Page 1 of 2

NR 226
Sept 2013 Session
Exam 1
Chapter 16 20 Nursing Process, Chapter
41 Fluid and Electrolyte, acid base balance, IV therapy, blood administration, IV flow rate
calculation
Blue Print
Nursing 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 collection

Where 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 steps
Patient-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 approaches

Critical 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 data
Interpreting 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 data

Subjective date- What the patient says it is quote
1. 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 diagnosis

Clinical judgment about the patient in response to an actual or

NANDA

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)

Objective data- Conditions that you can see or feel or observe, FACT
Nursing diagnosis and components of how to correctly write a nursing diagnosis
Medical 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 errors
Errors 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 chest
Errors 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 phase
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.
(Seven) Guidelines in writing nursing care plan goals
Goals 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 obstruction
Patient 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 response
3) 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-frame
6) 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 needs
Effect 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 process
Reassessing 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 complications
Anticipate 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 community
Direct care, indirect care and collaborative care
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 community. Collaborative care involves a team of healthcare
professionals to implement the interventions.

Nursing sensitive outcome

Nursing-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 behaviors
Patient describes surgical outcomes in discussion with surgeon in 24 hours.

Page 2 of 2

NR 226
May 2013 Session Exam 1
Chapter 16 20 Nursing Process, Chapter
41 Fluid and Electrolyte, acid base balance, IV therapy, blood administration, IV flow rate
calculation
Blue Print
Fluid and Electrolyte, Acid Base Imbalances, Blood Transfusion and IV
Fluid = 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
water

Extracellular 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 swellcerebral 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 implications

Always 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 crossmatched 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 blood
Tranfusing 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 delivered
2) The blood is compatible to the patients blood type listed in the medical records
3) The right pt receives the blood
Two 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 site
A Verified 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.
P Perform 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 solution
b. Verbalize appropriate labeling of IV bag
c. Prepared short extension tubing with proper
connector and IV tubing, maintaining
sterility
d. 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 VAD
b. Allow site to dry then apply skin protectant
c. Apply sterile dressing over site
d. 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.
Verbalize 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

A
P

Verified health care providers order for accuracy

and completeness. Verbalize 6 Rights.
Perform hand hygiene, organize appropriate
equipment

Comments

Open sterile packages using sterile aseptic

technique
I
*

E
*

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.
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 intact
Name, title, date, time

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

Never add anything to blood.

Definitions
Flow Rate: the speed in which the IV flow.
Drop Factor: the number of drops for 1mL of fluid to go in.
Macro tubing: 10-15-20
Micro tubing: 60 drop factor (micro and 60 are synonymous)

GTT =volume to be infused

1mL
Notes: Never round up. Drop factor is by gravity not pump
100 mL=100 mL/hr
10 hrs

3000 mL NS over 24 hrs 15gtt/min

Gtt->15gtt x 3000mL x 1 hr = 31.25 ggts/min
Min 1 mL 24 hrs
60min 31 gtts/min
600 mL LR (lactaded renal) over 3 hours
mL 600mL = 200 mL/hr
hr
3 hrs
300 mg IVPB in 100 NS over 45 min
mL 100mL x 60min = 133mL
min 45min
1hr
1hr