Term
6 rights of medication administration |
|
Definition
PATIENT MEDICATION---ck allergies, compatibility DOSE----remember to put rate here ROUTE---be sure meds are IV TIME---30 minutes before or after time DOCUMENTATION---depends on facility |
|
|
Term
|
Definition
Fluid overload Air embolism Sepsis |
|
|
Term
|
Definition
Complication---CHF, Pulmonary edema S/S----moist crackles, edema, dyspnea, fast shallow respirations TX: decrease IV rate, high fowler's, asses VS, breath sounds, notify MD... Prevent: monitor infusions carefully, infusion pump |
|
|
Term
|
Definition
Complication---shock, death S/S---dyspnea, cyanosis, hypotension, weak rapid pulse, chest,shoulder and low back pain RX: Clamp cannula IMMEDIATELY, place client on left side in TRENDELENBURG position--keeps air bolus in R atrium, assess VS and breath sounds, call MD.. Prevent: Luer-lock adapter on all lines, air detector alarm on IV pump |
|
|
Term
|
Definition
Do not let administration set hit floor! S/S----abrupt increase temp, backache, headache, N/V/D, chills, general malaise, increase P, RR severe: vascular collapse, septic shock RX: symptomatic culture cannula tip, tubing, solution, establish new IV site Prevention: asepsis, inspect site freq... change site q48-72h, soln q24h, tubing q72h |
|
|
Term
|
Definition
Infiltration Extravasation Phlebitis Thrombophlebitis Occlusion |
|
|
Term
|
Definition
diffusion of solution or medication into surrounding tissue S/S----edema around insertion site, leakage of fluid at insertion site, discomfort and COOLNESS, decreased IV flow rate RX: stop infusion, discontinue IV, assess site for tissue damage, restart Iv proximal to infiltration site, warm or cool compress LESSEN RISK: monitor site, secure well, avoid areas of flexion, use smallest catheter |
|
|
Term
|
Definition
similar to infiltration, vesicant (destroys tissue) solution into surrounding tissue (dopamine, Ca solution, chemotherapy) S/S--Coolness, edema, discomfort, leakage of fluid, decreased IV flow rate LESSEN RISK: give thru side port of an infusing IV solution to dilute, check patency of IV cath q1-2h per hospital protocol |
|
|
Term
|
Definition
inflammation of vein r/t chemical(drug), bacterial, or mechanical (movement) irritation--increased with large cannula, certain med's more irritating (K, AB) S/S---red WARM area around insertion site or along vein, swelling, pain and tenderness RX: discontinue IV, and restart, warm moist compresses Prevent---aseptic technique, anchor cannula well |
|
|
Term
|
Definition
presence of clot plus inflammation in vein S/S---localized pain, swelling, redness and WARMTH, sluggish flow rate, fever malaise RX: Discontinue IV, and restart, warm moist compresses, be aware of cellulitis--may need antibiotics..can become septic! |
|
|
Term
|
Definition
CAUSE--kinked IV tubing, empty bag, failure to flush line after intermittent infusion of med. S/S---Decreased flow rate, BLOOD BACKFLOW into tubing RX: discontinue and restart---do NOT flush if blood clots (may dislodge and cause PE) PREVENT---flush INT after med, secure tubing to prevent kinking and maintain patency |
|
|
Term
Indications for blood transfusions |
|
Definition
1. provide adequate blood VOLUME and prevent hemorrhagic shock 2. increase O2 carrying capacity of blood 3. replace blood platelets and clotting factors to maintain homeostasis |
|
|
Term
|
Definition
Hct of 40% lasts up to 42 days 400-500 cc given in cases of sudden and excessive blood loss restores VOLUME, RBC, and BP! |
|
|
Term
|
Definition
Hct of 70% approx 250-300 cc whole blood that has 80% of plasma removed given when RBC's needed but not the VOLUME-severe anemia... hemodynamically stable, BP is ok.. |
|
|
Term
|
Definition
lasts up to 1 year 200-250 cc 1-2 hrs coagulation factors |
|
|
Term
|
Definition
lasts 5 days 1 unit=5-10,000 platelets (normal range=150-300,000) 1 unit 5-10 minutes thrombocytopenia, chemo side effects administer as rapidly as possible |
|
|
Term
Pre-Procedure for transfusion of blood/blood products |
|
Definition
verify order consent form, explain procedure verify Type and Cross match Baseline vitals--if elevated Temp, call MD 18 or 20 gauge needle may premedicate with benadryl/tylenol w/order obtain blood--ck w/another nurse--ABO comp. and RH comp, pt/donor ID #'s, check for cloudiness |
|
|
Term
Procedure for blood tranfusion |
|
Definition
Glove, filter in line(fibrin clots) administer within 30 min of removal from fridge NEVER piggyback with other IV fluids NS ONLY--D5W will lyse cells 1st 15 min SLOW (no more than 5 ml/hr)-stay w/pt 1st 15 min increase rate after 15 min if no reaction monitor VS-per hospital policy (q15minx4,q30min afterwards) complete within 4 hours, change tubing q2units |
|
|
Term
|
Definition
Dispose of blood bag/tubing in red bag Document intake Geriatrics---increased risk of circulatory overload/CHF |
|
|
Term
|
Definition
Whole Blood--witin 4 hrs (prefer 2) to decrease bacterial growth Packed RBC's within 2 hours Platelets within 30-60 min (decrease clumping) |
|
|
Term
|
Definition
---acute hemolytic reaction--- ----allergic reaction--- ---circulatory reaction---- ----sepsis--- ----febrile reaction----- primarily caused by incompatibility, contaminated blood, or too rapid infusion |
|
|
Term
|
Definition
HARD---FAST---first 15 min, life threatening! ABO or Rh incompatibility fever, chills, lumbar/flank pain, burning along vein, chest pain, dyspnea can progress to vascular collapse, renal failure, DIC EMERGENCY---stop transfusion!! NS--TKO...notify MD--send blood and bag to bank obtain blood and urine specimens, document |
|
|
Term
Nonhemolytic Febrile Reaction |
|
Definition
Most common temp elevation of 1degree or more w/o explanation antibodies to leukocytes or platelets--increased risk w/multiple transfusions chills, fever, headache, N&V STOP transfusion (clamp off), NS TKO, call MD, monitor VS --may restart with antipyuretics and antihistamines |
|
|
Term
|
Definition
may lead to ANAPHYLAXIS!-antibodies to plasma proteins itching, hives, flushing--severe: bronchospasm, laryngeal edema, shock STOP transfusion (clamp off), NS TKO, call MD may restart w/antihistamines if not severe Prevent: antihistamines before, wash blood before |
|
|
Term
|
Definition
rapid administration, poor kidney perfusion (history of CHF, cardiomyopathy) Dyspnea, orthopnea, tachycardia, anxiety, JVD, crackles, increased BP can progress to pulmonary edema STOP transfusion, elevate HOB, call MD slow rate, diuretics if ordered-- Prevent: diuretics after units |
|
|
