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Lab notes • Non-Tunneled

Flushing Techniques o Fast access
• SASH = saline, actual drug, saline, heparin o Large bore into SVC
• SAS = saline, actual drug, saline o 1-4 lumens
o Most responsible for infections
IV Therapy lab: • Tunneled = change injection caps Q72h
Peripheral vs. central line= defined by where tip is placed. o Long term
o Chronically ill
Common IV complications o Ideal for active pt’s
• Interstitial IV = placed outside vein, causing pain @ o Tunneled and cuffed in surgery
site & drugs can cause corrosion
o Scar tissue grows around cuff
• Phlebitis = local infection
o types
• Fluid overload = peripheral or pulmonary edema
 Hickman, Broviac, Groshong, Hohn,
• Thrombophlebitis = inflammation of vein (red, warm, Leonard
swollen) o Nsg. Care:
• Catheter embolism = tip of cath breaks off.  No drsg needed after heals
• Bleeding  Clean QD
• Nerve damage  SASH QD (Groshong= no heparin,
• Tendon damage valve prevents regurgitation= don’t
• Ligament damage clamp
• Needle stick injuries • PICC
• Sepsis o Inserted thru basilica, cephalic, or median
• Arterial puncture = big artery in wrist cubital veins
o Best for daily up to 6 mths
CVAD Lab = Central Venous Access Device o Measure often
Tip in SVC, except femoral = tip in IVC o Fluids infuse slower
All central lines are sterile drsg. Changes o Can draw blood = NO vacuum container
• Port
Types: o Up to 2,000 punctures

o Chest, arm, or abdomen
o Easy to flip over
o Can separate from attached tubing or occlude
o Use Huber needle to access-
 45 degree angle
 Had IV tubing attached to needle
 Aspirate to check patency
o Nsg. Care
 Sterile
 Discard initial 5-10ml
 Draw blood 10 ml using vacuum
container
• Complications:
o Tip in atria
o Tip in jugular vein
 Hears bubbling in ear when flushed
sudden earache on side of cath
o Malfunction
 Inability to infuse fluid @ rate
 Must be repositioned to obtain blood
return
 Visible collateral chest vein
Blood Administration
o 19 gauge or larger, free flowing IV
o No dextrose or LR = induce RBC hemolysis
o No additives given thru tubing unless cleared with NS
o Reaction will occur within 15 mins or 50ml of
transfusion
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o PRBC’s should not be infused quickly unless
emergency
o Blood unrefrigerated for 4hrs or more should be
returned to blood bank
Blood Transfusion Reaction
o Acute Reaction
o STOP transfusion
o Maintain patent IV with NS
o Notify blood bank and MD STAT
o Recheck identify tags
o Monitor VS & UOP
o Tx sx’s per MD orders
o Save blood bag and tubing and send to bank for
exam
o Complete necessary reports
o Collect required blood and urine samples
o Document
Acute Transfusion Reactions
1. Acute Hemolytic Reaction
• ABO incompatibility
• Sx’x: chills, fever, low back pain,
flushing, tachycardia, Tachypnea,
hypotension, vascular collapse,
hemoglobinuria, acute jaundice,
dark urine, bleeding, ARF, shock,
cardiac arrest

• TX: tx shock if present, send for
UA, maintain Bp. Diuretics,
indwelling Cath (I/O). Dialysis if
ARF
2. Febrile Nonhemolytic
• Sensitization to donor WBC’s,
platelets, or plasma protein.
• Sx’s: sudden chills, fever
(>1degree), H/A, flushing,
anxiety, muscle pain
• TX: antipyretics. DON’T
RESTART unless MD orders.
3. Mild allergic reaction
• Foreign plasma proteins
• SX’s: Flushing, itching, urticaria
(hives)
• TX: antihistamines, transfusion
may be started slowly. DON’T
RESTART IF FEVER OR
PULMONARY SX’s DEVELOP
4. Anaphylactic and sever allergic reaction
• SX’s: anxiety, urticaria,
wheezing, progressing to
cyanosis, shock, and possible
cardiac arrest.
• TX: CPR if indicated, EPI ready.
DON’T RESTART
5. Circulatory overload
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• SX’s: cough, dyspnea,
pulmonary congestion, H/A,
HTN, tachycardia, distended
neck veins
• TX: place pt upright with feet
dependent, diuretics, O2,
morphine, phlebotomy may be
indicated
6. Sepsis
• SX’s: rapid onset chills, high
fever, V/D, marked hypotension
or shock.
• TX: culture, send bag with tubing
for study TX with antibiotics, IV
fluids
Blood Products
1. PRBC’s
o 1u= 250-350ml
o Decreased danger of overload
o More component specific
o Indications:
o Sever or symptomatic anemia
o Acute blood loss
2. Frozen RBC’s
o Can be stored 3yrs @ 188.6 F
o Must be used 24hrs p thawed
o Indications
o Autotransfusion
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o Pt with previous febrile reaction to transfusion o Stored for 1yr

o Infrequently used o Must be used when thawed
3. Platelets o Indications
o Prepared from whole blood within 4hr after o Replacement of clotting factors (esp. factor
collection VIII & fibrinogen)
o 1u= 30-60ml
o Multiple units can be obtained from one donor
o Can be kept @ room temp 4 1-5 days depending on Delayed Transfusion Reactions
storage bag o Delayed Hemolytic
o Agitate periodically o Fever, mild jaundice, decreased HCT
o Indications o Hepatitis B
o Bleeding secondary to thrombocytopenia o Increased liver enzymes, anorexia, malaise,
o Platelet levels <10,000-20,000 N/V, fever, dark urine, jaundice
4. FFP- Fresh frozen plasma o Tx: symptomatically
o 1u= 200-250ml o Hepatitis C
o Rich in clotting factors but no platelets o Usually less severe
o Stored for 1yr o Tx: symptomatically
o Used within 24hr after thawing o HIV
o Indications o Can be asymptomatic, flu-like sx’s
o Bleeding secondary to decreased clotting o Iron Overload
factors (DIC) o CHF, arrhythmias, impaired thyroid & gonadal
5. Albumin fxn, diabetes, arthritis, Cirrhosis
o Stored 4-5 yrs o TX: symptomatically
o 5% or 25% solution o Graft-vs.-host disease
o Indications o Fever, rash, diarrhea, hepatitis
o Hypovolemic shock o No effective therapy
o hypoalbuminemia o Other
6. Cryoprecipitates & Commercial concentrates o Cytomegalovirus, HTLV-1 and those causing
o 10-20ml / bag Malaria
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o Lung sounds
o V.S.
Before Transfusion
o Type STOP Transfusion IF:
o Consent o Temp increase by 1degree
o Order o Run NS- separate tubing
o IV 118-19 gauge in adults
o Given within 30 mins or being removed from frig
o Check expiration date/time, color, cloudiness, red cell
clumping
o RBC compatibility checked Q72hrs
o 2 nurses must sign compatibility card
o NS only solution given with blood or components
o Always transfused with filter
o NO MORE THAN 15-30ml IN THE FIRST 15mins
o Sx’s of reaction- chilling, H/A, N/V, back pain,
SOB, dark red urine, dizziness, rash
o Normally run @ 125-150ml /hr
o Needs to be run in 4hrs.
o V.S. Q5-15 min 1st 15 mins, 15-20 mins
o Document- time, type, amt, VS, reaction sx’s

Two sources
o Autologous= donated by recipient
o Homologous= donated by others

Assess before transfusion

o Urine color
o Pain
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o Kussmaul respirations = rapid, deep

o Cheyne Stokes = abnormal pattern alternating periods
of apnea & deep, rapid breathing
o Biot’s= irregular with apnea Q4-5 cycles

Tracheal deviation = occurs away from side of tension

Pneumothorax or a neck mass
-but-
Toward the side of a Pneumonectomy or lobar Atelectasis

Respiratory Cardiac
Ph: 7.35-7.45 th
PMI = 5 intercostal space 2in left of midline
PaCO2- 80-10 mm Hg
PaCO2- 35-45 mm Hg Layers:
HCO3- 22-26 mEq/L 1. Endocardium- inner
2. Myocardium- middle muscle
Diaphragm contains Phrenic Nerve = C3 & C5 3. Epicardium- fibrous outer
o Complete injury above C3= total diaphragm paralysis
Spinal curvatures that affect breathing 4 valves
o Kyphosis 1. tricuspid – Right atria & ventricle
o Scoliosis 2. Pulmonic semilunar valve
o Kypho-scoliosis 3. Mitral – Left atria & ventricle
4. Aortic semilunar valve
Calculating pack year= Packs per day (x) # yrs smoked
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Conduction System of the Heart:

1. SA node (pacemaker of heart)
2. AV node
3. Bundle of HIS
4. Purkinje Fibers

AV node & Bundle of HIS supplied with blood from Right

coronary artery.

P = SA node firing 0.11 secs or less

PR interval = SA node to ventricles 0.12-0.20 secs
QRS = AV nodes fires 0.05-0.12 secs
ECG ST segment = norm isoelectric or depressed 0.5-1mm
1 box= 0.04 secs (width) T = repolarization of ventricles
1 box = 1mm (height) U= if seen= delayed ventricular repolarization (associated with
hypokalemia)
o Elevated = longer repolarization (bradycardia)
o Decreased = tachycardia

CO = amt of blood pumped by each ventricle in 1min

CO=SV (X) HR
o Normal = 4-8 L/min
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 Increased parasympathetic
CI=CO (/) BMI  Decreased pressure
o Normal 2.8-4.2 L/min/m2 o Chemoreceptor’s
 Changes in HR and arterial pressure in
EF = amt of vol. ejected with each contraction response to decreased O2, increased
o Normal 50-70% CO2, & decreased pH
 Stimulation causes increased cardiac
Preload = amt of blood in ventricles @ end of diastole activity

Afterload = peripheral resistance against which the left Bp in lower extremities = 10 mm Hg more than upper
ventricle must pump extremities

Starlings Law Ausculatory Areas:

To a point, the more the fibers are stretched, the greater their o Aortic Area
force of contraction o 2nd ICS right sternum
o Pulmonic Area
Cardiac regulation
o 2nd ICS left sternum
o Autonomic nervous system:
o Tricuspid Area
o Sympathetic nervous system (Fight or Flight)
o 5th ICS close to sternum
 Increased HR
o Mitral Area
 increase speed of impulse to AV node
o 5th ICS left midclavicular line
 Increased force of atrial & ventricular
o ERB’s Point
contractions
o 3rd ICS left near sternum
 Increase vasoconstriction
o Precordial area = between apex & sternum
o Parasympathetic (vagus nerve)
o Heaves are sustained lifts in the chest wall in the
 Decreased HR
Precordial area that can be seen or palpated.
 Decreased conduction to AV node
Valvular disorder may be suspected= vibrations are felt
o Baroreceprtors Cardiac Diagnostic Testing
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o ECG
o Holter monitoring Fluid and Electrolytes
o Transtelephonic event recorders 1 Liter H20 = 2.2 LBS (1kg)
o Exercise/Stress Testing
o Chemical Stress Test- INJ Dobutamine Normal Electrolytes
o Blood Studies HCO3 = 22-26
Cl- = 96-106
Phosphate = 2.8-4.5
Invasive Studies
Protein = 6-8
o Cardiac Cath & Coronary Angiography
K+ = 3.5-5.0
o Pt c/o temp, hot & flushed
Mg+ = 1.5-2.5
Na+ = 135-145
Mean Arterial Pressure = MAP Ca+ = 9-11
MAP=DBP (+) 1/3 pulse pressure (SBP-DBP)
Fluid Movement
Valsalva Maneuver = test baroreceptors reflex (cause = o Diffusion
decreased venous return) that’s why do it when removing
central line o High concentration  low concentration
o Facilitated Diffusion
o Specific carrier molecules (passive)
o Active Transport
o Moves against the gradient- requires energy
o Osmosis
o Movement of H2O from
decreased solute conc.  increased solute conc.
to (=). No energy
o Hydrostatic Pressure
o Force within a fluid compartment
o Oncotic Pressure
o Pressure exerted by colloids (proteins) in
solutions
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Fluid Spacing Electrolyte Imbalances

1. 1st spacing= normal distribution of fluid
2. 2nd spacing= accumulation of interstitial fluid Hypernatremia:
EDEMA • Causes: H20 loss or Na+ gain
3. 3rd Spacing= accumulation in portion of body not easily • Manifestations
exchanged with the rest of the ECF. Unavailable for o Twitching
functional use (ascites & edema associated with burns) o Intense thirst
o Agitation, restlessness, flushed skin
Regulation of Water Balance o Bp variations
1. Hypothalamic = release of ADH
• TX:
2. Pituitary = ADH
3. Adrenal Cortical = o Fluids
a. cortisol (glucocorticoids)
b. aldosterone Hyponatremia:
(mineralcorticoids) • Causes: H2O gain or Na+ loss
4. Renal = • Manifestations:
5. Cardiac = Atrial Natriuretic Factor (ANF) o Seizures, coma
6. GI = insensible H2O loss o Irritability
o Bp irregularities
o N/V
• TX:
o Fluid restriction
o Fluids with Na+

Hyperkalemia
• Causes: excess K+ failure to eliminate (ARF)
• Manifestations
o Irritability, anxiety
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o Abdominal cramping o Hyperglycemia

o Diarrhea o Present U Wave
o LE weakness, parasthesias o Flat T-Wave
o Irregular pulse o Enhanced dig effect
o Cardiac stand still (sudden K+ increase) • TX:
o Tall peaked T-wave o KCL supplement (UOP @ least 0.5ml/kg/hr)
o Prolonged PRI o Increase dietary intake
o ST depression o IV K+ (may cause pain @ site)
o Absent p-wave
o Widening QRS Hypercalcemia
o V-Fib • Manifestations
o Ventricular Stand still o Lethargy, weakness
• TX: o Depressed reflexes
o Diuretics (eliminate) o Decreased memory, confusion
o IV Insulin o Personality changes
o IV Bicarb o Psychosis
o Calcium Gluconate IV o N/V, anorexia
o ECG monitoring o Bone pain, FX
o Polyuria, dehydration
Hypokalemia • TX:
• Manifestations: o Loop diuretics
o Fatigue o Isotonic Saline solution (NS 3000-4000ml/day)
o Muscle weakness o Synthetic Calcitonin
o Leg cramps o Decrease diet
o N/V, ileus o Mobilization & weight bearing exercise
o Soft flabby muscles, parasthesias
o Decreased reflexes Hypocalcemia
o Weak irregular pulse • Manifestations
o Polyuria o Fatigued
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o Depression, anxiety o Muscle weakness

o Confusion o osteomalacia
o Numbness & tingling in extremities & region • TX:
around the mouth o Oral supplementation, diet
o Hyperreflexia, muscle cramps
o CHVOSTEK’s Sign-facial twitching
o Trousseau’s sign- hand twitch when Bp cuff
inflated Hypermagnesemia
o Tetany, laryngeal spasm • Manifestations
• TX: o Decrease neuromuscular and CNS fxn
o IV/Oral Ca+ (no IM’s) o Lethargy, drowsiness
o Increased diet + Vit. D o N/V
o Decreased DTR’s
Hyperphosphatemia o Resp. and cardiac arrest
• Manifestations • TX:
o Hypocalcemia o Prevention
o Deposition in skin, visceral, cornea, blood o IV calcium chloride or calcium gluconate
vessels, soft tissue o Fluids to promote urinary excretion
• TX: o Renal failure = dialysis
o Decrease diet (dairy products)
o Hydration (dilute) Hypomagnesemia
o Correct Ca+ levels • Manifestations
o Neuromuscular & CNS hyperirritability
Hypophosphatemia o Confusion
• Manifestation: o Hyperactive DTR’s
o CNS dysfunction o Tremors, seizures
o Rhabdomolysis o Resembles hypocalcemia
o Wasting of Mg+, Ca+, HCO3 • TX:
o Cardiac arrhythmias
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o Oral/diet (green veggies, nuts, bananas, oranges,

peanut butter, chocolate)

Acid-Base Balance
Respiratory Acidosis
• Increased CO2 (hypoventilitation)

Respiratory Alkalosis
• Decreased CO2 (hyperventilitation)

Metabolic Acidosis
• Decreased HCO3 (sever diarrhea)

Metabolic Alkalosis
• Increased HCO3 (prolonged vomiting, GI suction,
baking soda ingestion)

Solutions:
Hypotonic
• ½ NS

Isotonic
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• D5W o Oils, margarine, milk, grains, meats

• NS • Vit. K
• LR o Green leafy veggies, meats, eggs, dairy

Hypertonic Water soluble:

• D10W • B-complex
• 3% NS o Grains, cereal, bread, meat
• D5W ½ NS • Vit. C
• D5 NS o Citrus fruits, green veggies
• TPN

Fluid replacement
Colloids: Volume expanders Insulin Lab
Released from Beta cells in Islets of Langerhans
• Dextran
• Hetastarch Types of Insulin:
• Amino acids 1. Rapid acting
Crystalloids • 5-15 mins
• Dextrose • 2-4 hr duration
• Saline 2. Short Acting
• LR • Onset 30-1hr
• Peak 2-4 hr
Vitamins and Minerals • Duration 6-8hr
Fat soluble: can cause toxicity (stored)
3. Intermediate Acting
• Vit. A
• Onset 1-2h
o Fruits, yellow & green veggies, fish dairy
• Peak 6-12 hr
• Vit. D
• Duration 18-24 hr
o Diary & margarine
4. Long Acting
• Vit. E
• Onset 4-8 hr
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• Peak 14-20 hr
• Duration 24-36 hr Hyperglycemia
• > 300
Storage: • DKA= coma
• Unopened = refrig until needed o Polyuria, polyphasgia, Kussamul resp.’s, fruity
• Opened breath, CO2 < 15, increased serum K+
o Room temp = 1mth • Hyperosmolar nonketoic coma
o Refrigerated = 3 mths o Polyuria, glycosuria, severe dehydration

• TX:
Hypoglycemia o NS  D5W
• Blood glucose < 50-60 o ½ NS
• Diaphoretic, pale, weak, anxious, o K+ replacement (almost always)
irritable, confused, blurred
vision, increased HR, H/A,
decreased LOC
• TX:
• 50% dextrose (D50) IVP
(unconscious)
• Fast acting carbs (candy 10-20g
Q10-20 mins) (conscious)