P 1.

< Na+, K+, Ca++

P 2. IV therapy
< Indications, types, needles, etc

P 3. Types of IV solutions
< Hypertonic, hypotonic, isotonic (indications for each)

P 4. Math calculations P 5. Crystaloid versus Colloid P 6. Complications of IV’s

Intravenous Fluids

P IV fluids and medications, and total parenteral nutrition will be considered. P IV therapy and safe administration of IV meds is very critical because absorption in pharmacokinetics is eliminated. P What the nurse puts into the vein is immediately distributed, there is no taking back a mistake. P It is critical for the nurse to be very familiar with all drugs and electrolyte solutions administered IV.

Net movement of fluids within compartments

Fluid shifts in disease
P Fluid loss:
< GI: diarrhoea, vomiting, etc. < renal: diuresis < vascular: haemorrhage < skin: burns

P Fluid gain:
< Iatrogenic: < Heart / liver / kidney failure:

Renal regulation of sodium and potassium balance

Sodium (Na+) Discussion

P Most abundant cation (90% of the electrolyte fluid) and the chief base of the blood. P Primary functions are to chemically maintain osmotic pressure, acid base balance and to transmit nerve impulses. P Normal level is 135 -145 mEq/L

Sodium (Na+) 000000000
Hyponatremia (a decreased level) reflects a relative excess of body water, rather than a low total sodium level.

P Causes include: Severe burns, CHF , Edema (dilutional) , NG suction P Excessive fluid loss (severe diarrhea, vomiting, sweating), drugs such as diuretics P Excessive IV induction of non electrolyte fluids (glucose), diabetic acidosis P Addison’s disease, malabsorption syndrome P Severe nephritis, pyloric obstruction, Hypothyroidism

Sodium (Na+)00000000000000
Hypernatremia (an increased sodium level) is uncommon

P Causes include: Dehydration d/t insufficient water intake, Primary aldosteronism P Coma, Cushing’s disease, Diabetes insipidus P Tracheobronchitis

Potassium (K+)

P Most abundant principle electrolyte of the intracellular fluid (90 % found within the cell) P Principle function relates to electrical activity of heart, acid base balance, nerve conduction P Normal value is 3.5 -5.3 mEq/L

Potassium (K+)
Hypokalemia (decreased levels) is the shifting of K+ into cells, K+ loss from GI and biliary tracts, renal K+ excretion, and reduced K+ intake:

P Causes include: diarrhea, vomiting, starvation, malabsorption P Excessive sweating, Draining wounds, burns, P Respiratory alkalosis, Diuretics, DKA

Potassium (K+)

Calcium (CA++)

P Only ionized calcium can be used by the body in such vital processes as: P Muscular contraction, cardiac function, transmission of nerve impulses, and blood clotting P Normal values: 8.6 -10.0 mg/dl

Calcium (Ca++)
Hypocalcemia (decreased total calcium)

P Causes: alkalosis, pancreatitis, hyperphosphatemia, immobility, removal of parathyroids during surgery

Calcium (Ca++)
Trousseau’s sign

Calcium (Ca++)
Chvostek’s sign

< NaCl, .45NaCl, NS, .9NS < LR < D5W, D5W.45NS, D5WLR < 50cc, 100cc, 250cc, 500cc, 1000cc

Intravenous therapy
P Peripheral IV therapy is the most common method of gaining access to the client’s venous system. P Used to replace fluids, electrolytes, and nutrient losses, anti-infectives, blood products, Dyes P Orders are necessary for initiation of therapy = (1) Specific type of solution; (2) Rate of administration; (3)Volume of infusion; (4) Time of infusion intended

P Intravenous fluids are usually provided to:
< Provide volume replacement < Administer medications, including electrolytes < Monitor cardiac functions

Indications for an IV
P 1.Establish or maintain a fluid or electrolyte balance P 2 Administer continuous or intermittent medication P3 P4 P5 P6 P7 Administer bolus medication Administer fluid to keep vein open (KVO) Administer blood or blood components

Administer intravenous anesthetics Maintain or correct a patient's nutritional state P 8 Administer diagnostic reagents P9 Monitor hemodynamic functions

P Steel Needles: Eg: Butterfly catheter. They are named after the wing-like plastic tabs at the base of the needle. P They are used to deliver small quantities of medicines, to deliver fluids via the scalp veins in infants, and sometimes to draw blood samples (although not routinely, since the small diameter may damage blood cells). These are small gauge needles (i.e. 23 gauge). P

P Over the Needle Catheters Example: peripheral IV catheter. This is the kind of catheter you will primarily be using.

P Catheters (and needles) are sized by their diameter, which is called the gauge. P The smaller the diameter, the larger the gauge. P Therefore, a 22-gauge catheter is smaller than a 14-gauge catheter. P Obviously, the greater the diameter, the more fluid can be delivered. To deliver large amounts of fluid, you should select a large vein and use a 14 or 16-gauge catheter. To administer medications, an 18 or 20-gauge catheter in a smaller vein will do.

P For example, a patient comes into the ED with gastroenteritis and is dehydrated from vomiting and diarrhea. P Acutely, she receives a fluid bolus to expand her intravascular volume. Her blood chemistry shows that her electrolytes are a bit off, so the IV fluid is adjusted to bring them within normal parameters. P She is also given medication for nausea via her IV. She will remain on maintenance IV fluids until she is able to drink adequate amounts of fluids.

Types of IV FLUIDS

P Isotonic fluids P Hypertonic fluids P Hypotonic fluids

Types of IV FLUIDS
Isotonic fluids

P Close to the same osmolarity as serum. They stay inside the intravascular compartment, thus expanding it. P Can be helpful in hypotensive or hypovolemic patients. P Can be harmful. There is a risk of fluid overloading, especially in patients with CHF and hypertension. P Examples: Lactated Ringer's (LR), NS (normal saline, or 0.9% saline in water).

P Isotonic fluids contain an approximately equal number of molecules (blue dots) as serum so the fluid stays within the intravascular space. P Remember that fluid flows from an area of lower concentration of molecules to an area of high concentration of molecules (osmosis) to achieve equilibrium (fluid balance). P In this example, there is no fluid flow into or out of the intravascular space.

Hypotonic fluids
P Have less osmolarity than serum (i.e., it has less sodium ion concentration than serum). It dilutes the serum, which decreases serum osmolarity. Water is then pulled from the vascular compartment into the interstitial fluid compartment. Then, as the interstitial fluid is diluted, its osmolarity decreases which draws water into the adjacent cells. P Can be helpful when cells are dehydrated such as a dialysis patient on diuretic therapy. May also be used for hyperglycemic conditions like diabetic ketoacidosis, in which high serum glucose levels draw fluid out of the cells and into the vascular and interstitial compartments. P Can be dangerous to use because of the sudden fluid shift from the intravascular space to the cells. This can cause cardiovascular collapse and increased intracranial pressure (ICP) in some patients. P Example: .45% NaCl, 2.5% dextrose

P Hypotonic fluids contain a lower number of molecules than serum so the fluid shifts from the intravascular space to the interstitial space (represented by the green arrows). P This decreases the interstitial space osmolarity (because of the increase of fluid and constant number of molecules within it) which then causes fluid to move into the cells. Note that the green arrows represent fluid movement, not molecule movement.

Hypertonic fluids
P Have a higher osmolarity than serum. Pulls fluid and electrolytes from the intracellular and interstitial compartments into the intravascular compartment. Can help stabilize blood pressure, increase urine output, and reduce edema. P Rarely used in the prehospital setting. Care must be taken with their use. Dangerous in the setting of cell dehydration. P Examples: D5W.45% NaCl, D5WLR, D5W NS, blood products, and albumin

P Hypertonic fluids contain a higher number of molecules than serum so the fluid shifts from the interstitial space to the intravascular space (represented by the green arrows). P This increases the interstitial space osmolarity (because of the loss of fluid and constant number of molecules within it) which then causes fluid to leak out of the cells.

There are two main groups of fluids

P Crystalloid P Colloid

P Are isotonic and remain isotonic and are therefore, effective volume expanders for a short period of time. P However, both the water and the electrolytes in the solution can freely cross the semipermeable membranes of the vessel walls (but not the cell membranes) into the interstitial space, and will achieve equilibrium in two to three hours. P They are ideal for patients who need fluid replacement. P When using an isotonic crystalloid for fluid replacement to support blood pressure from blood loss
< remember that 3 mL of isotonic crystalloid solution are needed to replace 1 mL of patient blood. This is because approximately two thirds of the infused crystalloid solution will leave the vascular spaces by about one hour.

P Generally, a good rule of thumb is that initial crystalloid replacement should not exceed three liters before whole blood is instituted. P Continued use of crystalloids runs the very real risk that the fluid that has leaked into the interstitial space will result in edema, primarily in the lungs (pulmonary edema). P Examples: Lactated Ringer's (LR), NS (normal saline).

P These contain molecules (usually proteins) that are too large to pass out of the capillary membranes and therefore remain in the vascular compartment. P The large protein molecules give colloid solutions a very high osmolarity. As a result, they draw fluid from the interstitial and intracellular compartments into the vascular compartment. P They work well in reducing edema (as in pulmonary or cerebral edema) while expanding the vascular compartment. P Colloids can produce dramatic fluid shifts and place the patient in considerable danger if they are not administered in a controlled settings. P Examples: albumin and steroids

The rules of fluid replacement:

P Replace blood with blood P Replace plasma with colloid P Resuscitate with colloid P Replace ECF depletion with saline P Rehydrate with dextrose

How much fluid to give ?

P What is your starting point ?
< Euvolaemia ?( normal ) < Hypovolaemia ?( dry ) < Hypervolaemia ? ( wet )

P What are the expected losses ? P What are the expected gains ?

What are the expected losses ?

P Measurable:
< urine ( measure hourly if necessary ) < GI ( stool, stoma, drains, tubes )

P P Insensible:
< sweat < exhaled

What are the potential gains ?

P Oral intake:
< fluids < nutritional supplements < bowel preparations

P IV intake:
< colloids & crystalloids < feeds < drugs

Veins of the Hand

P 1. Digital Dorsal veins P 2. Dorsal Metacarpal veins P 3. Dorsal venous network P 4. Cephalic vein P 5. Basilic vein

Veins of the Forearm

P 1. Cephalic vein P 2. Median Cubital vein P 3. Accessory Cephalic vein P 4. Basilic vein P 5. Cephalic vein P 6. Median antebrachial vein

Flow Rates

P Microdrip sets Allow 60 drops (gtts) / mL through a small needle into the drip chamber P Macrodrip sets Allow 10 to 15 drops / mL into the drip chamber

P Fluid may be ordered at a KVO or TKO rate. This means to Keep the Vein Open, or run in fluids very slowly, enough to keep the vein open, but not really deliver much volume. P At times, you may desire a faster flow rate. This is usually expressed in mLs / hour. In other words, how much fluid do you want your patient to receive each hour? A common "maintenance" amount, for instance, would be "run it in at 125 an hour". Your patient would receive 125 mL of fluid every hour. P Unless you are using an electronic pump to deliver the fluid at precise amounts, you will need to learn how to set a flow rate yourself. This is usually done by counting the number of drops that fall into the clear drip chamber on the IV administration set in one minute. To do this, you must know what size administration set you are using (micro or macrodrip). Plug the numbers into the following formula and you've got it! P (volume in mL) x (drip set) gtts P ------------------------------------ = -----P (time in minutes) min

Intravenous Fluids

P Who Needs Them? P What’s Maintenance? P How Much H20?

Maintenance IV Fluids

< 100 cc/kg/d 1st 10 Kg < 50 cc/kg/d 2nd 10 Kg < 20 cc/kg/d for every Kg > 20 Kg

P Na? P K? P Dextrose? P

Maintenance IV Fluids
P 70 Kg person
< 1000cc + 500cc + 1000cc = 2500cc=105cc/hr < Na 140-280 meq/d = 200 meq/2.5L = 80meq/L < 1/2NS =77 meq/L < KCl 70 meq/d = 70 meq/2.5L = 28meq/L < + 20 meq KCl/L < D5 1/2NS + 20 meq KCL/L @ 105 cc/hr


P Order reads 1000ml of 5 percent dextrose in water (D5W) at 125 ml/ h. You have available 20 drop factor tubing. Calculate the drops per minute.
< ML/hrX DF
– --------------– – Minutes = gtt/min

----------------- = 60 42 gtt/min

P Order reads 3000ml of a multiple electroyte fluid over 24 hours. You have available 20 drop factor tubing. Calculate the drop per minute. P Formula: P ml/h X DF 125 X 20
– ---------------- = – Minutes --------------- = 60 42 gtt/min


Complicated IV calculations

P Order to read: Order: Nipride 1 g IV in 250 mL D5w at 4 mcg/kg/min for a patient weighing 250. Administer at _____ mL/hr? P http://home.sc.rr.com/nurdosagecal/ P http://www.accd.edu/sac/nursing/math/defaul t.html

Complications Of IVs

P Bruising - may occur at any time during an episode of intravenous therapy


P Infection - adhering to aseptic technique is vital in the prevention of intravenous related infections. Asepsis should be maintained at insertion, during clinical use and at removal of the device.

P Infiltration - the inadvertent administration of non-vesicant solution/medication into surrounding tissues. P Although the solution is non-vesicant, tissue damage may still occur. P Regular monitoring of infusion sites, choice of correct access device/intravenous dressing and the use of in-line pressure monitors may help to reduce the extent to which infiltration occurs P Discontinue the IV, place cold compress on to decrease swelling then warm compress to move fluid out of the interstitial spaces

P Extravasation - the inadvertent administration of a vesicant substance into the tissues can have disastrous outcome.


P Infusion Phlebitis - inflammation of the vein associated with infusion phlebitis is seen in this photograph. Careful/regular monitoring of intravenous access sites is recommended.

Systemic Complications

P Systemic complications include sepsis, pulmonary thromboembolism, air embolism, and catheter-fragment embolism.

Parental nutrition (TPN) (Hyperalimentation)
P Parental nutrition is the administration through a central or other intravenous line of essential proteins, amino acids, carbohydrates, vitamins, minerals, trace elements, lipids, and fluid. P Used to improve or stabilize the nutritional status of cachectic or debilitated patients who cannot take or absorb oral nutrition to maintain their nutritional status. P Adverse effects many include mechanical problems (IV lines), infections, metabolic imbalances, gallstone development, nausea

P TPN solutions are hyperosmotic (three to six times the osmolarity of normal blood) P Fluid shifts can stimulate fluid shifts between body fluid compartments. P Hyperglycemia (hyponatremia and hypokalemia) can cause osmotic diruresis = dehydration P If client has an accompanying cardiac or renal dysfunction = over hydration, CHF, pulmonary edema

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