LESSON 1

Choosing an IV Site:
PARENTERAL FLUID THERAPY
● When no other route of administration is
available, fluids are administered by iv in
hospitals, outpatient diagnostic and
surgical settings, clinics, and homes to
replace fluids, administer medications, and
provide nutrients.
Purpose:
- To provide water, electrolytes, and nutrients to
meet daily needs
- Replace water and correct electrolyte deficits
- To administer medication and blood products

TYPES OF IV SOLUTION
1. Isotonic Solution (D5W, PNSS, Plain IVT COMPLICATIONS
LR)
SYSTEMIC COMPLICATION
• Have the same osmolality as body fluids
● Air Embolism
• Increase extracellular fluid volume
● Fluid Overload
• Do not enter cells because no osmotic force
● Infection
exists to shift the fluid
● Febrile Reaction
~Only solution compatible to blood (PNSS)
~This prevents clumping of blood and hemolysis
LOCAL COMPLICATION
~WOF: fluid overload (hyponatremia), lung
● Infiltration/extravasation
sound=crackles
● Phlebitis And Thrombophlebitis
~It can stabilize glucose but too much can cause
● Hematoma
hyperglycemia
AIR EMBOLISM
2. Hypotonic Fluids A bolus of air enters the vein through an
• Are more dilute solutions and have a lower inadequately primed IV line from a loose
osmolality than body fluids connection during tubing change or during
• Cause the movement of water into cells by removal of IV.
osmosis
• Should be administered slowly to prevent Signs And Symptoms:
cellular edema ● Palpitation
~It has low concentration than blood ● Dyspnea
~Makes the cell swell ● Coughing
~Not advisable for patient with cerebral edema ● Jugular vein distention
3. Hypertonic Solutions ● Wheezing and cyanosis
• Are more concentrated solutions and have a ● Hypotension
higher osmolality than body fluids ● Weak rapid pulse
• Cause movement of water from cells into the ● Altered level of consciousness
extracellular fluid by osmosis ● Petechiae

Treatment:
● Immediate clamping of IV tubings
● Place patient in left side: Trendelenburg
position
● Replace IV fluids before it run outs to
prevent air embolism
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 ● Cool to touch skin
● IV fluid leaking from the iv site
FLUID OVERLOAD
Also known as circulatory overload due to rapid Treatment:
Administration of fluids ● Stop the infusion
● Isotonic solution with normal ph
Signs and Symptoms: → elevate the affected site
● Increase blood pressure ● Hypertonic solution with abnormal PH
● Jugular vein distention -→ cold compress
● Dyspnea
● Moist cough crackles Extravasation → unintentional administration of
a vesicant solution or medication into surrounding
Treatment: tissue (vasopressors, potassium, calcium,
● Decrease IV rate MGSO4, chemotherapeutic drugs)
● Place patient in high fowler's position: to
prevent further fluid overload and to Signs and Symptoms:
decrease venous return in the periphery ● Pain and burning sensation
● Use infusion pump to prevent fluid ● Redness at the site
overload ● Blistering
● Inflammation
INFECTION
Treatment:
Pyogenic substances enters the bloodstream that
● Antidote specific to the medication
causes infection
● Removal of cannula
~IV fluid should be change every 72 hours/ 3
● Application of warm compress from
days
alkaloids
Signs and Symptoms:
● Cold compress for alkylating and antibiotic
Local ~ happens due to inflammatory cytokines
vesicant
● Redness,
● Swelling
NOTE: Comatose patient, anesthetized patients,
● Drainage at site
diabetes patient, patient with peripheral and
Systemic
cardiovascular disease are at greater risk for
● Chills
extravasation.
● Fever
● Body malaise PHLEBITIS
● Headache Inflammation of the vein
● Nausea
● Backache Types:
● Tachycardia ● Mechanical
● Chemical
Treatment: ● Bacterial
● Maintain strict aseptic technique
● Change IV tubings Signs and Symptoms:
● Change IV site when soiled ● Red
INFILTRATION AND EXTRAVASATION ● Warm
● Pain or tenderness
Infiltration → unintentional administration of a
● Swelling
non vesicant solution or medication into
surrounding tissue
Treatment:
● Restart iv in another site
Signs and Symptoms:
● Apply warm compress
● Edema
● Maintain strict aseptic technique
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 ● Use appropriate cannula size
● Select a site considering medication and
fluids
● Change iv site according to agency policy
and procedures
THROMBOPHLEBITIS
Presence of a clot and inflammation in the vein
LESSON 2
FLUID VOLUME DISTURBANCES
Fluid Imbalances
● Hyperosmolar Imbalance
● Hypoosmolar Imbalance
● Isotonic Volume Deficit
● Isotonic Volume Excess

Signs and Symptoms:

HYPEROSMOLAR IMBALANCE
● Localized pain
● Redness ● “Dehydration”
● Warmth ● The cells shrink
● Swelling ● Sodium excess or water deficit
● Immobility ● Initial manifestation: thirst
● Sluggish flow rate ● Indicator: weight loss (due to loss of
● Fever water), decreased uo (concentrated urine)
● Malaise (UO must be 1:1 or 75 kg:75 cc)
● Leukocytosis ~Loss of water than electrolyte - mas maraming
natitirang electrolyte
Treatment: Signs and symptoms:
● Discontinue iv infusion ✓Dry mouth and throat ~ dehydrated
● Cold compress followed by warm ✓Warm, flushed, dry skin
compress ✓Soft, sunken eyeballs ~common sign of
● Elevating the extremity dehydration for kids
● Restarting the line in the opposite ✓Dark concentrated urine
extremity ✓Altered loc
● Avoid flushing ✓Increased hct , bun, serum electrolyte levels
(nagkakaroon ng alteration sa kidney function
HEMATOMA kasi dumadami yung BUN dahil hindi naffilter ng
Blood leaks into the tissue kidney since kulang sa water yung body)
✓VS: hyperthermia; tachycardia; tachypnea;
Signs and Symptoms: hypotension
● Ecchymosis
● Swelling at the site Collaborative Management:
● Leakage of blood at the insertion site ● Fluid replacement ~ hypotonic solution to
rehydrate cells
Treatment: ● Oral care for dry mouth and throat ~ due
● Remove the needle or cannula to possible cracks in mucous membrane
● Apply light pressure with sterile dry ● Safety measures for altered loc
dressing ● Identify and treat the underlying cause
● Apply ice to the site to avoid extension of (ex: enteral feedings, renal failure, DM)
the hematoma
● Elevate the extremity
● Restart the line in the other extremity

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 inappropriate hormone - for low
hematocrit) sodium deficit)

HYPOOSMOLAR IMBALANCE
● Also known as water intoxication
● This is caused from shifting fluids from the
ECF to ICF
● The cells swell ISOTONIC VOLUME DEFICIT
● There is sodium deficit or water excess (HYPOVOLEMIC)
● The most dangerous effect is increased Signs and symptoms:
ICP (can cause the cell to swell and can ✓Weight loss ~ due to electrolyte and water loss
contribute to more swelling and cause ✓Oliguria (urine specific gravity is high)
rupture in the medulla oblongata) ✓Dry mucous membrane of the mouth
● Too much hypotonic solution can also ✓Poor skin turgor
cause hyperosmolar ✓Postural hypotension
✓Tachycardia; tachypnea~ the initial signs
Signs and symptoms:
✓Changes in mental status (confusion, Collaborative management:
incoordination, convulsions) ● Administer fluids with sodium
✓Sudden weight gain ● Meticulous oral care
✓Peripheral edema ● Promote safety
● Identify and correct underlying cause
Collaborative Management: (hemorrhage, profuse sweating, vomiting,
● Fluid restriction diarrhea, draining intestinal fistulas,
● Administration of diuretics as prescribed ~ colostomies)
Loop diuretics: furosemide
● Infusion of hypertonic saline per IV ~ ISOTONIC VOLUME EXCESS
(HYPERVOLEMIA)
hypertonic can shrink cell
● Promote safety Signs and symptoms:
● Assess neurologic status ✓Weight gain – best indicator for edema
● Identify and treat underlying cause ✓Dependent edema (sacral area, ankles and
(excess intake of electrolyte free fluid, feet)
repeated tap water enema can also cause ✓Tight, smooth shiny skin
water to go out; SIADH (syndrome of
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✓Cool, pale skin due to poor circulation in the 5. Decrease stroke volume
area 6. Decrease cardiac output
✓Neck vein engorgement 7. Decreased tissue perfusion
✓Weeping edema 8. Activation of SNS (compensates then
✓Clothings and shoes feel tight activation of RAAS)
✓Pleural effusion, pericardial effusion, ascites
~no movement of fluid due to equal osmolality
Indicat Compensat Progressiv Irreversible
~fluid accumulate in extracellular compartment or ory Stage e Stage Stage
~weeping edema
~accumulation of fluid in peritoneum (abdomen) BP ↑ ↓ Less than Palpatory
Collaborative management: 100 mmHg
● Sodium and fluid restriction
HR ↑ ↑ More than Erratic
● High protein diet ~to prevent edema, the 150 bpm
proteins help to hold salt and water inside
the blood vessels so fluid does not leak RR ↑ ↑ Shallow - Intubated
out into the tissues. Rapid
● Elevate edematous body parts ~to
UO ↓ ↓ 0.5 Anuria
promote venous return ml/kg/hr
● Protect edematous body parts from
prolonged pressure, injury, extremes of Orienta ALOC Lethargy Comatose
heat and cold, tion
● Keep the skin dry and well lubricated
Skin Cold/Clamm Petechiae Jaundice
● Administer diuretics as ordered y
● Regulate ivf accurately
● ~no corticosteroids because it retains Acid Respiratory Metabolic Profound
sodium Base Alkalosis Acidosis Acidosis
● Diuretics: only potassium sparing,
spironolactone like thiazides and amiloride Stages of Shock:
HYPOVOLEMIC SHOCK Compensatory stage
Progressive stage
~happens when 750ml to 1500 ml of fluid loss
Irreversible stage
from intravascular space (equivalent to 20% fluid
loss)
Nursing intervention:
Causes:
● Treatment goal: fluid resuscitation, correct
● Burns ~shifting from intravascular space
underlying cause
to interstitial space
● Bleeding → apply pressure to the bleeding
● Massive bleeding from injury or surgery
site
~normal bleeding for NSD = 100 ml then
● Obtain iv access
for CS = 100 ml to 300 ml
● Collect laboratory (cbc, hct, abg,
● Excessive fluid loss (vomiting, diarrhea)
electrolyte, bun and creatinine
● ~Sedate pt to decrease oxygen usage
Signs and symptoms:
● Passive leg raising position to increase
● Initial sign: hypertension
venous return to increase cardiac output
● Hypotension
● Fluid replacement: PNSS must be running
● Tachycardia
for only 4hrs, KVO, 18 to 20 gauge
● Tachypnea
Fluids for hypovolemic shock:
Pathophysiology:
● Crystalloids (given to correct metabolic
1. Fluid loss
acidosis) (if 1 ml is loss then give 3 ml =
2. Decrease intravascular space
ratio is 3:1): normal saline or lactated
3. Decrease venous return
ringer
4. Decrease preload
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 ● Watch out for fluid volume overload LESSON 3
(edema, and jugular vein distention)
ELECTROLYTE IMBALANCES
● Auscultate fluid in the lungs → crackles
● Blood and blood products: PRBC,
platelets or fresh frozen plasma (FFP) Electrolytes Normal Function
● Warm fluids can only enter pt’s body to Values
avoid hypothermia
Sodium 135-145 Controls water
● FFP is only given when crystalloids
MEQ/L movement and
doesn’t take effect retention
● Platelets or FFP must be consumed within
15 minutes Establishing the
electrochemical state
Quiz: necessary for muscle
1. True or False: Hypovolemic shock occurs contraction and the
transmission of nerve
where there is low fluid volume in the interstitial
impulses
compartment. FALSE
2. A patient who is experiencing hypovolemic Potassium 3.5-5 MEQ/L Promotes contraction of
shock has decreased cardiac output, which cardiac, skeletal and
contributes to ineffective tissue perfusion. The smooth muscles
decrease in cardiac output occurs due to?*
Calcium 8.2-10.3 Maintains hardness of
DECREASE IN CARDIAC PRELOAD MEQ/L or teeth and density of
4. You’re providing care to a patient who has 4.5-5.1 mg/dl bones
experienced a 45% loss of their fluid volume and
is experiencing hypovolemic shock. The patient Magnesium 0.62-0.95 Aids in neuromuscular
has hemodynamic monitoring and fluid MEQ/L or transmission
1.3-2.3 mg/dl
resuscitation is being attempted. Which finding
indicates the patient is still in hypovolemic shock? Phosphorus 0.8-1.45 Maintains bone and
LOW CENTRAL VENOUS PRESSURE MEQ/L or teeth structure
5. A patient is 1 hour post-op from abdominal 2.5-4.5 mg/dl
surgery and had lost 20% of their blood volume
Chloride 97-107 Acts with sodium to
during surgery. The patient is experiencing signs
MEQ/L maintain body
and symptoms of hypovolemic shock. What osmolality
position is best for this patient? MODIFIED
TRENDELENBURG
6. A patient in hypovolemic shock is receiving Kidney Function
rapid infusions of crystalloid fluids. Which patient A. Non Excretory
finding requires immediate nursing action? ● RAAS
PATIENT EXPERIENCES DYSPNEA AND ● Vitamin D Synthesis → Calcium
CRACKLES IN LUNG FIELDS Reabsorption
7. A patient is receiving large amounts of fluids ● Produces Hormone → Erythropoietin
for aggressive treatment of hypovolemic shock. →Stimulate bone marrow to produce RBC
The nurse makes it a priority to? WARM THE and Hgb → Regulate acid base →
FLUIDS Secretes acid via urine → Maintain level of
8. What is the fluid compartment that is found HCO3 →Chemical reaction to produce
inside the blood vessels? HCO3 → Produce prostaglandins
9. Which statement below is the most accurate → Vasodilator = increase tissue perfusion
about the process of osmosis? WATER WILL in kidney
MOVES FROM A SOLUTION WITH A HIGHER
SOLUTE CONCENTRATION TO A SOLUTION B. Excretory (urine formation)
WITH A LOWER SOLUTE CONCENTRATION. ● Tubular Infiltration - 90 to 125 ml of
blood/min
○ H2O
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 ○ Electrolytes
○ BUN & Creatine
○ Uric Acid
● Tubular Reabsorption - 124 ml/min
● Tubular Secretion - 1ml/min
UO: 30-60 cc/min
SIGNS AND SYMPTOMS:
● Hyperkalemia = all ↑ except HR and UO
● Hypokalemia = all ↓ except HR and UO
● Hypercalcemia = ↓
● Hypocalcemia = ↑
● Hypernatremia = dehydration
● Hyponatremia = overload
● Nursing intervention:
SODIUM IMBALANCES
● Normal value: 135-145 meq/l
● Sodium must be present for glucose to be
transported to the cell
● Controls ECF osmotic pressure
● Necessary for neuromuscular functioning,
intracellular chemical reactions.
● Maintains acid-base balance
● As sodium is reabsorbed, water is also
absorbed
● Daily requirement is minimum of 2gm/day
● Sodium - regulates H2O inside and
outside of cell, regulate muscles
contraction, transmission of nerve
impulses, prominent in extracellular
compartment
HYPONATREMIA
Causes:
1. Not consuming enough sodium
2. Diuretics “thiazides”
3. Vomiting (gi suction)
4. Diarrhea
5. Sweating
6. Low secretion of aldosterone
7. Siadh
● ↑Aldosterone = ↑Na & ↑H2O retention
then ↓K
● ↓Aldosterone = ↓Na & ↓H2O retention
then ↑K
Signs and symptoms (SALT LOSS):
● Seizures and stupor
● Abdominal cramping
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● Lethargic
● Tendon reflex diminished, trouble
concentrating
● Loss of urine and appetite
● Orthostatic hypotension, overactive bowel
sound
● Shallow respirations (happens late due to
skeletal muscle weakness)
● Spasms of muscle
● Main three s/sx: Confusion, fluid overload,
dehydration
Medical management:
● Administer hypertonic solution
● Administer loop diuretics as ordered
● Measure intake and output
● Monitor daily weight
● Restrict fluid
● Instruct the client to increase oral sodium
intake as prescribed and inform the client
about the foods to include in the diet
HYPERNATREMIA
Causes:
1. Cushing syndrome = ↑Cortisol
2. Primary hyperaldosteronism
3. Hypertonic solutions and excessive use of
sodium bicarbonate
4. Corticosteroids
5. Not drinking enough water or losing too much
water
6. Increased intake of sodium
Signs and symptoms (FRIED):
● Fatigue
● Restless
● Increased reflexes (progress to siezures
and coma)
● Extreme thirst
● Decreased urine output, dry mouth/skin
Medical Management: ● Decrease BP
● Hypotonic solution (0.3%nacl)
● Isotonic non saline solution (d5w) Diagnostics:
● Diuretics ● ECG changes: flat T waves, inverted T
waves, depressed ST segments, elevated
Nursing intervention: U wave
● Increase oral fluid intake ● Metabolic alkalosis
● Restrict sodium
● Monitor for cerebral edema if the client is Medical management:
receiving D5% or hypotonic saline solution ● IV replacement = potassium flouride
● Administration of 40-80 meq/day of
potassium
POTASSIUM IMBALANCES
● KCL
● 3.5-5.5 Meq/l
● Excitability Of Nerves And Muscle Nursing intervention:
● ICF Osmotic Pressure ● Instruct the patient about foods high in
● Maintains Acid-base Balance and Normal potassium
Kidney Function ● Administer oral supplement with meals
● K Deficit → Alkalosis = s/sx: diarrhea ● Monitor for constipation and decrease
● K Excess → Acidosis = s/sx: nausea & bowel sound (since walang magsstimulate
vomiting ng peristalsis)
● Potassium function: muscle
contraction/heart

HYPOKALEMIA
Causes:
1. K- wasting diuretics
2. Corticosteroid, sodium penicillin, carbenicillin,
and amphotericin
3. Vomiting and gastric suction
4. Diarrhea
5. Prolonged intestinal suction, ileostomy
6. Villous adenoma
7. Metabolic alkalosis
8. Hyperaldosteronism
9. Cushing syndrome Precaution with KCL
10.Hyperinsulinism ● KCL is never given by iv push, im, or sq
● K+ wasting = furosemide, mannitol ● A dilution of no more than 1 meq/10 ml of
● K+ sparing = spironolactone, amiloride, solution is recommended
thiazide ● Rotate and invert the iv solution → to
ensure that the potassium is
Signs and symptoms: ● Distributed evenly throughout the iv
● Metabolic alkalosis solution
● Fatigue ● The maximum recommended infusion rate
● Anorexia is 5-10 meq/hr never exceed 20 meq/hr
● Nausea and vomiting ● If the pt. Receives 10 meq/hr should be
● Muscle weakness placed on a cardiac monitor → if ecg
● Polyuria changes, stop the infusion immediately
● Decreased bowel motility / abdominal ● Peaked T waves = ↑K
distention
● Paresthesia
● Leg cramps/hypoactive reflexes
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HYPERKALEMIA 2. Oral intake inadequate (alcoholism)
Causes: 3. Wound drainage (especially gi system)
1. Cellular Movement Of K from intracellular To 4. Low vitamin d levels
extracellular (burns, tissue Damage, Acidosis) 5. Chronic kidney disease
2. Adrenal Insufficiency 6. Increased phosphorus levels in the blood
3. Renal Failure 7. Using medication (mg supplements, laxatives,
4. Excessive Potassium Intake loop diuretics, calcium binder drugs)
5. Drugs (k-sparing Drugs (spironolactone, 8. Mobility issues
Aminoride, Thiazides, Triamterene, Ace Inhibitors,
Nsaids) Signs and symptoms (CRAMPP):
● Confusion
Signs And Symptoms (MURDER): ● Reflexes hyperactive
● Muscle Weakness ● Arrhythmias (prolonged qt interval)
● Urine Production Little Or None ● Muscle spasm
● Respiratory Failure ● Positive trousseau’s
● Decreased Cardiac Contractility ● Positive chvostek’s
● Early Signs Of Muscle Twitches
● Rhythm Changes: Tall Peaked T-waves,
Flat P Waves, Widened QRS, and
Prolonged PR Interval
Diagnostics:
● Metabolic Acidosis
● Peaked T-waves

Medical Management:
● IV Calcium Gluconate = for ↓ effects of K
● Sodium Bicarbonate = for acidosis
● Glucose And Insulin
● Loop Diuretics
● Albuterol
● Kayexalate = (sodium polystyrene
sulfonate) Side Effect: constipation,
cannot be given if constipated
● Dialysis
Nursing Management
● Monitor Cardiac, Respiratory,
Neuromuscular, Renal, and GI Status
● Stop Iv Potassium If running and hold any
potassium supplements
● Initiate Potassium Restricted Diet And
Remember Foods That Are High In
Potassium
CALCIUM IMBALANCES
● 4.5-5.5 meq/l
● Vitamin D and P must be present for CA to
be absorbed from the GIT
Medical management:
● Administer iv calcium gluconate as
ordered
● Administer oral calcium with vitamin d
supplements
● Aluminum hydroxide antacids (tums)
Nursing intervention:
● Encourage intake of foods high in calcium
● Safety precaution
● 0.9% sodium chloride solution should not
be used with calcium
● Calcium replacement can cause postural
hypotension
● Seizure precaution
● Monitor airway for laryngospasm
● Advise the patient to avoid alcohol,
caffeine, cigarette smoking, laxative

HYPOCALCEMIA
Causes:
1. Low parathyroid hormone
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HYPERCALCEMIA
Causes:
1. Hyperparathyroidism
2. Increased intake of calcium supplements
3. Glucocorticoids usage
4. Calcium excretion decreased with thiazide*
diuretics & renal failure, cancer of the bones
5. Lithium usage

Signs and symptoms (WEAK):

● Weakness of muscle
● Ecg changes (shortened qt interval)
● Absent reflex
● Kidney formation

Medical management:
● IV administration of PNSS
● administering iv phosphate
● furosemide
● calcitonin

Nursing intervention:
● Increasing patient mobility and
encouraging fluids
● Patients are encouraged to drink 2.8 ro
3.8 l (3 to 4 quarts) of fluid daily
● Adequate number in the diet is
encouraged to onset the tendency for
constipation

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