Nursing Skills Scenarios

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Scenario 1: Ivy Flowing- 47yo F:
Assessment: Infiltration of IV: Swelling (from increased tissue fluid), Pallor/coolness around venipuncture sites (caused by decreased circulation), IV in place for 2 days r/t dehydration (Need to change IV q 72 hrs), IV rate is appropriately running (Infiltration possibly decreases flow rate) S/S: Erythema, Edema, Spongy feeling in the area, Swelling around the site, Fluid flow may be decreased or stopped, Pain from tissue edema (increasing proportionally as the infiltration progresses)Next RN action: Stop infusion and d/c IV: warn pt of poss. burning when removing catheter, turn off IV tubing clamp, clean site and place sterile gauze above site and withdraw catheter, check to make sure intact, apply pressure for 2-3 minutes and secure w/tape. To reduce discomfort: raise the extremity to promote venous drainage and decrease edema, wrap extremity in a warm, moist towel for 20 min. 3 to 4 times daily to promote venous return, increase circulation, and reduce pain/edema Rationale for interventions: Stopping IV flow reduces damage and prevents more fluids from entering the surrounding skin. Explaining to pt there might be burning when removing catheter prepares pt to cooperate during procedure. Turn IV tubing roller clamp to “off”/turn EID off to prevent spillage of IV fluid. Cleaning site w/antimicrobial swab removes secretions around skin puncture site. Place clean dry gauze over site to cause less irritation to the puncture site and prevent damage to pt vein. Check cannula for intactness after removal b/c a broken catheter tip can cause embolus, and emergency situation. Apply pressure and tape gauze to skin to control bleeding RN next action: If IV therapy is still needed, insert a new cannula into vein in another extremity (IV therapy can continue, but not in the same extremity). Elevate affected extremity (to decrease the swelling of the arm and promote venous drainage).Wrapping extremity in warm, moist towel for 20 minutes for 3-4 times during the day (to promote venous return, increase circulation, and reduce pain and edema). Document degree of infiltration and intervention (using the infiltration scale from 0-4) Fluid balance concerns and nursing interventions: Ineffective hydration: Intervention: Insert new IV in another extremity to allow therapy to continue (Fluid requirements for fluid resuscitation must be adequate to restore intravascular volume, hemodynamic stability, and tissue perfusion). Electrolyte imbalance: Intervention: Monitor vital signs at least three times a day. Notify provider of significant deviation from baseline (Vital sign changes can lead to orthostatic hypotension, bradycardia, tachycardia, respiratory depression, and EKG changes) Safety needs and nursing interventions: Venous/Arterial Insufficiency: Intervention: Check pulses bilaterally, using a Doppler stethoscope if necessary, notifying the physician immediately if pulses is not present (Diminished or absent peripheral pulses indicate arterial/venous insufficiency or ischemia). Venous Thrombosis: Intervention: Note skin color and temperature (Skin pallor or mottling, cool or cold skin, or absent pulses can signal obstruction which is an emergency situation) Educational needs and nursing interventions: Prevention of further illness/injury: Intervention: Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing (Early assessment and intervention help prevent serious problems from developing). Treatments for pain: Intervention: Demonstrate the use of appropriate non-pharmacological approaches in addition to pharmacological approaches for helping to control pain, such as application of heat and/or cold, distraction techniques, relaxation breathing, visualization, rocking, stroking, music listening, and television watching (Nonpharmacologic interventions are used to complement, not replace, pharmacolologic interventions)

Scenario 2: R. Dehisced...
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