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 thats 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 outcomes
Reducing the risk of adverse events
Integrating medication administration into the patients 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 patients 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 patients 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 patients medication profile, which
includes genetics, age, gender, current medications, and medical history. Become
familiar with your patients 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 individuals 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 fatsoluble 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 patients 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 patients 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 patients health history,
medication data, vital signs, physical assessment, psychosocial and cultural
considerations, and learning needs.
Health history
Review the patients 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 patients 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 medications distribution is likely
to be altered.
The ability of a medication to pass through an organs biological barrier depends on
the organ and the medications 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 metabolized
medications are determined by the
chemical composition of the medication.
Drugs can be excreted through the
kidneys, liver, bowel, lungs, or exocrine
glands, including the skin and
mammary glands. Evaluate the patients
renal and hepatic function, bowel
motility, ventilatory ability, and skin
integrity, as these determine the rate of
excretion and the potential for
prolonging the mediations actions.
Lactation is a special consideration,
since there is a risk that a breastfeeding
infant will ingest drug metabolites excreted by the mammary glands.
Medication data
The patients 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 patients 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
agencys pharmacists.
Physical assessment and vital signs
Ongoing assessment of your patients physical condition may affect when and how to
administer a prescribed or a PRN medication. It also provides a baseline for postmedication 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 patients 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 patients
IV access. Some IV medications cause
pain and venous irritation if
administered into small peripheral
veins, in a concentrated solution, or at
too rapid an infusion rate. It might be
necessary to access a larger vein,
request a dilution more appropriate for
peripheral administration, or adjust the
IV rate (with the providers approval).
Central IV access should be established
for vasoconstrictive medications and for
medications and solutions that can
cause tissue damage with
extravasation. Learn about a medications implications for administration, and ensure
that your patients venous access line is patent and will accommodate the medication
as ordered.

Take the patients 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 agencys 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 patients level of
understanding and develop an
individual teaching plan. If appropriate,
include family members in medication
teaching. Pre-administration teaching
for IV medications includes the
medications name and dose, desired
action, frequency of administration, and
possible adverse effects specific to your
patient. Also include teaching about IV
therapy; instruct patients and family
members to report pain or swelling at or distal to the IV catheters 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 and
therapeutic intravenous (IV) medication administration. Todays IV
infusion pumps can make this process seem simple. They deliver
precise volume-controlled infusions, and many can be
programmed to calculate dose and flow rates. Despite these
conveniences, knowing how to calculate IV flow rates correctly will
help you verify equipment accuracy and help prevent adverse
events related to medication errors. Knowing how to perform
these 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 patients 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 patients 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
manufacturers 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 patients
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 medications 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 agencys 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 agencys 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
agencys 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
agencys 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 agencys policy.

Prevention: Always follow the manufacturers or the pharmacys 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 agencys 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 agencys 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 manufacturers or the pharmacys
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 agencys policy.

Prevention: Always follow the manufacturers or the pharmacys guidelines for

selecting the proper solution for piggyback and large-volume medication
infusions. Always check and cross-reference medication compatibilities. If your
agencys 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 agencys policy for waste procedures and documentation and for
crediting the patients 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 agencys 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 agencys 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 drugs 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 drugs 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 genebased 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
medications 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 patients 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 patients potential for gene-based drug responses and
medication interactions.
When administering drugs with dose-based responses, such as opioids or antihypertensive 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
patients primary healthcare provider. Document known and newly diagnosed
allergies on your patients chart; include them on the medication administration
record and the patients allergy band. Include medication effects in your patienteducation 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 agencys 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 patients
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
agencys policies and procedures. Connect a normal saline-filled 10-mL syringe to the
catheters access port, release the catheters 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 agencys 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
catheters 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 patients 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 patients 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 agencys 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 agencys 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 patients condition. Learn about your
role in central-line infection prevention, and follow your agencys 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 agencys 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 pushpause technique and then to secure the line clamp. Follow your agencys policy for
the frequency, solution, and volume to be used to maintain the lines 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 facilitys 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
patients 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 drugs 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 doublecheck 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, it
is sometimes necessary to give only a
portion of a tablet. To break a scored
tablet in half, use a cutting device to
improve accuracy. If the tablet does not
break evenly, discard it, if your facilitys
policy allows it, and cut another tablet.
If it is a controlled substance, follow
your facilitys policy for discarding these
drugs. Keep in mind that it is difficult to
confirm that you are giving the correct
dose 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 patients favorite foods and beverages as this might diminish the patients 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 patients 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 facilitys 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 patients 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 patients medical record number on
the medication administration record against the patients 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 patients 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 patients 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 patients 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 patients 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 agencys 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 addon 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
agencys 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 agencys 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 agencys policy.
How can I give two IV piggyback medications scheduled for the same time?
Check your agencys policy for dose administration-time guidelines. Many policies
allow infusion within 30 minutes before and after the scheduled time. Depending
on the infusions 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 patients 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 agencys 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 3.0
pH of this fluid is closer to 7 than NS
What is in Normal Saline?
154 mEq Na, 154 mEq Cl
More 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 it
Dobhoff 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), %O2
Pt 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 RR
Vent mode - only PRVC