaluate-Determine if goals and expected outcomes are achieved Repeat process if outcomes have not been met. Nursing Process Assessment phase purpose The nursing process is a critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness. The nursing process is a variation of scientific reasoning. Practicing the five steps of the nursing process allows you to be organized and to conduct your practice in a systematic way. You learn to make inferences about the meaning of a patients response to a health problem or generalize about the patients functional state of health. Through assessment, a pattern begins to form. Databases The purpose of assessment is to establish a database about the patients perceived needs, health problems, and responses to these problems. In addition, the data reveal related goals, experiences, health practices, values, and expectations about the health care system. Critical thinking skills help you to synthesize relevant information and use it in a purposeful way.

Problem Orientated Approach to data collectionWhere is it? How bad is it? Is it intermittent or continuous? What makes it worse? What makes it better? Problem focused unless the patient is being admitted. Patients who are being admitted need a full assessment.Patient centered interview stepsPatient-centered interview = An organized conversation with the patient (focus on patient not your own agenda) Page 212-213 Set the stage (preparation, environment, greeting). (temperature, lighting) Set an agenda/gather information about patients concerns. Collect the assessment or nursing health history; assure the patient of confidentiality. Terminate the interview (cue the end). Paraphrase to make sure the patient understands. Cue by looking at your watch, Were about to wrap this up.Open-ended vs. closed-ended questions Close-ended questions require short answers and clarify previous information or provide additional information. Back-channeling (active listening prompts all right, go on uh-huh) Probing with open ended questions Because a patients report includes subjective information, validate data from the interview later with objective data. Obtain information (as appropriate) about a patients physical, developmental, emotional, intellectual, social, and spiritual dimensions.

Types of assessment approachesCritical Thinking Approach to Assessment Assessment involves collecting information from the patient and from secondary sources (e.g., family members, medical records, health care providers), along with interpreting and validating the information to form a complete database. Two stages of assessment: Collection and verification of data Analysis of dataInterpreting and data validating Interpreting and validating assessment data. Validation of assessment data consists of comparison of data with another source to determine accuracy of the data.

Sources of data Patient (interview, observation, physical examination)the best source of information Family and significant others (obtain patients agreement first) Health care team Medical records Scientific literature Nurses experience

Subjective data verses objective dataSubjective date- What the patient says it is quoteObjective data- Conditions that you can see or feel or observe, FACT1. Medical diagnosis Identification of a disease condition based on specific evaluation of signs and symptoms, results of diagnostic test and procedures, medical history

2. Nursing diagnosisNANDAClinical judgment about the patient in response to an actual or potential health problem (North America Nursing Diagnosis Association)(acute pain, nausea)

3. Collaborative problem Actual or potential physiological complication that nurses monitor to detect a change in patient status (surgical wound: infection; nurse monitor for fever and other s/s of infection, MD orders antibiotics, dietician ordered diet high in protein)

Nursing diagnosis and components of how to correctly write a nursing diagnosisMedical diagnoses dont have a place in nursing diagnoses

Provides a precise definition of a pts problem that gives nurses and other members of the health care team a common language for understanding the pts needs. Allows nurses to communicate (written and electronic) what they do among themselves with other health care providers and the public. Distinguishes the nurses role from that of the physicians or other health care provider. Helps nurses to focus on the scope of nursing practice Foster the development of nursing knowledge Promotes creation of practice guidelines that reflect the essence of nursing.Components of a nursing diagnosis PES:Problem; NANDA-I label (Impaired physical mobility) Etiology; etiology or related to factor (incisional pain) Symptoms; symptom or defining characteristics (evidence by restricted turning and positioning)

Nursing diagnosis errorsErrors in Interpretation and analysis of data-Following data collection, review your database to decide if it is accurate and complete. Review data to validate that measurable, objective physical findings support subjective data. (when a patient describes difficulty breathing you also want to listen to lung sounds, assess respiratory rate, and measure the patients chestErrors in data clustering- occur when data are clustered prematurely, incorrectly, or not at all. Premature clustering of data occurs when you make the nursing diagnosis before grouping all data.Errors in the diagnostic statement- Clinical reasoning leads to a higher quality of nursing diagnosis, which eventually leads to etiology specific interventions and enhanced patient outcomes. The more competent you become in diagnostic reasoning, the more likely it is that you will correctly select diagnostic statements.

Nursing process phases and what is done in each phaseThe five steps-Assess- Gather info about the patients condition-Diagnose-Identify the patients problems-Plan-Set goals of care and desired outcomes and identify appropriate nursing actions-Implement-Perform the nursing actions identified in planning-Evaluate-Determine if goals and expected outcomes are achieved Repeat process if outcomes have not been met.

(Seven) Guidelines in writing nursing care plan goalsGoals and outcomes need to meet established intellectual standards by being relevant to patient needs, specific, singular, observable, measurable, and time limited. Goal A broad statement that describes the desired change in a patients condition or behavior An aim, intent, or end Expected outcome Measurable criteria to evaluate goal achievement Sometimes several expected outcomes must be met for a single goal. Direct nursing care. Are written sequentially, with time frames Prostatectomy Goal: Understanding post operative risks Expected outcome: Patient identifies sign and symptoms of wound infection Patient explains signs of urinary obstructionPatient centered reflect patient behaviors and responses expected as a result of nursing interventions

Singular goal or outcome address only one behavior or response Observable to know if change has taken place

Measurable patients response, do not use vague terms such as normal stable Time limited when you expect the response to occur, realistic and reasonable time frames

Mutual factors set goat with nurse and patient increases the patients motivation Realistic for the patient to reach, provides patient with a sense of hope and increases motivation and cooperation

1) Patient centered- Patient will ambulate to the nurses desk and back (not- turn the patient every two hours)2) Singular goal or outcome-Each goal and outcome should address only one behavior or response3) Observable- The goal or outcome should be observable (how else can you prove it)4) Measurable-Values describing quality, quantity, frequency, length, or weight allow you to evaluate outcomes precisely. (avoid vague terms such as: adequate, acceptable, or stable)5) Time-Limited- Discuss with patient and decide on a realistic time-frame6) Mutual Factors- Make sure that the patient and nurse are in agreement on the expected outcomes, goals, and time-frame.7) Realistic-The time allotted for care is short. You must be able to set goals that are realistic for you and your patient. Priority setting Use the ABCs to direct you to the highest priority. 1st priority chest trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, acute neurological deficit and chemical splashes to the eye(s) (emergent) 2nd priority simple fracture, asthma without severe respiratory distress, fever, hyper tension, abdominal pain, renal stone (urgent) 3rd priority minor laceration, sprain, cold symptoms (non urgent) Ordering of nursing diagnoses or patient problems uses determinations of urgency and/or importance to establish a preferential order for nursing actions. Helps nurses anticipate and sequence nursing interventions Classification of priorities: (consider Maslows hierarchy)

Prostatectomy HighEmergent (safety, oxygenation, circulation, unique patient situation physiological and psychological)Acute pain Intermediate (non emergent, non life threatening)Deficient knowledge Low(not always directly related to a specific illness or prognosis) Affect patients future well-being and could focus on long-term health needsEffect on sexual function

The order of priorities changes as a patients condition changes. Priority setting begins at a holistic level when you identify and prioritize a patients main diagnoses or problems. Patient-centered care requires you to know a patients preferences, values, and expressed needs. Ethical care is a part of priority setting. When priorities are less clear, dialog with the patient, family and other health care providers is needed.

Types of interventions independent, dependent, collaborative Nurse initiated; require no supervision from others IndependentActions that a nurse initiates elevate an edematous extremity, reposition patient to relieve pain Physician initiated; nurse advocate if treatment is appropriate and clarify order DependentRequire an order from a physician or other health care professional starting an IV, inserting a Foley, administering a medication Collaborative; nurse advocate if treatment is appropriate and clarify order InterdependentRequire combined knowledge, skill, and expertise of multiple health care professionals dietary, PT, respiratory Implementation processReassessing the patient every time you interact with them>>Reviewing and revising the existing nursing care plan>>Organizing resources and care delivery (equipment and personnel)>>Anticipating and preventing complicationsAnticipate and Prevent Complications Identify risks to the patient. (risk of pressure ulcer) Adapt interventions to the situation. Evaluate the relative benefit of a treatment vs. the risk.Initiate risk prevention measures.Modification of an Existing Written Care Plan Revise data assessment. Revise the nursing diagnoses. Revise specific interventions. Determine how to evaluate whether you have achieved outcomes.Implementation skills Cognitive skills Application of critical thinking in the nursing process (know the rationale for interventions and normal and abnormal physiological and psychological responses) Interpersonal skills Developing a trusting relationship, expressing a level of caring, and communicating clearly with a patient and his or her family (perceptive of the patients verbal and non- verbal communication) Psychomotor skills Integration of cognitive and motor activities (for example; understand the anatomy and pharmacology-cognitive- and use good coordination and precision to administer injection)

Nursing intervention defined A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes.Interventions include direct care (interactions with patients) and indirect care (performed away from the patient but on behalf of the patient or group of patients) measures aimed at individuals, families, and/or the communityDirect care, indirect care and collaborative careDirect care (interactions with patients) and indirect care (performed away from the patient but on behalf of the patient or group of patients) measures aimed at individuals, families, and/or the community. Collaborative care involves a team of healthcare professionals to implement the interventions.

Nursing sensitive outcomeNursing-sensitive outcome is a measurable patient or family state, behavior, or perception largely influenced by and sensitive to nursing intervention. Examples are: Reduction in pain frequency, incidence of pressure ulcers, and incidence of falls.

Evaluation measures Evaluation is an ongoing process. If outcomes are met, patient goals are met. Positive evaluations occur when nurses meet desired outcomes. Positive evaluations lead nurses to conclude that interventions were successful. (does patient's condition or well-being improve?) Unmet or undesirable outcomes reveals the patient has not responded to interventions as planned. You conduct evaluation measure to determine if your patients met expected outcomes, not if nursing interventions were completed.Standards of Evaluation American Nurses Association (ANA) Defines standards of professional nursing and steps of the nursing process. Competencies include: Being systematic Using criterion-based evaluation Collaborating with patients and other professionals Using ongoing assessment data to revise care plan Communicating results to patients and families

Expected outcomes Goal = Expected behavior or response that indicates resolution of a nursing diagnosis or maintenance of a healthy state. A summary statement of what will be accomplished when patient has met the expected outcome. Patient expresses acceptance of health status by day of discharge (for the nursing diagnosis of anxiety). IV site will remain free of phlebitis. Expected outcome = End result that is measurable, desirable, and observable and translates into observable patient behaviorsPatient describes surgical outcomes in discussion with surgeon in 24 hours.

Page 2 of 2NR 226 May 2013 Session Exam 1Chapter 16 20 Nursing Process, Chapter 41 Fluid and Electrolyte, acid base balance, IV therapy, blood administration, IV flow rate calculationBlue PrintFluid and Electrolyte, Acid Base Imbalances, Blood Transfusion and IVFluid = Water that contains dissolved or suspended substances such as glucose, mineral salts, and proteins.

Fluid amount = Volume.

Fluid concentration = Osmolality.

Fluid composition (electrolyte concentration)

Degree of acidity = pH

Intracellular Fluid (ICF)= Fluids within cells ~2/3 of total body waterExtracellular Fluid (ECF) = Fluid outside of cells ~1/3 of total body water Three divisions: Interstitial; between cells and outside blood vessels Intravascular; liquid portion of blood Transcellular; cerebrospinal, pleural, peritoneal, synovial

Lab values: Na, K, Ca, Cl, Mg, and signs and symptoms of hyper and hypo and value of PH, PaCO2, HCO3 (bicarbonate)

Determine Acid Base Imbalances and etiology of (what can cause) those imbalances and nursing implications Acid production, buffering, and excretion interplay to create balance. Acids release hydrogen (H+) ions; bases (alkaline substances) take up H+ ions. The more H+ ions present, the more acidic the solution Degree of acidity is reported as pH. pH scale: 1.0 (very acid) to 14.0 (very base) pH of 7.0 is neutral; normal arterial blood is 7.35 to 7.45. Maintaining pH within this normal range is very important for optimal cell function. Measured by ABGs. Discuss how ABGs are drawn. Occlude the radial and ulnar veins and have the patient clench fist. Release the ulnar vein only and have the patient unclench fist. The hand should be white at first and gradually turn pink again as blood fills the hand. If the hand remains white, the ulnar vein is damged and you will not be able to draw ABGs through that hand because you might damage the radial vein and the patient will then lose their hand.

Extracellular fluid volume imbalances Extracellular fluid volume (ECV) deficit Hypovolemia means decreased vascular volume and often is used when discussing ECV deficit. ECV excess too much isotonic fluid in extracellular compartments too much Na yields swelling and fluid weight gain Osmolality imbalances: page 888 table 41-3 Sodium (NA+) 136-145 mEq/L Hypernatremia, water deficit; hypertonic Hyponatremia, water excess water intoxication; hypotonic, cells swell-cerebral dysfunction when brain cells swell Clinical dehydration = ECV deficit and hypernatremia combined Acid excretion systems: lungs and kidneys Lungs excrete carbonic acid. Kidneys excrete metabolic acids. Excretion of carbonic acid When you exhale, you excrete carbonic acid in the form of CO2 and water. Excretion of metabolic acids The kidneys excrete all acids except carbonic acid.

Acid base Imbalances Types of acidosis: respiratory and metabolic Types of alkalosis: respiratory and metabolic Respiratory acidosis Arises from alveolar hypoventilation Lungs unable to excrete enough CO2 Excess carbonic acid in the blood decreases pH. Respiratory alkalosis Arises from alveolar hyperventilation Lungs excrete too much CO2 Deficit of carbonic acid in the blood increases pH. Metabolic acidosis Arises from increase in metabolic acid or decrease in base (bicarbonate) Kidneys unable to excrete enough metabolic acids, which accumulate in the blood Results in decreased level of consciousness Metabolic alkalosis Arises from direct increase in base (bicarbonate) or decrease in metabolic acid Results in increased blood bicarbonate Kidney or lung cannot compensate for itself. Kidneys compensate for respiratory imbalances. Respiratory system compensates for metabolic imbalances. These compensatory mechanisms do not correct the problem, but they assist the body in adapting. However, if the underlying condition is not corrected, these compensatory mechanisms will fail.

Determine Electrolyte and Fluid Imbalances and etiology of (what can cause) those imbalances and nursing implications Intake and absorption Distribution Plasma concentrations of K+, Ca2+, Mg+, and phosphate (Pi) [2.7 4.5 mg/dl] are very low compared with their concentrations in cells and bone. Concentration differences are necessary for normal muscle and nerve function. Output Normal: Urine, feces, and sweat Abnormal: Vomiting, drainage, drainage tubes and fistulas Potassium (K+) 3.5 -5.0 mEq/L Hypokalemia Hyperkalemia Calcium (Ca2+) 8.4 10.5 mEq/L (Ionized 4.5 - 5.3) Hypocalcemia Hypercalcemia Magnesium (Mg2+) 1.5 2.5 mEq/L Hypomagnesemia Hypermagnesemia

Blood transfusion and nursing implicationsAlways use Normal Saline with blood!!If a reaction occurs, do not allow any more of the blood or fluid in tubing to enter the patient!!!Change the tubing down to the hub and hang normal saline!! We will never use that blood again, it will be sent back to the distributer or the lab for investigation. Do not throw it away.

Blood component therapy = IV administration of whole blood or blood component (RBCs, plasma, platelets) Blood groups and types must be matched to the patient. O blood universal donors. AB blood universal recipients. RH negative or positive consideration. Autologous transfusion-collection and infusion of patients own blood (usually donated 6 weeks preoperative) Transfusing blood requires a physician order. Transfusion reactions and other adverse effects Pre-transfusion assessment always includes VS.Blood verification by two RNs or RN and LPN

Nursing actions for transfusion reactions and other adverse effects Acute intravascular hemolytic (acute kidney injury)- worst case scenario, low back pain (kidneys) could result in kidney failure, fever, chills, low back pain, flushing, tachycardia, tachypnea, hypotension, hemoglobinemia, sudden olguria (acute kidney injury), circulatory shock, cardiac arrest, and deathStop transfusion and save blood bag and administration set for investigation. Keep IV site open with normal saline infused through new tubing. Maintain BP and treat shock as ordered, if present. Obtain blood samples slowly to avoid hemolysis; then send for serological testing. Send urine specimen to laboratory. Give diuretics as prescribed to maintain urine flow. Insert indwelling urinary catheter or measure each voiding to moniter hourly urine output. Dialysis may be required if acute kidney injury occurs. Patient safety! Do not transfuse additional RBC-containing components until transfusion service provides newly cross-matched units. Febrile non hemolytic (most common)-Sudden shaking, chills (rigors) fever rise headache, flushing, anxiety and muscle painStop transfusion. Give antipyretics as prescribed: avoid aspirin in thrombocytopenic patients. Patient Safety! Do not restart transfusion. Mild allergic- Flushing, itching, hives (urticaria)Stop transfusion temporarily, give anti-histamine as directed. If symptoms are mild and trasnsient, restart transfusion slowly (moniter)Patient Safety! Do not restart transfusion if fever, pulmonary symptoms, or hypotension develop. AnaphylacticAnxiety, urticaria, dyspena, wheezing, progressing to cyanosis, severe hypotension, circulatory shock, possible cardiac arrestStop transfusion. Have epinephrine ready for injection (0.4 mL of 1:1000 solution subq or 0.1 mL of 1:1000 solution diluted to 10 mL with saline for IV use). Provide blood pressure support as ordered. Initiate CPR if indicated. Circulatory overload- Dyspnea, cough, crackles, or rales in dependent portions of lungs; distended neck veins when upright (fluid overload).Turn down transfusion rate or stop transfusion. Place patient upright with feet in dependent position. Administer prescribed diuretics, oxygen, or morphine. Phlebotomy may be indicated. Sepsis- Rapid on-set of chills, high fever, severe hypotension, and circulatory shock. May occur: vomiting, diarrhea, sudden oliguria (acute kidney injury), DICStop transfusion. Obtain culture of patients blood and send bag with remaining blood to transfusion services for further study. Treatment as ordered; antibiotics, IV fluids, vasopressers, glucocoticoids. Infiltration, Phlebitis, local infection, extravasation Complications page 910-911, table 41-12, 41-13, 41-14 Fluid overload; pulmonary edema fluid overload infiltration; IV fluid enters subq tissue, IV catheter becomes dislodged (remove catheter and apply warm compress) Extravasation; vesicant (tissue damaging) drug enters tissues (remove catheter and apply a warm compress) (Call pharmacy!!) Phlebitis; inflammation of the inner layer of the vein local infection; infection at catheter point of entry can occur during infusion or after catheter removed) Bleeding at the infusion site; oozing or continuous seepage of blood at venipuncture site

Nursing implications for set up and transfusion of bloodTranfusing blood requires a healthcare providers order. Perform a thorough assessment before administering a transfusion and monitor carefully during and after the transfusion. Pretransfusion assessment; educate pt, has the pt ever had a transfusion or transfusion reaction before? Explain the procedure to the pt and instruct the pt to report any s/s immediately. Obtain baseline vitals so you can compare during transfusion.Verify 3 things:1) Blood components ordered are the ones delivered2) The blood is compatible to the patients blood type listed in the medical records3) The right pt receives the bloodTwo RNs or a RN and a LPN must check the label on the blood and compare it to the medical records (If they do not match, notify the bank immediately to prevent further errors).When administering blood you need an 18g catheter (a 20g may be used for only two units). Prime the tubing with saline to prevent hemolysis or RBC breakdown. Intitiate the transfusion slowly for detection of reactions. Maintain the ordered flow rate, monitor for reactions, assess vitals, and promptly record all findings. Stay with the pt for the first 15 minutes. Pts are at the highest risk for a reaction within the first 15 minutes. Continue to monitor the pts vitals periodically. Ideally the flow rate is 1u/2hr.This may be lengthened to 4 hours if the pt is at risk of ECV. Anything over four hours is at risk for contamination because the blood warms and is an ideal breeding ground for bacteria.Central venous catheters are used for severe blood loss (hemorrhaging) and a blood warmer is used. Rapid administration of cold blood can cause cardiac dysrythmias. Initiating IV and discontinuing IV Fluids infuse directly into the blood stream, sterile technique is necessary Equipment Vascular access devices (VADs) [larger the gauge the smaller the catheter], tourniquets, clean gloves, dressings, IV fluid containers, various types of tubing, and electronic infusion devices (EIDs), also called infusion pumps Initiating the intravenous line [once you have withdrawn the needle, you cannot advance the needle back into the catheter for risk of shearing off the tip of the catheter resulting in a pulmonary embolism and MI] Regulating the infusion flow Electronic infusion devices (EIDs or IV pumps)Non-electronic volume control devices [tubing sizes micro 60, macro 10, 15 or 20 gtts]Start most distal site. Avoid sites that are red or look infected, infiltrated or signs of thrombosis. Try to avoid flexion areas.

Complications page 910-911, table 41-12, 41-13, 41-14 Fluid overload; pulmonary edema fluid overload infiltration; IV fluid enters subq tissue, IV catheter becomes dislodged Extravasation; vesicant (tissue damaging) drug enters tissues Phlebitis; inflammation of the inner layer of the vein local infection; infection at catheter point of entry can occur during infusion or after catheter removed) Bleeding at the infusion site; oozing or continuous seepage of blood at venipuncture siteAVerified health care providers order for accuracy and completeness. Verbalize 6 Rights.

Assessed patients need for, previous experience with and understanding of IV therapy

Evaluated fluid and electrolyte balance, obtained baseline abnormalities, labs, risk factors, clinical factors/conditions that would respond to or be affected by IV administration

Determined if patient is to undergo planned procedures/surgeries.

Obtained information from approved source about IV fluids, admin, potential incompatibilities, side effects, monitoring and the need for special catheters or tubing.

PPerform hand hygiene, organize appropriate equipment

Open sterile packages using sterile aseptic technique

Checked IV solution, scanned barcodes if present.

Prepare IV tubing and solution a. Check IV solutionb. Verbalize appropriate labeling of IV bag c. Prepared short extension tubing with proper connector and IV tubing, maintaining sterilityd. Spike the IV bag aseptically; compress drip chamber and release, to fill one-half full with IV solution.e. Correctly prime tubing (free of air bubbles), place roller clamp approximately 2-5 cm (1-2 inches) below drip chamber and move to closed position.f. Hang IV bag appropriately

I*Performed hand hygiene.

*Introduce self as SN, Provided privacy, Identified patient using at least two identifiers. Determine with patients allergies, especially to latex, adhesive or iodine.

*Explain procedure and assist to appropriate position, provide adequate lighting. Raise bed to a comfortable height. Apply gloves.

Apply tourniquet appropriately and identify interventions to distend veins with associated patient education

Clean venipuncture site correctly using a circular motion spiraling out approximately 2 inches and let dry.

Anchored vein, stretched skin properly, warned patient, perform venipuncture bevel up at 10 to 30 degree angle slightly distal actual site of venipuncture in direction of vein, observe for blood return in the flashback chamber.

Lowered catheter until almost flush with skin and advanced catheter until hub is at venipuncture site.

Stabilize catheter with non-dominant hand, release tourniquet

Apply direct pressure on vein above catheter with middle finger of non-dominate and removed stylet safely and dispose into sharps container.

Initiate the infusion

Quickly connected and secured extension tubing or normal saline lock to catheter, flush and observe for swelling at site,

Verbalize signs of infiltration and appropriate interventions

Secure cannula and apply sterile dressing over site.a. Cleansing site of blood if needed while stabilizing VADb. Allow site to dry then apply skin protectantc. Apply sterile dressing over sited. Apply tape over site e. Label dressing: initials, date, time, angiocath gauge

Secure tubing appropriately-curl loop of tubing alongside arm and place second piece of tape directly over tubing.

Open roller clamp To Keep Open (TKO) rate.

Provide instructions to patient of signs and symptoms of complications and to notify nurse if any occur.

EVerbalize care and maintenance of IV: Monitor patient, IV site, and flow rate every 1-2 hours

Verbalize documentation of procedure a. Details of IV(site, # of attempts/caths, angiocath gauge, date, time, initiated by)b. Patients response to IV

*Remove all equipment, lower the bed to the lowest level, side rails up, call light within reach, and place the patient in a comfortable position. (dispose of stylet in sharps container if not done previously)

*Remove gloves and perform hand hygiene.

Goal: Discontinuing Peripheral IV Access

SUComments

AVerified health care providers order for accuracy and completeness. Verbalize 6 Rights.

PPerform hand hygiene, organize appropriate equipment

Open sterile packages using sterile aseptic technique

I*Performed hand hygiene.

Introduce self as SN, Provided privacy, Identified patient using at least two identifiers. Determine with patients allergies, especially to latex, adhesive or iodine.

*Explain procedure and assist to appropriate position, provide adequate lighting. Raise bed to a comfortable height. Apply gloves.

Close roller clamp. Remove tape on curl loop of tubing alongside arm.

Remove IV site dressing. Remove any tape that secures catheter. Do not use scissors.

Place sterile gauze over venipuncture site and apply light pressure while withdrawing catheter, suing slow, steady motion. Keep hub parallel to skin. Do not raise catheter before it is completely out of vein.

Inspect catheter tip for intactness after removal.

Keep gauze in place and apply continuous pressure to site 2 to 3 minutes and assess bleeding. If patient is on anticoagulants, apply steady pressure longer (5-10 minutes) and access bleeding.

Apply sterile folded gauze dressing over insertion site and secure with tape.

E*Remove all equipment, lower the bed to the lowest level, side rails up, call light within reach, and place the patient in a comfortable position.

*Remove gloves and perform hand hygiene.

Document IV discontinued, amount of IV fluid infused, catheter intactName, title, date, time

IV flow rate equations (ALL QUESTIONS WILL BE FLOW RATE!!!)

Never add anything to blood.

DefinitionsFlow Rate: the speed in which the IV flow.Drop Factor: the number of drops for 1mL of fluid to go in.

Macro tubing: 10-15-20Micro tubing: 60 drop factor (micro and 60 are synonymous)

GTT =volume to be infused 1mLNotes: Never round up. Drop factor is by gravity not pump

100 mL=100 mL/hr10 hrs

3000 mL NS over 24 hrs 15gtt/min

Gtt->15gtt x 3000mL x 1 hr = 31.25 ggts/minMin 1 mL 24 hrs 60min 31 gtts/min

600 mL LR (lactaded renal) over 3 hours

mL 600mL = 200 mL/hrhr 3 hrs

300 mg IVPB in 100 NS over 45 minmL 100mL x 60min = 133mLmin 45min 1hr 1hr