Chamberlain College of Nursing
Fundamentals of Nursing
fe66; IV 96 1
Homeostasis:
To maintain a stable, relatively constant condition
 Body fluids and
components in constant
motion in an eff...
Metastatic
Breast
Cancer
Decreased
Sodium
Hypercalcemia
Chemotherapy
Nausea/Vomiting
Fluid Volume
Overload
IV fluids
fe66;...
Intake and output (et al) to be equal
fe66; IV 96 4
Water
 What it does
 Transportation of
nutrients, electrolytes and
oxygen to the cells
 Excretion of waste
products
 R...
1 liter Weighs 1 kilogram
 Patient weighs 78
kilograms
 Has vomiting and
diarrhea
 Daily weights are
initiated
 Patien...
Intake and Loss
Intake:
 Fluids: 1500 mL/day
 Solid Foods 800 mL/day
 Metabolism 300 mL/day
Loss:
 Kidneys 1200mL-1500...
Intake and output
 Measurable
 Intake
 Oral and tube feedings
 Parental fluids
 Enemas
 Retained irrigant
 Not Meas...
Electrolytes
 Chemicals dissolved in body fluid
 Distribution of electrolytes affects fluid balance
 Helps regulates in...
Fluid and Electrolyte Labs
Electrolyte Normal Action
Sodium 135-145 mEq/dl Water
Potassium 3.5-4.5 mEq/dl Nerves, muscles,...
.25
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Fluid and Electrolyte : Labs
 BUN- nitrogen in the blood from urea
 Creatinine- byproduct of muscle metabolism
 Hematoc...
Osmolality & Osmolarity
 Both terms refer to concentration of a solution
 Concentration creates osmotic pressure (pullin...
Two Compartments of Fluid in the
Body
 Intracellular fluid (ICF)—fluid within cells (70%)
 Extracellular fluid (ECF)—flu...
Distribution of Fluids
 Intracellular fluid (ICF) – fluid within cells (70%)
 Vital for normal cell function
 Contains ...
Distribution and Transport of Fluids
and Particles
Diffusion Osmosis Active Transport Filtration
Definition:
The process
w...
Osmolarity of a Solution
Hypotonic Isotonic Hypertonic
# of particles fewer than
plasma.
A hypotonic fluid will
shift and ...
Regulation of Water Balance:
Other controlsKidneys:
Juxtaglomerular
Apparatus
Kidneys:
Adrenal Cortex
Hypothalamus Heart
S...
Fluid Spacing
 First spacing
 Normal distribution of fluid in ICF and ECF
 Second spacing
 Abnormal accumulation of in...
Gerontologic Considerations
 Decreased body weight 45-50% instead of 60%
 Places them at higher risk for f/e imbalances
...
.50
fe66; IV 96 21
Fluid and Electrolyte Disorders
 Fluid Volume Deficit
 Fluid Volume Excess
 Hypernatremia/ Hyponatremia
 Hyperkalemia/...
Extracellular Fluid Volume
Imbalances
 ECF volume deficit (Hypovolemia)
 Abnormal loss of normal body fluids
 diarrhea,...
Fluid Volume Deficit:
Hypovolemia or Dehydration
 Fluid Intake is less than Fluid Output:
 Hypovolemia—water and electro...
Causes of Fluid Volume Deficit
• Prolonged fever
• GI Losses: Watery diarrhea, Vomiting, drainage from tubes
• Loss of pla...
Fluid Deficit: Signs & Symptoms
Moderate Severe
Thirst
Dizziness
weakness
confusion
anxiety
Postural hypotension
Flushed, ...
Lab Values
 Hypovolemia: Loss of fluids and electrolytes.
(Excessive fluid loss like hemorrhage)
 Increased Hematocrit/H...
1015
 1215
fe66; IV 96 28
Lab Values
 Dehydration
 Elevated Hematocrit
 Elevated Sodium
 Increased serum osmolality
 Urine specific gravity gre...
Fluid Volume Deficit:
The Nursing Process
 Diagnoses:
 Deficient fluid volume
 Risk for imbalanced fluid volume
 Readi...
Treatment for Fluid Volume Deficit
Replace missing fluids
 Dehydration: Oral fluids or IV
 Low sodium, hypotonic like 0....
Nursing management: FVD
 VS
 LOC changes
 Safe environment
 I and O
 Daily weights
 Lab values
 Skin turgor and int...
Extracellular Fluid Volume
Imbalances
 Fluid volume excess (Hypervolemia)
 Excessive intake of fluids,
 Abnormal retent...
Fluid Volume Excess: Over
hydration
 Excessive retention of either just water or water and
sodium.
 s/s and treatment wi...
1030
 1230
fe66; IV 96 35
Fluid Volume Excess:
Signs & Symptoms
 Edema
 Dependent areas first
 Face and whole body later (anasarca)
 Skin: taut,...
Fluid Volume Excess: Treatment
 Restrict sodium and water intake
 May give hypertonic fluids
 VS
 Respiratory status
...
Electrolytes: What are they?
 Substances that split when put in water
 Separate into IONS:
 CHARGED PARTICLES: +positiv...
Electrolytes
• Measurement:
• International standard is mill moles per liter (mmol/L)
• U.S. uses milliequivalent (mEq)
• ...
Major Electrolytes in Brief
 Sodium:135-145mEq/L (fluids; acid-base; nerve and muscle cells)
 Potassium:3.5-5mEq/L (flui...
Sodium: Hypernatremia
 NA+= >145 mEq
 (Norm: 135-145 mEq)
 Water loss or excess Na+
 Decreased Na+
excretion- renal fa...
1045
 1245
fe66; IV 96 42
Sodium: Hyponatremia
 Na+=<135 mEq
 (Norm: 135-145 mEq)
 Water excess or loss of
Sodium
 Dilution- polydipsia,
diabete...
Potassium: Hyperkalemia
 >5.0 mEq
 (Norm 3.5-5 mEq)
 Major Intracellular cation
 Na+/K+ Pump- No
hormonal control
 So...
Hyperkalemia
 Symptoms
 MURDER
 M- muscle weakness
 U-Urine-oliguria, anuria
 R-Respiratory distress
 D-Decreased ca...
Potassium: Hypokalemia
 >3.5 mEq
 (Norm 3.5-5.0 mEq)
 Cardiac Function
(decreased excitability of
cells)
 Causes: vomi...
Hypokalemia
 Signs/Symptoms
 Dysrhythmia, weakness,
nausea/vomiting,
paralytic ileus,
constipation, decreased
blood pres...
Potassium Intravenous
Supplements
 Must have adequate
urine output (at least
600 mL/Day)
 Never IV push- cardiac
arrest ...
1100
 100
fe66; IV 96 49
Hypercalcemia
 >10.5 mg
 (Norm 9.0-10.5 mg)
 Bones- primary source
 Affects transmission of
nerve impulses, heart
and ...
Hypercalcemia
 Hypercalcemia
 Nausea, constipation
 Cardiac Arrest
 Decreased excitability,
tetany, increased heart,
i...
Hypocalcemia
 <9.0 mg
 (Norm 9.0-10.5 mg)
 Removal of parathyroid,
immobility,
malabsorption, renal
failure post menopa...
fe66; IV 96 53
Phosphate 3.0-4.5 mEq
 Hyperphosphatemia
 Cause: renal failure,
tumors, lysis syndrome,
 s/s- Calcium deposits in
joint...
Magnesium 1.3-2.1 mEq
 Hypermagnesemia
 Cause: increased intake,
MOM, Maalox, Chronic
kidney disease
 s/s lethargy,
nau...
1115
 115
fe66; IV 96 56
Electrolytes: Food sources
 Sodium
 Table salt/processed and canned foods/deli
 Potassium
 Bananas/citrus/melon/aprico...
Administering Medications
 Mineral-electrolyte preparations
 often powders dissolved in water or juice
 diluted so they...
Acid-Base Balance
 Chemical balance in the body is regulated by acidity or
alkalinity, which is measured by the pH value
...
Acid–Base Balance: Where’s the hydrogen?
 Our acidity defines us. It’s a delicate balance,
without which life cannot be s...
pH
 Normal values 7.35-7.45
 Compatible with life 6.8 - 8.0
 Body fluids maintained normal values by:
 Buffers, Respir...
ABG’s: Measuring acid-base
 pH 7.35-7.45
 Hydrogen ion concentration
 PaCO2: 35-45mmHG
 Arterial carbon dioxide- Carbo...
1130
 130
fe66; IV 96 63
Causes of Acid-Base Balance
Metabolic Acidosis
Diabetic ketoacidosis
Diarrhea
Renal failure
Shock
Aspirin overdose
Sepsis
...
Acid/Base Compensation
 Lungs
 eliminates or retains
carbonic acid
 Very fast/efficient to
respond to change
 Alters r...
Let’s Practice …
Mr. Lowery, 54, suffered an acute anterior wall MI and
is now in cardiogenic shock. ABGs show:
pH: 7.27
P...
fe66; IV 96 67
fe66; IV 96 68
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Rationales and objectives of
parenteral therapy
 Maintenance therapy for daily body requirements
 Replacement therapy fo...
Intravenous Therapy
 Delivery method considerations
 Purpose of therapy
 Length of time the infusion is to run
 Diagno...
General Guidelines/Short
Peripheral Catheters
 Short Peripheral Catheter:
 Use the smallest size catheter to accommodate...
General Guidelines:
Peripherally inserted central
catheter
 Major factors:
 Therapy will continue for 1 month or more
 ...
Placement of Peripherally Inserted
Central Catheter (PICC)
fe66; IV 96 74
Central Lines
 Large Lumen Catheter surgically placed into a central
vein (subclavian or internal jugular)
 Used for:
 ...
1015
 1215
fe66; IV 96 76
Central Line Considerations
 Surgically placed (not PICC)
 Placement verified by x-ray (Superior Vena Cava)
 Sterile dr...
Implanted Ports
 Fluid reservoir is surgically inserted in a subcutaneous
pocket(usually upper chest) with catheter via t...
IV Solutions
Isotonic Hypotonic Hypertonic
Isotonic fluid stays
inside the bloodstream
or intravascular
compartment.
Ex:
0...
Skills:
Administering Parenteral Fluids
 The nurse should observe for the following guidelines:
 Monitor the solution in...
Skills:
Administering Parenteral Fluids
 Intravenous Therapy/Venipuncture
 Before the procedure, assemble and make ready...
Skills:
Administering Parenteral Fluids
 Intravenous Therapy/Venipuncture
 Intravenous Monitoring
 Patency
 A conditio...
1030
 1230
fe66; IV 96 83
Skills:
Administering Parenteral Fluids-
complications
 Intravenous Therapy/Venipuncture
 Phlebitis
 This results from ...
2011 Recommendations of the
Infusion Nurses Society
Phlebitis Scale
Grade Clinical Criteria
0
1
2
3
4
No symptoms
Erythema...
Infiltration Scale
Symptoms 0 1 2 3 4
Blanching    
Edema < 1 inch 1-6 inches > 6 inches >6 inches,
pitting
Cool to to...
Extravasation
 Definition: seepage of IV medication into tissue
 Cause: vein has ruptured allowing vesicant to seep
into...
Severed Catheter
 Catheter “broke” off an tip entered the circulatory
system
 Rare but deadly.
 Pain at site, decreased...
Complications of IV therapy
Infection: redness, warmth, pain, hardness, fever,
purulent drainage
If infection is suspected...
1045
 1245
fe66; IV 96 90
Skills for Administering Parenteral
Fluids
 Intravenous Therapy/Venipuncture
 Septicemia
 A systemic infection occurs f...
Nursing care of the IV patient
 Check IV order for completeness, accuracy
 I and O and Weights
 Monitor rate of infusio...
Blood Transfusions : Process
 Verify physician order; Obtain Consent
 Patient must have a type and cross-match blood sam...
Blood Transfusion Reactions
 Caused by:
 Blood incompatibility
 Allergic sensitivity
 Signs and Symptoms:
 Change in ...
Skills:
Blood Transfusion Reactions
 Blood Transfusion Reactions
 If the infused blood is not compatible with the patien...
fe66; IV 96 96
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Transcript of "Fluid and electrolytes (celestesversion) 3"

  1. 1. Chamberlain College of Nursing Fundamentals of Nursing fe66; IV 96 1
  2. 2. Homeostasis: To maintain a stable, relatively constant condition  Body fluids and components in constant motion in an effort to maintain homeostasis  Transporting water, electrolytes, oxygen, nutrients in and cell metabolism waste or unnecessary components out.  Many conditions or diseases can disrupt  Sweating  Altered Fluid Intake  Vomiting  Diarrhea  Diabetes  Organ Failure fe66; IV 96 2
  3. 3. Metastatic Breast Cancer Decreased Sodium Hypercalcemia Chemotherapy Nausea/Vomiting Fluid Volume Overload IV fluids fe66; IV 96 3
  4. 4. Intake and output (et al) to be equal fe66; IV 96 4
  5. 5. Water  What it does  Transportation of nutrients, electrolytes and oxygen to the cells  Excretion of waste products  Regulation of body temperature  Lubricator, insulator, and shock absorber of joints and membranes  Medium for food digestion Water composition in  60% in Adult  Increased in Child  Decreased in Older Adult  Found in Foods (not ETOH)  2000 mL-3000 mL/day  1 liter H2O=1 kg body weight fe66; IV 96 5
  6. 6. 1 liter Weighs 1 kilogram  Patient weighs 78 kilograms  Has vomiting and diarrhea  Daily weights are initiated  Patient dropped to 75 kilograms  How much fluid is he deprived?  78 kilograms - 75 kilograms _______ 3 kilograms loss 3 kilogram loss: 3 kg 1 liter 1 kg fe66; IV 96 6
  7. 7. Intake and Loss Intake:  Fluids: 1500 mL/day  Solid Foods 800 mL/day  Metabolism 300 mL/day Loss:  Kidneys 1200mL-1500 mL  Skin 500-600 mL/day  Lungs 400 mL/day  GI tract 100-200 mL/day  Drainage: ??? fe66; IV 96 7
  8. 8. Intake and output  Measurable  Intake  Oral and tube feedings  Parental fluids  Enemas  Retained irrigant  Not Measurable:  Solid foods  Metabolism  Measurable  Urine  Emesis  Feces  Drainage from body cavity  Not Measurable:  Sweating  Vaporization fe66; IV 96 8
  9. 9. Electrolytes  Chemicals dissolved in body fluid  Distribution of electrolytes affects fluid balance  Helps regulates intake, output, acid/base balance, hormones  Sodium  Major Extra cellular electrolyte  Controls and regulates WATER balance  Potassium  Major Intra cellular electrolyte  Helps maintain intracellular water balance  Transmits nerve impulses, muscle contraction fe66; IV 96 9
  10. 10. Fluid and Electrolyte Labs Electrolyte Normal Action Sodium 135-145 mEq/dl Water Potassium 3.5-4.5 mEq/dl Nerves, muscles, heart Chloride 98-106 mmol/dl Osmotic pressure, acid base balance Calcium 9.0-10.5 mg/dl Nerve, heart, blood clotting Phosphate 3.0-4.5 mEq/dl Calcium (inverse relationship) fe66; IV 96 10
  11. 11. .25 fe66; IV 96 11
  12. 12. Fluid and Electrolyte : Labs  BUN- nitrogen in the blood from urea  Creatinine- byproduct of muscle metabolism  Hematocrit- volume percentage of erythrocytes  Hemoglobin- the iron containing pigment of the red blood cells  Urine Specific Gravity- Urine Concentration  BMP (“Chem 7)  (Basic Metabolic Panel)- Na+, K+, Cl-, BUN, Creatinine, CO2, Glucos  CMP (Chem 14)  (Comprehensive Metabolic Panel) Na+, K+, Cl-, Ca+, BUN, Creatinine, CO2, Glucose, Liver Enzymes, (ALT, AST, Bilirubin) Alkaline Phosphatase, Total Protein, Albumin fe66; IV 96 12
  13. 13. Osmolality & Osmolarity  Both terms refer to concentration of a solution  Concentration creates osmotic pressure (pulling power)  Higher concentration = greater pulling power  Normal value 275 – 295 mOsm/L  Osmolality  Concentration of particles per kilogram of water  Osmolarity  Concentration of particles per liter of solution (not necessarily water) Terms often used interchangeably fe66; IV 96 13
  14. 14. Two Compartments of Fluid in the Body  Intracellular fluid (ICF)—fluid within cells (70%)  Extracellular fluid (ECF)—fluid outside cells (30%)  Includes intravascular and  interstitial fluids  transcellular  Think of it as 3 compartments:  Inside the cells  Blood & Blood vessels  Tissue fe66; IV 96 14
  15. 15. Distribution of Fluids  Intracellular fluid (ICF) – fluid within cells (70%)  Vital for normal cell function  Contains oxygen, electrolytes, & glucose  Extracellular fluid (ECF) – fluid outside cells (30%)  Interstitial fluids – surround cell  Intravascular fluids – plasma within vascular system  Transcellular fluids – cerebrospinal, pericardial, pancreatic, pleural, intraocular, biliary, peritoneal, & synovial fluid *** To maintain proper fluid balance, the distribution of fluid between the two compartments must remain relatively constant. fe66; IV 96 15
  16. 16. Distribution and Transport of Fluids and Particles Diffusion Osmosis Active Transport Filtration Definition: The process where by solutes move from an area of higher concentration to an area of lower concentration. Molecules are randomly vibrating The fluid with more particles more concentrated has more pulling power. Fluid will get pulled across a membrane from a more dilute area to a more concentrated area. Osmolarity: The pulling power or concentration of a solution. Particles “swimming upstream” *pushing* The molecules need a ”push” to get across the membrane. Energy is required. (ATP) Example: Sodium- potassium pump Solutes can only pass through the capillary walls. Membranes act as barriers. We need pressure to get across. Capillary Osmotic Pressure fe66; IV 96 16
  17. 17. Osmolarity of a Solution Hypotonic Isotonic Hypertonic # of particles fewer than plasma. A hypotonic fluid will shift and flow into a more concentrated solution. # of particles just like plasma. Two isotonic fluids on different sides of a barrier stay put! # of particles greater than plasma A hypertonic fluid will pull a less concentrated solution into itself. fe66; IV 96 17
  18. 18. Regulation of Water Balance: Other controlsKidneys: Juxtaglomerular Apparatus Kidneys: Adrenal Cortex Hypothalamus Heart Sense low sodium volume Release renin Converts angiotension I to Angiotension II Stimulates release of aldosterone (RAAS) Senses low serum osmolarity or low sodium Releases aldosterone Reabsorbs sodium Increases K+excretion in to the urine Increases serum osmolarity Excretes sodium in the urine Senses high serum osmolarity or high Na+ Stimulates thirst Triggers release of ADH: vasopressin Retains water in blood Concentrates urine Mild constriction of blood vessels Decreases serum osmolarity Senses increased volume : stretch receptors in the right atrium Secretes ANP, BNP Inhibits ADH Stops RAAS Increased Na+excretion through urine stops reabsorption of Na+ Dilates blood vessels Decreases serum osmolarity fe66; IV 96 18
  19. 19. Fluid Spacing  First spacing  Normal distribution of fluid in ICF and ECF  Second spacing  Abnormal accumulation of interstitial fluid (edema)  Third spacing  Fluid accumulation in part of body where it is not easily exchanged with ECF fe66; IV 96 19
  20. 20. Gerontologic Considerations  Decreased body weight 45-50% instead of 60%  Places them at higher risk for f/e imbalances  Decreased muscle mass  Structural changes-  Kidneys decreased GFR, decreased renin/aldosterone  Decreased creatinine clearance, decreased ability to concentrate. Decreased ability to conserve water  Loss of Subcutaneous tissue, decreased thirst, musculoskeletal changes, mental status changes, incontinence- leading to withholding the water to not be incontinent, then becoming dehydrated. fe66; IV 96 20
  21. 21. .50 fe66; IV 96 21
  22. 22. Fluid and Electrolyte Disorders  Fluid Volume Deficit  Fluid Volume Excess  Hypernatremia/ Hyponatremia  Hyperkalemia/ Hypokalemia  Hypercalcemia/ Hypocalcemia  Hyperphosphatemia/ Hypophosphatemia  Hypermagnesemia/Hypomagnesemia fe66; IV 96 22
  23. 23. Extracellular Fluid Volume Imbalances  ECF volume deficit (Hypovolemia)  Abnormal loss of normal body fluids  diarrhea, fistula drainage, hemorrhage  Inadequate intake  Access, desire, medication influence  Plasma-to-Interstitial fluid shift  Edema, 3rd Spacing  Treatment: replace water and electrolytes with balanced IV solutions fe66; IV 96 23
  24. 24. Fluid Volume Deficit: Hypovolemia or Dehydration  Fluid Intake is less than Fluid Output:  Hypovolemia—water and electrolyte losses about equal  Clinical Dehydration—more water lost than electrolytes  Fluid volume deficit + hypernatremia fe66; IV 96 24
  25. 25. Causes of Fluid Volume Deficit • Prolonged fever • GI Losses: Watery diarrhea, Vomiting, drainage from tubes • Loss of plasma or whole blood: Burns, Hemorrhage, Traumas, Surgery • Excessive sweating • Renal failure • Hyperglycemia • Inability to drink or express thirst (confused) • Concentrated tube feedings • Third-space shifts • Use of diuretics fe66; IV 96 25
  26. 26. Fluid Deficit: Signs & Symptoms Moderate Severe Thirst Dizziness weakness confusion anxiety Postural hypotension Flushed, dry skin Possible fever Dry mucous membranes Decreased urine output; dark yellow to amber Change in skin turgor (?) Weight loss HR RR BP Lethargy progressing to coma Dry, cracked tongue Cold, clammy skin delayed capillary refill Tenting Dark or no urine (less than 30 ml/hour) No tears or sweat Sunken eyeballs fe66; IV 96 26
  27. 27. Lab Values  Hypovolemia: Loss of fluids and electrolytes. (Excessive fluid loss like hemorrhage)  Increased Hematocrit/Hemoglobin  Increased BUN  Elevated specific gravity fe66; IV 96 27
  28. 28. 1015  1215 fe66; IV 96 28
  29. 29. Lab Values  Dehydration  Elevated Hematocrit  Elevated Sodium  Increased serum osmolality  Urine specific gravity greater than 1.030  We’ve lost water, but not electrolytes. More particles, less fluid. fe66; IV 96 29
  30. 30. Fluid Volume Deficit: The Nursing Process  Diagnoses:  Deficient fluid volume  Risk for imbalanced fluid volume  Readiness for enhanced fluid balance  Currently in balance but have many risk factors  Goals/Outcomes:  Restore fluid loss  Identify patients at risk  Maintain balance between fluid intake and output  Prevent fluid imbalance fe66; IV 96 30
  31. 31. Treatment for Fluid Volume Deficit Replace missing fluids  Dehydration: Oral fluids or IV  Low sodium, hypotonic like 0.45 NS  Why: Blood is concentrated; Na level is high  Hypotonic solutions will draw fluid into cells and swell them if given too quickly  Administer gradually  Hypovolemia: Isotonic fluids  0.9NS or Lactated Ringer’s/blood transfusion PRN  Why: Restore blood volume and normalize BP fe66; IV 96 31
  32. 32. Nursing management: FVD  VS  LOC changes  Safe environment  I and O  Daily weights  Lab values  Skin turgor and integrity  IV access  Urinary catheter fe66; IV 96 32
  33. 33. Extracellular Fluid Volume Imbalances  Fluid volume excess (Hypervolemia)  Excessive intake of fluids,  Abnormal retention of fluids  Congestive Heart Failure, Renal Disease, Medication influences  Interstitial-to-plasma fluid shift  Treatment: remove fluid without changing electrolyte composition or osmolality of ECF fe66; IV 96 33
  34. 34. Fluid Volume Excess: Over hydration  Excessive retention of either just water or water and sodium.  s/s and treatment will be similar  Causes:  kidney, heart, or liver failure  Too rapid infusion of IV fluids  Corticosteroids  Labs: Hemodilution: More water than particles  Low H and H  Low or normal Na  Decreased serum osmolality  Decreased BUN fe66; IV 96 34
  35. 35. 1030  1230 fe66; IV 96 35
  36. 36. Fluid Volume Excess: Signs & Symptoms  Edema  Dependent areas first  Face and whole body later (anasarca)  Skin: taut, shiny  Bounding pulse/elevated BP  JVD: Jugular vein distention  SOB; crackles; cough  Weight gain  LOC: confusion/lethargy  Muscle cramps/weakness  Nausea fe66; IV 96 36
  37. 37. Fluid Volume Excess: Treatment  Restrict sodium and water intake  May give hypertonic fluids  VS  Respiratory status  I and O  Lab values  Daily weights  Raise HOB  Safety and Comfort  Meds as needed to help organ function  Teaching and prevention fe66; IV 96 37
  38. 38. Electrolytes: What are they?  Substances that split when put in water  Separate into IONS:  CHARGED PARTICLES: +positive or CATIONS -negative or ANIONS  Found in ALL fluid compartments  Cations are supposed to equal Anions:  +Sodium, Potassium, Calcium, Magnesium  -Bicarbonate, Chloride, Phosphorous fe66; IV 96 38
  39. 39. Electrolytes • Measurement: • International standard is mill moles per liter (mmol/L) • U.S. uses milliequivalent (mEq) • Electrolyte Composition: • ICF • Prevalent cation is K+ • Prevalent anion is PO4 3 • ECF • Prevalent cation is Na+ • Prevalent anion is Cl fe66; IV 96 39
  40. 40. Major Electrolytes in Brief  Sodium:135-145mEq/L (fluids; acid-base; nerve and muscle cells)  Potassium:3.5-5mEq/L (fluids; cell excitability)  Calcium: Ionized Calcium 4.5-5.5mg/dl (teeth; bones; clotting; nerve/muscle cells)  Magnesium: 1.5-2.5 mEq/L (nerve/muscle cells; cellular reactions)  Chloride: 95-105mEq/L (fluids; pH and acid-base balance)  Bicarbonate:22-26(arterial)mEq/L,24-30(venous) (acid-base balance)  Phosphate:2.8-4.5mg/dl acid-base balance; metabolism) Cations (+) Anions (-) Na+ Sodium K+ Potassium Ca+ Calcium Mg+ Magnesium Cl- Chloride HCO3 - Bicarbonate HPO4 2- Phosphate SO4 2- Sulfate fe66; IV 96 40
  41. 41. Sodium: Hypernatremia  NA+= >145 mEq  (Norm: 135-145 mEq)  Water loss or excess Na+  Decreased Na+ excretion- renal failure, corticosteroids  Increased NA+ intake- eating too much salt/ hypertonic IV fluids  Increased water loss, fever, infection, hyperventilation, sweating, diarrhea You are “FRIED” F-Fever R-Restless I-Increased fluid retention E-Edema D-Decreased urine output Extreme: Mental status change, fever, seizures Treat the etiology- diuretics, Na+ restriction, avoid Na+ foods, seizure precautions fe66; IV 96 41
  42. 42. 1045  1245 fe66; IV 96 42
  43. 43. Sodium: Hyponatremia  Na+=<135 mEq  (Norm: 135-145 mEq)  Water excess or loss of Sodium  Dilution- polydipsia, diabetes, SIADH, CHF  Increase excretion of Na+- sweating, diuretics, GI wound drainage, renal disease  Decreased intake of Na+ NPO, low NA+ diet, severe vomiting, diarrhea  Symptoms  Confusion, headache, CNS, neurological (BRAIN)  Abdominal Cramps, Nausea, vomiting  Replace Na+ (usually IV )  Hypertonic solution (3% Na+ Solution)  Fluid Restriction if caused by fluid excess fe66; IV 96 43
  44. 44. Potassium: Hyperkalemia  >5.0 mEq  (Norm 3.5-5 mEq)  Major Intracellular cation  Na+/K+ Pump- No hormonal control  Source: primarily diet  Avocado, fish, bananas, OJ, raisins, dried fruit, meat, milk, fruits, vegetables  Oral supplements, IV supplements  Route of loss: Kidneys/urine Disrupts Cardiac Function- increased cell excitability Hyperkalemia- cause is primarily from kidney dysfunction False high results: lab inaccuracies  Poor lab collection practices/improper specimen handling  Prolonged tourniquet  Old blood, cell destruction, acidosis, hypoxia, exercise, catabolic state, K+ sparing diuretics (spironolactone) fe66; IV 96 44
  45. 45. Hyperkalemia  Symptoms  MURDER  M- muscle weakness  U-Urine-oliguria, anuria  R-Respiratory distress  D-Decreased cardiac contractility  E-ECG changes  R-Reflexes: hyperreflexia or anreflexia  Treatment:  Cardiac Monitoring  Kayexelate (oral or rectal)  Calcium gluconate, Lasix  Stop K+ in IV fluids  Avoid foods high in potassium  Dialysis if severe fe66; IV 96 45
  46. 46. Potassium: Hypokalemia  >3.5 mEq  (Norm 3.5-5.0 mEq)  Cardiac Function (decreased excitability of cells)  Causes: vomiting, NG suction, diarrhea, diuretics, laxatives, insulin, metabolic alkalosis, rapid cell building, B12 or erythropoietin to increase RBC fe66; IV 96 46
  47. 47. Hypokalemia  Signs/Symptoms  Dysrhythmia, weakness, nausea/vomiting, paralytic ileus, constipation, decreased blood pressure, weak pulse, increase digoxin, muscle weakness, paralysis, diuresis  Treatment  Cardiac Monitor  Foods high in potassium  Watch for digoxin toxicity  Potassium IV only if good output  Spironolactone  Treat constipation fe66; IV 96 47
  48. 48. Potassium Intravenous Supplements  Must have adequate urine output (at least 600 mL/Day)  Never IV push- cardiac arrest potential  Cardiac Monitor  Assess IV site often- Very irritating- prefer CVC  Always dilute- no more than 20 mEq/hr; no more than 40 mEq in IV bag fe66; IV 96 48
  49. 49. 1100  100 fe66; IV 96 49
  50. 50. Hypercalcemia  >10.5 mg  (Norm 9.0-10.5 mg)  Bones- primary source  Affects transmission of nerve impulses, heart and muscle contractions, blood clotting, formation of teeth and bones  Must have Vitamin D to absorb  Dietary intake GI absorption  Parathyroid hormone-  causes Ca+ to increase Ca+ to release from bones and increase Vitamin D  Decrease kidney excretion of Ca+ Calcitonin decreases calcium absorption, inhibits bone reabsorption fe66; IV 96 50
  51. 51. Hypercalcemia  Hypercalcemia  Nausea, constipation  Cardiac Arrest  Decreased excitability, tetany, increased heart, interrupts muscle cell  Prolonged immobilization, renal failure  Lethargy, confusion, sever muscle weakness, fractures, kidney stones, increased clotting time  Treatment:  Get rid of calcium, Lasix,  Hydration 3- 4000mL/day,  weight bearing activity  NO antacids fe66; IV 96 51
  52. 52. Hypocalcemia  <9.0 mg  (Norm 9.0-10.5 mg)  Removal of parathyroid, immobility, malabsorption, renal failure post menopausal  Treatment:  Calcium supplements, diet increase Calcium with Vitamin D supplement  Biggest risk: Thyroid surgery  Signs/Symptoms: CATS  C- Convulsion  A-Arrhythmias  T- Tetany  S- Spasms/Stridor  Trousseaus- Carpal/pedal spasms  Chvostec’s sign- facial nerve fe66; IV 96 52
  53. 53. fe66; IV 96 53
  54. 54. Phosphate 3.0-4.5 mEq  Hyperphosphatemia  Cause: renal failure, tumors, lysis syndrome,  s/s- Calcium deposits in joints, skin, kidneys, eyes, hypocalcemia, tetany, neuromuscular irritability  Treatment: Correct Hypocalcemia (inverse relationship)  Hypophosphatemia  Cause: malnutrition, malabsorption, alcohol abuse, too many antacids  s/s- CNS depression, confusion, muscle weakness, dysrhythmias, fractures  Treatment: oral supplements, decrease calcium intake, IV replacementfe66; IV 96 54
  55. 55. Magnesium 1.3-2.1 mEq  Hypermagnesemia  Cause: increased intake, MOM, Maalox, Chronic kidney disease  s/s lethargy, nausea/vomiting, loss of deep tendon reflexes, respiratory/cardiac arrest  Treatment: avoid magnesium containing foods/drugs, dialysis if severe  Hypomagnesemia  Cause: prolonged fasting, starvation, alcohol abuse,  s/s increased deep tendon reflexes, confusion, tremors, seizures, cardiac changes  Treatment oral supplements, increased green vegetables, nuts, bananas oranges, peanut butter, chocolate fe66; IV 96 55
  56. 56. 1115  115 fe66; IV 96 56
  57. 57. Electrolytes: Food sources  Sodium  Table salt/processed and canned foods/deli  Potassium  Bananas/citrus/melon/apricots/broccoli/potatoes  Magnesium  Grains/beans/green leafy veg/seafood/meat/chocolate  Calcium  dairy fe66; IV 96 57
  58. 58. Administering Medications  Mineral-electrolyte preparations  often powders dissolved in water or juice  diluted so they don’t taste so bad and don’t irritate the stomach  Sudden hyperkalemia can cause cardiac arrest  POTASSIUM GIVEN IV PUSH IS LETHAL (Never, never, never do this !!!)  Diuretics  Rid body of excess fluid (and electrolytes!)  Must be monitored closely to prevent further imbalances.  Intravenous therapy  Use appropriate solutions fe66; IV 96 58
  59. 59. Acid-Base Balance  Chemical balance in the body is regulated by acidity or alkalinity, which is measured by the pH value  Arterial Blood Gas (ABG) analysis is the best way to evaluate acid-base balance and oxygenation  Our body must maintain a delicate balance between acidity and alkalinity in order for life to be maintained  Common Health problems which lead to imbalance  Diabetes mellitus  Vomiting and diarrhea  Respiratory conditions fe66; IV 96 59
  60. 60. Acid–Base Balance: Where’s the hydrogen?  Our acidity defines us. It’s a delicate balance, without which life cannot be supported. All our internal chemical reactions can only take place within the right acid-base environment.  Acid  substance that releases H+ ion when dissolved in water  Base  substance that will bind with H+ ion when dissolved in water fe66; IV 96 60
  61. 61. pH  Normal values 7.35-7.45  Compatible with life 6.8 - 8.0  Body fluids maintained normal values by:  Buffers, Respiratory system, Renal system fe66; IV 96 61
  62. 62. ABG’s: Measuring acid-base  pH 7.35-7.45  Hydrogen ion concentration  PaCO2: 35-45mmHG  Arterial carbon dioxide- Carbonic Acid  HCO3: 22-26mEq/L  Bicarbonate fe66; IV 96 62
  63. 63. 1130  130 fe66; IV 96 63
  64. 64. Causes of Acid-Base Balance Metabolic Acidosis Diabetic ketoacidosis Diarrhea Renal failure Shock Aspirin overdose Sepsis Metabolic Alkalosis Loss of gastric secretions Overuse of antacids K+ wasting diuretics Respiratory Acidosis Hypoventilation COPD Airway obstruction Drug overdose Chest trauma Pulmonary edema Neuromuscular disease Respiratory Alkalosis Hyperventilation Hypoxia Anxiety High altitude Pregnancy Fever fe66; IV 96 64
  65. 65. Acid/Base Compensation  Lungs  eliminates or retains carbonic acid  Very fast/efficient to respond to change  Alters rate/depth of respirations  Faster rate/more depth - eliminates CO2 and pH rises  Slower rate/less depth retains CO2 and pH lowers  Kidneys  Regulate by selectively excreting or conserving bicarbonate and hydrogen ions  Slower to respond to change  Takes hours to days to restore H+ ion concentration. fe66; IV 96 65
  66. 66. Let’s Practice … Mr. Lowery, 54, suffered an acute anterior wall MI and is now in cardiogenic shock. ABGs show: pH: 7.27 PaCO2: 38 HCO3 - : 14 What is his acid/base status ??? fe66; IV 96 66
  67. 67. fe66; IV 96 67
  68. 68. fe66; IV 96 68
  69. 69. fe66; IV 96 69
  70. 70. Rationales and objectives of parenteral therapy  Maintenance therapy for daily body requirements  Replacement therapy for present losses  Restoration therapy for concurrent or continuing losses:  Hemorrhage  Low Platelets  Vomiting  Diarrhea fe66; IV 96 70
  71. 71. Intravenous Therapy  Delivery method considerations  Purpose of therapy  Length of time the infusion is to run  Diagnosis, age, and health history  Type of solution used or what drugs are being administered  Condition of veins  Peripheral lines vs. Central lines vs. Ports fe66; IV 96 71
  72. 72. General Guidelines/Short Peripheral Catheters  Short Peripheral Catheter:  Use the smallest size catheter to accommodate therapy Size of Catheter Use 14-16 gauge Trauma, large volume at a rapid rate 18 gauge Surgical patient, rapid administration of fluids and blood products 20-24 gauge Most medical/surgical patients, daily use 22-24 gauge Older adults, small vein access fe66; IV 96 72
  73. 73. General Guidelines: Peripherally inserted central catheter  Major factors:  Therapy will continue for 1 month or more  Therapy includes administration of a vesicant infusion or long-term antibiotic therapy fe66; IV 96 73
  74. 74. Placement of Peripherally Inserted Central Catheter (PICC) fe66; IV 96 74
  75. 75. Central Lines  Large Lumen Catheter surgically placed into a central vein (subclavian or internal jugular)  Used for:  Long Term Therapy  All IV Therapies  Blood Draws  Bad peripheral veins  Large fluid volumes  Total parenteral nutrition fe66; IV 96 75
  76. 76. 1015  1215 fe66; IV 96 76
  77. 77. Central Line Considerations  Surgically placed (not PICC)  Placement verified by x-ray (Superior Vena Cava)  Sterile dressings and technique  Flushing and Locking per facility policy  Complications include: Central Line Infection, pneumothorax, hemothorax, cardiac perforation,  Watch for: SOB, chest pain, cough, hypotension, tachycardia, anxiety after or during insertion fe66; IV 96 77
  78. 78. Implanted Ports  Fluid reservoir is surgically inserted in a subcutaneous pocket(usually upper chest) with catheter via the internal jugular or subclavian vein with the tip resting in the superior vena cava  All IV Therapies can be administered through the port  Have a low infection rate  Has cosmetic advantages  Must use non-coring needle to access fe66; IV 96 78
  79. 79. IV Solutions Isotonic Hypotonic Hypertonic Isotonic fluid stays inside the bloodstream or intravascular compartment. Ex: 0.9% NS LR (contains Na+, Cl+, K+, & Ca+ ) A hypotonic fluid will shift and flow into a more concentrated solution. Draw fluid from vessels and move fluid into the cells. Ex: D5W 0.45% NS A hypertonic fluid will pull a less concentrated solution into itself. Draw fluid out of the cells and into the blood Used for panic low Na levels (115) Ex: 3% NS 5% NS fe66; IV 96 79
  80. 80. Skills: Administering Parenteral Fluids  The nurse should observe for the following guidelines:  Monitor the solution infusion rate  Infuse the amount of prescribed solution.  Maintain the patency of the IV catheter.  Monitor site every 1 to 2 hours or as per policy  During parenteral therapy, the patient’s I&O should be recorded. fe66; IV 96 80
  81. 81. Skills: Administering Parenteral Fluids  Intravenous Therapy/Venipuncture  Before the procedure, assemble and make ready the equipment.  Assess the patient’s veins (start distally)  Select and clean a puncture site. Follow strict aseptic principles  Perform venipuncture.  Begin infusion.  Teach the patient about the signs and symptoms of problems and ways to perform activities while on IV therapy. fe66; IV 96 81
  82. 82. Skills: Administering Parenteral Fluids  Intravenous Therapy/Venipuncture  Intravenous Monitoring  Patency  A condition of being opened and unblocked  Flow rate is ordered by the physician.  Assess tubing for kinks or obstructions.  Inspect and palpate the site for complications  Assess for signs and symptoms of fluid overload. fe66; IV 96 82
  83. 83. 1030  1230 fe66; IV 96 83
  84. 84. Skills: Administering Parenteral Fluids- complications  Intravenous Therapy/Venipuncture  Phlebitis  This results from mechanical irritation (the needle moving in the vein), the low pH of some IV solutions, and highly concentrated additives.  Classic Signs  Erythema, warmth, edema, and discomfort  Applying warm compresses to the inflamed area lessens discomfort. fe66; IV 96 84
  85. 85. 2011 Recommendations of the Infusion Nurses Society Phlebitis Scale Grade Clinical Criteria 0 1 2 3 4 No symptoms Erythema at access site with or without edema Pain at access site with erythema or edema Pain at access site with erythema or edema plus streak formation and palpable cord Pain at access site with erythema and edema, streak, palpable cord>1 inch in length & purulent drainage fe66; IV 96 85
  86. 86. Infiltration Scale Symptoms 0 1 2 3 4 Blanching     Edema < 1 inch 1-6 inches > 6 inches >6 inches, pitting Cool to touch     Pain +/- +/-  Mild to moderate; numbness  Moderate to severe; Circulatory impairment Blood or vesicant therapy  fe66; IV 96 86
  87. 87. Extravasation  Definition: seepage of IV medication into tissue  Cause: vein has ruptured allowing vesicant to seep into surrounding tissues  Symptoms: swelling, redness, pain, blisters  Extravasation kit may be used to neutralize the damage fe66; IV 96 87
  88. 88. Severed Catheter  Catheter “broke” off an tip entered the circulatory system  Rare but deadly.  Pain at site, decreased BP, weak rapid pulse, cyanosis  Apply tourniquet above site of pain  Notify MD stat  Monitor and support patient  Avoid causing by:  Never reinserting a needle through a catheter after withdrawing it.  Remove catheter slow & parallel to skin  Inspect catheter after removal fe66; IV 96 88
  89. 89. Complications of IV therapy Infection: redness, warmth, pain, hardness, fever, purulent drainage If infection is suspected, determine whether culture of catheter is needed PRIOR to discontinuing fe66; IV 96 89
  90. 90. 1045  1245 fe66; IV 96 90
  91. 91. Skills for Administering Parenteral Fluids  Intravenous Therapy/Venipuncture  Septicemia  A systemic infection occurs from pathogens introduced into the circulating bloodstream.  Signs and Symptoms  Fever, chills, prostration, pain, headache, nausea, and vomiting  Antibiotic therapy is vigorously initiated if blood cultures verify a septicemia condition. fe66; IV 96 91
  92. 92. Nursing care of the IV patient  Check IV order for completeness, accuracy  I and O and Weights  Monitor rate of infusion (IV fluids can kill!)  Remember the size and age of your patient (don’t overload them!)  Change site, dressing, tubing and solution per agency policy (usually every 24 hours)  Documentation:  Date, time, site, type of catheter inserted  Type and amount of fluid infused  Patient’s response to therapy and teaching fe66; IV 96 92
  93. 93. Blood Transfusions : Process  Verify physician order; Obtain Consent  Patient must have a type and cross-match blood sample performed  Large bore catheter: 18 gauge  Administer with 0.9% Normal Saline  Baseline vital signs, hold and notify if abnormal  Pre-medication may be ordered: Diphenhydramine, Acetaminophen Double check with two RNs at patient’s bedside: Everything must match!  Begin transfusion slowly- watch for reactions  Observe closely for first 15 min- Stop immediately if any sign of reaction  Blood may not hang longer than 4 hours fe66; IV 96 93
  94. 94. Blood Transfusion Reactions  Caused by:  Blood incompatibility  Allergic sensitivity  Signs and Symptoms:  Change in Vital Signs, fever, chills, rash, hypotension, shock STOP TRANSFUSION  Treatment: give Normal Saline, prepare for emergency drugs; save tubing  Anaphylactic Reaction is promptly treated with antihistamines, steroids, and epinephrinefe66; IV 96 94
  95. 95. Skills: Blood Transfusion Reactions  Blood Transfusion Reactions  If the infused blood is not compatible with the patient’s blood type, an acute hemolytic reaction will occur.  A transfusion reaction is an emergency. Transfusion is stopped immediately and the reaction must be treated intensively to reduce complications and death of patient.  Signs and symptoms  Statement of “not feeling right”  Chills, fever, low back pain, pruritus, Hives/Rash, hypotension, nausea and vomiting, decreased urine output, hematuria, chest pain, dyspnea, shock fe66; IV 96 95
  96. 96. fe66; IV 96 96
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