Patient Assessment & Care Planning Flashcards

What precaution applies to chlorhexidine skin antisepsis in preterm neonates and infants younger than 2 months?

Answer: Use it with caution because of the risk of skin irritation and chemical burns

INS advises using chlorhexidine with caution in premature infants and infants under 2 months because of skin injury risk.

Which tool is designed to standardize the assessment of peripheral catheter phlebitis?

Answer: Visual Infusion Phlebitis (VIP) scale

The VIP scale grades phlebitis from 0 to 5 based on signs such as pain, erythema, and a palpable cord.

Which palpation finding indicates a vein that is suitable for cannulation?

Answer: Soft, bouncy, and refills quickly after compression

Healthy veins feel soft and resilient and refill quickly, while cord-like veins suggest sclerosis or thrombosis.

Which medication is considered a vesicant and affects device and site selection?

Answer: Norepinephrine

Norepinephrine is a vasopressor vesicant that can cause tissue necrosis if it extravasates.

A patient with significant coagulopathy needs a nontunneled CVC. Which insertion site should generally be avoided?

Answer: Subclavian vein

Pressure cannot easily be applied to the subclavian vein, so bleeding there is hard to control.

Where is the optimal tip position for a PICC?

Answer: Lower third of the superior vena cava at or near the cavoatrial junction

A tip at the lower SVC or cavoatrial junction provides high blood flow and reduces the risk of thrombosis and malfunction.

Which teaching point is correct for a patient going home with a PICC?

Answer: Cover the site with an impermeable cover when showering and avoid submerging the arm

The dressing must stay dry and intact, and submerging the site in water raises the risk of infection.