Fluids And Electrolytes

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Fluids And Electrolytes

  1. 1. F L U I D S<br />AND <br />ELECTROLYTES<br />
  2. 2. Water overview<br />*Water comprises about <br /> 60% -70% of the total body <br /> weight <br />*Varies with<br /> age<br /> weight<br /> gender<br />
  3. 3. Factors that Determine the Amount of Water Content<br />Age – the older we get, water content is lesser<br />Sex/Gender – males have more water than females<br />Body size/Weight– thin people have more water than chubby ones<br />
  4. 4. Normal Composition in Average Man<br /><ul><li>When a person loses more than 10% of his total body fluids,he can DIE!!!</li></li></ul><li>Functions of Water in the Body<br /><ul><li>-Transportingnutrients to cells and </li></ul> wastes from cells <br /><ul><li>-Transporting hormones, enzymes, blood</li></ul> platelets, and red and white blood cells<br /><ul><li>-Facilitating cellular metabolism and proper </li></ul> cellular chemical functioning<br /><ul><li>-Facilitating digestionand promoting elimination
  5. 5. -Acting as asolventfor electrolytes and </li></ul> non-electrolytes<br /><ul><li>-Acting as a tissue lubricant and cushion
  6. 6. -Helping maintain normal body temperature</li></li></ul><li>Two Compartments of Fluid in the Body<br /><ul><li> Intracellular fluid (ICF)(60-70%)</li></ul>- fluid within cells<br /> - K is the major component<br /><ul><li> Extracellular fluid (ECF)(20-30%)</li></ul>- fluid outside cells<br /> - Na & Cl<br />
  7. 7. Interstitial – between the cells<br />Intravascular – inside the blood vessel<br />Transcellular – CSF, saliva, GIT secretions and tears<br />
  8. 8. LOSS of WATER<br />Routes and daily body fluid excretion<br />
  9. 9. SENSIBLE<br />- An individual is aware of losing that water.<br />
  10. 10. GIT / Feces<br />Water loss through defecation/feces is 200cc<br />
  11. 11. KIDNEYS / Urine<br />Water loss through urination is 1,500ml<br />
  12. 12. INSENSIBLE<br />- An individual is unaware of losing that water.<br />
  13. 13. SKIN / Perspiration<br />Water loss through perspiration is 600ml <br />
  14. 14. LUNGS / Respiration<br />Water loss through respiration is about 300ml – 350ml<br />
  15. 15. Causes of Increased Water Loss<br />Causes of Increased <br />Water Gain<br /><ul><li>Fever
  16. 16. Diarrhea
  17. 17. Diaphoresis
  18. 18. Vomiting
  19. 19. Gastric suctioning
  20. 20. Tachypnea
  21. 21. Increased sodium intake
  22. 22. Increased sodium retention
  23. 23. Excessive intake of water
  24. 24. Excess secretion of ADH</li></li></ul><li>Electrolytes<br />
  25. 25. Electrolytes<br /><ul><li>Anelectrolyteis a substance, that when dissolved in water, gives a solution that can conduct electricity </li></ul>Ion -atom or molecule carrying an electrical charge<br /> cation –develop a positive charge<br /> ex. Na, K, Ca, Mg<br /> anions –develop a negative charge<br /> ex. Cl, HCO, PO4<br />These charges are the basis of chemical interactions in<br />The body necessary for metabolism and other function <br />
  26. 26. Functions of electrolytes<br />-promotes neuromascular irritability<br />-maintenance of body fluid osmolarity<br />-regulation of water balance<br />-distribution of body fluids between compartments<br />-Conduct an electric current that transports energy thoughout the body<br />
  27. 27. Effects of Electrolytes<br /><ul><li>The loss of electrolytes in the body can lead to an unbalance of fluids in the body and the pH, and a damage of the electric potential between the nerve cells that transmit the nerve signals (Encarta)</li></li></ul><li>Major Electrolytes/Chief Function<br />Sodium- support muscle contraction and nerve impulse transmission<br />Potassium— chief regulator of cellular enzyme activity and water content<br />Calcium- formation of bones and teeth, nerve impulse, blood clotting, muscle contraction, B12 absorption<br />Magnesium— support bone mineralization, protein building, muscular contraction, nerve impulse t.<br />Chloride — maintains osmotic pressure in blood, produces hydrochloric acid<br />Bicarbonate — body’s primary buffer system<br />Phosphate— involved in important chemical reactions in body, cell division and hereditary traits<br />
  28. 28. Regulation of Body Fluid Compartments<br />Processes:<br /><ul><li>Osmosis</li></ul>fluid move across a semi -<br /> permeable membrane from an <br /> area of low solute concentration <br /> to an area of high solute <br /> concentration until equilibrium <br /> is achieved.<br />
  29. 29. Diffusion<br /><ul><li> The movement of particles in all directions through a solution.
  30. 30. The process by which a solute (substance that is dissolved) may spread through a solution or solvent (solution in which the solute is dissolved).</li></li></ul><li><ul><li>Active Transport
  31. 31. Physiologic pump that moves from an area of lower concentration to higher concentration with the use of ATP.
  32. 32. The sodium-potassium pump is an example of active transport.</li></li></ul><li>Osmolarity<br />Describes the concentration of solutes or dissolved particles<br />Filtration<br />is the movement of solutes and solvents by hydrostatic pressure. <br />- the movement is from an area of greater pressure to an area of lesser pressure.<br />Osmotic pressure <br /> is the amount of hydrostatic pressure needed <br /> to stop the flow of water by osmosis <br /> -pressure exerted by proteins<br />Hydrostatic pressure<br /> pressure exerted by fluid on blood vessel wall<br />
  33. 33. Types of IV Solutions<br />ISOTONIC – balance osmotic pressure<br /> Solute concentration is equal to that of the serum<br /> Fluid doesn’t shift because they’re equally concentrated and already in balance<br />Solution has the same osmolality as the extracellular fluid.<br /> Examples: D5W ; Normal Saline<br />* Doesn’t cause shrinking or swelling of the cell<br />
  34. 34. HYPERTONIC SOLUTION<br />Greater pressure than that of the blood serum<br />Fluids tend to move out of the less concentrated solution into the more concentrated <br />Solutions have a higher concentration of solute and are more concentrated than extracellular fluids. Net movement intracellular to extracellular<br /> Examples : 3% saline; 5% saline<br />* Causes the cell to shrink<br />
  35. 35. HYPOTONIC SOLUTION<br />Lesser pressure than that of the blood serum<br />Fluid shifts from the hypotonic solution into the more concentrated compartment to equalize the concentrations<br />Solutions have a lower concentration of solutes and is more dilute than extracellular fluid . Net movement extracellular to intracellular<br /> Examples : 1/2 Normal Saline; 1/3 Normal Saline<br />* Causes the cell to swell<br />
  36. 36. WATER BALANCE<br />THIRST – hypothalamus<br />Hormones<br /> a. ADH – posterior pituitary gland<br /> - reabsorption of water<br /> b. Aldosterone – adrenal gland<br /> - Na retention, H2O retention<br />
  37. 37. ADH<br />Hypothalamus senses low blood volume  pituitary gland secretes ADH into the bloodstream <br />  ADH causes the kidney to retain water <br />  water retention boosts blood volume <br />
  38. 38. ALDOSTERONE<br />Produced as a result of the renin-angiotensin mechanism<br />Acts to regulate fluid volume<br /><ul><li>Angiotensin II stimulate the adrenal gland to release aldosterone
  39. 39. Aldosterone causes the kidneys to retain Na and water
  40. 40. Increases fluid volume and sodium levels</li></li></ul><li>Renin - angiotensinsystem <br />BP decreased  renin  angiotensinogen<br />angiotensin 1<br />angiotensin 2<br />
  41. 41. Renin – angiotensinsystem<br />Angiotensin 2<br />aldosterone peripheral<br /> vasoconstriction<br /> increase Na reabsorption<br />increase water reabsorption<br />Increase plasma volume<br /> increase blood pressure<br />
  42. 42. VOLUME DISTURBANCES<br />
  43. 43. FLUID VOLUME DEFICIT<br />
  44. 44. Description:<br />Dehydration in which the body’s intake is not sufficient to meet the body’s fluid needs.<br />The goal of treatment is to restore fluid volume, replace electrolytes as needed, and eliminate the cause of the fluid volume deficit.<br />
  45. 45. CAUSES<br />Diabetes insipidus<br />Fever<br />Diarrhea<br />Renal failure<br />Lack of fluid intake<br />Malnutrition<br />Vomiting<br />Diaphoresis<br />
  46. 46. Poor skin turgor<br />Sunken fontanels<br />Dry mouth<br />Scanty urine<br />No perspiration<br />Sunken eyeballs<br />Weight loss<br />No tears<br />Weak<br />Lethargy<br />Dizziness <br />Extreme thirst<br />Dry skin<br />SIGNS AND SYMPTOMS<br />
  47. 47. Encourage increase oral fluid intake<br />Administer IVF (LR or NSS)<br />Monitor I & O<br />Replace fluid loss gradually over 48 hours<br />Monitor Na levels, urine specific gravity<br />MANAGEMENT<br />
  48. 48. FLUID VOLUME EXCESS<br />Increase water<br />CAUSES<br />Excess fluid or sodium intake<br /> a. IV administration of NSS or LR<br /> b. High intake of dietary Na<br />Fluid and Na retention<br />Fluid shift into the intravascular space<br /> a. Burn<br /> b. use of plasma CHON or albumin<br />
  49. 49. Edema<br />Increase in weigHt<br />Puffy eyelids<br />Poor skin turgor<br />Tachypnea<br />Dyspnea<br />Signs and symptoms<br />
  50. 50. MANAGEMENT<br />Monitor I & O<br />Limit water<br />Skin care<br />Turn patient every 2 hours<br />O2<br />Limit Na<br />Monitor electrolyte values<br />
  51. 51. ELECTROLYTE IMBALANCES<br />
  52. 52. SODIUM (Na+)  135-145 mEq/L<br />-principal cation in ECF<br />-average daily requirements 2-4 grms/day<br />-responsible for:<br /> -serum osmolality<br /> -water retention<br /> -neuromuscular activity “Na pump action”<br /> -acid- base balance<br />-foods high in Na<br /> -salted foods ex. ham, corned beef, cheese etc.<br />-regulated by the kidneys<br />-influenced by hormone aldosterone<br />-Chloride frequently appears in combination with Na+ion.<br />
  53. 53. Hyponatremia:<br />serum sodium level falls below 135 mEq/L. <br />Cells become swollen.<br />Etiology:<br />a. loss of Na<br />b. gains of water<br />c. Disease states associated with <br /> ADH (Vasopressin)<br />
  54. 54. Clinical manifestations<br />(Hyponatremia) <135mEq/L<br />CNS changes<br />Lethargy, headaches<br />Confusion<br />Seizures<br />Coma<br />nausea/vomiting<br />Hemiparesis<br />Diarrhea, abdominal cramps<br />Pale dry skin<br />
  55. 55. Nursing Intervention<br />1.Evaluate precipitating cause is corrected<br />2.monitor Na serum level<br />3.Evaluate clinical manifestations of Na loss<br />4.Maintain pts. safety<br />5.Administer prescribed treatment, IV therapy<br />
  56. 56. Hypernatremia:<br />Serum sodium is more than 150 mEq/L.<br />Cells shrink. <br />Etiology:<br />Water deprivation<br />Excessive salt ingestion<br />Increased insensible loss<br />Water loss diarrhea<br />Prolong fever or diaphoresis w/o water replacement<br />Na containing parenteral solutions, corticosteroids, some antibiotics<br />Near salt water drowning<br />Diabetes insipidus- polyuria, polydipsia<br />
  57. 57. Clinical manifestations (hypernatremia)<br />Serum Na+>145 mEq/L<br />Thirst<br />Nausea and vomiting<br />Flushed, dry skin<br />Fever<br />Dry sticky membranes<br />Rough, dry, swollen tongue<br />CNS effects<br />Restlessness, agitation<br />Muscular twitching, tremor, hyper-reflexia<br />Disorientation, hallucinations<br />Stupor, coma<br />
  58. 58. Nursing Interventions<br />1.Evalute precipitating cause and correct<br />2.Monitor serum Na level<br />3.Evaluate clinical manifestations of hypernatremia<br />4.Administer prescribed treatment<br />5.Report abnormal findings to MD<br />6.Patient education for future prevention<br />
  59. 59.
  60. 60. POTASSIUM (K+): 3.5-5.0 mEq/L<br />-Principal cation in ICF, 97%<br />-Cannot be measured in the cells<br />-Acute abnormal levels are life threatening<br />1. K+<2.5 or>7.0-cardiac arrest<br /> 2. K+<3.5-hypokalemia<br /> 3. K+>5.5-hyperkalemia<br />-Responsible for:<br /><ul><li>Conduction of nerve impulses
  61. 61. Skeletal and cardiac muscle activity
  62. 62. Intracellular osmolality
  63. 63. Enzyme action for cellular metabolism </li></li></ul><li>POTASSIUM (K+): 3.5-5.0 mEq/L<br />-80-90% excreted in the GIT in urine<br />-10-20% excreted in by GIT in feces<br />-Poorly stored in the body<br />-Daily intake is essential (40-60mEq/L)<br />-Foods high in K+<br />Green vegetables<br />Dry fruits<br />Nuts<br />Meat<br />Cocoa, brewed coffee<br />
  64. 64. Hypokalemia:<3 mEq/L<br />Etiology<br />GI loss<br />Diarrhea, GI suction, vomiting, laxatives<br />Renal loss<br />K loss diuretics, aldosterone, steroids<br />Glucocorticoids, sweat, some antibiotic<br />Shift into cells<br />Insulin, alkalosis,TPN<br />Poor intake<br />Anorexia, alcoholism, debilitation, neglect<br />
  65. 65. Clinical manifestations ( hypokalemia)<br />Fatigue, weakness<br />Cramps, restless legs<br />Decreased reflexes<br />Quadra-paralysis<br />Respiratory muscle<br />-Renal<br />Impaired conc. Of urine<br />Dilute frequent urination<br />Resistance to ADH, kidney exchange Na for K<br />-CV<br />Sensitivity to digoxin<br />Decreased BP<br />
  66. 66. Cont.<br />Clinical manifestation (hypokalemia)<br />-ECG changes<br />Flat T waves<br />U wave<br />Arrhythmias/cardiac arrest<br />-GI<br />Decreased motility, paralytic ileus<br />Anorexia, nausea, vomiting<br />
  67. 67. Nursing interventions<br />Be aware of pt.at risk for K excess<br />Assess pt.taking K+P.O. for GI upset<br />Be aware that there are many forms of K+ supplements available. Check physicians order carefully<br />Assess and educate pt.concerning nutrition for adequate K+ intake<br />
  68. 68. Hyperkalemia: <br />serum value of >6 mEq/L<br />Etiology:<br />Pseudo hyperkalemia<br />Excess K+ intake<br />Renal excretion<br />Drugs<br />Shift of K+ out of cells<br />
  69. 69. Clinical manifestations (hyperkalemia)<br />-ABD cramping, nausea, diarrhea<br />-Lower extremities muscle weakness<br />-Irritability<br />-Paresthesias of face, tongue, feet and hands<br />-Flaccid muscle paralysis<br />-Bradycardia, irregular heart rate, cardiac standstill<br />-ECG changes<br />Tall, peaked T waves, prolonged PR<br />Widened QSR <br />
  70. 70. Hyperkalemia: serum value of >6 mEq/L<br />
  71. 71. Nursing Interventions<br />Monitor serum K+ report value >5.3<br />Caution hyperkalemiapts.to avoid foods high in K+ like:<br />Chocolates, coffee, tea, dried fruits and beans, meat and eggs, bananas<br />Monitor for U/O<br />Administer fresh blood as ordered<br />Regulate IV w/ K+ carefully<br />Utilized good phlebotomy techniques<br />
  72. 72. CALCIUM :<br />8.5-10.5 mg/dl or 4.5-5.8 mEq/L<br />Functions:<br /><ul><li>Formation of bone and teeth
  73. 73. Contraction of muscle, relaxation, activation and excitation
  74. 74. Maintaining cardiac contraction
  75. 75. Cellular strength and permeability
  76. 76. Blood coagulation
  77. 77. Blocks sodium transport into the cell
  78. 78. Transmission of nerve impulses</li></li></ul><li>Calcium ImbalancesEtiology<br />Hypocalcemia<br /><4.5/9 mg/dl<br />Diet<br />Chronic renal failure<br />Mal absorption syndromes<br />Alcoholism<br />Acute pancreatitis<br />Loop diuretics<br />Citrated blood<br />alkalosis<br />Hypercalcemia<br />>5.5/11 mg/dl<br />98%<br />Hyperparathyroidism<br />Thiazide diuretics <br />malignancy<br />Immobility<br />Vit.A & D overdose<br />Ca cont. antacids<br />Renal dysfunction<br />Steroid<br />acidosis<br />
  79. 79. Clinical manifestations (hypocalcemia)<br />Irritability<br />Decreased memory<br />Delusions, hallucinations<br />Hyperreflexia<br />Parasthesias<br />+ Chvostek’s sign<br />+ Trousseau’s sign<br />Laryngeal spasm, resp.arrest<br />Tetany, seizures<br />Abd’l. cramps<br />ECG<br />Prolonged QT interval<br />
  80. 80. Nursing Interventions<br />Monitor serum Ca, VS, ECG<br />Give PO Ca supp.30 mins.before eating<br />Be aware of safe administration of IV Ca<br />Teach clients to eat food high in Ca, Vit.D, protein<br />Take necessary precautions for confusion, seizure<br />Assess for prolong bleeding<br />
  81. 81. Clinical manifestation (Hypercalcemia)<br />Headache, confusion<br />Decreased memory<br />Psychosis, stupor, coma<br />Muscle weaknesses, fatigue<br />Depressed reflexes<br />Anorexia, N/V<br />Bone pain, fractures<br />Polyuria, dehydration<br />Nephrolithiasis ( kidney stones)<br />ECG<br />Shortened QT interval<br />
  82. 82. Nursing Interventions<br />Monitor serum Ca, VS, ECG<br />Mobilization and wt. bearing activity<br />Diet low in Ca<br />Dilute urine to prevent renal calculi formation<br />Hydrate w/ isotonic solutions<br />Promote excretion w/loop diuretic<br />Watch for digitalis toxicity<br />
  83. 83. DEHYDRATION<br />
  84. 84. Dehydration: Definition<br />defined as "the excessive loss of water and electrolytes from the body“<br />Dehydration can be caused by losing too much fluid, not drinking enough water or fluids, or both. <br />
  85. 85. Dehydration: Definition<br />Infants and children are more susceptible to dehydration than adults because of their smaller body weights and higher turnover of water and electrolytes. <br />So are the elderly and those with illnesses<br />
  86. 86. Causes of Dehydration<br />when losses are not replaced adequately, a deficit of water and electrolytes develop.<br />vomiting or diarrhea<br />acute illness where there is loss of appetite and vomiting<br />Excessive urine output ex. diabetes or diuretic use <br />Excessive sweating (sports)<br />Burns<br />
  87. 87. Since diarrhea and vomiting are the most common causes of dehydration in children, the volume of fluid loss may vary from 5 ml/kg (normal) to 200 ml/kg<br />Concentration of electrolytes lost also varies<br />NaCl and K are the most common electrolytes lost through stools<br />
  88. 88. Dehydration:Checking the main symptoms<br />History taking and do a thorough physical examination<br /> classify type of dehydration depending on the amount of water and electrolytes lost<br />These are reflected by the signs and symptoms the child will present<br />
  89. 89. Dehydration: Classification<br />Dehydration is classified as no dehydration, some dehydration, or severe dehydration based on how much of the body's fluid is lost or not replenished. <br />When severe, dehydration is a <br />life-threatening emergency<br />DEATH<br />
  90. 90. Clinical signs of dehydration<br />
  91. 91.
  92. 92. Poor Skin Turgor<br />
  93. 93. WHO Treatment Plan A<br />Three rules of home treatment:<br />give extra fluids<br />continue feeding<br />advise when to return to the doctor<br />(if the child develops blood in the stool, <br />drinks poorly, becomes sicker, or is not <br />better in three days).<br />
  94. 94. WHO Treatment Plan B<br />ORS(ml) <br /> the mother slowly gives the recommended amount of ORS by spoonfuls or sips<br />Note: If the child is breastfed, breast-feeding should continue.<br />After 4 hours, reassess and reclassify dehydration, and begin feeding to provide required amounts of potassium and glucose. <br />Wt kg x 75 for 4h<br />
  95. 95. WHO Treatment Plan B<br />If there are no more signs of dehydration, do Plan A. <br />If there is still some dehydration, repeat<br />Plan B.<br />If the child now has severe dehydration, do Plan  C.<br />
  96. 96. WHO Treatment Plan C<br />-Give IV infusion<br />-If IV infusion is not possible, fluids should be given by nasogastric tube. <br />-If none of these are possible and the child can drink, ORS must be given by mouth. <br />Note: In areas where cholera <br />cannot be excluded for patients <br />less than 2 years old with severe <br />dehydration, antibiotics are <br />recommended. Start Cotrimoxazole.<br />
  97. 97. WHO Treatment Plan C<br />100 ml/kg of PLR<br />Normal saline does not correct acidosis or replace potassium losses, but can be used. Plain glucose or dextrose solutions are not acceptable for the treatment of severe dehydration.<br />
  98. 98. REMEMBER:<br />Do not give:<br />Very sweet tea, soft drinks, and sweetened fruit drinks. <br />(These are often hyperosmolar (high sugar content).<br />Can cause osmotic diarrhea, worsening dehydration and hyponatremia. <br />Also to be avoided are <br /> fluids with purgative <br /> action and stimulants <br /> (e.g., coffee, some<br /> medicinal teas or infusions).<br />
  99. 99. Assessment of Dehydration<br />Graded according to the signs and symptoms that reflect the amount of fluid lost.<br />There are usually no signs or symptoms in the early stages<br />As dehydration increases, signs and symptoms develop. Initially, thirst, restlessness, irritability, decreased skin turgor, sunken eyes and sunken fontanelles.<br />As more losses occur, these<br /> effects become more pronounced. <br />
  100. 100. Signs of hypovolemic shock (SEQUELAE)<br />diminished sensorium (lethargy)<br />Lack of urine output<br />Cool moist extremities<br />A rapid and feeble pulse<br />Decreased BP<br />Peripheral cyanosis<br />DEATH.<br />
  101. 101. Summary of Management According to Degree of Dehydration<br />
  102. 102. Summary of Management According to Degree of Dehydration<br />
  103. 103. Summary of Management According to Degree of Dehydration<br />
  104. 104. INTRAVENOUS<br />FLOW RATES<br />
  105. 105. IV TUBING<br />
  106. 106. Calculating Administration Rates<br />One must know two key components before using the formula:<br /><ul><li>Drop factor of the IV administration set
  107. 107. Amount of solution to be infused over one hour</li></li></ul><li>Rate Calculations <br />Macrodrip Set<br /><ul><li>10 drops = 1 ml
  108. 108. 15 drops = 1 ml
  109. 109. 20 drops = 1 ml</li></ul>Microdrip Set<br /><ul><li>60 drops = 1 ml</li></ul>Blood Set<br /><ul><li>10 drops = 1 ml</li></li></ul><li><ul><li>Calibrated in drops per ml-this calibration is needed in calculating flow rates.
  110. 110. Macrodrip set is used for routine adult IV administration, depending on the manufacturer and the type of tubing.
  111. 111. 10/15, 15/60, 20/60, commonly drop factor.
  112. 112. A macrodrip set is used when more exact measurements are needed, such as in pediatric units.</li></li></ul><li>FORMULA<br />Drip Rate (gtts or mgtts/min) =<br />Total no. of ml x Drip Factor Total no. of min. <br />
  113. 113. Total number of ml<br />qtts/min= × drop factor<br /> Total number of hours <br /> 1000ml = × 20gtts/ml 8hours<br /> = 41-42gtts/min<br />Doctor’s Order: Start D5LR 1L to infuse over 8 hours the drop factor is 20qtts/ml,compute for the drops/minute.<br />
  114. 114. Ex. gtts/min. Doctor’s order: Start 500ml of NS to infuse over 300 minutes. The drop factor is 10 gtts/ml. compute for the gtts/min.?<br />Gtts/min = total no. of ml X drop factor<br /> total no. of hour <br /> = 500ml X 10gtts/ml<br /> 300mins. <br /> = 16.66 gtts/min<br />
  115. 115. Ex. gtts/min. Doctor’s order: Start 500ml of NS to infuse over 300 minutes. The drop factor is 10 gtts/ml. compute for the gtts/min.?<br />Gtts/min = total no. of ml X drop factor<br /> total no. of hour <br /> = 500ml X 10gtts/ml<br /> 5 hours 60<br /> = 16.66 gtts/min<br />
  116. 116. FORMULA<br />ml per hour =<br />Total no. of ml<br /> Total no of hours<br />
  117. 117. total number of ml<br /> Cc /hr=<br /> total number of hours<br /> 1000ml<br /> =<br /> 80ml/hour<br /> = 12.5hour<br />Doctor’s Order: 1000ml of D5NM to infuse at a rate of 80cc/hour. A nurse determine that it will take, how many hours for 1L to infuse?<br />total number of ml<br />Cc/hour =c<br />
  118. 118. <ul><li>Start D5LR 1L to run for 10 hours. Compute for cc/hour?</li></ul> total number of ml<br />cc/hour=<br /> total number of hour<br /> 1000cc<br /> = <br /> 10hours<br /> = 100cc/hour <br />
  119. 119. Ex. Gtts/min D5NM 1L has been ordered by Dr. Dy for his post-mastectomy patient to be infused at rate of 20gtts/minute. In how many hours will the said IVF last?<br />Gtts/min = _____total no. of ml_____ X drop factor<br /> total no. of hour <br /> = __1,000ml__ X 15<br /> 20 gtts/min 60 <br /> = 15,000<br /> 1,200<br /> = 12.5 hours<br />
  120. 120. Other factors affecting Flow Rate:<br />Gauge of the catheter<br />Viscosity of the infusate<br />Height of the IV stand<br />Condition of the veins<br />Condition of the patient<br />
  121. 121. COMPLICATIONS<br />Circulatory Overloadcan occur if an IV is not regulated and IV fluids infuse to rapidly for the patient’s body to handle. <br />Signs of fluid over load:<br />Tachycardia<br />Increase Blood pressure<br />Headache<br />Anxiety<br />Wheezing or signs of respiratory distress<br />Diaphoresis<br />Restlessness<br />Distended neck veins<br />Chest pain<br />
  122. 122. - If an IV is running behind schedule-colaborate with the physician to determine the patients ability to tolerate an increased flow rate particularly patients with cardiac, pulmonary and renal problem.<br />A nurse should never arbitrarily speed up an IV to catch up if the IV is running behind the schedule.<br />Whenever an IV rate is increased the nurse should assess the patient for increased heart rate, increase respiration or lung congestion-indication of fluid overload.<br />
  123. 123. AFTERCARE<br />Regulating IV fluids is an ongoing process from the time that an IV is started until it is completed. Hourly checks of an IV should include assessing the pt’s response to the IV, the rate of an IV flow, how much fluid has infused, how much fluid remains to be infused, and the condition of the IV insertion site. Adjust the rate if the IV is not flowing at the rate that was ordered.<br />
  124. 124. If IV fluid is flowing in slowly, the nurse should check for a kink in the tubing or a position of problem. If an IV is flowing to rapidly, it may be leaking out around the IV insertion site. The whole system from the insertion site to the IV bag should be examined.<br />
  125. 125. Thank you very much for listening<br />
  126. 126. MAINTENANCE REQUIREMENTS<br />HOLIDAY-SEGAR METHOD<br />BODY SURFACE AREA METHOD<br />
  127. 127. HOLIDAY-SEGAR METHOD<br />Estimates caloric expenditure in fixed weight categories<br />Assumption<br />100 cal metabolized : 100 mL water<br />Not suitable for neonates < 14 days<br />Overestimates fluid needs<br />
  128. 128. HOLIDAY-SEGAR METHOD<br />
  129. 129. EXAMPLE<br />What is the maintenance fluid rate for a an 8 year old child weighing 25 kg using the Holiday-Segar Method?<br />
  130. 130. 100 x 10 = 1000 ml<br />+ 50 x 10 = 500 ml<br />+ 20 x 5 = 100 ml<br /> 1600 ml/day <br />
  131. 131. 4 x 10 = 40 ml<br />+ 2 x 10 = 20 ml<br />+ 1 x 5 = 5 ml<br /> 65 ml/hr<br />
  132. 132. EXERCISE<br />Using the Holiday-Segar Method, what is the full maintenance requirement and rate for a 10 year old patient who weighs 37 kg?<br />
  133. 133. BODY SURFACE AREA METHOD<br />Assumption: caloric expenditure is related to BSA<br />Not used in children < 10 kg<br />
  134. 134. BSA METHOD<br />STANDARD VALUES FOR USE IN BODY SURFACE AREA METHOD<br />
  135. 135.
  136. 136. BSA Formula<br />Surface area (m2) = ht (cm) x wt (kg)<br /> 3600 <br />
  137. 137. EXAMPLE<br />Using the BSA method, what is the maintenance requirement of an 8 year old who weighs 25 kg and is 132 cm tall?<br />
  138. 138. BSA Formula<br /> 0.92 m2 = 132 cm x 25 kg<br /> 3600 <br />
  139. 139. Water = 1500ml/0.92/day = 1630 ml<br />Na+ = 40 mEq/0.92/day = 43.5 mEq<br />K+ = 30 mEq/0.92/day = 32.6 mEq <br />
  140. 140. EXERCISE<br />Using the BSA Method, what is the maintenance requirement of a 12 year old boy who weighs 37 kg and is 142 cm tall?<br />
  141. 141. DEFICIT THERAPY<br />Calculated Assessment<br />Clinical Assessment<br />
  142. 142. CALCULATED ASSESSMENT<br />Fluid deficit (L) = preillness weight (kg) – illness weight (kg)<br />% Dehydration = (preillness weight – illness weight)/preillness weight x 100%<br />
  143. 143. CLINICAL ASSESSMENT<br />
  144. 144. FLUID REPLACEMENT<br />
  145. 145. ICF & ECF COMPARTMENTS<br />
  146. 146. ICF & ECF COMPARTMENTS<br />In dehydration, there are variable losses from the extracellular and intracellular compartments<br />Percentage of deficit is based on total duration of illness<br />
  147. 147.
  148. 148. BASIC<br /> MATH CONCEPTS<br />
  149. 149. DECIMALS<br />All figures to the left of the decimal point are whole numbers<br />All figures to the right of the decimal point are decimal fractions<br />. 385 = . 3 8 5<br />tenths<br />.385 = 385<br /> 1000<br />hundredths<br />thousandths<br />.38 = 38<br /> 100<br />.3 = 3<br /> 10<br />
  150. 150. CHANGING FRACTIONS TO DECIMALS:<br />Fractions can be changed to decimals by dividing the numerator and the denominator<br />¾ = 3 ÷ 4 = 0.75<br />
  151. 151. PERCENTAGE<br />Percentage ( % ) means hundredths<br />Percent ( % ) is the same as a fraction with denomination as 100.<br /> 3% = <br />3<br />100<br />45<br />100<br />45% =<br />
  152. 152. CHANGING PERCENT TO A DECIMAL & CHANGING DECIMAL TO PERCENT<br />To change percent to a decimal, remove the percent sign and divide the number by 100 or move the decimal point two places to the left.<br /> 4% = 4/100 = .04 or 0.04<br />To change a decimal to a percent, multiply by 100 or move the decimal point two places to the right and place % sign.<br /> 0.04 X 100 = 4% or 0.04 = 4% <br />
  153. 153. RATIOA Ratio consists of two numbers as separated by a colon ( : )<br /> e.g. 1 : 4 <br />A ratio indicates that there is a relationship between the two numbers.<br />A ratio is an indicated fraction.<br /> e.g. ¼ = 1 : 4<br />The numbers in ratio must be expressed in the same terms. <br /> e.g. 3 inches : 2 feet = 3 : 24<br /> (feet changes to inches)<br />
  154. 154. PROPORTION<br />It is a statement showing that the two ratios have equivalent values<br /> 1 : 50 = 2 : 100<br />If one value is not known, it can be solved by using the term X.<br /> 1 : X = 2 : 100 or <br />means<br />extremes<br />1 2<br />X 100<br />~<br />
  155. 155. THE METRIC SYSTEM<br />It is the international decimal system of weights and measures<br />¤ In the metric system, fractions are expressed as decimals<br /> ¤ In the decimal system, the fraction ½ is written as 0.5<br />METRIC SYSTEM<br />Liter = vol. of fluids milli = one thousandths<br /> Gram = weights of solids centi = one hundredths<br /> Meter = measure of length deci = one tenth<br /> mcg = one thousandths<br />
  156. 156. RULE OF CONVERSION<br />When converting from a larger unit of measure to a smaller unit, multiply the larger unit by (1000, 100, 10) or move the decimal to the right.<br />When converting a smaller unit of measure to a larger unit, divide the smaller unit by (1000, 100, 10) or move the decimal to the left.<br />e.g. 2.5 grams = ___________ mg.<br />
  157. 157. APOTHECARIES SYSTEM<br />Grain (gr) Dram Ounce Minims Pounds<br />Approximate Equivalent Value:<br /> 1 gr = 60 mg<br /> 1 ml = 15 minims (16 minims)<br /> 1 ounce = 30 ml<br /> 1 ounce = 30 Gm<br /> 1 kg = 2.2 pounds<br /> e.g. 60 gr = _________ mg.<br /> 4 oz = _________ ml.<br />
  158. 158. HOUSEHOLD MEASURES<br /> 1 teaspoon (tsp) = 4 – 5 ml<br /> 1 Tablespoon (Tbsp) = 3 teaspoons (tsp)<br /> 1 Tablespoon = 15 ml<br /> 1 milliliter = 15 drops (gtts)<br /> e.g. 5 ml = ______<br />
  159. 159. CONVERSION OF TEMPERATURE<br />Normal Temperature = 37°C = 98°F<br /> Conversion of Centigrade (Celsius) to Fahrenheit:<br /> Conversion of Fahrenheit to Centigrade (Celsius):<br />°C = 5 ( °F ) – 32<br /> 9<br />°F = 9 ( °C ) + 32<br /> 5<br />
  160. 160. Interpretation of Doctor’s Order for Drugs<br />The nurse must understand the order perfectly before acting on it <br />> The Drug<br />> The Dose<br />> The Route<br />> The Frequency<br />If any of the above are unclear or open for interpretations, it is the Responsibility of the nurse to clarify the order with the physician.<br />
  161. 161. Example:<br /> The order reads : Inderal 2 x4<br /> a. What is the Drug?<br /> b. What is the Dose?<br /> c. What is the Route?<br /> d. What is the Frequency?<br /> e. Do<br />es this order need clarification?<br />The order reads : Lasix 10 mg IV 1 ml O.D.<br /> a. What is the Drug?<br /> b. What is the Dose?<br /> c. What is the Route?<br /> d. What is the Frequency?<br /> e. Does this order need clarification?<br />
  162. 162. BASIC<br /> MATH CONCEPTS<br />
  163. 163. DECIMALS<br />All figures to the left of the decimal point are whole numbers<br />All figures to the right of the decimal point are decimal fractions<br />. 385 = . 3 8 5<br />.385 = 385<br /> 1000<br />tenths<br />.38 = 38<br /> 100<br />thousandths<br />hundredths<br />.3 = 3<br /> 10<br />
  164. 164. CHANGING FRACTIONS TO DECIMALS:<br />Fractions can be changed to decimals by dividing the numerator and the denominator<br />¾ = 3 ÷ 4 = 0.75<br />
  165. 165. PERCENTAGE<br />Percentage ( % ) means hundredths<br />Percent ( % ) is the same as a fraction with denomination as 100.<br /> 3% = <br />3<br />100<br />45<br />100<br />45% =<br />
  166. 166. CHANGING PERCENT TO A DECIMAL & CHANGING DECIMAL TO PERCENT<br />To change percent to a decimal, remove the percent sign and divide the number by 100 or move the decimal point two places to the left.<br /> 4% = 4/100 = .04 or 0.04<br />To change a decimal to a percent, multiply by 100 or move the decimal point two places to the right and place % sign.<br /> 0.04 X 100 = 4% or 0.04 = 4% <br />
  167. 167. RATIOA Ratio consists of two numbers as separated by a colon ( : )<br /> e.g. 1 : 4 <br />A ratio indicates that there is a relationship between the two numbers.<br />A ratio is an indicated fraction.<br /> e.g. ¼ = 1 : 4<br />The numbers in ratio must be expressed in the same terms. <br /> e.g. 3 inches : 2 feet = 3 : 24<br /> (feet changes to inches)<br />
  168. 168. PROPORTION<br />It is a statement showing that the two ratios have equivalent values<br /> 1 : 50 = 2 : 100<br />If one value is not known, it can be solved by using the term X.<br /> 1 : X = 2 : 100 or <br />means<br />extremes<br />1 2<br />X 100<br />~<br />
  169. 169. THE METRIC SYSTEM<br />It is the international decimal system of weights and measures<br />¤ In the metric system, fractions are expressed as decimals<br /> ¤ In the decimal system, the fraction ½ is written as 0.5<br />METRIC SYSTEM<br />Liter = vol. of fluids milli = one thousandths<br /> Gram = weights of solids centi = one hundredths<br /> Meter = measure of length deci = one tenth<br /> mcg = one thousandths<br />
  170. 170. RULE OF CONVERSION<br />When converting from a larger unit of measure to a smaller unit, multiply the larger unit by (1000, 100, 10) or move the decimal to the right.<br />When converting a smaller unit of measure to a larger unit, divide the smaller unit by (1000, 100, 10) or move the decimal to the left.<br />e.g. 2.5 grams = ___________ mg.<br />
  171. 171. APOTHECARIES SYSTEM<br />Grain (gr) Dram Ounce Minims Pounds<br />Approximate Equivalent Value:<br /> 1 gr = 60 mg<br /> 1 ml = 15 minims (16 minims)<br /> 1 ounce = 30 ml<br /> 1 ounce = 30 Gm<br /> 1 kg = 2.2 pounds<br /> e.g. 60 gr = _________ mg.<br /> 4 oz = _________ ml.<br />
  172. 172. HOUSEHOLD MEASURES<br /> 1 teaspoon (tsp) = 4 – 5 ml<br /> 1 Tablespoon (Tbsp) = 3 teaspoons (tsp)<br /> 1 Tablespoon = 15 ml<br /> 1 milliliter = 15 drops (gtts)<br /> e.g. 5 ml = ______<br />
  173. 173. CONVERSION OF TEMPERATURE<br />Normal Temperature = 37°C = 98°F<br /> Conversion of Centigrade (Celsius) to Fahrenheit:<br /> Conversion of Fahrenheit to Centigrade (Celsius):<br />°C = 5 ( °F ) – 32<br /> 9<br />°F = 9 ( °C ) + 32<br /> 5<br />
  174. 174. Interpretation of Doctor’s Order for Drugs<br />The nurse must understand the order perfectly before acting on it <br />> The Drug<br />> The Dose<br />> The Route<br />> The Frequency<br />If any of the above are unclear or open for interpretations, it is the Responsibility of the nurse to clarify the order with the physician.<br />
  175. 175. Example:<br /> The order reads : Inderal 2 x4<br /> a. What is the Drug?<br /> b. What is the Dose?<br /> c. What is the Route?<br /> d. What is the Frequency?<br /> e. Does this order need clarification?<br />The order reads : Lasix 10 mg IV 1 ml O.D.<br /> a. What is the Drug?<br /> b. What is the Dose?<br /> c. What is the Route?<br /> d. What is the Frequency?<br /> e. Does this order need clarification?<br />
  176. 176. GENERAL FORMULA FOR DRUG CALCULATION<br />1. D<br />x Q<br /> S<br />2. Calculation by Ratio : Proportion<br /> 8 mg : x = 16 mg : 1 tab<br /> (works for any computation of Dosage if you have a given and a need to determine the unknown).<br /> Rule : <br />1. Units for each ratio must be the same.<br /> 2. Units for each ratio must be placed in the same order.<br />
  177. 177. Computation of Dosages:<br />When the dose prescribed is in milligram (mg) and the dose available is in Gram (Gm) or vice versa.<br />E.g. The order reads : 0.008 Gm of Morphine Sulfate IV q 4 hours prn for pain. Ampule available is labeled 10 mg/ml.<br /> 1. What do you know?<br /> 0.008 Gm - 8 mg<br /> 10 mg/ml - <br /> 2. What do you need to know? Known<br /> amount in cc for 0.008 Gm dose<br /> 3. Setting up the proportion:<br /> a. the units for each ratio must be placed in the same order<br /> b. the units for each ratio must be the same ( mg to mg )<br /> 8mg : X = 10 mg : ml<br />
  178. 178. 4. solve for the correct dosage<br /> 8 mg : X = 10 mg : ml<br /> 10 mg X = 8 mg/ml<br /> X = 8 mg/ml<br /> 10 mg<br /> X = .8 ml<br />
  179. 179. When the dose is ordered in one system and the dose on hand is in another system.<br /> E.g. The order reads : codeine sulfate ¼ gr P.O. q 8 hrs PRN for pain. Tablets on hand are labeled 0.015 Gm tablets.<br /> 1. What do you know? Known<br />¼ gr 1 gr = 60 mg<br /> 0.015 Gm / tab 1 Gm = 1000 mg<br />¼ = .25<br /> 2. What do you need to know?<br /> # of tablets for ¼ gr dose<br />
  180. 180. 3. Setting up the proportion<br /> a. the units for each ratio must be the same<br /> b. the units for each ratio must be placed in the same order.<br /> .25 gm : X = 0.015 gm : 1 tab<br /> 15 mg : x = 15 mg : 1 tab <br /> 4. Solve for the correct dosage:<br /> 15 mg : x = 15 mg : 1 tab<br /> 15 mg x = 15 mg / tab<br /> x = 15 mg / tab<br /> 15 mg<br /> x = 1 tab<br />
  181. 181. Computation of Correct Insulin Dosage<br />U - 40 means<br />U - 80 means<br />U - 100 means<br />Insulin syringes are calibrated according to the strength of insulin with which it is to be used.<br />U 40 insulin needs a U 40 syringe<br />U 80 insulin needs a U 80 syringe<br />
  182. 182. X 1 ml = ml needed<br />If this can not be done, the dose can be converted to milliliters<br />Dose Required<br />Dose on Hand<br /><ul><li> Serious error can occur if incorrect syringe or incorrect b calculations are used
  183. 183. It is essential that all insulin be checked by a second RN to confirm that errors in dosage are not made and error in the type of insulin were not made.</li></li></ul><li>Fractional Dosages in Infants and Children<br />
  184. 184. Children’s Doses<br />Clarks’ Rule:<br />weight of child in pounds X A.D. = child’s dose<br /> 150<br />Body Surface Area e.g. Wt = 10 kg<br />BSA X A.D. = child’s dose <br /> 1.7<br /> BSA = 4(wt in kg) + 7 = BSA in m²<br /> wt in kg + 90<br /> = 4(10 kg) + 7 = 47<br /> 10+ 90<br /> = .47 m²<br /> Child’s dose = .47 m² X 500<br /> 1.7<br />
  185. 185. Youngs’ Formula:<br />Age of child in Years X A.D. = Child’s dose<br /> Age of child + 12<br />
  186. 186. CALCULATION OF FLUID VOLUME(BASED ON BODY WEIGHT)<br />1. WEIGHT --- 1 – 10 kg. --- 100ml/kg.<br /> Eg. Wt = 8 kg. --- 800cc<br />2. WEIGHT --- 11 – 20 kg.--- 1,000+50ml/excess b.wt.<br /> Eg. Wt = 15 kg. 1,000=250ml = 1,250ml<br /> 15 50<br />-10 X 5<br /> 5 250<br />3. WEIGHT > 20 kg.<br /> Eg. Wt = 27 kg. 1,500 + 20 ml/excess b.wt.<br /> 1,500 + 140 ml = 1640 ml.<br /> 27 20<br />-20 X 7<br /> 7 140<br />
  187. 187. Calculation of IV Flow Rates<br />Calculation of cc/hr is essential in most IV therapy.<br /> Volume <br /> # of hrs<br /> E.g. 1 L over 8 hrs = 125 cc/hr<br /> 50 cc over 20 minutes = 150 cc/hr<br />= cc/hr<br />
  188. 188. Calculation of gtt/min (Long Method)<br />STEPS :<br /> 1. Need to know cc/hr to calculate<br /> 2. Gtt factor = gtt / ml<br /> gtt factors : macrodrip 10, 15, 20 gtts/ml<br /> microdrip 60 gtt/ml<br />EXAMPLE : LONG METHOD<br />Doctors Order : Run 1L D5W over 8 hours<br /> Microdrip - 1000 ml ÷ 8 hours = 125 cc/hr<br />125 cc x 60 gtt/ml = 125 gtt/ml<br /> 60 min 1 <br />10 gtt/ml set 125cc x 10 gtt/ml = 20 – 21 gtt/min<br /> 60 min 1<br /> 15 gtt/ml set 125cc x 15 gtt/ml = 31 gtt/min<br /> 60 min 1<br /> 20 gtt/ml set 125 cc x 20 gtt/ml = 41 – 42 gtt/min<br /> 60 min 1<br />
  189. 189. SHORT METHOD<br />cc / hr ÷ 6 for 10 gtt / min<br /> cc / hr ÷ 4 for 15 gtt / min<br /> cc / hr ÷ 3 for 20 gtt / min<br /> cc / hr = gtt / min for microdrip set<br />
  190. 190. Sources<br />Fluids & Electrolytes, Lippincott Williams & Wilkins<br />Fluids & Electrolytes, Walters Kluwer<br />Nelson’s Texbook of Pediatrics<br />WHO department of child and adolescent development<br />(Medline Plus)<br />http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/000982.htm<br />
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