NCM112 Prelims - GMJ

SL - Module 1 Fluids & Electrolytes

Introduction IV PARTS
- Fluid, electrolyte, and acid-base balances within the body
are necessary to maintain health and function of all body
systems.
- These balances are maintained by the intake and output of
water and electrolytes and regulation by the renal and
pulmonary systems.
FUNCTIONS
1. Keep body hydration
2. Maintains acid-base balance (pH)
3. Helps in muscle functions
4. Maintain nervous system function
MAIN ELECTROLYTES IN BODY FLUID IV INSERTION SITES
1. Dorsal arch vein (foot)
2. Dorsal arch vein (hand)
3. Median cubital vein
4. Scalp vein
5. Saphenous vein
SIZES OF IV CANNULA

Calcium Muscle contraction, nerve 4.5 – 5.5

function, blood clotting, cell mEq/L
division, healthy bones &
teeth
Chloride Fluid balance in the body 97 – 107
mEq/L
Potassium Regulates heart contraction, 3.5 – 5.3
maintain fluid balance mEq/L
Magnesiu Muscle contraction, nerve 1.5 – 2.5
m function, heart rhythm, bone mEq/L
strength, generating energy
& building protein
Sodium Fluid balance & for muscle 136 – 145
contraction, and nerve mEq/L
function
NURSING PROCEDURES IDEAL IV INSERTION
- Assisting in IV fluid therapy 1. Place tourniquet 2-3 inches above site
- Preparing client for IVF insertion & maintaining IVF 2. Place traction on vein and skin using non dominant hand
infusion 3. Pierce skin then advance to vein
- Discontinuing IV infusion & converting to heplock 4. When flashback appears advance entire catheter or needle
- IV complications unit 1/16 inches to 1/8 inches to ensure catheter is in vein
- Types of IVF 5. Thread catheter off needle and into vein, withdraw needle
- IV computations and activate safety mechanism
INTRAVENOUS THERAPY TYPES OF IV INFUSIONS
 It is the administration of fluids into a vein. Hypertonic Isotonic Hypotonic
 It can be administered centrally (into a large vein near the Higher solute – Equal solute Higher solute –
heart) outside inside
 Peripherally (into the veins of the extremities or scalp) Higher water – Equal water Higher water –
RATIONALE inside outside
- Maintain or replace body stores or water, electrolytes, Water moves – No net movement Water moves – in
vitamins, protein, fats, calories in the patient who cannot out
maintain an adequate intake by mouth. Cell shrinks Normal Cell swells
- Restore acid-base balance a) Isotonic – treatment of vascular dehydration;
- Restore blood component volume replaces sodium & chloride.
- Administer safe and effective infusion of medications by Lactated Ringers, D5 Water, Plain Normal Saline
using the appropriate vascular access b) Hypotonic – hypertonic dehydration; vomiting &
- Provide nutrition while resting the GI tract diarrhea
- To establish lifeline for emergency medications .45% Na Cl
GENERAL GUIDELINES c) Hypertonic - Hypovolemic shock Hemorrhagic
- Note the duration of the therapy shock Acidosis, Heat related disorder Peritonitis,
- Type of infusion Heat Exhaustion Diabetic Disorder
Hyponatremia, Burns, Hemorrhagic hypovolemic
- Type of IV fluids and its effect
shock, Liver disease, Hepatic encephalopathy
- Rate of Infusion
PREPARING CLIENT FOR IVF INSERTION AND
- Size of catheter to use
MAINTAINING IVF INFUSION
- Condition of the veins Intravenous route is the primary method of supplying the
- Medical condition of the client to assist in choosing the patient with fluids and medications via veins when the patient
IV site cannot take them orally.
RATIONALE  The device maintains venous access in patients who are
1. Monitor the solution drip rate and maintain the infusion as receiving IV medication regularly or intermittently but
ordered who
2. Infuse the amount of prescribed solution RATIONALE
3. Maintain the patency of IV catheter - To maintain patent access to the vein without necessity of
4. Prevent complications associated with IV therapy running IV fluids in the body.
5. To make drugs and fluids instantly available for - To help improve client mobility, as client can walk and
circulation move without the IV stand, pump, or tubing.
EQUIPMENTS - To prevent blood clot formation.
 IV cannula EQUIPMENT
 IV solution a. Intermittent Infusion cap or device
 Scissors b. Clean gloves
 IV administration set c. Antiseptic swab
 IV stand or pole d. Sterile saline for injection or heparin flush solution
 IV starter kits (10 units/ml or 100 units/ml) in a syringe
 IV infusion pump e. Tape or transparent dressing
 Gloves STEPS IN CONVERTING RUNNING IV TO HEPARIN
 Towel or underpad LOCK
 Commercial device to secure site 1. Verify the physician’s order to convert IV infusion to
 Armboard saline lock.
 Vein scanner device 2. Perform hand hygiene.
SPECIAL CONSIDERATIONS 3. Identify the client. Explain the procedure and reason for
1. Keep IV fluid sterile discontinuing the IV. Prepare materials at bedside.
2. Hang fluids at correct height 4. Stop IV infusion.
3. Carefully regulate the flow 5. Scrub the connection area between the hub and IV tubing
4. Monitor I&O when patient is receiving IVF and blood for 15 seconds and let dry for 30 seconds.
5. Assess the site frequently for signs of complications 6. Disconnect the IV tubing and screw the heparin lock.
PLANNING & IMPLEMENTATION Place a sterile cap on the end of the IV tubing. If tubing
a) Explain the procedure to the client will be reconnected for later infusion.
b) Wash hands and follow infectious protocol 7. Scrub the hub for 15 seconds and let dry for 30 seconds.
c) Expose necessary site only 8. Insert saline syringe gauge 25 needle into the hub of the
d) Inspect patient’s hand & forearms, then select site. tubing. Pull back gently and watch for blood return. Inject
Choose the most distal site possible saline slowly.
e) Ensure correct solution is being infused 9. Clean the rubber diaphragm with an antiseptic swab.
f) Observe rate of flow every hour Insert syringe into the diaphragm. Inject heparin slowly
g) Inspect patency of the tubing into lock to keep it patent.
h) Check site for fluid infiltration (Accumulation of IV fluid 10. Remove syringe from the diaphragm and clean it with
in the tissue surrounding an IV needle site, Phlebitis, IV antiseptic swab. Discard needle in sharps container.
site bleeding due to premature removal of torniquet or pt 11. Assess the site for any signs of leakage, irritation, or
is under anticoagulants) infiltration.
DOCUMENTATION 12. Remove gloves and dispose all used materials. Wash
- Perform follow up based on findings that deviated from hands.
what is expected or normal. Consider UO, compared to EVALUATION & DOCUMENTATION
intake, tissue turgor, urine specific gravity, V/S, and lung  The IV is discontinued and the intermittent infusion
sounds. device is placed without complications.
- Regularly check the patient for intended & adverse effects  Examine site at regular intervals. Note patency and ease
of the infusion. Report significant deviations from normal of flushing.
to the doctor.  Documentation data and time IV was discontinued, and
- Record the status of IV insertion site & any adverse effect saline lock was placed and any unusual findings at
responses from the client insertion site.
- Document the client’s IV fluid intake at least every 8
hours according to agency policy
- Include the date & time; amount & type of solution;
container number; flow rate; client’s general response

CONVERTING IV TO HEPARIN LOCK

HEPARIN LOCK
 Intermittent infusion device is a small plastic device with
a resealing rubber entry that is screwed onto the hub of
the existing IV catheter or butterfly needle tubing.
 Filled with dilute heparin or saline solution to prevent
blood clot formation
LOCAL COMPLICATIONS OF IV THERAPY CAUSES
1. PHLEBITIS - Line clamped for too long
CAUSES - Interrupted IV flow
- Poor blood flow around venous access device - Blood clots
- Friction from cannula movement in vein - Unflushed Heparin lock
- Venous access device is too long S/S
- Clotting at cannula tip Drug/solution with high or low a) Blood backflow in line,
PH b) Discomfort at the IV site,
COMMON MEDICATIONS THAT CAN CAUSE c) IV flow is not increasing when raised up
PHLEBITIS NURSING INTERVENTION
 Phenytoin - Use mild flush injection. Don’t force. If it is unsuccessful
 Diazepam Re-insert the IV Line
 Erythromycin PREVENTION
 Tetracycline  Maintain IV flow rate
 Vancomycin  Flush freely after intermittent piggyback administration
 Amphothericin  Have patient walk with his arm bent at elbow to reduce
 40 mEq/L or more doses of KCL risk of backflow
SIGNS & SYMPTOMS
a) Tenderness at the tip of and proximal to venous access 5. VEIN INFILTRATION OR PAIN AT THE IV SITE
device CAUSES
b) Redness at the tip of the cannula and along the vein - Solution with high or low pH or high osmolarity.
c) Vein is hard on palpation - 40meq Potassium Chloride, Phenytoin, IV Antibiotics like
d) Elevated temperature Vancomycin or Erythromycin
NURSING INTERVENTION S/S
- Remove Venous access device a) Pain during infusion
- Apply Warm Compress b) Blanching
- Notify physician if patient has fever c) Red skin over vein during infusion
- Document patient’s condition/intervention d) Rapidly developing signs of Phlebitis
PREVENTION NURSING INTERVENTION
 Restart Infusion using larger vein or smaller gauge to - Decrease the flow rate
ensure adequate flow - Use electronic device to have a steady flow
 Tape device securely to prevent motion PREVENTION
 Dilute solutions before administration. (Refer to Facility
2. EXTRAVASATION policy)
CAUSES  If long term therapy of Irritating drug, ask physician to
Venous access device dislodged or perforated vein use the central IV line
SIGNS AND SYMPTOMS
a) Swelling above IV site 6. HEMATOMA
b) Discomfort / burning/pain CAUSES
c) Tightness - Leakage of blood from needle displacement
d) Decrease skin temperature - Inadequate pressure when cannula is discontinued
e) Blanching - Vein punctured through opposite wall
f) Slow flow rate S/S
g) Absence of backflow a) Tenderness at Venipuncture site
NURSING INTERVENTION b) Bruised area around the site
- Stop the infusion immediately c) Inability to advance or flush IV line
- Apply ice or warm compress NURSING INTERVENTION
- Elevate limb. - Remove the venous access device
- Check Pulse and capillary refill for circulation - Apply pressure and warm soaks to affected area.
- Restart infusion above infiltration site or another limb - Recheck for Bleeding
- Documentation of your intervention PREVENTION
PREVENTION  Choose vein that can accommodate the size of the cannula
 Check IV site frequently  Release tourniquet as soon as insertion is successful
 Don’t obscure area with tape
 Ask the patient to report any pain or swelling 7. THROMBOSIS
CAUSES
3. CANNULA DISLODGEMENT - Injury to endothelial cells of vein wall, allowing platelets
CAUSES to adhere and thrombi form
- Loosened tape or tubing snagged in bed linens S/S
- Partial retraction of cannula a) Painful, reddened, and swollen vein
SIGNS / SYMPTOMS b) Sluggish or stopped IV flow
a) Loose tape NURSING INTERVENTION
b) Cannula partly out of vein - Remove cannula, restart infusion in opposite limb.
c) Solution infiltrating - Apply warm soak.
NURSING INTERVENTION - Watch for IV Therapy related infection.
- Retape without pushing the cannula back into the vein. If PREVENTION
it is pulled out apply pressure to IV site with sterile  Use proper Venipuncture techniques to reduce injury to
dressing vein.
PREVENTION
 Tape Venipuncture device securely on Insertion

4. OCCLUSION