IV Site Management Guidelines

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Questions and Answers

What is a primary consequence of applying pressure to an infiltrated area?

It can induce phlebitis.

It can facilitate medication absorption.

It can cause hematoma. (correct)

It can enhance blood flow.

Which outward symptom is characteristic of phlebitis?

Bleeding at the venipuncture site.

Swelling of the entire limb.

Hard, cord-like tenderness at the site. (correct)

No visible signs at the infusion site.

In cases of thrombophlebitis, what does the vein feel like to the touch?

Cool and spongy.

Hard and cord-like. (correct)

Warm but flexible.

Soft and pliable.

What approach should be taken regarding venipuncture in specific locations?

Avoid venipuncture over an area of active infection. Signup and view all the answers

What is a recommended method for securing an IV cannula?

Anchor it securely with tape. Signup and view all the answers

Which action is indicated when administering irritating solutions?

Select a smaller cannula than the vein. Signup and view all the answers

Why might an armboard or splint be necessary during IV therapy?

To prevent IV site movement if the client is restless. Signup and view all the answers

What should be documented when complications arise at the IV site?

All observations and photographs as per agency policy. Signup and view all the answers

What should be checked in fluid containers to minimize the risk of infection?

Cracks, leaks, cloudiness, or other evidence of contamination Signup and view all the answers

How often should IV tubing be changed according to CDC recommendations?

Every 96 hours Signup and view all the answers

What occurs systemically from the entry of microorganisms into the body?

Infection Signup and view all the answers

When should the IV site dressing be changed?

When soiled or contaminated Signup and view all the answers

Who is considered an at-risk client for infections?

Immunocompromised clients with conditions like cancer or HIV Signup and view all the answers

What information should be labeled on the IV site, bag, or tubing?

Date and time to ensure timely changes Signup and view all the answers

What is the maximum time IV solutions should hang?

24 hours Signup and view all the answers

What preventative measure can help reduce local infections at the IV insertion site?

Maintaining clean and sterile techniques during insertion Signup and view all the answers

What should be done if tissue damage from extravasation is suspected?

Notify the PHCP immediately Signup and view all the answers

What is a common local sign of infection at the venipuncture site?

Swelling Signup and view all the answers

Which action is essential in preventing infection while managing an IV site?

Maintaining strict asepsis Signup and view all the answers

Which of the following indicates systemic infection?

Headache and nausea Signup and view all the answers

What is the purpose of documenting tissue condition and findings from an IV site assessment?

To comply with agency policy requirements Signup and view all the answers

What indicates a high risk for infection related to venipuncture?

Diminished immune response Signup and view all the answers

Which among the following is NOT a recommended action for monitoring the IV site?

Neglecting to assess the IV site regularly Signup and view all the answers

Which condition signifies extravasation at an IV site?

Seepage of irritant solutions into tissues Signup and view all the answers

What is the purpose of placing a client in the Trendelenburg's position during tubing or cap changes?

To facilitate the Valsalva maneuver and reduce air embolism risks Signup and view all the answers

Which symptom should prompt the immediate notification of the PHCP when administering a high concentration of dextrose solution?

Restlessness Signup and view all the answers

What may be a necessary assessment for a client receiving a high concentration dextrose solution?

Checking the client's medication history for corticosteroids Signup and view all the answers

If a client's blood glucose level is above 200, what should be prioritized in their care?

Monitoring and adjusting infusion rates Signup and view all the answers

What action should be taken if a client exhibits weakness and confusion after receiving a high concentration of dextrose?

Monitor blood glucose levels closely Signup and view all the answers

What instruction should be given to a client to perform the Valsalva maneuver effectively?

Hold your breath, bearing down as if having a bowel movement Signup and view all the answers

Which of the following conditions must be avoided when placing a client in Trendelenburg’s position?

Respiratory distress Signup and view all the answers

What is the risk associated with administering a high concentration dextrose solution too quickly?

Severe hyperglycemia and potential diabetic crises Signup and view all the answers

What should be done if discontinuation of PN is prescribed?

Gradually decrease the flow rate while increasing oral intake. Signup and view all the answers

Which of the following is true regarding the care of the IV catheter after removal?

Change the dressing daily until the insertion site heals. Signup and view all the answers

What action should be taken to prevent an air embolism during IV therapy?

Clamp all ports of the IV catheter when changing or not in use. Signup and view all the answers

Which sign or symptom indicates a potential air embolism?

Chest pain and apprehension. Signup and view all the answers

What is a key reason why central lines should not be left in without a valid purpose?

They pose a risk of infection. Signup and view all the answers

When assessing nutritional status before discontinuation of PN, which parameters should be recorded?

Body weight, serum electrolyte levels, and laboratory results. Signup and view all the answers

In the case of an air embolism, what is an immediate intervention?

Clamp all ports of the IV catheter. Signup and view all the answers

What should be continuously monitored in patients receiving PN?

Oral intake and laboratory results. Signup and view all the answers

Study Notes

IV Therapy Management

Avoid rubbing infiltrated areas to prevent hematomas; documentation and photographs of IV sites may be required by policy.
Phlebitis is inflammation of the vein, often due to mechanical or chemical trauma; characterized by heat, redness, and tenderness without swelling or hardness.
Thrombophlebitis involves cord-like hardness and tenderness at the site, with sluggish blood flow, indicating a risk for clot formation.
Use an appropriately sized IV cannula; avoid very small veins for irritating solutions, and refrain from using lower extremities for IV access.
Securely anchor the cannula to prevent movement; may use an armboard or splint for restless clients.

Extravasation and Infection Risks

Extravasation occurs when vesicant solutions leak into surrounding tissues, risking necrosis; immediate PHCP notification is crucial.
Monitor for local infection signs: redness, swelling, drainage; systemic infection symptoms include chills, fever, malaise.
Maintain strict asepsis during venipuncture to prevent infection; assess risks prior to venipuncture.
Regularly check fluid containers for integrity to minimize contamination risks; adhere to CDC recommendations for IV tubing changes every 96 hours.
Label IV sites and containers to track dates and times for timely changes; IV solutions should not hang longer than 24 hours.

Nutritional Support and Discontinuation

Evaluate nutritional status before discontinuing parenteral nutrition; gradually reduce flow rate for 1-2 hours while increasing oral intake to prevent hypoglycemia.
Post-IV catheter removal, change dressings daily until healed; central lines should be used prudently to avoid infection risks.

Complication: Air Embolism

Occurs when the catheter system is opened or IV tubing is disconnected; symptoms include chest pain, dyspnea, hypotension, and a loud churning sound upon auscultation.
Interventions: clamp all IV catheter ports, place the client in a left side-lying position with the head lower than the feet, administer oxygen, and notify the PHCP.
Educate clients on Valsalva maneuver during tubing changes to prevent air embolism.

Complication: Hyperglycemia

Can arise from high dextrose concentration or insufficient insulin; symptoms include restlessness, confusion, and elevated blood glucose over 200.
Monitor blood glucose levels in clients with a history of glucose intolerance; adjust infusion rates accordingly and notify the PHCP.

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Description

This quiz focuses on best practices for managing IV sites, including how to handle infiltrated areas and the importance of documentation. Learn the appropriate actions to take when encountering issues such as hematomas and when to take photographs for documentation purposes.