Question

Please read the question carefully, I need the answer typed because sometimes I can't read hand writings.

Mr. Turn is a 45-year-old patient with the following order:

Vancomycin, 1500 mg, IV, q8hr

Mr. Turn is currently receiving a dose of Vancomycin through his antecubital (AC) peripheral IV (PIV) line. He will need to receive the medication for another 2 weeks.

Upon assessment of his PIV site, Mr. Turn complains of extreme pain. You notice there is a red streak extending up the vein, and you can palpate a venous cord 0.75 inches in length running up the arm along the vein.

What is your assessment of Mr. Turn’s PIV site – is it good or bad? How would you rate his PIV site on the phlebitis scale (see “Phlebitis Scale” on Bb in “First Exposure” content area)?

What do you think caused Mr. Turn’s phlebitis score?

Select a pertinent nursing diagnosis for Mr. Turn.

What would be your next nursing action(s) regarding Mr. Turn’s PIV?

Answer 1

1.Peripheral IV site is bad

2..Score 4 on phlebitis scale (Palpable cord less than 1 inch and no fever)

3.Vancomycin has low ph and irritant drug. Infiltration of vancomycin might have caused phlebitis.

4.Risk for altered tissue perfusion r/t Intravenous filtration as evidenced by redness and client expressing discomfort

5.Stop infusion and resite cannula, treatment for phlebitis