Life after Nclex-RN

The most common routes of parenteral medication are intravenous (IV) -  administered directly into the circulatory system; IM - administered into the muscle; SC - administered into the subcutaneous tissue (fatty tissue); and (ID) intradermal - administered into the outer layers of the dermis. My focus with this entry are IV access devices.

The most common IV access devices are:

Peripheral Intravenous Catheters, an example is the butterfly catheter. As the name suggests, these catheters are inserted into a peripheral vein (arms, legs, etc.) to draw labs.

Central Venous Access Device. It is a catheter which is placed in a large central vein under sterile conditions in order to give medication, fluids or blood products.

The 4 most common types of central lines are:

PICC Line (Peripherally Inserted Central Catheter). It is a long catheter that extends from an arm or leg vein into the largest vein (superior vena cava) near the heart and typically provides central IV access for several weeks, but may remain in place for several months. It is similar to other central lines as it terminates into the superior vena cava. However, unlike other central lines, its point of entry is from the periphery of the body the extremities. It can be inserted by a specifically trained nurse or physician.

A non-tunneled central catheter is larger caliber than a PICC line, and is designed to be placed via a relatively large, more central vein such as the jugular vein in the neck or the femoral vein in the groin. It is inserted by a physician and is considered short term, and usually stay in for less that 6 weeks.

A tunneled catheter is inserted inside a major vein for a period of weeks, or months so that blood can be repeatedly drawn or medication and nutrients can be injected into the patient’s bloodstream on regular basis.

Unlike a standard peripheral IV which is for short term use, a vascular access catheter is more durable and does not easily become blocked or infected. The tunneled catheter, which has a cuff at one end that stimulates tissue growth to help hold it in place, is used when access to the vein is needed for longer than three months and many times each day. This catheter is commonly used for patients requiring dialysis. Examples of the tunneled catheter include HICKMAN® catheters, BROVIAC® catheters and GROSHONG® catheters.

This type of catheter has portions that hang outside the skin, and is used by connecting directly to the out side ports of the catheter. This type of catheter must be protected from getting pulled or getting wet.

A mediport catheter, or subcutaneous implantable port, is a permanent device that consists of a catheter attached to a small reservoir, both of which are placed under the skin similar to tunnel catheters. This catheter is placed completely under the skin. There are no restrictions on showering or bathing.

Here is the mainframe for management mastery.

1- Determine which client to see first. Choose the more acute, unstable client.

Unstable Client: The client who is medically fragile who requires an increased level of care, emergency interventions, and monitoring for fluctuating vital signs. Example, a client with low blood sugar or a client with sudden changes in routine neuro checks.

This can be tricky, as not all complex clients are unstable. A client can be complex and stable at the same time.

Case #1: A 36 year old single mother with 4 children is discharged home after a right mastectomy. She has a lot of physiological & psychosocial problems, causing her to be a complex client, but she is STABLE. She has been discharged home! If you have to pick between a stable and an unstable client on Nclex, go for the unstable first. This is an example of a stable, but complex client.

Case #2: You may think that a client with chronic lung disease is unstable because of airway. But if there is no information in the question to make you think the client is in any acute distress, hold off going to see that client first while you examine the other options. Remember, that it took this client a long time to develop chronic lung disease.

Consider what the data is saying about that client RIGHT NOW, AT THE MOMENT.

Look at the complexity of the client. Which client has the most possible complications? This is another good rule of thumb to remember when determining which client to see first. Which client had the most problems?

Remember that all clients will sound critical in each question answer option. Nclex does this on purpose, so don’t get upset.

Just because someone is in pain does not mean that they are about to progress to death. Pain never killed anyone! We do take pain seriously, but beware: there could be another answer that is a better option to choose. The pain of a myocardial infarction indicates a much more life-threatening situation than routine postop pain.

Always remember, you should assess a client with a life-threatening problem before visiting your other clients.

Case #3: You have 2 clients on your home health route that need to be seen today. Who do you see first? The client complaining of postop hip replacement pain, or the diabetic client who is scheduled for a fasting blood sugar? What’s the worst possible scenario that each client can experience? The postop client could be suffering from hip dislocation. But the diabetic client is fasting! If his sugar gets too low it can cause convulsions, seizures, even coma.

Remember, this is nclex world, not real world nursing. In real world nursing you would call the diabetic client, tell them to eat something, and inform them that you will draw the fasting blood sugar tomorrow, thus enabling you to go see the client who is in pain.

2- Never assign an unstable client to an LPN.

Case #4: Your assigned client has a head injury; the intracranial pressure is being monitored. The client has noticeable pupillary changes. Is this an immediate concern? Remember, when “head things” start happening, they happen FAST and can bring DEATH quickly if they are not acted upon immediately. Pupillary changes are a sign that ICP is increasing.

3- A new admission is considered unstable. The RN should retain this client for herself.

Remember, the RN has the ultimate responsibility and accountability for the management of client care. She is responsible for the actions and inaction’s of herself and others.

-Marlene Hurst, Hurst Review