Isotonic solutions
Same concentration as body fluid/plasma
250-375 mOsm
NO FLUID SHIFT OUT OF CELL OR INTO VASCULAR SPACE
Sample Solutions:
.9NS – Normal Saline
LR – Lactated Ringers
Hypotonic solution
Less concentrated than plasma Below 250 mOsm FLUID MOVES INTO THE CELLS AND OUT OF THE VASCULAR SPACE, cells swell Sample Solutions: .225, .33, and .45 NS D5W D5.225NS, D5.45NS, D2.5W
Hypertonic solution
More concentrated than plasma Above 375 mOsm FLUID MOVES OUT OF CELLS INTO INTRAVASCULAR SPACE, Cells shrink Sample Solutions: D10W and higher conc D5NS D5RL TPN
Crystalloids
Capable of crystallization Dextrose NaCL Electrolyte solutions Alkalizing and Acidifying Agents
Colloids
Expand plasma volume – pull fluid into the bloodstream Albumin Dextran Hydroxyethyl starches Gelatins
Nursing care for crystalloid solutions
Monitor for signs of fluid overload Assess urine output and specific gravity Monitor lab values Maintain rate per orders Intake and Output
Nursing care for colloid solutions
Assess for history of allergic response Monitor urinary output Monitor lab values Evaluate CVP or jugular vein distention Maintain infusion rate Monitor for fluid overload – B/P, dyspnea, bounding pulse, Monitor for bleeding
What IV solution is the most commonly prescribed
LR
Sodium chloride solution
Percentages: .25, .45, .9 (Normal saline), 3 and 5
Treats sodium depletion
ECF replacement when chloride loss greater or equal to Na loss
Metabolic alkalosis
Used for blood administration
Precautions – can cause hypernatremia, low potassium, acidosis when continuous infusion of .9NS
WATCH FOR CIRCULATORY OVERLOAD
Balanced electrolyte solution
Ringers Solution and Lactated Ringers (Hartmann’s)
LR most commonly prescribed
Used for trauma, alimentary fluid loss, dehydration, sodium depletion, acidosis, and burns
Ringers - also to restore fluid balance before and after surgery
Can be used for patients with liver disease unable to metabolize lactate
DISADVANTAGES – Don’t use in renal failure, can worsen sodium retention, CHF, renal insufficiency
Albumin
Natural plasma protein
Expands proportionate to amount of circulating blood
No danger of serum hepatitis
Improves cardiac output, reduces edema, and raises serum protein levels, maintains electrolyte balance (low sodium), promotes diuresis
CAUTIONS – Allergic reaction, circulatory overload, pulmonary edema, can alter lab findings
Dextran
Comes in low (40) and high molecular weight (70)
Treating SHOCK
EXPANDS BY ONCE OR TWICE ITS OWN VOLUME
Improves microcirculation
CAUTIONS – HYPERSENSITIVITY REACTIONS, INCREASED RISK OF BLEEDING, CIRCULATORY OVERLOAD
IV use only
HYDROXYETHYL STARCHES(Hetastarch, Pentastarch)
Synthetic, made from starch
Hespan 6 or 10%
Less toxic, less expensive
HEMODYNAMICALLY SIGNIFICANT PLASMA VOLUME EXPANSION
Permits retention of intravascular fluid
CAUTIONS – ALLERGIC REACTION, RISK OF INTRACRANIAL BLEEDING, ANEMIA OR BLEEDING DUE TO HEMODILUTION
Gelatins
Replacing blood volume due to acute blood loss
Large molecular weight protein
Priming heart – lung machines
Three types –
succinylated or modified fluid gelatins, urea- crosslinked, and oxypolygelatins
CAUTIONS – ANAPHYLACTOID REACTIONS, high calcium and potassium with urea linked,
Passive diffusion
Passive movement of water, ions, and lipid-soluble molecules randomly in all directions from a region of high concentration to an area of low concentration
Filtration
Transfer of water and dissolved substances from a region of high pressure to a region of low pressure; the force behind it is hydrostatic pressure
Osmosis
Movement of water from a lower concentration toward a higher concentration across a semipermeable membrane
Sensible fluid loss
urine output, GI tract
Insensible fluid loss
500 – 1000 mL per day
Lungs and skin
Assessments for fluid deficit/excess
Cardiovascular
- Deficit: increased pulse rate, decreased blood pressure, narrow pulse pressure, slow hand filling, decreased pulse volume
- Excess: bounding pulse, increased pulse rate, jugular vein distention, overdistended hand veins
Assessments for fluid deficit/excess
Respiratory
- Deficit: lungs clear
- Excess: moist crackles, respiratory rate >20, dyspnea, pulmonary edema
Assessments for fluid deficit/excess
Integumentary system
Deficit: decreased turgor, decreased skin temperature
Excess: warm, moist skin; fingerprinting over sternum
Assessments for fluid deficit/excess
Special senses
- Deficit: dry conjunctiva, sunken eyes, decreasing tearing, sticky mucous membranes, dry cracked lips, extra longitudinal furrows
- Excess: periorbital edema
Metabolic Acidosis: base bicarbonate deficit
Metabolic acidosis (HCO3 deficit) is characterized by a low pH and low plasma HCO3 level Etiology Loss of HCO3 Respiratory or circulatory failure Ingestion of certain drugs or toxins Septic shock
Tx for metabolic acidosis
Reversing the underlying cause
Eliminating the source
Administering NaHCO3 IV when pH is equal to or less than 7.2
NOTE: Give NaHCO3 cautiously to avoid patient developing metabolic alkalosis and pulmonary edema secondary to sodium overload
Metabolic Alkalosis: base bicarbonate excess
Metabolic alkalosis HCO3 excess is a clinical disturbance characterized by a high pH and high plasma HCO3 concentration
Etiology
Gain of HCO3
Loss of hydrogen ion (gastric suctioning and vomiting) Renal loss of hydrogen
Tx for metabolic alkalosis
Reversing the underlying cause
Administering sufficient chloride for the kidney to excrete the HCO3
Replacing potassium if a chloride deficit is also present
Respiratory Acidosis: Carbonic Acid Excess
Respiratory acidosis is caused by inadequate excretion of carbon dioxide and inadequate ventilation resulting in increased serum levels or carbon dioxide and H2HC03
Etiology
Pulmonary, neurologic, and cardiac causes
Aspiration of foreign body
Pneumothorax
Severe pneumonia
Overdose of sedatives
Tx of respiratory acidosis
Improve ventilation
Administer bronchodilators or antibiotics for respiratory infections
Administer oxygen as indicated
Administer adequate fluids to keep mucous membranes moist
Respiratory Alkalosis: Carbonic Acid Deficit
Respiratory alkalosis is usually caused by hyperventilation which causes “blowing off” of carbon dioxide and decrease in H2HCO3
Etiology
Pulmonary disorders that produce hypoxemia
Hypoxemia-induced fever, pneumonia, CHF, asthma
Stimulation of respiratory centers: anxiety, salicylate overdose
Tx of respiratory alkalosis
Treat the source of anxiety
Administer a sedative as indicated
Treat the underlying cause
Normal pH of arterial blood
7.35-7.45
Cations
Sodium — Na+
Potassium — K+
Calcium — Ca+
Magnesium — Mg++
Normal range for Sodium
135 – 145 mEq
Sodium deficit causes
Hyponatremia
GI loss
Losses from skin
Hormonal factors (SIADH, oxytocin)
Pharmacological agents (nicotine, morphine)
Signs and symptoms of Hyponatremia
Anorexia Muscle cramps Feeling of exhaustion Apprehension Fingerprint edema Neurological symptoms Serum sodium
Sodium deficit Tx
Replace sodium and fluid losses through diet or parenteral fluids
Restore ECF
Correct any other electrolyte losses
Sodium excess causes
Hypernatremia
Deprivation of water
Hypertonic tube feeding with inadequate water supplement
Excessive parenteral administration of sodium solutions
Increased insensible loss
Profuse sweating, heat stroke
Signs and symptoms of Hypernatremia
Marked thirst Elevated body temperature Swollen tongue Red sticky mucous membranes Disorientation Serum sodium >145 mEq
Hypernatremia Tx
Infusion of isotonic solution (0.9% NACL)
Use of diuretics
Normal range for Potassium
3.5 – 5.5 mEq/L
Potassium deficit causes
Hypokalemia
GI or renal losses Increased perspiration Shifting of extracellular potassium Protracted vomiting Heat loss Shifting into the cells Poor dietary intake
Signs and symptoms of Hypokalemia
Neuromuscular changes (fatigue, muscle weakness, diminished deep tendon reflexes) Vomiting Irritability Sensitivity to digitalis Serum potassium
Tx of potassium deficit
Treatment: mild hypokalemia — dietary or oral supplements
Administer infusion of 20 – 40 mEq per liter
K+ is below 2 mEq/L, monitor patient’s ECG and administer potassium by means of secondary piggyback set in volume of 100 mL
Review guidelines for administration of potassium
Potassium excess causes
Hyperkalemia
Gain of potassium by intake or by shift from ICF to ECF
Excessive administration of potassium parenterally
Drugs: potassium, indomethacin, beta blockers
Serum potassium >5.5 mEq
Signs and symptoms of Hyperkalemia
ECG changes
Metabolic acidosis
Vague muscle weakness, flaccid paralysis
Nausea, cramping diarrhea
Tx of potassium excess
Restrict dietary potassium in mild cases
Discontinue supplements of potassium
Administer IV calcium gluconate for cardiac symptoms
Administer sodium bicarbonate (alkalinizes the plasma)
Administer regular insulin (10 – 25 U) in 10% dextrose solution
Peritoneal dialysis
Normal range for calcium
8.5 – 10.5 mg/dL
Calcium deficit causes
Hypocalcemia
Intestinal malabsorption, altered regulation of calcium Loss through diarrhea, wound exudate Acute pancreatitis Hyperphosphatemia Prolonged NG tube suctioning Surgical hypoparathyroidism
Signs and symptoms of hypocalcemia
Neuromuscular symptoms: numbness of fingers, cramps in muscles
Hyperactive deep tendon reflexes
Positive Trousseau’s sign
Chvostek’s sign
Tx of hypocalcemia
Alleviate underlying cause
Administration of calcium gluconate
Calcium excess causes
Hypercalcemia
Excessive release of calcium from the bone, malignancy
Excessive calcium intake
Signs and symptoms of hypercalcemia
Neuromuscular symptoms: muscle weakness, lethargy, deep bone pain, pathologic fractures
Constipation, anorexia, nausea, vomiting, polyuria
Total serum calcium more than 10.5 mg/dL
Tx for hypercalcemia
Treat underlying disease Administer saline diuresis Give inorganic phosphate salts Hemodialysis or peritoneal dialysis Lasix 20 – 40 mg every 2 hours Calcitonin
Normal range for magnesium
1.5 – 2.5 mEq
Magnesium deficit causes
Hypomagnesemia
Chronic alcoholism
Malabsorption syndromes
Critically ill patients
Drugs: aminoglycosides, diuretics, digitalis
Signs and symptoms of Hypomagnesemia
Serum Mg,1.5 mEq/L ECG: tachydysrhythmias Neuromuscular symptoms Positive Chvostek’s and Trousseau’s signs Paresthesia of feet and legs Painfully cold hands
Tx for Hypomagnesemia
Administer oral magnesium salts
Administer 40 mEq magnesium sulfate IV in dextrose in water
Administer 1 – 2 g of 10% solution of magnesium sulfate by direct IV push
Magnesium excess causes
Hypermagnesemia
Renal failure
Hyperparathyroidism
Excessive magnesium administration
Medications high in magnesium (antacids, laxatives)
Signs and symptoms of Hypermagnesemia
Serum magnesium >2.5 mEq Neuromuscular symptoms: flushing Lethargy, depressed respiration Hypotension Heart block Cardiac arrest
Tx of Hypermagnesemia
Decrease oral magnesium intake
Administer calcium gluconate to antagonize the action of Mg
Support respiratory function
Peritoneal dialysis
Care of patients with diarrhea
- Teach hand hygiene
- Provide info about foods that can cause diarrhea (highly spiced foods, high-fat foods, greasy foods)
- monitor stools, fluid balance, serum electrolytes, skin integrity
- BRAT diet
- Electrolyte replacement fluids
Local effects of IV therapy
- Nerve injury
- local infection
- venous spasm
- Hematoma
- phlebitis
- Infiltration/extravasation
Systemic effects of IV therapy
- Blood stream infection (BSI)
- Circulatory overload and pulmonary edema
- Air embolism
- Speed shock
Nerve Injury
- Immediate sharp pain during venipuncture shooting pain up arm or pain or tingling in hand or fingertips
- Tx: stop venipuncture, notify LIP, apply pressure
- Prevention: Avoid lateral surface of wrist, antecubital area, ventral surface of wrist, avoid probing, reduce risk for infiltration or extravasation as above, make only 2 attempts
Local Infection
- Redness and swelling at site possible exudate of purulent material
- Tx: Discontinue catheter, culture site and cannula, apply sterile dressing over site, administer antibiotics as ordered
- Prevention: practice aseptic technique during venipuncture and site maintenance
Venous spasm
- Sharp pain at IV site associated with infusion slowing of infusion resistance to PICC or midline removal
- Tx: Apply a warm compress to the site with infusion still running, Restate the infusion if spasm continues, consult with interventional radiology for resistance of line removal
Prevention: Dilute medication, keep IV solution at room temperature, administer infusion at prescribed rate
Bloodstream Infection (BSI)
- Fever, chills, diaphoresis, tachycardia, tachpnea, change in mental status, hypoxemia, decreased urine output, hypotension, evidence of decreased perfusion or dysfunction
- Tx: Notify LIP, restart new IV system, obtain cultures, initiate antimicrobial therapy ordered, monitor pt closely
Prevention: Hand hygiene, aseptic tech with all aspects of infusion related care, attention to skin antisepsis prior to placement and with ongoing site care, preference to use chlorhexidine and alcohol solutions, Attention to intact dressings over VAD, Attention to needle-less connector disinfection, Carefully inspect solutions, Follow standards of practice related to rotation of sites and hang time of solutions
Circulatory overload and pulmonary edema
- Rapid weight gain increase in BP, HR, bounding pulse, edema, I&O, rise in central venous pressure, SOB, crackles in the lungs, cough, distended neck veins, restlessness and headache
- Tx: Call rapid response team, decrease IV flow rate, place pt at high fowler position, keep the pt warm, monitor vitals, administer oxygen as ordered, administer drug therapy
- Prevention: Monitor the infusion, maintain flow at the prescribed rate, monitor I&O, daily weights, know the patients cardio hx, do not catch up infusions, instead recalibrate, Use electronic infusion devices (EIDs) that have dose-error reduction systems and anti-free-flow administration sets
Air embolism
- Lightheadedness, dyspnea, cyanosis, tachypnea, expiratory wheezes, cough, mill wheel murmur, chest pain, hypotension, change in mental status, confusion, coma, seizures
- Tx: Call rapid response team, place pt in Trendelenburg position, administer oxygen, monitor vitals
- Prevention: Remove all air from administration sets, Use lure-lock connections, follow protocol for catheter removal
Speed shock
- Dizziness, facial flushing, headache, tightness of chest, hypotension, irregular pulse, progression of shock
- Tx: stop infusion immediately, call rapid response team
Prevention: Use an EID, monitor the infusion rate, administer IV push medications over appropriate time frame
Site selection and IV therapy
- Type of solution: irritating fluids, such as certain antibiotics and potassium chloride, select large vein in forearm
- Condition of the vein
- Duration of therapy: start with most distal veins first
- Cannula size: small-gauge catheters take up less space in the vein, allowing for blood flow around the catheter, and cause less trauma when inserted
- Patient age
- Patient preference
- Patient activity
- Presence of disease or previous surgery
- Presence of shunt or graft: do not use pts arm or hand that has a patent graft or shunt for dialysis
- Patients receiving anticoagulation therapy: these pts have a propensity to bleed