ATI Critical Care

Your responsibilities include: • inserting peripheral IV catheters • starting continuous IV infusions • administering medications • monitoring IV sites

Providers prescription includes: • type of fluid • the volume the client needs • rate to infuse the fluid

Administering IV Fluids • large-volume continuous IV infusions • Large volume IV bolus • Intermittent IV infusion • IV Bolus medication - short lasting

IV Flow Rates Large-volume IV bolus

• Given rapidly to replace fluid loss resulting from: • dehydration • shock • hemorrhage • burns • trauma

• Dextrose 5% in 0.45% sodium chloride • (D5W 0.45% NaCl) • 250 mL over 15 min • Monitor for: wheezing dyspnea, or other indications of fluid overload • Use a large gauge angiocatheter or central line to allow rapid

infusion of the fluid

Calculating dosages for continuous IV infusions • Infusion pump for continuous IV medication infusions

• use electronic pump for continuous IV medications • Units/hr, mg/hr, mg/min, mcg/kg/min • Titrate dosage to maintain prescribed parameters • Check dosage with another nurse

IV Heparin • Anticoagulant; prevents blood clots • Give initial IV bolus, then continuous IV infusion:

• Follows acute myocardial infarction • Prevents additional clot formation for venous thrombosis

• Initial IV bolus: units/kg • Continuous infusion: units/kg/hr

IV Magnesium Sulfate • Electrolyte that activates many intra-cellular enzymes; helps regulate

skeletal muscle contractility & blood coagulation • Acute myocardial infarction, cardiac arrest, seizures secondary yo

eclampsia, preterm labor, magnesium deficiency • Monitor:

• cardiac & neuromuscular status • serum Mg levels • hypotension • depresses cardiac function • depressed or absent deep tendon reflexes • respiratory depression

• IV bolus: mg/kg, or • Continuous IV infusion: mg/hr

IV Labetadol (Trandate) • Antihypertensive

• 3rd generation adrenergic receptor blocking agent with alpha & nonselective beta activity

• alpha blockade results in vasodilation to decrease peripheral resistance & lowers blood pressure

• Beta blockade decreases heart rate, myocardial contractility, & rate of conduction through the AV node

• the vasodilation makes it effective in severe hypertension • Severe hypertension • Monitor:

• vital signs • cardiac status • hypotension • bradycardia • nausea

• dizziness • sweating

• IV bolus: mg • Continuous IV infusion: mg/min

IV Dopamine • Cardiac stimulant, vasopressor

• aka Intrepid is an alpha & beta adrenergic agonist • activates beta-1 receptors in the heart & increases cardiac output

leading to increased tissue perfusion • activates dopamine receptors in the kidneys, which dilate renal

vessels leading to increased GFR & urinary output • Used treatment of:

• Heart failure • cariogenic shock • septic shock

• Continuous IV infusion: mcg/kg/hr • Monitor:

• vital signs • cardiac status for:

• tachycardia • dysrhythmias • angina pain • MI

• High doses can cause alpha-1 activation leading to local vasoconstriction so monitor for extravasation

Titrating Continuous IV Medication Infusions Titrating a continuous IV medication infusion is adjusting the medication amount in small amounts to maintain assessment findings within a prescribed range

• Continuous client monitoring • Dosages based on parameters

• Parameter examples: • blood pressure • heart rate • cardiac output • sedation level

• Accurate dosage calculation • Medications:

• dopamine • heparin • nitroprusside • norepinephrine • dobutamine • nitroglycerin

IV Nitroprusside (aka Nipride) • Non-nitrate vasodilator, antihypertensive • Causes direct vasodilation of arteries & veins, rapidly reducing BP • Used for hypertensive crisis

• effects start immediately; critical to monitor BP within prescribed range

• Continuous IV infusion: mcg/kg/min • Monitor:

• vital signs • cardiac status for:

• profound hypotension • bradycardia • tachycardia • ECG changes

• tinnitus • blurred vision • fatigue • absent reflexes • change in mental status (can indicate thiocyanate toxicity)

IV Nitroglycerin (Tridil) • Organic nitrate • Vasodilator of arteries and veins • Results in:

• rapid reduction of blood pressure • decrease in venous return • decreases cardiac oxygen demand

• Useful for: • Acute coronary syndrome • angina • myocardial infarction • acute hypertensive crisis

• IV bolus: mg

• Continuous infusion: mcg/min • Monitor:

• vital signs • cardiac status • orthostatic hypotension • reflex tachycardia • headache

• Remember: use glass bottles or non-polyvinyl chloride plastic & designated tubing

Administering IV bolus Medications • Injecting small amounts of medication, concentrated or diluted, over

a short period of time (1-2 minutes) • Flush line with solution first

• usually 10 mL of 0.9% NaCl • Never administer if:

• Site is tender, red, swollen • Resistance flushing the line

• Ensure IV catheter is patent • Give medication as specified • Use a different syringe to flush the IV catheter

Administering by Continuous IV Infusion • You must endure the medication you are administering is

comparable with IV solution • Administer through an IV port that’s closest to a client

Follow these steps: 1. Wipe IV port with antiseptic swab (15 seconds) 2. Close the roller clamp or clamp 3. Insert the syringe into he port 4. Gently inject the medication over 1 minute 5. Remove syringe 6. Unclamp tubing 7. Recheck IV infusion rate

Bolus Mini-injection System Preloaded Bolus Mini-injection systems

• Easy access, quick delivery during an emergency Provides one dose

• Atropine • Lidocaine

• Sodium Bicarbonate • Epinephrine

• Administer through central line • Two parts: vile, injector

• Remove the caps from the vile & injector • Line up vile & injector & turn vile clockwise about 3 turns until

medication enters injector area • Push vile through end of syringe to remove air • Cleese port closest to client (15 seconds) • Close roller clamp or clamp • Remove medication cap • Insert medication into IV port

Extra info:

Nursing Responsibilities Intravenous (IV) medications are delivered by three methods: IV bolus (push), as a secondary or “piggyback” intermittent infusion, or by continuous infusion in a large volume of solution. With each of these methods, potent drugs are rapidly absorbed and distributed throughout the circulatory system to arrive at target tissues and organs, initiating desired responses as well as the potential for adverse reactions. Nursing responsibilities for IV medication administration include: Supporting positive outcomesReducing the risk of adverse eventsIntegrating medication administration into the patient’s plan of care Providing patient and/or family education Basic IV Medication Safety Nursing responsibilities for the safe and effective administration of intravenous (IV) medications begin with the standards of practice common to all routes: Know and perform the six rights of medication administration – right patient, right drug, right dose, right route, right time, and right documentation. Check the medication at least three times against the medication administration record (MAR) prior to administration – as you remove the drug from the storage area, as you prepare the drug, and at the patient’s bedside just before you administer the drug. Only administer medications you have prepared or those that have been prepared by a licensed pharmacist.Only administer medications that have been labeled appropriately.Perform accurate dosage calculations.

Remember that, once you have administered an IV medication, it enters the bloodstream immediately and begins to affect target tissues and organs. Take diligent care to avoid errors in dosage calculations, preparation, and administration. It is also crucial to know the desired action and side effects of each medication prior to administration and the antidote if one is available. What medical conditions affect how the drug is absorbed, distributed, metabolized, and excreted by the patient? How does one medication interact with other drugs or IV infusions? Developing a “look it up” habit broadens your knowledge of commonly prescribed IV medications and helps ensure safe delivery of these potent drugs. IV Medications & the plan of care When an IV medication is prescribed, your patient might have unique physical or emotional needs that make the IV route preferable or necessary. The nursing process provides a framework for assessing need, planning and implementing delivery, and evaluating the patient’s response to IV medications. Indications for IV medications (or, in some cases, for other routes) include:

• A patient who is unwilling or unable to swallow • A drug whose action is adversely affected by digestive secretions • A drug that would irritate the gastrointestinal tract if given orally • A drug used for anesthesia or procedural sedation • A medication that is only effective or available in IV form • The need to determine a precise, accurate dose (because intravenous

absorption is more complete and predictable than that of other routes) • A drug that requires monitoring and maintaining therapeutic blood levels • An emergency situation when a drug must act rapidly

As with all medications, IV drugs are prescribed and dosed to treat specific conditions, with additional consideration for the patient’s medication “profile,” which includes genetics, age, gender, current medications, and medical history. Become familiar with your patient’s medication profile. It provides information essential for planning and implementing effective IV medication therapy. Genetics. Genetic-based differences in drug metabolism are possible and should be considered when patients have unexpected responses to medication dosing. Often, these genetic-based differences are shared by members of the same ethnic group, so these differences are often categorized that way. An example is that some people of African or Asian decent might be sensitive to the toxic effects of antihypertensive and antipsychotic drugs and might require dose adjustments to provide therapeutic effects. This variation is due to genetic alterations in specific drug-metabolizing enzymes and becomes apparent in an individual’s response to the medication. Age. Remember that the liver inactivates and metabolizes most drugs, while the kidneys eliminate the byproducts (metabolites) of the drugs from the body. This is important to consider when providing IV medication to the very young or very old.

Young children lack fully developed hepatic and renal function. They metabolize and excrete drugs inefficiently, making children more susceptible to toxic effects. Likewise, diminishing hepatic and renal function prolongs drug action in older adults, who are also more likely to have other conditions affecting drug response such as altered cardiac, pulmonary, and immune function. Older adults are also likely to experience drug-drug interactions due to the treatment of multiple health problems. Gender. In general, men and women can respond in different ways to the same medication. For example, women tend to have a higher percentage of body fat while men have a higher percentage of body fluid, thus women might accumulate fat- soluble drugs over time. Other considerations for women are the ability of some drugs to cross the placenta and that of some drugs to be found in breast milk. When providing any medications to women who are pregnant or may become pregnant or who are breastfeeding, be knowledgeable about safe use during pregnancy and lactation. Physical characteristics and health status. Body surface area, height, and weight are used to calculate many drug doses, especially for children. Overweight and underweight adults might also require dose adjustments. Problems that can affect IV dose requirements include renal and hepatic impairment and cardiac and pulmonary dysfunction. Knowing your patient’s medical history, including current medications, allergies, and intolerances, helps you assess appropriate responses and alerts you to possible adverse effects. Patient Teaching Prior to initiating IV medication therapy, assess your patient’s prior knowledge and ability to participate in education sessions. Explain or reinforce the indications and expected response of each medication. Instruct the patient about reportable symptoms, such as pain, burning, itching, or swelling at the IV site, as well as other potential reactions specific to the medication. Premedication Assessment Nurses are responsible for knowing the implications of IV medication administration and applying critical thinking to support positive outcomes and to reduce the risk of adverse events. Assessing your patient prior to administering any medication provides you with information necessary for effective planning and implementation of care, as well as a baseline from which you can evaluate post-administration response. Premedication assessment should include a review of the patient’s health history, medication data, vital signs, physical assessment, psychosocial and cultural considerations, and learning needs. Health history Review the patient’s health history for any conditions that might affect IV drug absorption, distribution, metabolism, or excretion. This information will help you assess for the desired action of the medication and predict any possible adverse

effects. Sources for this information include the patient’s history and physical exam, current laboratory data, and medication and allergy lists. Pharmacokinetics Drug distribution relies on blood flow to the intended sites of action, biological barriers, and protein-binding capacity. If the patient has a medical condition that limits blood flow to or perfusion of target tissues, the medication’s distribution is likely to be altered. The ability of a medication to pass through an organ’s biological barrier depends on the organ and the medication’s composition. For example, the blood-brain barrier is selective for fat-soluble medications, while the placenta is nonselective, creating a higher risk of medication-induced fetal complications. Serum proteins such as albumin affect distribution by binding to medications. Low serum protein, as found with malnutrition and advanced age, allows more unbound medication to circulate, creating the potential for increased medication activity or toxicity. Metabolism is primarily the function of the liver, although the kidneys, lungs, intestines, and blood also play a role. Any disease process that impairs the ability of these organs to detoxify and remove biologically active chemicals will affect metabolism. Sites for the excretion of metabolizedmedications are determined by thechemical composition of the medication.Drugs can be excreted through thekidneys, liver, bowel, lungs, or exocrineglands, including the skin andmammary glands. Evaluate the patient’srenal and hepatic function, bowel motility, ventilatory ability, and skinintegrity, as these determine the rate ofexcretion and the potential forprolonging the mediation’s actions.Lactation is a special consideration,since there is a risk that a breastfeedinginfant will ingest drug metabolites excreted by the mammary glands. Medication data The patient’s medication history, including allergies, provides information that guides medication choice and helps achieve optimal patient response. Find out if your patient has taken a drug similar to that prescribed, and if the patient has had any adverse reactions to similar drugs. Check the patient’s medication history for prolonged use of medications for a chronic condition, and find out if they must be

continued. Check for any medications that could create issues of drug tolerance or drug withdrawal. Review current medications prior to administering any IV medication. You are responsible for knowing as much as possible about each medication you give. This knowledge includes therapeutic intent, possible actions, drug interactions and compatibilities, normal dose ranges, the usual route, side effects, and nursing implications for administration and monitoring. Sources of this information include drug guides, textbooks, medication package inserts, electronic sources, and the agency’s pharmacists. Physical assessment and vital signs Ongoing assessment of your patient’s physical condition may affect when and how to administer a prescribed or a PRN medication. It also provides a baseline for post-medication evaluation. Patient assessment may include a complete or focused physical exam, vital signs, sedation score, and pain score. The physical assessment can be directed toward a specific system or value. For example, always check your patient’s heart rate and blood pressure prior to administering antihypertensive medications or any drugs that decrease or increase the heart rate. The provider may have specified parameters for when to give or withhold those drugs. Also, be aware of medications that are known to cause problems like bronchospasm, rash, flushing, or mental-status changes. Check for these findings before giving the drug so that you can identify any changes after drug administration. Include an assessment of the patient’sIV access. Some IV medications causepain and venous irritation ifadministered into small peripheralveins, in a concentrated solution, or attoo rapid an infusion rate. It might benecessary to access a larger vein,request a dilution more appropriate forperipheral administration, or adjust the IV rate (with the provider’s approval).Central IV access should be establishedfor vasoconstrictive medications and formedications and solutions that cancause tissue damage withextravasation. Learn about a medication’s implications for administration, and ensure that your patient’s venous access line is patent and will accommodate the medication as ordered.

Take the patient’s vital signs before giving any IV medication. IV medication administration can alter blood pressure, heart rate or rhythm, respiratory rate, or ventilatory function. Be sure to obtain a pain score prior to giving analgesics and a sedation score prior to giving medications that cause mental-status changes. Follow your agency’s policy for using any specific scoring or assessment tools. Psychosocial and cultural considerations Apply psychosocial considerations and culturally congruent nursing care to all forms of medication administration. Cultural beliefs, attitudes, and social values may differ in areas such as expression of pain, acceptance of “western” medicine, and issues surrounding end-of-life care. The use of IV medications can cause additional anxiety or concern related to fears of addiction or needles. Your awareness and understanding will promote medication compliance and improved patient outcomes. Patient teaching Evaluate your patient’s level ofunderstanding and develop anindividual teaching plan. If appropriate, include family members in medicationteaching. Pre-administration teachingfor IV medications includes themedication’s name and dose, desiredaction, frequency of administration, andpossible adverse effects specific to yourpatient. Also include teaching about IVtherapy; instruct patients and familymembers to report pain or swelling at or distal to the IV catheter’s insertion site. Calculating intravenous flow rates Delivery of the correct medication, dose, and volume at the appropriate infusion rate and time is essential for safe andtherapeutic intravenous (IV) medication administration. Today’s IV infusion pumps can make this process seem simple. They deliverprecise volume-controlled infusions, and many can beprogrammed to calculate dose and flow rates. Despite theseconveniences, knowing how to calculate IV flow rates correctly will help you verify equipment accuracy and help prevent adverseevents related to medication errors. Knowing how to performthese simple calculations is also helpful when a programmable pump is unavailable, not to mention when calculations are part of pre-employment testing.

The first step in determining IV flow-rate calculations is to check the medication label. Compare the label to the medication administration record (MAR) for the correct patient, medication, dose, time, and route. You should perform this comparison a total of three times before you begin the infusion. IV medications are diluted in a variety of concentrations and delivered in a variety of dose rates. Be sure to clarify any questionable orders and use only approved abbreviations to avoid dangerous adverse events. Appropriate IV-medication infusion orders specify the dose to be given over a specific interval and the concentration of the drug in solution. You must calculate the unknown flow rate. There are three factors involved in performing calculations for IV medication infusions. If you know two factors, you can calculate the third by using the basic formula: The concentration of medications is the amount of drug diluted in a given volume of IV solution, usually measured in units, micrograms (mcg), milligrams (mg), or grams (gm). The dose of the medication is the amount of drug ordered for infusion over a specific length of time. Doses have varying units of measurement. The length of time is either by the minute or by the hour. If the medication is dosed by weight, the calculation is made using the patient’s weight in kilograms (kg). The flow rate determines how rapidly the infusion is delivered to the patient. On an infusion pump, the flow rate is set using using mL/hr. But you will not always have an infusion pump available, in which case you will have t drops per minute. A basic formula for calculating an IV flow rate in drops per minute without medications is: For example, the provider has ordered 1,000 mL of 0.9% sodium chloride (normal saline) to infuse over 8 hr. You have macrodrip tubing with a drop factor of 15 gtt/mL. You must calculate how many gtt/min to use to set the IV flow rate. Enter the known factors into the formula and solve. Solving the equation, you first have: Then reduce the fraction, and multiply. The IV flow rate is 31.2, or 31 gtt/min. When you are administering IV medications and must calculate rates, you need the following data: The unit of measurement used for the drug (units, mg, mcg)The dose to be delivered by unit of measurement (gtts, units, mg, mcg, dose/kg) The volume of the diluent (mL)The time over which each unit of drug is to be delivered (minutes, hours)The patient’s weight in kilograms (required for some medications) To calculate an unknown flow rate, use this formula: Step 1: Convert the drug concentration to a like unit of dose measurement. Step 2: Convert the desired flow rate to an hourly rate if necessary.

Step 3: Calculate the concentration of the drug in 1 mL of fluid.Step 4: Enter the known and calculated factors into the formula and solve. Example #1 mg/hr In this example, the units of measurement are already alike. You must determine only the drug concentration per mL, enter the factors into the f Example #2: units/hr Once again, the units of measurement are alike, only in units rather than mg. You must determine the drug concentration per mL. In this example, you must convert the dose time from minutes to hours and determine the drug concentration per mL. Example #4: mcg/min For this calculation, you must convert the drug concentration to a like unit of measurement, determine the drug concentration per mL, and convert the rate per minute to the rate per hour. First convert the concentration to like units of measurement (mg to mcg) and then determine the drug concentration per mL. Enter the known factors into the formula, convert the time to hourly, and solve. Example #5: mcg/kg/min The basic calculation is the same; however, the weight is factored in: First convert the drug concentration to the like unit of the dose (mg to mcg) and then determine the drug concentration per mL. Enter the known factors into the formula and solve. Example #6: gtt/min When delivering fluid without an infusion pump, you must check the IV tubing manufacturer’s specifications to determine the drop factor (how many drops per minute the infusion set delivers). Prior to starting the infusion, always double-check your calculations. Ask another qualified person to check your results with you if your agency policy requires it or if you are unsure of your results. Finally, remember that errors can and do happen. When assuming care for a patient with an active IV infusion, compare the infusing IV solutions with the patient’s medication record. By performing a few simple calculations, you can check the accuracy of the infusion device, prevent medication errors, and ensure optimal patient safety during IV medication therapy.

IV medication administration troubleshooting Inflammation and clot formation • Problem: The IV site is swollen, red, and warm.

• Possible cause: Inflammation of the vein with possible clot formation due to trauma, bacteria, or irritating solutions

• Assessment: The patient reports tenderness, burning, and irritation along the accessed vein. The rate of infusion has slowed. (With clot formation, the vein might have a palpable band along its path and the patient might have fever, leukocytosis, and malaise.)

• Intervention: Stop the infusion and discontinue the IV line. If you suspect clot formation, apply a cold compress first to decrease blood flow and to increase platelet aggregation at the site and follow it with a warm compress and elevation of the extremity to help reduce or eliminate the irritation. Establish new IV access proximal to the original site or in the other extremity if IV therapy must continue.

• Prevention: Make sure the medication’s concentration is appropriate for peripheral administration. Medications like potassium are more concentrated for central IV access and more dilute for peripheral access. Also be sure to use the appropriate-size catheter for the vein and aseptic technique for IV insertion. Anchor the IV well to prevent movement of the catheter and irritation of the vein. Change and rotate IV sites according to your agency’s policy. To prevent clot formation, avoid trauma to the vein at the time of insertion. Make sure all medications and fluids are compatible. Observe the IV site every hour during medication infusions to ensure patency and to watch for early signs of complications.

Infiltration • Problem: The tissue surrounding the IV insertion site is swollen, pale, and cool

to the touch. • Possible cause: Unintentional administration of solution or medication into the

surrounding tissue • Assessment: Leaking from the IV site with slowing or occlusion of fluid flow.

The patient reports tenderness, discomfort, and coolness in the area surrounding the IV insertion site.

• Intervention: Stop the IV infusion and discontinue the IV line. Elevate the extremity, apply warm compresses three to four times per day, encourage active range of motion, and follow your agency’s policy for site care and documentation of infiltrated IVs. Establish new IV access proximal to the original site or in the opposite extremity if IV therapy must continue.

• Prevention: Observe the IV site frequently during infusion. Avoid inserting IV access devices in areas of flexion. Secure IV tubing to minimize movement of the IV catheter within the vein. Use the smallest catheter possible for accommodating the vein.

Extravasation • Problem: The tissue around the IV site is pale or discolored and cool to the

touch. • Possible cause: Inadvertent administration of an irritant solution or medication

into the surrounding tissue. Vasoconstrictors, calcium, and chemotherapy drugs are examples of drugs known to cause tissue necrosis with extravasation. The area of tissue damage varies with the concentration of the medication, the quantity of extravasated fluid, and the duration of the extravasation process.

• Assessment: The pale or discolored tissue surrounding the IV insertion site shows signs of progressing to blistering and inflammation and could ultimately become necrosed.

• Intervention: Extravasation is an emergent situation, as it can cause serious tissue necrosis. Stop the IV infusion and discontinue the IV line. Consult your agency’s policy or a pharmacist for specific care of the extravasated tissue or use a medication manual to determine the appropriate care (for example, injection of phentolamine within the extravasation border). Follow your agency’s policy for proper documentation. Establish new IV access in the opposite extremity if IV therapy must continue.

• Prevention: Observe the IV site frequently during infusion. Avoid inserting IV access devices in areas of flexion. Secure IV tubing to minimize movement of the IV catheter within the vein. Use the smallest catheter possible for accommodating the vein. If central access is available, infuse solutions and medications known to cause tissue necrosis via central venous access.

Questionable reconstitution • Problem: Reconstituting a medication results in cloudiness, discoloration, or

precipitation of the diluent. • Possible cause: The wrong diluent was selected for reconstitution. It is also

possible that the visible change is appropriate for that medication. • Intervention: Never inject a questionable IV medication. If the medication has

been reconstituted improperly, discard it or return it to the pharmacy according to your agency’s policy.

• Prevention: Always follow the manufacturer’s or the pharmacy’s guidelines for selecting the proper diluent for a medication. Review the package insert or consult a pharmacist to verify the expected appearance of the reconstituted medication.

Precipitation during administration • Problem: While administering an IV bolus (push) medication, cloudiness or

precipitation forms in the tubing.

• Possible cause: The line was not flushed properly with normal saline prior to injecting an incompatible medication.

• Intervention: Stop the medication push immediately. Aspirate to withdraw fluid from the access line until you see blood return to the line. Precipitates can cause thrombophlebitis, so discontinue the IV line and restart it in the opposite extremity. Follow your agency’s protocol for wasting and crediting medication and prepare another dose to administer. Observe the site for signs of venous irritation.

• Prevention: Follow proper technique for flushing the IV line with normal saline before and after injecting IV medications.

  Questionable solutions • Problem: The IV fluid in the bag or a pre-mixed medication solution appears

cloudy or discolored or has visible precipitate. • Possible cause: The solution may be expired or contaminated or might have

been stored improperly (exposed to temperature extremes). • Intervention: Never administer questionable IV fluids. Discard or return

questionable or expired solutions according to your agency’s policy. • Prevention: Review the package insert or consult a pharmacist to verify the

expected appearance of the medication. Always store IV fluids and pre-mixed medication solutions according to the manufacturer’s or the pharmacy’s guidelines. Remove from stock and dispose of any IV bags that have expired or are not in their original, sealed packaging.

Drug/fluid incompatibility • Problem: The IV fluid or solution appears cloudy or has visible precipitate after

medication has been added. • Possible cause: Incompatibility of the drug to the solution or the drug-to-drug

mix • Intervention: Never administer questionable IV medications or compounded

solutions. If the medication has been mixed improperly, discard it or return it to the pharmacy according to your agency’s policy.

• Prevention: Always follow the manufacturer’s or the pharmacy’s guidelines for selecting the proper solution for piggyback and large-volume medication infusions. Always check and cross-reference medication compatibilities. If your agency’s policy permits multiple uses of one secondary line, make sure the current and previous solutions and medications are compatible. Otherwise, set up separate secondary lines and flush between medications.

Medication error potential • Problem: The wrong dose was prepared.

• Intervention: Discard the prepared dose and prepare a new dose correctly. Check your agency’s policy for waste procedures and documentation and for crediting the patient’s pharmacy account.

• Prevention: Adhering to the six rights of medication administration is essential for preventing medication errors.

Interrupted IV infusion • Problem: The line or pump occlusion alarm sounds. • Possible causes: The IV line is not patent, the IV is in a location that occludes

when the patient changes position, the tubing is kinked, the IV loop or line is clamped, the roller clamp is in the off position, or the pump was loaded improperly.

• Intervention: Begin at the patient, correcting each problem: Check for IV patency, tubing patency, and position; open all occluding clamps; and check the infusion pump settings and setup. If the location of the IV causes flow occlusion when the patient moves, consider restarting the IV line at another site.

� IV compatibility charts typically provide information about the compatibility of drugs combined in a syringe, combined at the Y-site of injection, if absolute incompatibility exists, or if data are insufficient to administer the drugs together safety. When administering more than two medications in one IV line, determine the compatibility of each medication with the other(s). Most drug reference manuals include compatibility charts listing commonly used IV medications. Often these charts have

limited information or unclear data. Many agencies now have computerized tertiary compatibility programs based on the results of published reports from primary drug studies. It is important to access all available resources to determine drug compatibility. If unsure, assume incompatibility.

Managing drug incompatibility Planning and implementing the administration of multiple scheduled IV medications require problem-solving and collaboration; drugs must be given at the prescribed frequency to maintain therapeutic drug levels and provide optimal benefits for the patient. However, standard administration times can cause conflict in infusion times and delay of therapy. The patient may have limited intravenous access due to inaccessible extremeties or poor peripheral circulation. These challenges are compounded when coadministration of medications is questionable or prohibited by incompatibility findings. Suggested tools available for solving these problems include the following: • Collaborate with other healthcare team members, including pharmacists. • Stagger dosing procedures for drug-dose-time management. Check agency

policies for staggering charts. • Suggest placement of a multilumen central IV access for patients with

inaccessible or limited peripheral veins. • If coadministration of incompatible agents is unavoidable, infuse the agents as

far apart time-wise as possible with a bridge or manifold device (such as using the proximal and distal ports) to allow minimal contact time of the two agents before administering them to the patient. Check your agency’s policy for the use of these devices.

• Ideally, incompatible agents should be replaced with compatible combinations when possible. Consult with the pharmacist and ask the physician for appropriate substitutions that will provide the same desired effect.

To minimize the risk of incompatibility of IV bolus (push) medications, be sure to flush before and after each medication with at least 10 mL of sterile normal saline or according to your agency’s policy.

IV medication interactions and medication compatibility Medication interactions Medication interactions result when a medication is used with another medication or substance that modifies the drug’s expected action. Medication interactions can develop between food and drugs, between prescribed and over-the-counter drugs including herbal products, and as drug-to-drug interactions. A medication interaction can increase or decrease the drug’s effect through changes in absorption, distribution, metabolism, or excretion. Since IV medications have a rapid effect,

understanding the concept of medication interactions helps you anticipate the potential results of drug combinations.

Synergistic effects develop when the combination of two or more drugs or substances results in a greater effect than that of separate administration would. An example is the combination of opioid analgesics, which are central nervous system (CNS) depressants, and other CNS depressants such as antihistamines or alcohol. Foods that produce pharmacologic activity can also have a synergistic effect on drugs that have a similar action. For example, patients who take monoamine oxidase inhibitors should avoid foods containing tyramines or tryptophan. Each releases catecholamines, and the combined effect can be life-threatening. A potentiating effect results when one drug increases the positive or negative effects of another. Often these drugs are given in combination intentionally; a common example is the drug regimen typically prescribed to treat tuberculosis.

Pharmacogenetics Pharmacogenetic research offers new insights about drug interactions and the importance of individualized drug therapy. Because nurses monitor the effects of administered medications, it is important to have a basic understanding of gene-based drug metabolism. Cytochrome P450 (CYP450) enzymes are essential for the metabolism of many medications. More than 50 drug-metabolizing isoenzymes have been found in humans; so far, 10 have been associated with functional polymorphism, a genetic variation in one or more specific isoenzymes. Unlike genetic defects, polymorphisms occur in more than 1% of humans, and CYP450 polymorphism is thought to be present in as many as 20% of specific populations. CYP polymorphism can make a patient more susceptible to the adverse effects of a medication or reduce a medication’s therapeutic action. Some drugs, hormones, and chemicals found in foods can inhibit or induce the function of CYP450 enzymes, resulting in significant drug interactions. Because so many drugs and substances have been identified in CYP450 interactions, it is helpful to reference a CYP450 chart. However, there are commonly used drugs associated with CYP450 polymorphism. It is helpful to become familiar with classes of drugs that can have unexpected effects or alter the therapeutic effects of other medications. Common drugs and classifications associated with CYP polymorphism include antidepressants, beta blockers, warfarin, opioids, antiepileptics, azole antibiotics, and statins. Many of these medications are administered intravenously, alone and in multidrug therapy.

Managing medication interactions

Obtaining an accurate medication history at the time of a patient’s admission is essential for preventing some avoidable drug interactions. Patients often neglect to mention their use of over-the-counter preparations, including vitamin supplements and unregulated herbal or alternative-medicine products that can interact with prescribed drug therapy. They might hesitate to divulge the use of these alternative therapies to “traditional” healthcare providers or be unaware of the significant role these preparations can play in clinical outcomes. When obtaining a family history for significant health risks, ask about any medication reactions in immediate family members. These questions might reveal valuable information about your patient’s potential for gene-based drug responses and medication interactions. When administering drugs with dose-based responses, such as opioids or anti-hypertensive drugs, use the least amount of drug to provide the desired effect. Do the same for drugs with synergistic characteristics; “start low, go slow” is a good rule of thumb for administering IV medications safely and effectively. Finally, be sure to document and report all adverse responses to medications to the patient’s primary healthcare provider. Document known and newly diagnosed allergies on your patient’s chart; include them on the medication administration record and the patient’s allergy band. Include medication effects in your patient-education plan. Teach patients and their families about the importance of avoiding known intolerances to medications and medication combinations. Drug compatibility While drug interaction refers to the combined systemic effect of medications, intravenous drug compatibility refers to the chemical stability of two or more medications when administered together. The standardized definition of compatibility is: • No visible or electronically detected indication of particulate formation, haze,

precipitation, color change, or gas evolution • Stable (less than 10% decomposition) for at least 24 hours in admixture or for

the entire test period (may be less than 24 hours)   Drug incompatibility Some drugs in combination will create a precipitate or discoloration due to chemical changes. Other drug combinations will be less obvious, but chemical changes could have altered the drugs’ effects. The designation of incompatible is made when a drug is unable to meet both of the preceding criteria.

Introduction to the use of specialized IV access devices

Specialized intravenous (IV) access devices are inserted by a physician or a nurse or other clinician who has had specialized training. These devices include peripherally inserted central catheters (PICCs), implantable venous access devices, and central venous catheters (CVCs). Specialized access devices are most often used for: • frequent or recurrent blood sampling for laboratory tests • an alternative to poor peripheral venous access • delivery of vasoactive medications • infusion of total parenteral nutrition (TPN) • large-volume or recurrent blood transfusions • long-term infusion of medications, such as antibiotics or chemotherapy • continuous monitoring of central venous pressure • assessment of hypovolemia or hypervolemia • placement of a pulmonary artery catheter • a transvenous pacemaker

Peripherally inserted central catheters (PICCs) PICCs are especially useful for IV therapy to help manage chronic health problems at home. In acute-care settings, a PICC can provide central access with fewer and less severe complications than can develop with central venous catheters. The most common complications of a PICC are phlebitis and catheter occlusion. PICC lines are ideally inserted percutaneously into the cephalic or basilic anticubital fossa, then advanced into the superior vena cava. Single- and double-lumen catheters are the most common, although the newer triple-lumen PICC devices are available in some facilities. Placement of a PICC is contraindicated for patients who have sclerotic veins and in extremities affected by mastectomy or radial artery surgery, a hemodialysis graft, or an arteriovenous fistula. Patients with PICC lines should not have blood-pressure measurements, venipunctures, or injections in the extremity with the PICC.

Specific care of a PICC site is detailed in each agency’s policies and procedures, but in general, it is recommended that you assess the insertion site and upper extremity at the start of each shift and every 4 to 8 hours or as indicated by the patient’s condition. Look for signs and symptoms of phlebitis, thrombophlebitis, venous occlusion, and infiltration: • pain along the vein • erythema • edema at the puncture site • ipsilateral (same-side) swelling of the arm, neck, or face • a change in arm circumference of more than 0.8 in (2 cm) from baseline Administration of medications via a PICC

To ensure placement of the catheter in the vascular space, assess for venous blood return and patency before beginning any IV infusion. When performing any task related to a PICC, be sure to adhere to the level of aseptic technique detailed in your agency’s policies and procedures. Connect a normal saline-filled 10-mL syringe to the catheter’s access port, release the catheter’s clamp, and gently aspirate to verify blood return. Flush with up to 10 mL of normal saline using a “push-pause” motion. This technique causes the flush solution to swirl within the catheter, which clears the line and maintains patency. Avoid using syringes with less than a 10-mL volume for flushing or instilling medication. Smaller syringes exert pressure exceeding 40 psi per square inch and may cause catheter rupture or fragmentation with possible embolization. After flushing the line, continue with medication administration or IV infusion. Always cleanse the access port before attaching the infusion tubing or the medication syringe.

Adequate flushing after medication administration is the most important factor for preventing the occlusion of a PICC by blood, fibrin, or medication residue. Using a 10-mL syringe filled with normal saline, inject the saline, again using the push-pause motion to create turbulence within the catheter. Your agency’s policy and the particular catheter in use determine the frequency of flushing and the solution and volume required to maintain catheter patency. Also, your agency may supply one of many anti-reflux Luer-activated devices designed to keep blood from flowing into the catheter’s lumen.

Implantable venous access devices An implanted venous access device, or port, is surgically implanted in a cutaneous pocket, usually in the chest wall. The device consists of an internal catheter connected to the patient’s venous system, and a reservoir covered by a disc 0.8 to 1.2 in (2 to 3 cm) in diameter and totally implanted under the skin. The disc, or septum, is accessed with a noncoring needle, which allows for repeated accessing without damage to the silicone core. The septum is capable of resealing following de-access. Ports provide venous access for intermittent or continuous infusions while keeping a patient’s body image intact when not being accessed. Ports are commonly used for patients requiring long-term IV access, such as those receiving chemotherapy or blood products, and for blood sampling. Administration of medications via an implanted venous access device Only nurses with specialized training should access and de-access an implanted device. Once the device is accessed, the noncoring needle is stabilized and secured to the skin over the septum and a dressing applied according to the agency’s policy. The device extension tubing is primed and locked.

Medication administration is similar to other venous-access processes: Cleanse the extension tubing port and proceed with the medication-administration procedure. During continuous or intermittent IV infusions, assess the port device for patency and signs of infiltration every 4 hours and as needed. Instill push medications at the rate recommended for the specific medication. Following medication administration, flush the extension tubing with 10 mL of normal saline. As with all central access catheters, avoid using syringes with less than a 10-mL volume for flushing or instilling medication. To ensure patency of the device, follow the saline flush with heparin as specified in your agency’s policy.

Central venous catheters Central venous catheters are most often placed in the internal jugular or subclavian vein, then advanced into the superior vena cava. They are placed by physicians or advanced practice nurses or other clinicians specially trained in the procedure. The catheter can have two, three, or four lumens spaced along the catheter. Each lumen has a designated purpose, depending on its location along the catheter. Because the distal lumen of the catheter lies nearest the right atrium, information about right-heart filling pressure and right-ventricular function and volume can be estimated when the associated port is connected to a transducer or water-manometer system. Other lumens are used for parenteral nutrition, continuous or intermittent fluid infusions, vasoactive medications, and blood products. The most common complication related to central venous catheters is infection. Assess the insertion site for signs of inflammation or infection at the start of each shift and every 4 to 8 hours or as indicated by the patient’s condition. Learn about your role in central-line infection prevention, and follow your agency’s policy for site care. Medication administration via central-line catheters Infusing medication and fluids through a central line is similar to the process used with a PICC. Always follow your agency’s policies for asepsis when making connections to the access port. If the port is to be locked following medication administration, it is typical to flush the line with 10 mL of normal saline using the push-pause technique and then to secure the line clamp. Follow your agency’s policy for the frequency, solution, and volume to be used to maintain the line’s patency.

Beyond the basics The clinical use of specialized intravenous access devices requires focused education and competency training beyond the scope of this module. These advanced skills include patient-safety considerations and infection-control practices, prevention and recognition of unexpected outcomes, and comprehension of hemodynamic values.

The Six Rights

The right drug Determining that you have the right drug involves checking the medication label against the medication administration record (MAR) at least three times before you administer the drug. The exact times you perform these three checks depend on how the drug is stored and your facility’s policy, but in most situations you would check as you remove each drug from the storage area, as you prepare each drug, and at the patient’s bedside before you administer each drug. In addition to checking the label against the MAR to make sure you have the right drug, check also that you have the right dose, are planning to give it by the right route, and that it is the right time. Verify the drug’s expiration date at this time as well.

The right dose Many facilities use a unit-dose system to help reduce the risk of medication errors. However, if your facility does not have a unit-dose system or you must prepare a medication from a larger volume or a different strength, you must perform conversions and dosage calculations. When you are new to practice or if you rarely perform calculations or are at all unsure about the dose, have another nurse double- check your work before you give the drug. Although policies differ from facility to facility, many require double-checking of doses of some medications, such as insulin and anticoagulants. When administering oral medications, itis sometimes necessary to give only aportion of a tablet. To break a scoredtablet in half, use a cutting device toimprove accuracy. If the tablet does notbreak evenly, discard it, if your facility’spolicy allows it, and cut another tablet.If it is a controlled substance, followyour facility’s policy for discarding thesedrugs. Keep in mind that it is difficult toconfirm that you are giving the correctdose after you divide a tablet, so this is a practice best avoided if at all possible.Policies about this practice vary widely,so be sure you understand what your facility requires should this situation arise. Some might allow this practice only in the pharmacy, for example, or might prohibit nurses from dividing unscored tablets. If a patient is unable to swallow pills, you might have to crush a medication and mix it with food or a beverage before administering it. Use a crushing device, such as a mortar and pestle. When mixing the medication, use the smallest amount of food or

fluid possible. Because medications can alter the taste of food, avoid mixing it with the patient’s favorite foods and beverages as this might diminish the patient’s desire to eat or drink them. Whenever you cut or crush a medication, clean the pill cutter or mortar and pestle before and after use. It is a good practice to check with a pharmacist or a drug guide before cutting or crushing a medication. Some medications, such as sublingual, enteric-coated, and timed-release preparations, must not be cut or crushed.

The right route The route you will use to administer the medication is indicated on the drug order. If this information is missing or the specified route is not the recommended route, notify the prescriber and ask for clarification. When giving an injection, verify that the preparation of the drug is intended for parenteral use. If you inject a preparation not intended for parenteral use, complications can result. Most drug manufacturers label parenteral medications “for injectable use only” to help prevent errors, so check the label carefully. The right time Medications are usually ordered to be given at certain frequencies, intervals, or times of day (such as “hour of sleep”). Become familiar with the medications you are giving, why they are ordered for certain times, and whether or not the time schedule is flexible. Some drugs must be given around-the-clock to maintain a therapeutic blood level. Other drugs should be given during the patient’s waking hours to allow uninterrupted sleep. Most facilities recommend a time schedule for administering medications ordered at specific intervals (q4h, q6h, q8h). Most facilities also have a policy indicating how soon before or how long after the scheduled time a drug can be administered. For routinely ordered medications, such as antibiotics, 30 minutes before or after the scheduled time is commonly acceptable. For example, if a medication is to be given at 0700, you can give it between 0630 and 0730 and still be administering it at the right time. In certain situations, medications must be administered at times other than those indicated by the facility’s time schedule. For example, a preoperative medication might be ordered to be given “stat” (immediately) or “on call” (right before a procedure). When medications are ordered on a PRN (as needed) basis, use your clinical judgment to determine the right time. For example, when a pain medication is ordered q4-6h, assess your patient’s pain level to determine whether your patient needs another dose after 4 hours or can comfortably wait longer. The following is an example of a medication administration schedule.

The right patient

Before giving a medication, make sure that you are giving it to the right patient. You must use two identifiers. For example, check the patient’s medical record number on the medication administration record against the patient’s identification band and ask the patient to state his or her full name. In some facilities, an electronic scanner will be used to match the patient’s medication administration record with the identification band. If the patient is confused or unresponsive, your two identifiers can consist of comparing the medical record number and the birth date on the MAR with the information on the patient’s identification band. If your patient is a child, ask the parents or legal guardian to identify the patient, in addition to comparing the information on the MAR with the information on the patient’s identification band. No matter how long you have been caring for the patient or how well you know the patient, each time you enter the room to administer a medication, you must use a minimum of two identifiers to confirm that you have the right patient. The right documentation Accurate documentation must be available before and after a drug is administered to ensure that it is prepared and administered safely. Medication orders should clearly state the patient’s first and last name, the name of the drug ordered, the dose, the route, the time the drug is to be administered, and the signature of the prescriber. If any of this information is missing, notify the prescriber before giving the medication. After you give a medication, place your initials in the designated space by the medication as soon as possible to indicate that you gave the dose. Failure to document or incorrect documentation can be considered a medication error in itself and can cause an error as well. Following the six rights of medication administration and checking the medication label against the MAR three times each time you prepare and administer a medication might seem redundant and unnecessary. However, taking shortcuts and not following procedures greatly increases your chances of making a medication error.

Frequently asked questions Can I use the same the same secondary tubing for more than one medication?

Establishing a secondary line creates a means for micro-organisms to enter the primary line. Repeated changes of secondary tubing increase the risk of contamination. To reduce this risk, “backflush” secondary tubing whenever possible and use it for the length of time your agency allows. Many infusion pumps have a backflush or “back-prime” setting that allows the primary fluid to flow upward through the secondary tubing into the piggyback bag. You can also backflush by opening the secondary clamp and lowering the piggyback bag below the level of the primary IV bag. Each of these methods flushes primary solution through the secondary tubing, clearing the tubing of medication and air.

Keep in mind, though, that some medications are incompatible and require separate secondary tubing. Check your agency’s policy for backflush protocols. Close answer

Would replacing the tubing more often help maintain the sterility of the IV infusion system?

To reduce the incidence of IV catheter-related infections, the Centers for Disease Control and Prevention (CDC) recommends that infusion tubing, including “add- on” devices, be replaced no more often than every 72 hours. Add-on devices include extension tubing, secondary tubing, and infusion-port adaptors. Always discard and replace tubing or add-ons if you suspect contamination. Check your agency’s policy, as it might differ.

Should I change the tubing no more often than 72 hours for all fluid infusions? Not necessarily. It is best to change any fluid that enhances microbial growth more often. For example, the CDC recommends changing infusion tubing on lipid emulsions every 24 hours. Check your agency’s tubing-change policy for specific fluids, especially for blood products, parenteral nutrition, and lipids.

Can I write the drug information directly on the IV bag? No. Never use a felt-tip marker or pen to write on the IV bag. The ink can penetrate the plastic and seep into the IV solution. Always use a facility- approved label to write the date, time, drug, dose, and infusion rate of the IV medication and/or solution plus any other information per your agency’s policy.

How can I give two IV piggyback medications scheduled for the same time? Check your agency’s policy for dose administration-time guidelines. Many policies allow infusion within 30 minutes before and after the scheduled time. Depending on the infusion’s duration, it might be possible to infuse the medications sequentially. Start the first medication 30 minutes prior to the due time, flush the line between infusions with sterile normal saline to avoid drug incompatibility issues, then begin infusing the second medication within 30 minutes after the scheduled time.

What if my patient’s primary IV or medication infusion cannot be stopped to administer PRN or scheduled IV bolus (push) medication?

Some IV medication and fluid infusions cannot be interrupted. In that case, start IV access at another site and administer the medication using the new IV lock.

Can I add medication to an existing bag or container of infusing IV fluid? No. Because there is no reliable way to determine the volume of fluid left in the bag, you would not be able to determine the exact concentration of the medication in the solution. Add medications only to new IV fluid containers.

Why do some medications require filtering prior to administration?

Drugs distributed in glass vials must be filtered on withdrawal from the vial to eliminate the possibility of drawing glass particles into the syringe. One process uses a standard needle to withdraw from the ampule and a filter needle to inject into the diluent bag. Another method uses a filter needle to withdraw the drug and a standard needle to administer it. Filter straws and other blunt filter devices are available for needleless systems.

What do filter tubing lines and inline filters do? Many drugs are filtered during the manufacturing process to remove particulates of a certain molecular size. Numerous recommendations exist for filtration after the manufacturing process, depending on the medication and on the agency’s policy. Many agencies require filtering all reconstituted powders; many require filtering all medications for particular patient populations (such as open-heart surgical patients). Check the recommendations for using a filter for a specific medication in an IV medication guide or consult a pharmacist. Using a filter when it is not recommended might reduce the potency of the medication.

Quizlet Questions

ICU capabilities Nurse:pt ratio of 1:1 or 1:2, hrly VS, hrly I&Os, bedside procedures, art lines, chest tubes, intubation, complex IV meds

IMC capabilities pt needs attention but not intense monitering, nurse:pt ratio of 1:2-3, cont telemetry

General floor capabilities VS q 4 hrs max, I&Os q 6-8 hrs, nurse:pt ratio of 1:4-6, last step out

Neurogenic shock tx vasoconstrictor meds, IV fluids

Cardiogenic shock eval CXR, ECG, cardiac enzymes, echo

Septic shock tx fluids, Abxs Hypovolemic shock tx fluids after R/O other causes

Crystalloid fluids NS or LR

Colloid fluids Blood products (PRBC, FFP, Albumin)

Explain the 4:2:1 ratio determines rate of maintenance fluids, based on body wt, 4 ml/kg for 1st 10 kgs of body wt (0-10kg)2 ml/kg for 2nd 10 kg of body wt (10-20 kg)1 ml/kg for remaining body wt (>20 kg)

Bolus fluids - use and types used for resuscitation when hypovolemic, fluids include LR and NS, half NS is NOT used

What is in Lactated ringers? Na 130, K 4.0, Cl 109, HCO3 28, Ca 3.0pH of this fluid is closer to 7 than NS

What is in Normal Saline? 154 mEq Na, 154 mEq ClMore acidotic than LR

Main areas to address in ICU meds Sedation, pain control, glucose control, Abxs, home meds

OG or NG tubes use and placement - for feeding or drainage of stomach (air or fluid), placed at bedside but always get CXR to confirm, 2 tubes in one (drainage port + air port)

NG tube vs. Dobhoff tube NG is large bore, can feed + drain with itDobhoff used only for feeding, small bore

When would a pt need an NG tube? bowel obstruction, after bowel sx, intubated/trauma pt at risk of aspiration

NG tube output

2L of fluids are made in stomach + saliva every 24 hrs, if output is < 2Ls - some fluid is getting past into GI tract(333ml per 4 hrs)

When should an NG tube be taken out? clamp NG tube, after 4 hrs if you get < 150 mls out with suction, you can pull the tube, may also have signs for bowel function

When would you have bile in the stomach? complex obstruction, obstruction distal to duodenum

What should do always do before pulling out an NG tube? check to see if it is working properly first, flush it

Chest Tubes drain air + fluid, bedside procedure, diameter in french system

French system: 3 Fr = 1mm (24 Fr = 8 mm)

G tube used for feeding + decompression of stomach, surgical placement, usually not put on suction, may be open to the air

J tube feeding tube in jejunum, surgically placed, almost never on suction

When would you use a J tube vs. G tube? stomach issues (motility disorders, pyloric obstruction, aspiration risk)

What are some disadvantages of a J tube? lower rate of feeding, loss of gastric hormones, more complicated procedure

JP Drains sterile suction, part of a closed system, placed in OR to drain serous fluid (blood), easily clogged

Urinary output Goal for most pts = 0.5ml/kg/hr

Central line (Triple lumen) locations Subclavian, Internal Jugular, Femoral veins

Arterial line locations radial + femoral artery, given you moment to moment BP + ABGs

Peripheral IV locations hand, antecubital fossa, rarely in lower exts

Narrow pulse pressure = compensatory vasoconstriction

Poiseuilles Law Less resistance to flow in shorter tube

When would you want a Central line? lack of peripheral IV access, mult meds needed, meds that require higher blood flow (pressors), frequent blood draws, moniters central venous pressure, cardiac output

Non-invasive ways to prevent intubation incentive spirometry, nasal cannula O2, 100% non-rebreather mask, CPAP, BiPAP

Non-rebreather masks deliver up to ___% inspired oxygen. 40%

Incentive spirometry can prevent __ atelectasis, lund deconditioning

BiPAP vs. CPAP BiPAP has less pressure on exhalation

ET tube used for pt w pulm dx or those who can't proect airway, placed at bedside or in OR, pt usually needs sedation + may be difficult to wean from vent

Tracheostomy

used for long-term ventilation, pts w facial fxs, or for ventilator weaning, can be managed as outpt/general floor, sits below vocal cords so pt can speak w cap, can be emergent or elective

Mechanical ventilation changes a system how? normally have negative pressure inside + positive pressure outside - changes that to positive pressure inside as we force air in w machine

Settings on Ventilators Volume of gas (tidal volume) based on body wt (7-10 ml/kg), frequency of Respiration, %O2, vent mode (PRVC or PS), and PEEP (positive end expiratory pressure)

what settings on a vent are for oxygenation? %O2 + PEEP

What settings on a vent are for ventilation RR + TV

What is PEEP + how does it help improve oxygenation? Positive end expiratory pressure - is the pressure they breathe against during expiration, it keeps the alveoli open + avail for gas exchange, positive pressure forces air across alveolar memb into capillary

PRVC mode on a Ventilator (Pressure Regulated Volume Control) you set TV + RR + %O2 + PEEP, machine delivers set TV unless it reaches max airway pressure (pressure regulated), pt can breathe over vent but will get full TV w each breathe, pt will need sedation*

PS mode on a ventilator (Pressure Support) constant flow of positive pressure gas, machine ends breath when flow of gas decreases, used to transition from intubation You set: In + Exhalation pressures (PEEP), %O2Pt sets: TV + RR (ventilation)

Changes in vent settings are made based on __. ABG results

When can you extubate a pt? Pt breathing on their own (PS setting, pt doing work of breathing), pt needs minimal O2 support (<40%), pt has adequate strength to initiate resp (tolerates PS mode for several hrs, calculate negative inspiratory force which correlates w strength)

Oxygenation: measured by __, fixed by__, vent modes that allow you to adjust it are __. measured by pO2, fixed by adjusting PEEP or %O2 (FIO2)Vent modes - PS + PRVC

Ventilation: measured by __, fixed by__, vent modes that allow you to adjust it are __. measured by pCO2, fixed by adjusting TV or RRVent mode - only PRVC